From 2019 to 2020, firearm-related deaths increased almost 30 percent among persons one to 19, twice as much as in the general population. Firearm violence increased during the pandemic, a group of researchers wrote in a May 19 letter to the New England Journal of Medicine (NEJM), but that doesn’t mean injuries will decrease as it recedes.
Patrick Carter, co-director of the Institute for Firearm Injury Prevention at the University of Michigan, one of the authors of the NEJM letter, believes there’s something that goes missing too often in impassioned fights around gun control. We need to approach the problem of firearm injury prevention as a public health problem, he says, with data-driven, science-based solutions.
The CDC made a move in this direction three decades ago. In 1993, a study it had funded through its National Center for Injury Prevention and Control found an association between guns kept in the home and increased risk of homicide by a family member. This was reported widely, and the National Rifle Association campaigned for the center to be closed.
While this didn’t happen, a provision added to a 1996 appropriations bill by Rep. Jay Dickey of Arkansas stipulated that none of the center’s funds could be used “to advocate or promote gun control.” Pushback against federal investment in a public health-based approach to gun injuries continued for decades, but since 2019 Congress has allocated $25 million annually to fund gun violence research.
As of this writing, there have been 34 new mass shootings in the U.S. since Robb Elementary, and the sense of urgency to “do something” about guns has reached new levels. “Everybody gets into their corners and has their opinion about what the solutions are,” says Carter. “But there is an approach to this that we've used with other public health issues and other injury-related health problems that is tried and true and that works.”
Carter spoke with Governing about how this might work. The interview has been edited for length and clarity.
Governing: What would it look like to approach firearm injuries as a public health problem?
Patrick Carter: I use the example of motor vehicle crashes. When we reached the peak of motor vehicle crashes deaths in the mid-1950s, the approach that we took to solving that problem was to broaden our thinking.
We went beyond, “This is a crash event that a single driver is responsible for,” to thinking about, “What are all the different aspects of the issue that are causing this and how do we address solutions that are focused on each aspect of the issue?"
We made roads safer. We changed the way cars are built to make them safer. We changed driver behavior, especially around drinking, and driving and speeding and wearing seat belts. We improved how we responded to crashes when they happen, so that we have a robust EMS system and trauma system that can rapidly take somebody and get them to the hospital to receive medical care.
We reduced motor crash injury by over 70 percent over the past 50 years. We haven't taken that same approach with firearms.
Governing: Where do school shootings fit in the context of all causes of youth deaths from guns?
Carter: School shootings and mass shootings of the kind that have made the news in the past couple of weeks are obviously horrific events and they garner a lot of attention. In terms of overall numbers, they represent a small aspect of the total number of deaths and injuries that we see from firearms.
About 65 percent of the firearm deaths that we see among children and teens are homicides. About 30 percent are suicides. About 3 percent to 4 percent are due to unintentional injuries, like a child finding a firearm that's not secured and it going off.
It’s the daily firearm deaths that accumulate over the course of the year that represent a large aspect of the problem. That's certainly not to diminish these horrific mass shootings in school settings.
Governing: But if you want to protect children from firearms, it doesn’t sound like hardening schools or arming teachers would take you very far.
Carter: It doesn't get at all aspects of the problem — there's no one solution that's going to get at all aspects of the problem. It's really going to be about addressing all of these different facets.
We also want to be cognizant of the potential for unintended consequences in some of the things that are being put forth. A big move in the past several years has been active shooter drills. Depending on how those are done, they can have significant mental health consequences and cause stress for students in the school environment.
Some of the most effective solutions back up and start in the prevention space, way upstream of the event. If we're only focused on how we address things at the time of a school shooting or a mass shooting, to limit the potential for injury in the event, then we haven't addressed any of the upstream factors that are a part of it.
For example, we know that in school shootings and mass shootings — especially where teens and adolescents are involved — that in about 75 percent of cases the firearm comes from their home or the home of a relative.
Increasing safe storage in homes is a key lever. If we're able to prevent teens from gaining access to firearms in their homes, we've prevented a downstream impact.
Governing: What might a public health-based approach to storage include?
Carter: Some of it is around individual change. We know that counseling by physicians and health-care providers and training by firearm trainers can be effective ways to increase safe storage. We also know that child access prevention laws can be a policy intervention that decreases access.
It’s that kind of approach that is needed, where we're thinking about things from all these different angles.
Governing: Your institute has been more successful than most in attracting funding to research gun injuries. More money has become available in recent years, hasn’t it?
Carter: Federal sources of funding were not available for the course of 25 or 30 years, the legacy of the Dickey Amendment. A little bit after Newtown and around Parkland, there was a shift and the federal government began funding firearm research again, somewhere in the neighborhood of $25 million a year in the past couple of years.
That’s a huge shift and really important for starting to develop this stream of research. But if you think about it on par with how we approach other issues with similar burden of disease, with the same type of numbers of people who are affected by a problem, that's a drop in the bucket.
Governing: How much funding should there be?
Carter: If you think about cancer, which is currently the fourth-leading cause of death among children and teens, cancer research far outpaces funding firearm research. That's not to say we should decrease cancer research funding. We need to be doing more in the space of firearm injury prevention, to fund it commensurate with the burden of disease.
Because of the number of years that there was no funding available, there's a lack of researchers in this space. We need to rebuild the field. There are centers focused on transportation safety and motor crash injury prevention at many academic institutions across the United States.
That doesn't exist for firearm research — there hasn't been funding in the field, so people haven't been going into it.
Governing: Is it really possible to shift calls to do something about guns to the public health arena?
(University of Michigan)
Carter: I have conversations with gun owners, with folks across the political spectrum. When the focus is on how we can decrease the number of people who are suffering injuries from firearms and dying from them, you can usually get people on the same page around thinking creatively about what the solutions are.
It's when people diverge into political corners around firearms and the Second Amendment that things go off the rails. I think people can come to common ground on trying to approach this as a science-based problem. It’s about shifting the viewpoint to that public health model.
We reduced car deaths in this country without taking cars off the road. In fact, there are more cars on the road every day now than there were in the 1950s.
Governing: Other than storage, are there policy solutions that address significant causes of injury?
Carter: I want to emphasize that it's important not to think about this as something that is only about policy solutions. There are solutions across the board, everything from individual-level things done by physicians or counselors or trainers to community-based solutions and policy solutions.
Different aspects of the problem are going to require different types of solutions.
If you focus specifically on the policy question, we know that states that have more comprehensive background check laws tend to have less firearm death. We know that in states where red flag laws have been implemented, there tend to be lower rates of suicides. So there is some suggestion, although there is more research needed, that they are an effective tool for temporarily removing firearms from people who may be at risk of harming themselves or others.
We can move the needle on things like this if we start to focus on them. If a new policy is put in place, we have to look at it. We have to study it. We have to understand how well it's being effective at what we're trying to do
Governing: Are there questions that need to be answered just to know what kinds of research are needed?
Carter: There are a lot of things we need to understand better. We published a research agenda for the field a few years ago that included something in the neighborhood of 45 top research questions that haven't been addressed.
How well do community violence interventions work? What’s the right way to do screening in health-care counseling? What's the right way to train new firearm owners? Is there a role, especially for teens and young adults, for some sort of graduated responsibility?
We did that with cars — we put graduated driver's licensing laws in place that sort of trained teens to drive in stages where they had to reach certain milestones, to prove that they could operate a vehicle safely in certain ways before they moved to the next step.
What's the role for fingerprint-specific firearms and fingerprint-specific storage safes, and how will that increase or change safe storage? What would be needed in order to get people to use those type of devices?
These are all examples of open questions. We’re going to need to grow the field if we're going to answer those questions.
Governing: Is funding research to ask and answer questions about the real causes of gun injuries the way out of divisive rhetoric?
Carter: That seems like the best approach to me. I've often said you're not going to solve this problem with two people arguing about what they think is the best solution.
It's best to use the data about what works and what doesn't work to help drive changes and solutions in this space, and to use models that we've done before. What we’ve done with motor vehicle crashes is a nice model — we developed engineering solutions, behavioral solutions, community solutions and policy solutions that address different aspects of the problem.
Governing: None of what you’re saying revolves around telling people they can’t have guns, does it?
Patrick Carter: Right.
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