Gun violence is rising. The national debate over gun control has stalled. And there are more guns than people in the U.S.
But that doesn’t mean addressing these problems is hopeless. Doctors and other health experts are pushing to reframe the terrible toll of violence, unintentional injury and suicide-by-firearm as a public health crisis — borrowing the same holistic, multipronged approach focused on harm reduction that has helped reduce deaths and other harm from car crashes, air pollution and sexually transmitted diseases.
Car crash deaths have declined by nearly half over the past 50 years, and fatalities per mile driven have dropped by nearly 85 percent. “That’s even though we drive more and there are more cars on the road,” said Emmy Betz, an emergency medicine professor at the University of Colorado School of Medicine. “We used a public health approach to understand the scope of the problem and risk factors and developed multiple potential interventions.”
Data showing teen drivers got into more crashes spurred licensing restrictions based on age. Engineering fixes, from seat belts to speed strips on highways, made driving safer for everyone. Better education and drunken driving campaigns helped drivers adopt safer practices. “All these things helped car crash death rates decline,” she said. “A seat belt law alone was not going to fix the problem.”
Similarly, a single gun control policy won’t solve the problems gun pose. But a harm-reduction approach widens the aperture of how we view the problem and what might be done to reduce the risk of firearm injury or death. In 2020, guns killed more than 45,000 people and seriously injured many more. Firearm-related injuries are among the top five leading causes of death for people under 44, and guns kill more children than anything else in the U.S.
“For most of our country’s history, we’ve addressed gun violence by looking almost exclusively at criminology and law enforcement,” said Shannon Frattaroli, a gun violence researcher at Johns Hopkins University. “From a public health perspective, there’s a more holistic picture.”
That picture includes community violence, but also suicide and unintentional injuries. Instead of waiting for something bad to happen and jailing offenders, the approach “looks for risk factors and opportunities to intervene early, so that we don’t have to see those harms to society occur,” she said. Often those interventions aim to address problems far upstream from when someone pulls a trigger.
Reducing community violence
A public health approach to curbing community violence starts with better understanding of where violence is happening, who is involved and why.
“In any city, you’re going to see stark differences in gun violence across neighborhoods,” said Daniel Webster, co-director of the Johns Hopkins Center for Gun Violence Solutions. “We need to understand why that is, it’s not just the natural state of things.”
Often, levels of gun violence reflect historical disinvestment and discrimination. “The effects of redlining policies dating back to the 1930s endure today. Current rates of gun violence, in essence, have been baked in because of those policy decisions,” he said. Other factors also influence gun violence, he said, “but there’s a continuation of policies over generations that protect wealth and cordon off disadvantage.”
More than half of the nearly 68,000 firearm deaths that occurred in 5- to 24-year-olds from 2007 to 2016 occurred in counties where 15 percent or more residents live below the poverty level, and firearm-related mortality risk was highest in the poorest counties, according to a 2021 study.
Targeting those potential root causes of gun violence can help alleviate it, Webster said. “Reducing blight in neighborhoods of concentrated disadvantage significantly reduces shootings,” he said. Converting vacant lots in Philadelphia to green spaces with grass and trees was associated with a nearly 30 percent reduction in police-reported gun violence in neighborhoods below the poverty line, according to a 2018 study. That tracked with residents’ perceptions of crime, which dropped by 36 percent. “It’s incredibly low cost, but high benefit,” Webster said.
Other small studies have shown similar benefits with interventions like demolishing abandoned buildings or reducing the density of alcohol vendors. “Policies that address affordable housing or transportation issues can be key as well,” Webster said. A public health approach is focused on “creating conditions where gun violence is rare,” he said. But too many of these programs are still relatively small-scale. “We need to know whether these programs can actually be part of a public safety system that functions as a system as opposed to a few neighborhoods with a few programs,” he added.
Oakland, California, offers one potential model. After many years of high homicide rates, in 2012 the city launched a multifaceted community violence intervention campaign. The campaign, which involves partnerships between community members, social service providers and law enforcement, sought to identify those at highest risk for engaging in violence and intervene in ways that connect stopping violence with services like mentoring, education and direct assistance. Over the next several years, shootings fell by 32 percent citywide, while most other big cities saw increases.
“It’s very impressive,” Webster said. “Homicides, shootings, arrests, excessive use of force by police, they all went down in response to this collaborative approach.”
Putting distance between at-risk individuals and firearms
Just owning a gun puts a person at much higher risk of suicide. In California, a 2020 study showed gun owners were about nine times more likely to die by suicide than non-owners. But putting time and space between firearms and people in distress can help.
“If a person in an impulsive, upset moment reaches for a gun, they don’t have a second chance; 90 percent of the time, they die,” said Betz. Reducing access to firearms in such moments can reduce the risk of death “not because the gun makes someone suicidal, but because a gun is lethal,” she said.
Storing guns in a safe or using trigger locks can add a barrier that can allows someone to change their mind, and research shows that locking up guns or keeping them unloaded reduces risk of suicide. Safe storage also makes it harder for kids or other unauthorized users to access weapons in times of distress.
Numerous states have various safe-storage laws, ranging from mandating household firearms be locked away at all times to including trigger-blocking safety locks in all gun sales. Evidence suggests such laws reduce risk of adolescent suicide by 13 percent. They also can help prevent kids from accidentally firing weapons.
Ensuring widespread adoption of safer storage practices will take more than laws. It requires really engaging with different gun-owning communities in ways that resonate and avoid conflict, Betz said. “Language like ‘common sense gun laws’ can be very offensive to some people, because you’re implying they have no common sense if they don’t agree,” she said. “It comes back to respect for differences and being willing to listen,” she said.
That kind of communication can help communities and families learn ways of recognizing when someone might be at risk and take action, Betz added. “We all go through periods when we’re not at our best, maybe it’s substance abuse, depression, a bad divorce, a lot of anger,” she said. “How do we as a community support [such people] to make sure they’re safe while getting treatment?”
That could involve storing guns in a safe space outside the home, including police stations or firearms retailers. But people at risk of harming themselves or others may not be open to such suggestions. In some states, so-called red-flag laws or Extreme Risk Protection Orders (ERPOs) allow law enforcement to temporarily remove guns from the situation.
“It’s a promising approach that doesn’t wait for the trigger to be pulled before intervening,” said Frattaroli. “Someone doesn’t just wake up one day and have overwhelming suicidal ideations or the desire to commit a mass shooting, often there are warning signs that the person is on a dangerous trajectory,” she said, including domestic violence or threats. ERPOs allow the community “to temporarily remove guns from the mix while we figure out what’s going on and how best to reroute that trajectory,” she added.
About 19 states and the District of Columbia have extreme-risk laws in place, and most are fairly recent. The specifics of implementation vary, but generally the laws allow concerned individuals (family members, law enforcement and clinicians in some states) to petition the court to force the person to turn over their guns for as much as a year. It also bars them from purchasing guns.
There’s limited data to evaluate how effective ERPOs are, Frattaroli said, in part because the laws are quite new and there’s lots of variability in implementation. But localities that are investing in implementation show promise, she said. While Florida is sometimes called the “Gunshine State,” it leads in ERPOs issued, Frattaroli said, in part because some areas, like Fort Lauderdale, have specific task forces dedicated to the practice.
Improving the effectiveness of these policies and practices, and developing new ones, will require continued research and experimentation into firearm harm reduction, Frattaroli said. “We have a lot of promising policy proposals, and I’m optimistic that there are more out there,” she said. To advocates of this approach, it’s about taking a step back from when the trigger gets pulled to ask how that gun got into those hands — and what sorts of interventions might stop it.
Thanks to Lillian Barkley for copy editing this article.