The U.S. Is in the Midst of a Public Health Crisis: Gun Violence

Far more Americans die of firearm-related causes than residents of any other high-income country. A recent study found that more than half of all adults in the United States have been directly impacted by gun violence, meaning they or a family member were threatened or hurt by a gun, or they witnessed someone being injured by one. Gun violence leads to roughly 30,000 inpatient hospital stays, 50,000 emergency room visits, and more than $1 billion in immediate medical costs every year, making it a veritable public health crisis. And while most of the associated costs are borne by Medicaid and Medicare, it’s American taxpayers who ultimately foot the bill.

In 2019, Singapore, Japan, Korea, and the United Kingdom had the lowest firearm mortality rates among high-income countries, with Singapore reporting no deaths at all. Rates in the U.S. were around five times that of France, Switzerland, and Canada.

The U.S. is the only high-income country with more guns than people — it has 46 percent of the world’s guns despite having only 5 percent of the world’s population. Firearm deaths are virtually nonexistent in many other high-income countries. One distinguishing characteristic between these nations and the U.S. is that access to guns is more strictly regulated. In Singapore, for example, people must pass annual background checks and safety tests to buy a gun, plus they have to belong to a gun club, which is also where guns must be stored. In South Korea, private citizens have access only to air rifles and hunting guns, which require a background check and license from the police. Firearms also must be stored at a police station when not in use. In the U.K., individuals must have a valid and police-verified reason to purchase a firearm, such as a job requirement, and they must pass a series of background checks.

In the U.S., private citizens can purchase firearms, including semiautomatic assault weapons, with relatively few restrictions. Federal laws such as the Gun Control Act of 1968 and the Brady Handgun Violence Prevention Act of 1993 prohibit some groups from purchasing firearms — including convicted criminals, people with mental disabilities, and dishonorably discharged military personnel — and mandate background checks for all unlicensed individuals purchasing a firearm through a federally licensed gun dealer. Additionally, the Bipartisan Safer Communities Act extended prohibitions to all people convicted of domestic violence for at least five years. However, many other firearm regulations vary state by state, and legal challenges can often limit the vigor of enforcement efforts.

How Can the U.S. Health System Address Gun Violence?

While limiting access to guns has the greatest potential to reduce firearm mortality, the experiences of other high-income countries suggest the U.S. health care and public health systems could play a significant role in preventing and managing gun violence. And although rates of gun violence in peer countries are so low that public health interventions tend to be focused on violence-at-large, U.S. policymakers could adapt some of these efforts to minimize gun violence.

For example, the Cardiff Model, pioneered in Wales, encourages hospitals to gather anonymous information from victims of crime, including when and where the violence took place, to help authorities identify high-risk locations and targeted intervention. The model was able to halve Cardiff’s crime rate while saving the health system more than $6 million annually. One study, which assessed the model in 14 other cities in England, found a 42 percent reduction in hospital admissions for violence-related injuries, saving roughly $15 in health system costs for every $1 spent. This violence-reduction technique has been adapted to target homicides in several U.S. cities, including Atlanta, which had one of the highest rates of homicides in the country in 2021. Gun violence is a pervasive issue that affects the entire nation, but it disproportionately impacts underserved Black and lower-income communities. Public health approaches must therefore be customized to address the unique needs of each community.

Beyond on-the-ground public health interventions, there is ample evidence that social drivers of health are risk factors for violent crime. In Singapore, access to safe, affordable housing is a government priority and a means to reducing social inequities. The government is responsible for housing the vast majority of residents, and neighborhoods are designed to provide commercial and recreational centers to foster community and ultimately improve health and reduce crime. Investment in early childhood education also has been found to minimize the chances of criminal behavior later in life. Yet on both fronts, the U.S. spends significantly less compared to other high-income countries.

Mitigating America’s Gun Violence Epidemic

Gun violence undermines physical and mental well-being on both an individual and community level. There was a 50 percent increase in the number of children and teens who died of gun-related causes between 2019 and 2021, making guns the leading cause of death from ages 1 to 19. But only a quarter of parents reported that their child’s pediatrician asked them about having guns in the home.

Some approaches have called for primary care physicians and pediatricians to be trained in addressing firearm safety during medical school. Several groups of primary care providers, family physicians, and pediatricians have proposed a multipronged approach that includes trainings for families on safer firearm-storage practices as well as hospital- and community-based violence intervention programs, which have been found to make communities safer.

In March of this year, President Biden announced several new proposals to reduce gun violence, including increasing the number of background checks, improving public awareness of safe storage, and more. Congress, however, has yet to act. In the meantime, the U.S. public health and health systems have a role in reducing gun violence through improving data collection, increasing research funding, training health care and public health workers, and facilitating collaboration across states and local partners. Inspired by the success of countries that have tackled gun violence as a public health issue, policymakers can adopt evidence-based measures to mitigate its devastating effects.

Acknowledgments

Munira Z. Gunja, Evan D. Gumas, and Joseph R. Betancourt, M.D., of the Commonwealth Fund; Vageesh Jain, MBBS (U.K. Harkness Fellow), of the Harvard T.H. Chan School of Public Health; and Megan L. Ranney, M.D., of the Yale School of Public Health.