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Reducing the Burden of Injury: Advancing Prevention and Treatment 5 Case Studies on Prevention The two leading mechanisms causing fatal injury in the United States are motor vehicles and firearms; in 1995, 42,452 people died from motor vehicle traffic injuries and 35,957 people died as a result of firearm injuries (Fingerhut and Warner, 1997). Over the past three decades, dramatic progress has been made in reducing motor vehicle injuries by understanding the factors that increase the risk of injury, designing interventions to reduce these risks, implementing and evaluating a wide array of interventions and assessing their benefits and costs, and providing a scientific foundation for individual and business choices and public policy judgments. However, a similar comprehensive multi-disciplinary approach has not been taken in relation to firearm injuries. The goal of this chapter is to explore the comprehensive approach that has been utilized successfully to promote motor vehicle safety and to recommend steps that could be taken to implement a similar effort to reduce firearm injuries. MOTOR VEHICLE INJURIES Although motor vehicle crashes remain the single largest cause of injury deaths in the United States, rates of motor vehicle deaths have declined substantially over the past 25 years, especially when the increasing numbers of drivers and the number of miles traveled are taken into account (Figure 5.1). Yearly fluctuations in the numbers of motor vehicle deaths (reaching a high of 56,278 in 1972) have taken place against a backdrop of increasing levels of exposure, including an increase in the number of licensed drivers and an increase in motor vehicle travel (NSC, 1997). In 1930, the number of miles driven in the United States was 206 billion, and the death rate was 15.97 per 100 million miles; in 1972, 1,268 billion
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Reducing the Burden of Injury: Advancing Prevention and Treatment Figure 5.1 Motor vehicle traffic injury deaths per 100 million vehicle miles in the United States, 1950–1996. Source: National Safety Council, 1997. miles were driven, with a death rate of 4.43; and in 1996, the figure was 2,467 billion miles driven, with a death rate of 1.76 per 100 million miles. Had the mileage death rate of 1972 prevailed in 1996, the number of deaths would have been almost 110,000 rather than 43,399. It has been estimated that between 1966 and 1990, 243,400 lives were saved as a result of federal highway, traffic, and motor vehicle safety programs (NHTSA and FHWA, 1991). Reasons for Progress: A Comprehensive Approach For the first six decades of motor vehicle traffic on the highways, the federal and state governments worked primarily on building and improving highways and roads, while state and local governments regulated who could drive and how; vehicle design was left to the marketplace. In most respects during those
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Reducing the Burden of Injury: Advancing Prevention and Treatment years the focus on reducing motor vehicle injury was on improving drivers' skills (Waller, 1994). Although the vehicles offered for sale in the 1950s were safer in many respects than those of earlier decades, the technology for protecting occupants in a crash had developed still further and offered potential gains in safety that were not being put into production (DeHaven, 1942; Stapp, 1957). In recent years, an increasingly sophisticated and comprehensive approach to the motor vehicle injury problem has developed that addresses safety issues for the driver, occupant, vehicle, and highway system (CDC, 1994). The conceptualization of this approach has been based largely on the work of William Haddon, who developed models for the systematic exploration of countermeasures to reduce or prevent injuries involving components of the causal sequence leading to injury—pre-crash, crash, and post-crash events (see Chapter 1 for a fuller description of the Haddon matrix; Haddon [1972, 1980]). When applied to motor vehicle safety, this approach involves addressing issues concerning the host (driver and passenger), agent (vehicle), and environment (roads and highways). The effort to reduce motor vehicle injuries has been both sustained and multi-pronged, involving surveillance systems; regulatory measures; behavioral, biomedical, and engineering research; state and local programs; and public support. This comprehensive, data-driven approach has been supported by stable federal funding and involves efforts at the federal, state, local, and private-sector levels. Surveillance National data systems have been instrumental in allowing trends in motor vehicle injuries to be tracked and injury patterns identified and in assessing the outcomes of prevention interventions. Data systems include the National Vital Statistics System, with information on deaths in the United States; the Fatality Analysis Reporting System (FARS), an in-depth collection of data on all fatal motor vehicle crashes on public roads; and the National Automotive Sampling System, which consists of the Crashworthiness Data System that collects detailed data through crash investigations and hospital injury data and the General Estimates System, a national probability sample of police-reported crashes. The federal government has also made major efforts to improve the quality and consistency of state data systems and has fostered linkages of data systems (e.g., police crash reports and hospital data). These data systems have been used both to identify research questions of importance and to address such questions with high-quality data. Surveillance data were essential for the enactment and assessment of legislation establishing the minimum age for the purchase of alcoholic beverages. In the early 1970s, about half of the states lowered their minimum age for alcohol purchase, from 21 to 18 in most cases. Beginning in 1976, states reversed course and began to raise the minimum age, a trend that continued into the early 1980s. Multistate research based on FARS and vital statistics data showed the beneficial ef-
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Reducing the Burden of Injury: Advancing Prevention and Treatment fects of this reversal on a national level (Cook and Tauchen, 1984; GAO, 1987). Without these data, it would have been necessary to try to obtain data for a large number of states and determine which data elements were comparable, a difficult task, or to rely on the accumulation of single-state studies, which by themselves are often unreliable because of small sample sizes. The research findings were instrumental in leading to federal legislation that influenced states to establish 21 as the minimum age for purchase of alcohol or to lose federal highway funds (Wagenaar, 1993). This policy is now in effect in all states and is credited with having saved 16,513 lives from 1975 through 1996 (NHTSA, 1996). Regulation and Legislation In 1966, legislation was enacted that marked a significant change in the nation's approach to reducing motor vehicle injuries. The National Highway Traffic and Motor Vehicle Safety Act authorized the federal government to set safety standards for new vehicles and equipment, and the Highway Safety Act of 1966 authorized the federal government to develop a coordinated national highway safety program. The two acts legislated, for the first time, a comprehensive national program addressing the human, vehicular, and environmental factors that lead to motor vehicle injuries. They allowed for the development of safety standards for new vehicles and equipment and also targeted human factors (e.g., driver fatigue, effects of alcohol on driving). In 1967, the National Highway Safety Bureau issued highway program standards that were to be adopted by the states, including requirements for driver education, driver licensing, alcohol countermeasures, school bus safety, and motorcycle safety laws. States had to report on annual progress and could be penalized by the withholding of federal highway funds if the programs were not implemented. Thus, many states enacted new safety programs and legislation to meet federal requirements. The passage of the Highway Safety Act of 1970 established the National Highway Traffic Safety Administration (NHTSA) as the successor to the National Highway Safety Bureau. NHTSA was charged with the responsibility of reducing deaths, injuries, and economic losses resulting from motor vehicle crashes and had regulatory, surveillance, research, and programmatic responsibilities, a mission and charges that it continues to implement. Additionally, the Federal Highway Administration works to improve highway safety and has regulatory jurisdiction over the safety performance of interstate commercial motor carriers and those carriers transporting hazardous materials. The federal regulatory program is designed to raise vehicle and highway safety standards and, despite legal impediments (Mashaw and Harfst, 1990), has led to a vehicle fleet that is far more crashworthy than 30 years ago. Initial resistance to federal regulation of vehicles has gradually subsided, so that there is currently a more cooperative relationship between federal regulatory agencies and industry.
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Reducing the Burden of Injury: Advancing Prevention and Treatment In addition to federal regulation, states and local governments have extensive regulatory and administrative responsibilities for highway safety, including driver licensing, driver education programs, motor vehicle inspections, setting speed limits, highway and road design and maintenance upgrades, and legislation and enforcement of traffic safety laws including those on alcohol-impaired driving, safety belt use, and use of child safety seats. The national objective of reducing motor vehicle injuries has been pursued under the constraint that regulations were to be aimed at improving safety per vehicle mile, without attempting to influence the amount that people drive. Policies such as improved public transportation, higher gas taxes, mixed-use zoning (access to goods and services available within residential areas), and others have been advocated at various times and places, but usually not in the context of the nation's effort to improve highway safety. Research There has been a significant federal, state, and private-sector investment in highway and traffic safety research. This multidisciplinary effort has focused on each of the four principal elements affecting motor vehicle safety—the human (driver and occupant), the vehicle, the roadway, and the socioeconomic environment. Increasingly sophisticated research has enriched the empirical foundation for informed policy debate and has led to improved safety features and effective prevention programs. Biomechanics research has provided information on injury mechanisms and human tolerances to trauma that has been used in testing vehicle crashworthiness and improving safety measures. Interventions to reduce alcohol-impaired driving and other human factors that affect highway safety have been developed and evaluated through extensive behavioral research. Engineering, highway planning, and other disciplines have contributed to improved vehicle and highway design and to the development of safety-enhancing features such as center high-mounted rear brake lights, improved tire and brake performance, breakaway sign and light poles, protective guardrails, and work-zone safety measures (TRB, 1990). Research by emergency medical services (EMS) and trauma care professionals has improved trauma services and trauma care, and rehabilitation specialists have focused research efforts on improving outcomes for individuals with traumatic brain injury or spinal cord injury due to motor vehicle crashes. Several federal agencies fund motor vehicle safety research. NHTSA funds research primarily on human factors and vehicle safety, while the Federal Highway Administration funds research on improving highway safety. Additionally, other federal agencies have focused on topic-specific transportation safety research. For example, the National Institute on Aging funds some research on the effects of aging on driving performance; the National Institute on Alcohol Abuse and Alcoholism has funded some research on the effect of alcohol on motor
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Reducing the Burden of Injury: Advancing Prevention and Treatment vehicle injury and on adolescent alcohol use and high-risk driving behaviors; the National Institute for Occupational Safety and Health (NIOSH) studies work-related vehicle safety issues; and the Health Resources and Services Administration and the National Center for Injury Prevention and Control (NCIPC) have funded EMS and trauma systems development and evaluation research. Further, there has been a significant private-sector investment in research through the automobile manufacturers, the Insurance Institute for Highway Safety (funded by more than 75 insurance companies), and nonprofit consumer groups. State and Local Programs The Highway Safety Act of 1966 created a partnership among federal, state, and local governments to improve and expand the nation's highway safety activities by establishing the State and Community Highway Safety Grant Program (the Section 402 program) (NAGHSR, 1998). This program's funding has provided for the establishment of a highway safety office in every state, headed by a Governor's Highway Safety Representative, and has enabled a state-level focus for coordinating traffic safety efforts. State offices of highway safety often work closely with driver licensing, driver education, state police, public health departments, and state highway departments, and provide a coordinating function across state agencies that have some responsibility for highway safety. Examples of effective use of 402 funding include evaluation of the effectiveness of motorcycle helmet laws, innovative programs to increase safety belt use, design and implementation of improved driver license examinations for different classes of vehicles, child safety seat programs, and evaluation of effects of changes in speed limits. The 402 programs enable states to serve as laboratories to test new highway safety programs; successful programs are adopted nationwide. Public Support Public support for motor vehicle safety has also played a role in the progress achieved, through the burgeoning interest in vehicle safety and consumer movements. A remarkable surge in interest in vehicle safety has occurred in the past decade with the maturation of the ''baby boom" generation. This increased interest has, in turn, provided overall support for highway safety initiatives, particularly child safety, and has influenced automakers to provide and emphasize safety features and to compete in a safety marketplace. Additionally, citizen activist groups such as Mothers Against Drunk Driving and Remove Intoxicated Drivers have been influential in improving highway safety. These groups elevate the visibility of the families of victims who died as a result of drunk driving and influence the public agenda, bringing pressure to bear on policy makers.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Ongoing Controversies Although substantial areas of consensus have emerged in highway safety regulation, several controversies continue, primarily related to the proper balance between safety, mobility, and individual freedom. Safety Versus Mobility Motor vehicle injuries are part of the price paid for enhanced mobility. It might be possible to eliminate serious motor vehicle injuries almost completely by disallowing motor vehicles that can exceed 25 miles per hour (mph). In practice, there is a balance between mobility and safety, although where the balance is best struck can be quite controversial. The setting of speed limits has been an area of ongoing discussion and changing legislation. It has been estimated that raising the speed limit on rural interstate highways in the late 1980s resulted in about 400 additional deaths annually (Baum et al., 1991) and that in the 32 states that raised speed limits in 1996,1 about 350 more deaths occurred in the subsequent year than would have been expected based on historical trends (NHTSA, 1998). Active Versus Passive Protection Passive measures, including most vehicle modifications, are those that protect individuals automatically without cooperation or action on their part, for example, motorcycle headlights that are automatically turned on by the ignition key to increase daytime visibility of the motorcycle. In contrast, active measures require individual action by the person to be protected, for example, relying on motorcyclists to remember to turn on their headlights each time they ride during daylight hours. The advantage of passive measures is that, once in place, they protect virtually everyone. Active measures must be implemented by each person on each occasion to provide protection. The effect of requiring all vehicles to be equipped with so-called passive protections is to make the benefit-cost or mobility-safety trade-offs at the societal level rather than the individual level. Clearly there are instances (as in the motorcycle headlight example above) in which passive measures are preferable, but in most cases such a clear-cut either/or situation does not exist. The overriding considerations in countermeasure choice are efficacy, effectiveness, acceptability, and cost. In reality, a combination of active and passive strategies is usually called for, and both have contributed to reductions in motor vehicle injuries. 1 The National Highway System Designation Act of 1995 (P.L. 104-59) eliminated the federally mandated national maximum speed limit of 55 mph.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Risk Compensation There is ongoing study of the extent to which individuals respond to safety-enhanced technology or environmental changes of which they are aware. Some drivers may compensate for, and thus offset, the safety gains of an improved or safety-enhanced product by reducing precautions or taking greater risks. For example, improved braking or handling can lead to increased speeds, closer following, and faster cornering (Evans, 1991). However, when the risk of injury is reduced in ways not apparent to the user, which is the case with most forms of automatic or passive protection, behavioral adaptation is unlikely to occur (Lund and O'Neill, 1986; Evans, 1991). Mandatory Requirements and Primary Enforcement The proper scope of mandatory or compulsory requirements for self-protection has long been an issue in the ethical literature on paternalism and public health (Cole, 1995). No one questions the legitimacy of informing people about the benefits of wearing safety belts or motorcycle and bicycle helmets, taking steps to persuade people to wear them, or using incentives to encourage safe behavior. However, it has proved difficult in many cases to change driver behavior through educational or persuasive techniques alone. Laws, such as those requiring safety belt use and wearing of helmets, have been successful, particularly when augmented by highly publicized enforcement programs and focused educational programs (Williams et al., 1996; Lacey et al., 1997). In recent years an important shift in public attitudes appears to have occurred, increasing the level of support for mandatory safety belt laws. The residual debate concerns the benefits and costs of increasing the level of enforcement. To what extent, and at what cost, would allowing primary enforcement2 increase the level of compliance and reduce injuries? Evidence indicates that, for a given level of enforcement, primary belt-use laws result in higher rates of usage (Campbell, 1988; NHTSA, 1995; Ulmer et al., 1995). Thus, states with secondary laws are not realizing the benefits that could be gained for the enforcement they are already supporting. Even so, there is concern among minorities that primary, or standard, enforcement could lead to police harassment. Additionally, mandatory motorcycle helmet laws remain controversial, although the evidence of effectiveness in preventing death and brain injury is well documented (Kraus et al., 1994; Kraus and Peek, 1995). 2 Primary, or standard, enforcement refers to the stipulation in the law allowing law enforcement officers to stop a driver on the basis of a safety belt use violation.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Access and Licensing Issues Screening and licensing are tools for regulating access to driving. In the United States, the courts have made a clear distinction between driving for financial gain (commercial driving) and driving for one's own personal purposes. In the latter case, the courts have ruled that the license is more than a privilege and cannot be denied or revoked without due process (Reese, 1965). Because mobility is recognized as so important in our society, states must be reasonably justified in restricting licensure (e.g., using licensing restrictions, suspensions, and revocations as methods to limit driving by individuals convicted of drunk driving) (Jacobs, 1989). Current controversies relate to restrictive licensing of teenagers and to age-based requirements for elderly drivers. Night-time driving restrictions for young beginning drivers reduce injuries (Williams and Preusser, 1997) but are debated in terms of fairness, and the needs and desires for mobility during adolescence on the part of teens and their families. Although cognitive, perceptual, and motor abilities are known to decrease with increasing age, these changes are highly individual, and screening for licensing restrictions is difficult. Opportunities for Further Progress Although significant progress has been made in reducing motor vehicle injuries, not all developments have been positive, and there are important opportunities for further gains. Numbers of motor vehicle deaths have risen slightly in recent years, although the decline in the mileage-based death rate has continued (NSC, 1997). Even though 49 states now have laws regarding safety belt use, national belt use is at a relatively low 61 percent (NHTSA, 1997). States have been reluctant to allow primary enforcement of safety belt laws or to institute strong enforcement programs of the type that has enabled Canadian provinces to achieve belt-use rates in excess of 90 percent (Transport Canada, 1998). Many states have raised speed limits in recent years, after Congress allowed states to do so without sanctions in 1995, and as a result, fatalities have increased (Farmer et al., 1997; NHTSA, 1998). Research is needed to continue to improve both the design and the use of safety features. Additionally, although airbags are effective in reducing injuries overall, further research is needed to prevent airbag-related deaths of children and others. The lack of injury reduction associated with antilock brakes—a highly touted safety feature—has been disappointing. A newly emerging issue concerns vehicle design mismatch between sport-utility vehicles and passenger cars. Opportunities for further progress include continued improvement of public transport systems and wider application of safety-related highway and traffic countermeasures that are known—on the basis of competent research—to be effective. For this to happen, increased public and political support is needed.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Additionally, with 50 separate legislatures, developing consistent countermeasures at the state level has proved difficult. The conditional funding mechanism for states to adopt federally endorsed injury prevention legislation has been effective when used, as in the case of the minimum age for the purchase of alcohol. Opportunities to increase use of this mechanism, rather than restrict its use, will be important to furthering progress. FIREARM INJURIES Firearm discharges kill almost as many people each year in the United States as motor vehicle crashes, yet the response to this threat to public safety has been quite different from the response to motor vehicle crashes. In the case of motor vehicles, the public and policy makers have demanded safer vehicles, better highways, and more stringent regulation and law enforcement directed at drivers. Together with improved trauma care, these measures have been effective over several decades in reducing the fatality rate per occupant mile. Unfortunately, there has not been a similar comprehensive response—or similar progress—in reducing firearm injuries. From 1962 to 1994, 992,388 people in the United States died from firearm-related injuries (Ikeda et al., 1997). Firearm deaths and death rates in the United States reached a 30-year high in 1993 (39,595 deaths) and declined in 1994 and 1995 (Fingerhut and Warner, 1997; Ikeda et al., 1997). Although a major cause of morbidity and mortality throughout the life span, firearm deaths particularly affect teens and young adults (mainly homicides) and the elderly (mainly suicides). In 1995, 35,957 people died as a result of firearm injuries; over half of these fatalities (18,003 deaths) were of persons 15–34 years old (Fingerhut and Warner, 1997). In 1995, a greater percentage of firearm deaths were due to suicide (51 percent) than homicide (43 percent) (Fingerhut and Warner, 1997). There were 1,225 unintentional firearm deaths in 1995 (3 percent of all firearm deaths) (Fingerhut and Warner, 1997). An international comparison of 26 industrialized countries found that the firearm death rate for U.S. children younger than 15 years was nearly 12 times higher than among children in the other 25 countries combined (CDC, 1997). There are similarities in the high degree of lethality of both motor vehicles and firearms. Each product has the potential to produce serious injury or death in a matter of seconds. However, whereas most motor vehicle injuries are unintentional, most firearm injuries are intentional. This difference in intentionality creates complexities in dealing with the emotional, psychological, and behavioral antecedents and consequences of firearm injury. However, this further challenge does not preclude—but rather emphasizes—the need for a concerted effort to focus the full breadth of scientific expertise on preventing and reducing the health consequences of firearm injury.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Current Overview and Future Opportunities The comprehensive scientific approach that has been fully implemented to address motor vehicle injuries is, by comparison, only a fledgling effort with regard to firearm injuries. Over the long term, an effective national policy directed at reducing the risk and severity of firearm-related injury requires a strong federal presence. The multipronged approach used to develop federal motor vehicle safety policy—surveillance, regulatory action, multidisciplinary research, support for state and local prevention initiatives, and public support—provides a useful model. The following section describes progress to date and focuses on future opportunities. Surveillance A number of national surveillance systems provide some data on firearm injuries (see Chapter 3 for additional information); however, there is no national surveillance system that provides detailed information on specific products and incidents—data that are needed to develop effective interventions to prevent and reduce firearm injuries. The Federal Bureau of Investigation's Uniform Crime Reporting (UCR) System is a voluntary system based on reports from law enforcement agencies. The Supplementary Homicide Report to the UCR System collects information on homicide incidents. Since 1973, the National Institute of Justice has conducted an annual National Crime Victimization Survey, in which cohorts of individuals ages 12 and older are queried semiannually about their experiences related to crime, including crimes involving guns. The Bureau of Alcohol, Tobacco, and Firearms' (ATF) Project LEAD (Law Enforcement Agency Data) includes an automated system that collects information gathered during traces of crime-related firearms. The Consumer Product Safety Commission's (CPSC's) National Electronic Injury Surveillance System (NEISS)—a sample of emergency room admissions—routinely includes information on nonpowder firearm injuries. A recent study performed by the Centers for Disease Control and Prevention (CDC) used NEISS to estimate all nonfatal firearm injuries in the United States (Annest et al., 1995). Vital statistics data compiled by the National Center for Health Statistics include information on suicide and unintentional injury as well as homicide deaths related to firearms (Fingerhut et al., 1992). In 1994, NCIPC funded seven state health departments to support the development, implementation, and evaluation of state-based firearm injury surveillance systems. These programs were three-year cooperative agreements with funding ending in 1997. Although these systems do provide some data, more complete surveillance systems are needed to monitor firearm injuries over time, to add detail that can guide prevention efforts, and to assess the effectiveness of interventions. The data collected should include geographic, sociodemographic, and product-specific information in addition to information on key causal sequence factors
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Reducing the Burden of Injury: Advancing Prevention and Treatment BOX 5.1 Brief Overview of Federal Firearm Laws and Regulations 1919 War Revenue Act imposed a federal excise tax on firearms. 1927 Firearms in U.S. mails, banned interstate mailing of firearms through the U.S. Postal Service. 1934 National Firearms Act regulated the sale of fully automatic weapons, silencers, sawed-off shotguns, and other "gangster-type weapons." 1938 Legislation mandated the licensing of dealers and manufacturers involved in interstate transactions and prohibited firearm sales to people convicted of certain crimes. 1958 Legislation required serial numbers on all guns except .22 caliber rifles. 1968 Gun Control Act placed additional restrictions on who could own guns, established minimum ages for purchase of long guns (18 years of age) and handguns (21 years of age), set minimum standards for imported firearms, established the federal firearm licensing system administered by ATF. 1986 Firearm Owner Protection Act banned further manufacture of automatic weapons and legalized interstate sale of long guns under specified conditions. 1988 Undetectable Firearms Act required plastic guns to be visible by x-ray or to trigger metal detectors. 1994 Brady Handgun Violence Prevention Act established federal requirements for a maximum five-day waiting period for handgun purchases in order to perform criminal background checks and increased the Federal Firearms License fee for gun dealers. 1994 Violent Crime Control and Law Enforcement Act banned manufacture and sale of any ammunition magazines with a capacity in excess of 10 rounds and banned manufacture and sale of semiautomatic rifles and handguns with specific characteristics. 1996 Domestic Violence Offenders Gun Ban prohibited gun purchase by individuals convicted of a domestic violence misdemeanor. SOURCES: National Committee (1989), Karlson and Hargarten (1997). Recent regulatory trends at the state level include laws to deter and punish criminal use of firearms, gun safe-storage laws that hold the gun owner responsible if children gain access to the weapon (Cummings et al., 1997), limits on handgun purchases to one per month (Weil and Knox, 1996), and the issuing of licenses for carrying concealed weapons. In contrast to highway and traffic safety, no federal leverage has been used that could encourage the development, application, or evaluation of stringent state legislative approaches to reduce the accessibility of firearms in situations in which they are likely to lead to death and
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Reducing the Burden of Injury: Advancing Prevention and Treatment injury or to implement well-evaluated educational programs or licensing arrangements for gun purchasers. Research There are numerous unanswered research questions concerning the role of firearms in injury occurrence and the optimal interventions for reducing firearm injury. The nation's recent focus on the larger issue of violence has increased research and program funding for violence prevention at the Department of Justice. Additionally, other federal agencies are conducting research on violence-related issues, including a focus on violence in the workplace by NIOSH and a focus on the biological and behavioral correlates of violence at the National Institute of Mental Health. The National Science Foundation has recently funded a university-based National Consortium on Violence Research. Federally sponsored research that is specifically focused on firearm injury has been funded primarily through the Office of Justice Programs. Additionally, the NCIPC has funded epidemiologic research and state surveillance efforts. The remainder of this section outlines some of the research questions and issues that should be considered in framing a comprehensive research agenda with the goal of reducing firearm injury. To design interventions that may protect particular high-risk groups identified by surveillance mechanisms—such as teens, inner-city dwellers, domestic violence victims, or the elderly—more information is needed on common causal sequences; victim and perpetrator attitudes toward guns, gun storage, and potential alternative self-protection devices; prevalence of gun use in various settings; and environmental and behavioral risk factors for gun misuse. Although most domestic violence fatalities are caused by guns, the role of guns in relationships that involve domestic violence—for example, in intimidation, self-protection, and other roles—has not yet been well studied. Patterns of mental stress related to prevalent or intimate exposure to gun injuries and death remain to be fully elucidated; such research is needed in multiple sociodemographic settings. Rigorous studies are required of the efficacy and effectiveness of interventions designed to reduce the risk of firearm injury. Research should be expanded on gun markets to elucidate the flow of firearms from the legitimate sector to the hands of minors and criminals, and how this flow might effectively be interdicted. The main "leakages" from legal gun commerce include theft from private vehicles and homes (more than half a million per year), casual transfers by friends and family, and illegal sales by licensed dealers (Cook and Ludwig, 1996). In some cities, interstate gunrunning is also an important source of guns in crime. Developing effective countermeasures that will limit illegal gun commerce requires im proved understanding of the economics of the relevant "black" and "gray" markets.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Research is also needed on the ways in which individuals of varying ages, sizes, and strengths use guns, locking devices, and bullets; the resulting information can guide product design toward measures that may reduce the risk of injury and death. Recent engineering innovations designed to increase safety include magazine interlocks that prevent firing when a pistol's magazine is removed but a bullet remains in the firing chamber, and multiple approaches to gun personalization that would limit firing to one person (Robinson et al., 1996). Evolving approaches to the design of guns, such as personalization and increasingly sophisticated automatic safety locks, require real-world testing to allow an understanding of the net effects that these will have on gun ownership, storage, misuse, and injury morbidity and mortality incidence and severity patterns. The biomechanics of gun injuries has been well studied in war situations but should be studied as well in civilian settings that involve wider variations in the age of victims, types of weapons and bullets, and social crowding contexts. Research is also needed on alternative personal protection devices and their risks and benefits, individual perception of the risk of injury from firearms, assessment of various approaches to risk communication, and the effective ways to convey safety information. Studies are necessary on the effectiveness of current acute medical treatments and on ways to improve such treatment so as to reduce death and permanent disability due to firearm injuries. The role of EMS personnel in clarifying injury circumstances and initiating psychosocial—as well as cardiorespiratory—treatment remains to be fully explored. One of the puzzles still to be solved in firearm research is the identity of the most informative measure of exposure. For example, one possible analogue of vehicle-miles traveled would be time in the presence of a person with access to a firearm (as compared with time in the presence of people), but such a measure is not empirically feasible. In the aggregate, number of licensed drivers and number of licensed firearm owners would be functionally equivalent exposure measures if licenses were required of gun owners (and if possession of a firearm without a license were as rare as driving a vehicle without a license), but this is not now the case. Presence of a firearm in the home has been used as an exposure measure, but its usefulness is limited to incidents in the home. It is conceivable that no single exposure measure can be utilized for firearm injuries in all locations and contexts. For unintentional injuries, presence of a gun in the home may be a suitable measure, but this does not work as well for intentional injuries. For assaultive injuries, including firearm injuries, one possible measure of exposure would be violent interactions, occurrences that are theoretically measurable through survey interviews. In the committee's view, further attention to this problem, both conceptually and empirically, is needed. This is a robust multidisciplinary research agenda that must be developed and implemented to identify optimal interventions for the reduction of firearm injuries. Two of the most pertinent lessons from motor vehicle safety research that can be applied to firearm safety research are that a comprehensive approach
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Reducing the Burden of Injury: Advancing Prevention and Treatment offers hope for the reduction of firearm morbidity and mortality and that many disciplines have important contributions to make. The strength of integrating work from varied disciplines is evident when the multidisciplinary approach is tried (OJJDP, 1996; Rand, 1997). Research by criminologists is needed to explain the economic, sociocultural, and psychological factors that affect the firearm-related criminal behavior of youths. Research by economists is needed to understand the flow of firearms in and between licit and illicit markets. Epidemiologic research is needed to clarify risks and risk factors and to explore the causal sequences of firearm injury. Biomechanical and clinical research is needed to explicate the acute and chronic effects of gunshot injuries. Mental health and substance abuse researchers can contribute to an understanding of the behavioral and biologic contributors to violence. Multidisciplinary collaboration on violence research has begun to emerge. Examples include the interdisciplinary Homicide Research Working Group, based in the American Society for Criminology, and the National Consortium on Violence Research. The committee believes that sustained advances in applied research bearing on prevention of firearm violence and other firearm injuries requires such collaborative efforts, including criminologists, economists, psychologists, bioengineers, epidemiologists, and clinicians, working within the comprehensive model of prevention that now shapes research on highway safety. State and Local Programs The federal government is involved in a growing number of criminal justice efforts to stem juvenile gun crime, and there are a number of local and private-sector initiatives to this end (OJJDP, 1996). However, there is no federal program, similar to NHTSA's Section 402 program, that would fund firearm injury prevention efforts in each state. Further, the federal government has not used federal revenue streams as leverage for the adoption of firearm injury prevention measures as it has for prevention of motor vehicle injuries. There are opportunities for encouraging states to improve data systems and implement programs with the goal of reducing firearm injuries. Congress should consider a two-step strategy for encouraging state and local governments to implement and evaluate strategies and programs for reducing firearm injuries, especially involving children and adolescents. First, program funds should be made available to support well-designed state or local program initiatives—encompassing the full range of interventions, including legislation—conditioned upon sound evaluation. Second, when specific programs and legislative approaches have been shown to reduce firearm injuries, Congress should make crime prevention funding through the Office of Justice Programs contingent upon the adoption and implementation of these successful approaches.
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Reducing the Burden of Injury: Advancing Prevention and Treatment The committee recommends the implementation of a comprehensive approach for preventing and reducing firearm injuries that includes firearm surveillance, firearm safety regulation, multidisciplinary research, enforcement of existing restrictions on access by minors and other unlawful purchasers, prevention programs at the state and local levels, and mobilization of public support. Ongoing Controversies The firearms debate is often contentious and polarized. In contrast to highway safety policy, no consensus has emerged among policy makers regarding many aspects of firearms policy. Although recent public opinion surveys reveal a large area of agreement on many policy issues (Teret et al., 1998), agreement is lacking among policy makers about the goals of national policy, or indeed whether there should be a national policy in this area; about the benefits and costs of restrictions on ownership, availability, and use of firearms; and about the balance that should be struck between safety-enhancing regulation and individual freedom. Some of these ongoing controversies are briefly described below. Issues of Individual Freedom There is ongoing debate over balancing the rights of individuals to own firearms for self-protection (and the security of loved ones) or for recreational use (e.g., hunting, target shooting) against societal concerns about the risk of harm in other contexts. There is general acceptance of the concept that individuals have legitimate rights to engage in recreational hunting or target shooting and to protect themselves and their families and friends, as well as ample evidence that handgun ownership provides a sense of greater security (Cook and Ludwig, 1996). The policy issue is how to balance the values of individual autonomy with the community's interest in reducing the risk of firearm fatalities and injuries. Instrumentality and Availability One of the issues examined in ongoing studies is the extent to which guns are instrumental in increasing the risk of death or injury, independent of other factors. The type of weapon used in any violent act, including suicide, may be an important determinant of whether the victim survives and of the risk of disability. Studies of this issue focus on the lethality of various types of weapons; the extent to which the intent of the assailant, rather than the weapon, determines the injury outcome; and the extent to which an individual's choice of weapon is calculated to ensure injury or death or is a matter of chance or access.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Additionally, there is ongoing discussion and study of the extent to which gun ownership, gun availability, or the expense and time required to acquire a firearm influences the likelihood that it will be used in a violent or suicidal act. Issues of access include studies on the effects of the presence of a firearm in a specific location (e.g., home or vehicle); gun commerce, including black markets for firearm purchase; and the effects of regulations on carrying concealed weapons. Child and Adolescent Vulnerability Another important issue involves the relative importance of child and adolescent vulnerability on the one hand and adult freedom on the other. Because they live in environments that are generally controlled by adults, children and adolescents are vulnerable to risks that result from adult decisions, including decisions to keep and use guns and decisions on gun storage, particularly in the home. When children and adolescents encounter a gun, they have a reduced capacity to make safe decisions because of their lack of experience, immaturity of judgment, and impulsivity. Their decisions can result in increased risk of injury related to play, assault, or suicidal behavior. Goals and Priorities for Action As noted above, a workable political consensus has not yet developed on the balance that should be struck between the prerogatives of firearm ownership and the reduction of firearm-related injuries, especially in a social context in which about 192 million firearms, including 65 million handguns, are in circulation (Cook and Ludwig, 1996). In the committee's view, a workable consensus is most likely to emerge if the discussion is focused less on ownership issues and more on the steps that can be taken to reduce the adverse health consequences of firearm use and to strengthen the scientific basis of policy making. In short, the points of departure for national firearms policy should be harm reduction and better science. Within the overall framework, initial priority should be given to measures that reduce the risk of harm to the most vulnerable segments of the population, particularly children and adolescents and that curtail the risk of firearm injury caused by children and adolescents. Even in the absence of a broad consensus about the aims of national policy, few people are likely to contest the ethical legitimacy of aggressive measures designed to reduce gun-related injuries to and by youths. In 1995, firearms were the second leading cause of death among children ages 10–14 years (48 percent of those deaths were homicides; Fingerhut and Warner ). In 1994, 185 children, ages 0–14 years, and 327 adolescents, ages 15–19 years, died from unintentional firearm injuries (Ikeda et al., 1997).
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Reducing the Burden of Injury: Advancing Prevention and Treatment Children and adolescents accounted for 23 percent of the arrests for weapons offenses in 1993. Between 1985 and 1993, the number of juvenile arrests for weapons offenses rose from under 30,000 arrests to more than 61,000 (Greenfeld and Zawitz, 1995). In what has been described as an ''age-related" epidemic of juvenile firearm use (Zimring, 1996), firearm homicides committed by youths under 18 increased 229 percent between 1985 and 1992 (Blumstein and Cork, 1996). A youth-centered injury prevention strategy is needed that would have several components: reducing the number of locations in which youth have access to guns, restricting their ability to gain access to the guns and ammunition in these settings, building features into guns that will reduce the risk of accidental or unauthorized use if the gun does get into the hands of youth, and building community coalitions to make youth environments safer. All reasonable steps should be taken to prevent access to, and possession of, guns and ammunition by children and adolescents (other than in supervised target shooting or appropriate hunting situations). Although recent federal legislation makes youth handgun sale and possession federal offenses, primary responsibility for enforcing such prohibitions lies with state and local governments. Enforcement efforts should be grounded in systematic research on firearm distribution patterns, focused on revealing the paths by which firearms find their way from initial adult purchase into the hands of children and adolescents. Legislation and judicial rulings punishing gun owners who fail to properly store and secure their weapons, or holding them liable for harm caused by people who have gained access to negligently stored or secured weapons, merit careful consideration and evaluation. Technologies and practices are now rapidly evolving that promise to make it easier to better secure weapons in the home and community, so that even if guns are obtained by youths or intruders, they will not be usable. Some of these approaches utilize trigger guards and other add-on locking systems (whose performance has not yet been well evaluated). Over a very long term, personalization of guns would be expected to have major benefits in reducing firearm injuries. If personalized firearms replace other weapons in home and community environments, they should eliminate child play injuries and shut down the firearm resale market and its pipeline to youth and criminals. Of course, even if all new weapons are personalized, it will take many years for personalized weapons to displace the existing supply of nonpersonalized ones. Reducing firearm injuries requires a long-term perspective. Perfecting the technology and stimulating the market for safer firearms are important goals for today, even though the full payoff will not occur for decades to come. Recent experience with tobacco control and alcohol-impaired driving suggests that strong community coalitions can stimulate public support and organize effective action around a powerful youth-centered public health theme. Local communities that want to keep guns out of the hands of children and adolescents now have access to strategic advice and technical assistance from many national
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Reducing the Burden of Injury: Advancing Prevention and Treatment resource centers and professional organizations, which can enable them to work out means to affect various steps in the gun distribution chain. Community coalitions can bring together law enforcement, public health, child protective services, and numerous citizen groups to develop, implement, and monitor a local plan to reduce youth gun access. Such a plan might include a wide variety of interventions, such as police enforcement strategies designed to disrupt local gun markets and to keep guns off the streets and out of schools; interventions focused on altering the "ecology of danger" (Wilkinson and Fagan, 1996) and changing norms relating to gun carrying and violence among urban youths; public education regarding the risks of gun ownership and the responsibility of adults for their firearms; and public education and legal measures promoting secure storage of weapons in the home. The committee recommends the development of a national policy on the prevention of firearm injuries directed toward the reduction of morbidity and mortality associated with unintended or unlawful uses of firearms. An immediate priority should be a strategic focus on reduction of firearm injuries caused by children and adolescents. To ensure the success of a youth-centered prevention initiative, Congress and relevant federal agencies (e.g., the Departments of Health and Human Services and Justice) should set national goals for reducing assaultive injuries, suicide, and unintentional injuries by young people using firearms. As a long-term commitment to this goal, consideration should be given to appointing a high-level task force for implementing and evaluating such an initiative. SUMMARY A comprehensive approach to reducing firearm injuries is necessary. Strengthened firearm and firearm injury surveillance efforts and multidisciplinary research initiatives can bring the depth and breadth of scientific and engineering expertise that is needed to develop and evaluate innovative firearm injury prevention measures. Designation of a federal agency to have regulatory jurisdiction over firearm safety issues, enforcement of current regulations, particularly on access to guns by children and adolescents, and expansion of state and local prevention programs are all necessary components of an effective comprehensive approach. The federal role should not involve the establishment of new bureaucracies but rather should be to provide national leadership and coordination to leverage the related programs at state and local levels, to generate new knowledge, and to promote the application of new findings. The committee believes that progress can be made in preventing and reducing the adverse
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