News & Notes from the Medical Field

Gun Violence in Indiana as a Public Health Issue by Dr. Steven Dunlop

According to the Indiana Department of Health there were 251 firearm homicides in Indiana in 2012, the most recent year for which data is available.  Homicide in Indiana is mostly an urban problem, four urban counties with 1/3 of the population account for 2/3rds of the homicides.

Homicide impacts the black community most heavily, which experienced 50% of the homicides while being only 9.5% of the population.  Young black men are especially at risk.  For young black men ages 15-24, homicide was the leading cause of death, accounting for 61% of all deaths in this age group, with a rate of 93 per 100,000.  For white males the same ages the rate was 3 per 100,000 and 3% of all deaths.  Homicide is also the leading cause of death for black men ages 25-34, the rate is 117 per 100,000, and accounts for 43% of all deaths, but for white males the same ages the homicide rate is only 6 per 100,000 and homicides account for 4% of all deaths.

Most homicides are intra-racial, blacks killing blacks and whites killing whites.  Beyond race and age, we know of other very significant risk factors for those likely to commit a homicide: a history of substance abuse, a criminal history, failure to complete high school, and unemployment.  Access to a firearm is also significant.  Homicides in young black males ages 15-34 were by firearm 86% of the time.  We know most homicides of males occur outside of the home and most occur with a weapon brought to the scene.  We know that many are not committed in the course of another crime but are precipitated by an argument or other dispute.

As an example, I saw a young man in the hospital who had beaten his girl friend and was threatened by her brother. Despite a history of assault and a restraining order, he was carrying a gun for protection after he left the hospital. He went to see the girlfriend who was staying with her grandparents.  When the grandfather confronted him, he impulsively pulled the gun and killed him, and moments later his wife.  I feel certain that his altercation with the older man would not have led to homicides if he didn’t have the gun.

What is the public health response to this information?  Public health embraces primary prevention, like lowering cholesterol and stopping smoking before the onset of heart disease.  Primary prevention of gun homicidal violence would include measures such as more young men through high school, better treatment for substance abuse and other mental health problems, especially for minority populations, and improving access to jobs through training and public transportation.  These measures are frequently mentioned in discussions of the homicide problem in Indianapolis.

These measures take a long time to have effects, and in the meantime there will be a pool of young men without good prospects, of whom a small percentage will be inclined to criminal behavior.

The next thing to think about is secondary prevention, making access to firearms more difficult for those not entitled to them by criminal history, age or mental illness.  Unfortunately, in our city, we are completely failing in keeping guns out of the wrong hands. High school students report ease in buying guns.  We seem to accept that every bad guy can have easy access to a gun as an immutable fact of life.

We need to change our thinking and reconsider the focus of law enforcement and our lack of sensible gun regulation.  We need law enforcement that targets gun trafficking and closely scrutinizes and uses sting operations on those gun stores that are the source of more than usual crime guns.  Better regulation means implementation of universal background checks for gun sales, requirements for the reporting of lost or stolen guns, and limitations on the number of handguns one person can purchase.  Together these efforts can make guns more difficult to obtain, and in states and cities where they are practiced, gun violence is less.

If you don’t keep the guns out of the wrong hands, then the next step is what I would call tertiary prevention, keeping people without a permit from carrying guns.

Towns in the Old West knew keeping guns off the streets was important.  Adam Winkler writes about a photograph taken in Dodge City in 1879.  “Everything looks exactly as you’d imagine: wide, dusty road; clapboard and brick buildings; horse ties in front of the saloon. Yet right in the middle of the street is something you’d never expect.  There’s a huge wooden billboard announcing,

“The Carrying of Firearms Strictly Prohibited.”

While people were allowed to have guns at home for self-protection, frontier towns usually barred anyone but law enforcement from carrying guns in public.”

Another historian has noted that towns that prohibited young men carrying guns had much lower homicide rates than those that did not.  Here in the US, New York City makes it much harder to get a permit to carry and also strictly enforces laws against carrying without a permit.  The homicide rate for that city has gone down steadily over several years to 1/3 of that for Indianapolis.

What should we do? I do not believe the 30% increases we have seen in homicides in the last few years reflects a big increases in the number of people at risk for this behavior. I believe it reflects increased access to weapons and carrying of weapons.

I think we should focus on actions directed at these two problems that should quickly bring results while we work toward primary prevention.  We need to do more to keep guns out of the wrong hands and strictly enforce penalties for carrying illegal guns, not just after one commits a crime but before that.

When police apprehend someone for any reason that is carrying illegally, that person should expect to spend time in jail.  Many homicides occur because someone is carrying a gun that shouldn’t be and finds themselves in a confrontation.  Secondary and tertiary prevention can bring rapid and profound decreases in homicides rates when the tools are available and used effectively as seen in NYC, Boston, and Los Angeles.