Stephen Dunlop, MD

June 14, 2020

Introduction (page 2-3)

Know the factors that led to the author’s interest in this subject and how it has been experienced by him in his life and work.

               Accidental death and injury from firearms (pages 3-5)

• Understand the relationship of firearm ownership and storage to risk of accidental firearm death and injury
• Know what features of firearm are particularly associated with risk of accidental death or injury.
• Learn what public health measures at the local or state level are available to reduce risk
• Learn what actions at a federal level could reduce inherent risk of firearm accidental death or injury
• Know the impact in terms of lives and injuries measures to prevent firearm accidents could have in Indiana

Firearms and suicide (pages 5-9)              

• Understand the scale of the relationship between household firearm ownership at a state level and the suicide rate for both firearm and non-firearm suicides.
•  Understand the scale of the increased risk for suicide in a home with a firearm.
• Be able to describe the modest lowering of risk when firearms and ammunition are securely stored separately.
• Be able to discuss factors which have been considered in understanding the increased risk of suicide when firearms are present: lethality, ease of access, no chance to change direction or  rescue. Be able to refute the argument that an individual desperate enough to make an attempt will eventually commit suicide. Be able to site the differences noted in firearm victims and other suicide victims that support that t he individual is often at lower risk of suicide than victims desperate enough fo other means
• Be able to discuss public health approaches to suicide reduction specific to forearms.
• Be aware of the number of lives that could be saved if fewer households had firearms.

               Firearms and Homicide (pages 9-22)

• Be able to discuss the greater complexity of homicide as a public health issue including the high percentage of on fatal injuries, the differential effects on different demographic groups,  and the impact of certain types of shootings with far reaching impacts on society (pages9-10)

Mass, school, and police shootings (pages 9-15)

• Be able to discuss the evidence that firearm access is the most important factor identified with the frequency of mass shootings in countries of the world.
• Be able to discuss the importance of the type of weapon to mass shootings, particularly assault rifles
• Be able to discuss the difficulties relating to identifying potential mass shooters and preventing their actions as an alternative to restricting access by all to certain firearms

Other Homicides (pages 15-22)

• Be able to discuss the significance of the source of firearms to school shootings Be able to discuss the high degree of relationship between perpetrators and victims of homicide and high degree to which homicide is not part of another felony act.
• Be able to discuss the importance of alcohol abuse and arguments as precipitants of homicides.
• Be able to discuss the importance of handguns as weapons of choice in homicides
• Know the demographics of homicide in Indiana in terms of age cohorts, race, and rural versus urban populations
• Be ble to discuss the extremely high incidence of homicide in young black males in Indiana’s cities
• Be able to discuss the large differences between Indianapolis, Fort Wayne, Boston, and New York in the incidence of homicide since 2006 that are not correlated with the percentage of Black population
• Be able to discuss the variety of firearm regulations that limit access to handguns  and limit the concealed carry of firearms in Boston and New York
• Be able to discuss the need to do away with state pre-emption of local gub regulation
• Discuss what the impact could be of lowering the homicide rate in Indianapolis in terms of lives

Firearms and self defense (pages 22-24)

• Be able to cite research studies and evidence from record keeping of reported events on the rarity of firearm self defense as well as the lack of evidence that firearm ownership has any effect on crime rates except to increase homicides and firearm assaults.
• Be able to point out the extreme rarity of a firearm used in self defense to the frequency of one used for intra familial violence, violence between intimate partners and accidental deaths
• Be able to discuss the  likelihood of a firearm owners firearm being used in a suicide, homicide of family friend or neighbor, accidental death, or a fatal shooting in self defense
• Be able to discuss the impossibility of surveys published of gun owners’ self reports as representing firearm self defense use.

Measure of firearm regulations effectiveness (pages24-25)

• Be able to discuss the evidence supporting the effectiveness of various firearm regulations
• Be able to discuss the importance of firearm regulation in moving society generally to lower levels of forearm ownership with the end result of decreased gun violence.

               Money and Guns page 26

• Be able to discuss findings on the cost of gun violence compared to the return in terms of jobs and economic output
• Be able to discuss both direct and indirect costs of gun violence

Introduction

I am writing this report to put into one document material I have presented over the years to both professional and citizen groups on gun violence, with a special focus on Indiana. In 1999 the Indiana Star requested letters on gun violence. I wrote one entitled “A shift away from the culture of guns” that was the spotlight letter for the op-ed page.¹ This led to an invitation to address the annual meeting of Hoosiers Concerned about Gun Violence (HCGV), a grass roots organization that started among parishioners of St. Thomas Aquinas church after a couple at the church were murdered by their 18 year old adoptive son who had purchased a gun a day or two earlier. Learning the purchase was legal which showed how easily guns fell into the wrong hands, they founded HCGV to advocate for changes in gun regulation and education on firearm violence in Indiana. I joined the group and later served as president of HCGV. In part, my role was to give talks on gun violence.

My first concerns about risks associated with firearms came as a teenager.  As a prank,  I surprised some friends by pointing a rifle at them, working the bolt, and spilling some live ammunition on the floor. Later, we went outside and fired the rifle, a WWI vintage Mauser that belonged to my older brother. The very loud bang and recoil startled me; I suddenly realized I could have ended someone else’s life and drastically changed my own life had my prank gone wrong. A similar prank involving Purdue students went wrong and a young man was killed.²

Fortunately for me, my prank hurt no one and my life stayed on course. Eventually, I became a psychiatrist. My next exposure to firearm violence was through my practice, in the aftermath of suicides, accidental shootings, and homicides. I thought that many of these incidents would likely not have ended tragically had a firearm not been readily available. For instance, there was the suicide of a middle school boy, whose family had removed firearms due to his impulsivity and moodiness. After a disappointment with a girl at school, he went to his grandparents where he knew a loaded gun was in a drawer and used it to kill himself. Another was a high school girl who came home one day from school, took her father’s pistol into the backyard, and killed herself. A family member I saw as a patient said the family never suspected anything or learned the motivation for what she did. In another instance, a patient reported her husband had walked into the room holding a pistol, said he couldn’t take it anymore, and shot himself. He had not seemed depressed, and had only commented he was having some problems at work. I have not had clinical experience of impulsive suicides by means other than firearms. These suicides were not like suicides I have known about in patients with severe or chronic mental illness, which have typically occurred after long periods of illness in patients who had been thinking about suicide at previous times.  The suicides involved a variety of means: carbon monoxide, hanging, self-immolation, and one with a firearm. I have also had experience dealing with patients in the context of accidental firearm deaths and homicides that I will mention when these topics come up in this report.

In the process of working with HCGV giving talks, holding events, writing letters to the editor, and testifying to the legislature, I have tried to keep up with the data on firearm violence and scientific studies of the relationship of firearms and the risk of injuries and deaths.  I wanted to know how well research supported my suspicions that the presence of firearms increases the risk of deadly outcomes in situations of mental illness, stress, and conflict, or, on the other hand, does firearm ownership bring protection from criminal victimization?  What is the balance of protection versus risk in firearm ownership? As HCGV is interested in the broad spectrum of gun regulation, I learned what I could about accidental firearm injuries, mass shootings, and firearm self-defense in addition to suicide and homicide.  While I have been doing this, gun violence in Indiana has worsened. As shown in Table 1, from 1999 to 2017 (the latest tabulated by the Indiana Department of Health), firearm suicide and homicide rates  in Indiana are higher for both firearm and non-firearm means. Suicides have increased by non- firearm means as well but firearms still account for more than half.  The increase in homicides is accounted for totally by firearm homicides.

Table 1. Suicide and Homicides by Firearm (FA) and by Other Means (NFA) in Indiana, rates are per 100,000 ³

Year	Number of FA Suicides	Rate of FA Suicides	Number of NFA Suicides	Rate of NFA Suicides	Number of FA Homicides	Rate of FA Homicides	Number of NFA Homicides	Rate of NFA Suicides
1999	364	6.13	257	4.32	266	4.42	114	1.88
2017	604	8.78	479	7.42	369	5.83	85	1.28

I. Firearm Accidental Injuries and deaths.

It should be no surprise that the rate of firearm injuries and death correlates with the frequency of firearms present in the home.  In a study by Hemenway and colleagues of 50 states over 19 years, the home ownership rate of firearms was related to the prevalence of firearm accidental deaths.⁴  The fatality rate was seven times higher in the four states with the highest ownership rates compared to the four with the lowest ownership rates. The rate of household gun ownership was approximately five times as high in the states with the highest gun ownership rates. How firearms are stored is related to risk. One study found that firearms kept loaded and unlocked more than doubled the risk of accidental death. ⁵

In Indiana in 2016, 19 people died from accidental shootings.⁶   Four times that number would be expected to have been injured, based on a large scale study of accidental firearm injury and death.⁷

The majority of firearm injury accidental deaths are in people younger than 24 and most are shot by someone else, usually of the same age and often a family member or friend.⁸ As an example, in my practice a woman came to see me struggling with the fact that her middle school aged son had accidentally shot and killed a friend. He used a shotgun which she had left loaded in the garage to kill copperhead snakes. The risk of accidental death from a firearm is many times higher than the very low risk of death from a copperhead snake.

Unlike teddy bears, there are no consumer safety standards for firearms. There is no requirement they not fire when dropped. One of my patients developed panic attacks after a firearm he carried for self-defense slipped out of his jacket pocket, hit the floor and fired, shooting one of the workers in his tanning salon in the abdomen. He carried the gun because he made frequent cash deposits at banks. He had never had to use it in any way for self-defense.

In a catalog of deaths related to firearms of concealed carry holders that are not related to self-defense, The Violence Policy Center includes three deaths in Indiana:  a seven year old was shot and killed when her father’s pistol fell out of his pocket, a six year old shot and killed his father, and a two year old killed himself with his mother’s gun.⁹ The two year old’s death isan example of another safety risk; there is no regulation on the amount of trigger pull needed to fire a pistol. There is also no requirement that firearms indicate a bullet in the chamber when the clip is removed. The death of an Indiana boy mentioned earlier is an example of what can happen when the person holding a gun with the clip removed doesn’t realize it could have a bullet ready to fire.

Public Health Recommendations to reduce accidental death from firearms:

• Public education on the relationship of firearms left loaded and unlocked and the risk of accidental death
• Storage regulations imposing penalties for gun owners who negligently allow firearm access to children or to persons who could not buy firearms from a licensed dealer ( for instance persons with felony convictions, subject to protective orders, or a history of commitment for mental illness). Locked gun storage would be an acceptable defense under the law.  Indiana only provides penalties for knowingly or recklessly allowing child access, a much weaker standard.  The Rand Corporation found the strongest support for child protective laws among the regulations they considered for lowering of the risk of both suicide and unintentional injuries and death.¹⁰
• Placing firearms under the purview of the Consumer Products Safety Commission in terms of preventing accidental use by small children, warning indicators of firing status, ability to withstand a drop without firing as well as  other safety features.  The U.S. General Accounting Office has estimated that 31% of unintentional deaths caused by firearms might be prevented by the addition of two devices: a loading indicator (23%), and a child-proof safety lock (8%) (the study found 8% of accidental shooting deaths were from shots fired by a child under six). ¹¹

Implications for Indiana

If accidental injuries and deaths involve about 100 people a year, safer firearms might prevent 30 of these and better storage through regulation and /or education much of the rest.

II. Firearms and Suicide

My interest in gun violence was initially related to suicide. With my suspicions, I was interested in what evidence links access to firearms and suicide risk. The first data I found was a relationship to the percentage of households with firearms and the suicide rate at the level of state populations. The second was studies comparing the presence of firearms in homes in which suicides had occurred with the presence of firearms in comparable homes in the same neighborhood which had not experienced a suicide. Next was the effect of firearm storage on suicide risk.

Percentage of Households with Guns and Suicide rates

Several studies have shown that the percentage of households in a community with at least one gun is related to the suicide rate in the community. Perhaps the best known is the study of suicide rates in two groups of states.¹² The first group was 15 states with the highest household gun ownership rates (which averaged 47%). The second group was 6 states with the lowest household gun ownership rates (which averaged 15%). The highest gun ownership states had 38.6 million inhabitants and the lowest had 39.6 million inhabitants. The data is shown in Table 2.

Table  2.  2000-2002 Firearm (FA) and non-Firearm (NFA) suicides in High Gun Ownership States (HGOS) and Low gun Ownership States (LGOS)

State Groups	FA Suicides	Rate/100,000 Per year	NFA Suicides	Rate/100,000 Per year	Total Suicides	Rate/100,000 Per year
HGOS	9749	8.4	5060	4.4	14809	12.8
LGOS	2606	2.1	5446	4.6	8052	6.8

As shown in Table 2, the rates for non-firearm suicides were very similar in both groups of states; the firearm suicide rates were four times higher in the HGOS. Other studies comparing countries have found a similar relationship between household gun ownership and suicide rates.¹³   Another review of studies also found suicide rates changing over time in the direction of changes in household firearm ownership rates.¹⁴

Access to Guns in a Home and Suicide Risk

Multiple studies have also looked at the risk for suicide represented by a firearm in the home.  In the study which found suicide rates changing with firearm ownership rates, , the authors, the authors analyzed together  14 studies that met the criteria for lack of bias, suitable controls and outcome measures. The analysis found suicides were 3.24 times more likely and homicides twice as likely for people living in homes with firearms.¹³

Firearm storage practices and suicide risk.

One study looked at how guns are stored in the home and the risk of accidental injury or suicide to people under age 20. The study found that the risk varies depending on how the gun is stored. The study compared 81 suicide attempts (95% fatal) and 25 unintentional injuries (52% fatal) that occurred in a home to someone less than 20 years old with 480 control homes where a gun was owned and someone under age 20 was living but no injury occurred. In homes where injuries had not occurred, guns were 24% more likely to be stored unloaded, 25% more likely to be stored locked, and 24% more likely to have ammunition stored separately from the firearm. ¹⁵

What explains the increased risk of suicide with the presence of a firearm?

 Studies are consistent with my notion that the presence of a firearm in a home increases the risk of a suicide in that home, and more households with guns in a community increase the number of suicides in the community. They do not answer the question of why this happens.

          Ownership of firearms, firearm suicide, and mental health history

One possibility is that homes whose members have histories of other risk factors for suicide, such as depression or suicidal thoughts, are more likely to own firearms.  This was addressed in a study that compared seven census regions in the United States .¹⁶  The study looked at the frequency of any history of major depression or serious suicidal thoughts reported by families in each region, the frequency of handgun ownership by families in the region, and the frequency of firearm and non-firearm suicide in the region. If regions with homes where people are more likely to have histories of suicidal thoughts or depression are regions where people are more likely to have handguns, then it could be that the presence of suicidal thoughts and depression is as important as the presence of handguns in rates of firearm suicides in an area.  Data on lifetime incidence of depression or suicidal thoughts came from the National Comorbidity Study, a structured survey of households in the census regions, data on gun ownership from the General Social Surveys of the National Opinion Research Center, and data on population, firearm and non-firearm suicide rates from the National Center for Health Statistics Mortality Files.  Suicide rates in the regions ranged from 9 to 18 per 100,000, firearm suicides from 4 to 12 per 100,000, and non-firearm suicides from 3.1 to 6.4 per 100,000. The per cent reporting major depression by region ranged from 15.2 to 20.9, history of suicidal thoughts by percent from 11 to 20. Household handgun ownership percentage  by region ranged  from 12 to 38.

Across all regions, household handgun ownership rates correlated with overall suicide rates (r=0.59), and more highly with firearm suicide rates (r=0.83). The frequency of handgun ownership was negatively correlated with non-firearm suicide rates (r=-.47).  The percentage of households reporting a history of major depression (r=-.10) or a history of suicidal thoughts (r=-.01) did not correlate with the frequency of handgun ownership. The frequency of suicidal thoughts did correlate with suicide rates, but the frequency of depression histories did not. This data suggests that the presence of firearms in homes does not relate to the level of two factors thought significant for suicidal risk: history of depression and history of suicidal thoughts. It also did not support that a history of depressive illness was related significantly to suicide risk. The study strongly supported the concept that the presence of firearms was related to suicide risk, particularly for firearm suicide.

          Features of firearm suicides

If the presence of a firearm is so important to the risk of suicide, are there features of firearm suicides that help explain this increased risk? The first feature to consider is the lethality of suicide attempts with firearms. For the year 1997, suicide attempt records were gathered from electronic discharge records of eight state-wide data sets of hospital and ER discharge diagnoses.¹⁷   The suicide attempts studied were only those that resulted in a record of treatment in the ER or hospitalization, so these were relatively serious physically or psychologically.  Suicides were gathered from state mortality records. For the states studied, there were 8110 suicides and 83,980 attempts, or a ratio of ten to one. Of the attempts, 92% were poison ingestion or cutting, but these two means resulted in only 14% of the suicides. Firearms were involved in 6% of the attempts but accounted for 54% of the fatalities. Firearm suicide attempts were 83% fatal. Hanging, gas poisoning (carbon monoxide mainly) and drowning were comparably lethal (40-65%), but less common, accounting for 24% of the suicides.  Certainly, given a choice of means, those who chose firearms are by far the most likely to die.

Another aspect of firearm suicides is the ease and rapidity with which they can be carried out. Most suicides occur shortly after a decision is made to make an attempt. The Harvard School of Public Health provides a review of seven studies on the issue.¹⁸  All the studies found short intervals between the decision and the attempt in most cases. One study, limited to survivors of medically serious attempts, found 24% reported less than five minutes between the decision and the attempt, 23% 5-19 minutes, and 23 % 20-60 minutes. Only 11% reported longer than one day. In an Australian study of survivors of self-inflicted gunshot wounds, 21 of 33 subjects (64%) stated the attempt was due to an interpersonal conflict with a partner or family member. Almost all reported it was impulsive, and most were young men without histories of major depression or psychosis. Other methods require more planning and take longer to result in death. Both these time factors provide an opportunity to change one’s mind and abandon the attempt, seek help, or be rescued. With a firearm, the attempt is followed immediately by the result, usually death.

These short time intervals suggest that there was a firearm ready at hand when the impulse occurred. Some firearms are purchased with suicide in mind, and there is an increased risk for suicide in the month after purchasing a handgun. However, the increased risk persists for many years after and most of the increase over expected suicides occurs after the first year of the purchase ¹⁹. In a separate study of handgun purchase and suicide, the median period from purchase to suicide was 10 years, though the relative risk was highest in the first year. ²⁰

An argument is sometimes made that people who attempt suicide and survive are likely to try again and succeed, so that using a firearm just brings a quicker end. As noted, many suicide attempts are made in the heat of some crisis. Survivors often report that the attempt has resolved the feeling of crisis and they doubt they will try again.  In fact, few end up dying by suicide. Of 1490 suicide attempters, 68 died, 73% of these by firearm. Only 2.3% of the survivors died by suicide during 3 to 25 years of follow-up. ²¹

The relevance of firearmpossession to the risk of suicide is also supported by studies indicating that there are significant differences between people who commit suicide with a firearm and those using other methods. A study of 1397 suicides in Finland found that firearm victims were less likely to have had psychiatric treatment or hospitalization, to have “coped psychosocially relatively well,” and that their suicides were also “associated with recent life events and alcohol in the blood”.  They were more likely to have a partner as well.²²  

The impulsivity of suicide attempts combined with access to a firearm explains the increased risk of suicide when firearms are present. In the setting of a crisis with suicidal ideation, the presence of a firearm dramatically increases the likelihood of a deadly outcome.

Suicide in Indiana

There were 1034 suicides reported in 2016 by the Indiana Department of Health, a rate of 15.4 per 100,000.  Of these, 57% (592) were by firearms and 43% (442) by other means.  Males accounted for 81% (839), of which 60% (507) were by firearms,  and women 19% (194) of which 44% (85) were by firearms.²³ Whites comprised 91% (944) and blacks 6% (63) with the remainder listed as other; 67% of all suicide victims were 55 years of age or younger. ²⁴   

What policies or actions could decrease the death rate from firearm suicide?

• A public information campaign concerning the increased risk of suicide when firearms are available in a home.
• Placing a waiting period into gun purchases could block people with short- term suicidal impulse from killing themselves. Evidence from the early years of the Brady bill, when there was a waiting period, showed such an effect for older white males.²⁵
• Safe storage of firearms has been shown to reduce risk for children and youth and should be required.¹⁵
• Red flag laws like gun restraining orders in California which allow family members to initiate firearm seizures or Indiana’s Laird law which allows police to initiate firearm seizures may prove useful in preventing suicide if widely enough used. In Indiana, most gun seizures have been suicide related. ²⁶  
• Permit to purchase requirements for handgun purchases have been correlated with lower firearm suicide. ²⁷

Implications for Indiana

Indiana’s percentage of suicide by firearms (57%) is below the firearm to non-firearm suicide ratio seen in the highest gun ownership states (66%), but well above the 32% seen in the lowest gun ownership states in the study reviewed above. In that study, non-firearm suicides were 7% higher where fewer households had firearms. Based on these observations, if Indiana was in the lowest category of firearm ownership among the states, Indiana might have seen about 475 non-firearm suicides and 224 firearm suicides for a total of 699 in 2018, a saving of 300 lives.

The lives saved would be mostly men, as they commit 60% of firearm suicides. They would also be mostly white, as whites committed 91% of the suicides in 2016.  By decreasing suicide rates, the number of years of life saved is much greater than for a similar decrease in the rate of death from diseases of later life such as cancer: 67 % of suicide victims were under age 55, whereas only 10% of cancer victims were under age 55.

III. Firearms and Homicide

I have had limited experience with patients who went on to commit homicides. I did have clinical contact with a young man who, unrelated to my contact with him, was in difficulty because of assault charges by a girlfriend. He learned she had dropped the charges, and went to her grandparents’ house where she was staying to pick her up.  He was  carrying a firearm for protection due to threats from his girlfriend’s brother. At the house. a he got in an argument  with the grandparents over the girl leaving with him . He ended up killing both the grandfather and grandmother with the pistol he was carrying. He was later apprehended without incident. From what I knew of him, I wouldn’t have expected this level of violence and  believe it was very unlikely these homicides would have occurred in the absence of the firearm.  This situation is similar to many homicides in that it followed an argument in a setting where no other crime was being committed.

Another case involved a young man I admitted for psychosis. He had been brought to the hospital at the instigation of his mother, who said he threatened her. He voluntarily signed admission papers, but as he was not covered for treatment at our hospital by his insurance, he was transferred to one where he had coverage. This man’s weapons had been removed from the home by the police, but were later returned to him after his hospitalization. Indiana had no legal basis to keep them at the time. He subsequently relapsed into psychosis, shot his mother and then began shooting in his neighborhood. Police were called and one officer was killed. These events were widely publicized  and  triggered the passage of a red flag law in Indiana which allows police to remove weapons from a dwelling in a circumstance which  they believe indicate imminent harm to self or others. The individual then must go through a court hearing process to have the guns returned. Unfortunately, removal of weapons in this fashion will not result in a report to the National Instant Criminal Background Check System so the individual is not prevented from purchasing another weapon.

Considering firearm homicide from the point of view of public health is more complex than considering firearm suicide:

• Unlike firearm suicide attempts which are overwhelmingly fatal, firearm assaults more often result in injury than death, so result in much higher costs to the medical system and more long term disability. Table 3 shows data on the relationship of firearm injury to death for suicide attempts, firearm assaults, and firearm accidents from a nationwide study of hospital records. ²⁸

Table 3. Injuries and Deaths from Firearm Suicide Attempts, Firearm Assaults, and Firearm Injuries, Averages per Year for 2010-2012²⁸

	FA Suicide Attempts	FA Assaults	Firearm injuries
	Number	Percent	Number	Percent	Number	Percent
Fatal	20,012	85%	11,256	19%	582	5%
Non-Fatal	3,531	15%	47,986	81%	11058	95%
Total Fatal and Non-Fatal Injuries 94, 425

IIIA. Mass, School, and Police Shootings

This section deals separately with firearm deaths that repercussions far beyond the individuals involved.

Firearm assaults that occur outside the home and involve multiple victims anonymous to the shooter have social costs far beyond the victims, their families or their specific communities. They occur in a wide variety of settings: theaters, work places, churches, schools, parks, etc., and are not localized geographically, thus they threaten everyone.

Unfortunately, mass shootings have become a staple of American life. Columbine, Aurora, Sandy Hook, Fort Hood, Charleston, El Paso, Las Vegas, and Stoneman High School are place names now known for mass shootings. The number and lethality of incidents is increasing.  The Violence Project maintains a data base of mass shootings.²⁹    They use the definition of four people killed in a public setting with firearms. The data base goes back to 1966 (the Texas Tower incident at the University of Texas is considered the first of these shootings in modern times). The following table shows the number of incidents per decade, the number killed, and the average killed per incident.

Table Four. Mass shootings by decade

Decade	1966-69	1970-79	1980-89	1990-99	2000-09	2010-19
Incidents	5	10	23	39	37	43
Number killed	37	55	150	231	238	528
Average deaths Per incident	7.4	5.5	6.5	5.9	6.4	12.2

Violence Project Data³⁰

The number of incidents has gone up dramatically since 1990 and the average number killed per incident since 2010. One finding to help explain the increase in victims per incident in the last decade is the much higher frequency of assault rifles used, 19 of 43 incidents compared with 6 of 37 in the previous decade. The average number killed when an assault rifle was present is 10.1; the number killed when some other firearm was present was 6.4.

Since about 30,000 people die from firearms every year, the proportion of mass shooting deaths is very small, less than 0.1%; however the effect of these shootings on society is great. These shootings are incidents from which you cannot protect yourself unless you stay at home. Vast resources are being put into schools and other places to guard against these events, though with little effect so far. After each shooting, there is often discussion of failure of a mental health system, part of the legal system, or some other social institution that perhaps could have identified and prevented the shooter from acting.

Three questions are raised by these events:

• Is the United States really unique in this regard?
• If so, is there something about our culture that breeds this violence?
• Can it be prevented or significantly decreased?

Like many aspects of gun violence, little research has been done. However, one researcher, Adam Lankford, has done an excellent study that provides answers to the first two questions.

Looking at data from 171 countries, Adam Lankford compiled a data set of 292 mass shootings that occurred over the time period 1966 to 2012.^31,32 He examined the relationship between the number of shootings and the suicide rate, the homicide rate, and the accessibility of firearms in each country. Of the 292 shootings, 90 (31%) occurred in the United States. Only four other countries had more than ten (The Philippines 18, Russia 15, and Yemen 11). In a statistical analysis that controlled for the country’s population, sex ratio, and percent of urbanization, suicide and homicide rates were not related to the frequency of shootings, only firearm accessibility (the number of civilian firearms per 100 people).  The statistical significance was extremely high for this association. At the time of this analysis, the US had the most accessible firearms, 89 firearms per 100 people; Yemen, was second at 55 per 100. Yemen was the only country with more shootings per 100 million people than the US, 40 compared to our 27. No other country had more than twenty. Our nearest neighbor, Canada, in which about 2/3 as many households have guns compared to the US, had less than 10 shootings per 100 million. ³²   That this number is lower than might be expected suggests that other factors than the number of firearms may play some role.

Here are the answers to the first two questions:

• The United States is exceptional in regard to mass shootings
• The aspect of our culture most related to this fact is our gun culture.

Decreasing the frequency and mortality from mass shootings

• Decrease the number of firearms capable of mass shootings, handguns or rifles capable of sustained fire and equipped with large magazines
• Identify potential shooters before they act

To consider decreasing the number of mass shootings, what would we need to do about our gun culture?  The most obvious answer is to decrease access to the types of firearms most commonly used, weapons capable of rapid fire from a large magazine. Both handguns and rifles are often used. Many countries strictly control or prohibit ownership of these kinds of firearms. Australia is an example. Australia introduced this policy nationwide after a shooting in Tasmania in 1996 that left 36 dead. It has not had another mass shooting since. Seven states and the District of Columbia have laws banning the sale of these weapons and two more regulate them. ³³   Due to the rarity of mass shootings and variance among the laws, it will take a long time to know how effective these measures will be. Canada, a country in which about two thirds as many households as in the U.S. own guns, bans assault rifles and requires special circumstances to own a hand gun. ³⁴  The lower than expected rate of mass shootings  in Canada in relationship to the number of households with guns, suggests promise for specific weapons restrictions that could lower the rate of mass shootings by half while still permitting wide ownership of firearms.

Another avenue to decrease the number of shootings is systematic attempts to identify potential shooters before they act. In a publication on this issue Lankford includes three factors that he draws from the studies of mass shooters: suicidal motives and indifference to life, sense of victimization, and desire for fame. ³⁵   A problem with this approach is the vast number of people who will show one or more of these features without presenting a risk for a mass shooting. For instance, 45,000 people commit suicide in the US each year and an estimated 25 times as many make an attempt (1.125 million). Millions more experience suicidal thoughts. Only a handful might become mass killers.

Another issue is what can be done even if someone is identified to have all of the factors but has not acted on them or committed any crime?  A law preventing all such persons purchasing or owning a firearm capable of mass murder would be unacceptable politically and extremely difficult to administer considering the number of people who would seek court relief from the restriction. Certainly, in dealing with depressed patients, clinicians routinely ask about access to firearms and try to get the patient to voluntarily give up control to a family member or someone else during the period of the illness. The red flag laws addressed earlier allow for legal intervention to remove guns in situations where there appears to be imminent risk of suicide or homicide. These laws are new and not widely used so there is no data on how effective they might be in preventing mass shootings.

The answer to the third question is yes; these shootings can be prevented or decreased:

• The first recommendation is to decrease access to all semiautomatic weapons with large magazines. Many countries have decided that access to these weapons by the general public carries such high risk that they have eliminated legal purchase or ownership. These policies have remained in place through many election cycles in our fellow English speaking democracies: England and  Canada, and they have been effective.
• A distant second consideration is to increase the scope of red flag laws to include legal intervention with people who have weapons and who indicate a desire or intention to make their mark by killing unidentified people. The present scope is generally those who indicate a desire to hurt themselves or other identified people. The law would need to effectively deny them access to guns. Evidence for this working is yet to be seen. The background check law would have to be modified to prevent these persons from purchasing a firearm.

Mass Shootings in Indiana

Using the Violence Project definition of at least four firearm deaths in a public setting, Indiana is fortunate to have only one listing in their data base, from a shooting in 2002 when a 54 year old man killed four people in his workplace.³⁰ However, if the definition of mass shootings is expanded to involve 4 or more victims injured or killed as used in the Gun Violence Archive’s listing of mass shootings, Indiana had 10 such incidents in 2019. ³⁶

In these 10 shootings, there were six deaths and 49 firearm injuries. Four of the incidents occurred in or outside bars between 2 and 5 AM. Two involved people at parties confronting each other as did one at a motorcycle club hangout. Two involved teens and young adults in or outside a downtown Steak and Shake restaurant confronting each other. Only one involved a possibly premeditated incident when two people were killed in a car and bystanders injured. All the others occurred because people, gathered to drink or party, got into altercations and unfortunately were carrying firearms.

These less deadly but still disturbing incidents suggest restricting carrying of firearms in or near the vicinity of bars.  Many bars do prohibit firearms, but cannot get police backup as no crime has been committed. As some of these involve persons who went to their car or home and returned with a weapon, extending the restriction to the parking lot or other property around the bar should be considered.

K-12 School Shootings

School shootings share with mass shootings an impact far larger than measured by the number of deaths. Shootings in K-12 schools traumatize all the students in a school. They force schools to take elaborate and expensive safety precautions and increasing anxiety on the part of parents, teachers, and staff.

The Washington Post has focused attention on shootings taking place in K-12 schools during regular school hours. They have cataloged 249 incidents in which 240,000 students were in school during the incident. There were 147 deaths and 310 injuries. Of note, 7 in 10 shooters were under age 18 and more than 85% brought the gun used from home or obtained it from a friend or relative.³⁷   As with mass shootings, the trauma affects many people beyond the victims and their families, and the concern about these shootings affects all children and their parents.

Keeping firearms out of schools is far better than coping with firearms in schools. That a child under age 18 has access to a firearm implies negligence on the part of an adult, often a parent.  Parents are rarely prosecuted, even when a child brings a loaded firearm which was stored unlocked in the home. In Indiana, criminal liability depends on an adult knowingly, intentionally, or recklessly giving access to a firearm by a child.³⁸   Since so many firearms in Indiana are stored loaded and unlocked, a child finding such a weapon in a closet or drawer and taking it to school would hardly be considered reckless on the part of the parent unless they had some reason to know the child’s intent. Mandated safe storage of firearms when children live where the gun is stored with felony penalties for the gun owner if the gun is used and someone is injured could dramatically reduce school shootings.

Police Shootings

The greatest significance e of police shootings, particularly those involving unarmed or  mentally ill individuals,   is their reflection of the racism in the American criminal justice system. The Washington post has maintained a database on police shootings in the United States. In a 2018 article, the Post reported that from 2015-2018 they found Blacks, who are 13% of the nation’s population, were 23 % of the victims in fatal shootings, and of the 7% of victims unarmed, Blacks were 36% of the victims.^38a  Outrage over these disparities, some of which have been well documented on videos, as well as other incidents of police violence have triggered massive protests around the country to address racism by police , the criminal justice system, and other racist practices in the United States for many years.

The public health approach to police shootings is for police to find ways of managing situations with less resort to violence and holding officers accountable for their behavior. For example, better training for police and collaboration with mental health services when police are called to a situation involving mental illness has been implemented in some departments.^38b

IIIB Other Homicides

The vast majority of homicides are not mass shootings or school shootings, both are fairly rare. The FBI Uniform Crime Report received data on reported 14,123 homicides in 2018. ³⁹   Of these, 88% involved a single victim. Of the homicides, 73% were by firearm and when the type of gun was specified, 90% of the firearms were handguns. One person shooting one other person with a handgun is the most common type of homicide. The FBI reported that 2,316 (16%) homicides were in or suspected to be in the commission of another felony, in 6,249 homicide was the only felony (44%) and in 5,508 homicides the information was unknown. The risk of a law abiding citizen having a firearm for self-defense that is used in a homicide would be limited to non-felony homicides occurring most often between people who come into conflict in the course of everyday life.

Homicide is often between people with close ties:  

In 2018, a substantial number of homicide victims were killed by intimate partners: 519 wives by husbands, 531 girlfriends by boyfriends, 119 husbands by wives, and 201 boyfriends by girlfriends, for a total of 10% of all homicides. Other immediate family members accounted for 6% of all victims. More distant family members, friends, neighbors, employees, and employers were another 5% of victims.  Altogether, these defined relationships existed in 21% of all homicides. Only 11% of these homicides were in conjunction with another felony. ³⁹ Homicides between acquaintances were an additional 19% of homicides. For these, 18% were felony murders, mostly involving robbery and narcotics felonies. Altogether 40% of all homicides of which 35% were non felony homicides involved people related or known to each other. For all the non-felony murders between people with close ties, 60% were precipitated by arguments. ³⁹

Homicides between intimate partners are often accompanied by the suicide of the partner committing the homicide. In their most recent report on murder suicides for the months January through June, 2017, The Violence Policy Center identified 296 murder suicide events; 60% involved an intimate partner, 96% were females and 94% involved a firearm.  In this way, intimate partner homicide resembles mass shootings as perpetrators often kill themselves. ⁴⁰

Firearm Ownership and Homicide Risk

People buy guns to protect themselves from outside threats. The fact that so many homicides do not involve outside threats leads to the question of whether or not guns in home protect against homicide or make homicide more likely. Three types of studies have been done that address this question.

The simplest study is to look at whether the percentage of homes with firearms is related to the firearm homicide rate in a community. If having a firearm in the home is protective, one would expect homicides to be less likely when many homes have firearms.

A study compared rates of household ownership of firearms and firearm and non-firearm homicide rates by state. The study controlled for poverty, alcohol consumption, degree of urbanization, unemployment, and non-homicide violent crime rates in each state over the period 1988-1997. There was a significant positive association between the percentage of households with guns and the firearm homicide rate.  In a sub analysis of the states with the highest and lowest rates of gun ownership, people in the high gun ownership rate states were 2.9 times more likely to die by homicide by any means, 4.2 times more likely to die by a firearm homicide and 1.6 time more likely to die from a non-firearm homicide.⁴¹ In this study more households with guns was associated with more, not less, firearm homicides.              

A more complex way to look at the question of home ownership of firearms and homicide risk is to compare households where a homicide occurred with matched households where no homicide occurred. In a recent analysis of 6 studies which looked at home ownership and homicide or suicide risk, the joint analysis showed an odds ratio of 2 (or twice as likely) for the risk of homicide to someone living in a home with a gun compared to someone not.¹³

A third study examined injuries and deaths due to firearms in the home. The study’s purpose was to look at the frequency with which firearm deaths or injuries in the home were the result of self-defense, suicide attempts, assaults or homicides, or an unintentional injury. The investigators used police and hospital records to find every firearm injury or death in three cities: Memphis over a 12 month period, and Galveston and Seattle over 18 month periods.⁴²

 In the time periods studied, 626 of 1915 firearm injuries occurred in or around a house. Of these 626, 8.6% were accidental shootings, 18.8% suicide attempts, 69.9% assaults, and 2.0 percent self-defense (including 0.5% by police). When the source of the firearm was known, a majority of assaults involved guns not in the home but brought to the home. When the source was known, 80% of suicide attempts and accidental shootings involved firearms in the home. For guns kept in the home, unintentional shootings, suicide attempts, and criminal assaults outnumbered justifiable shootings 22 to 1.

Of the 425 criminal assaults, 40 % (167) were by a stranger, generally during the commission of a robbery, 40% were by a non-intimate acquaintance of the victim,  and 19% by a spouse, intimate acquaintance, parent, sibling, other relative, or roommate of the victim; these shootings generally occurred during an argument or altercation.

Of shootings in self-defense, five were of an unknown intruder, three were of boyfriends by girlfriends, one was of a non-intimate acquaintance, and one was of one brother shooting another. When a stranger was involved in a criminal intrusion, citizens rarely used a firearm in self-defense. In the study of types of firearm injuries in the home, the type of firearm was a handgun in 87% of cases where this information was recorded.

Is the type of firearms owned in a community related to the risk of homicide?

When firearms are widely owned in a community, one question is whether handgun ownership is relatively more related to firearm violence than long gun ownership. The United States and Canada are two countries with widespread firearm ownership but different rates of handgun ownership and the reason guns are reported to be owned. Both countries have high levels of socioeconomic development and similar cultures.  A survey done by Gallup of Americans and Canadians in 2006 asked a matched group of subjects in each country if they had been victims of a crime in the past year. In each country 21% reported they had; 2% of Canadians and 3% of Americans reported being victims of a violent crime.⁴³   Of course, a survey cannot ask if the respondent has been a victim of a homicide. This is where Canada is very different from the United States. The homicide rates were much higher for the United States, especially for firearm homicides. In 2006, the firearm homicide rate for Canada was 0.6 per 100,000 and for the United States 4.3 per 100,000.^44,45   Homicides per 100,000 people by other means were similar, Canada 1.26 and the United States 1.93, about the same ratio as the ratio for violent crime generally reported.^{44, 45}  Both countries have many households with firearms, Canada has about 25% and the U.S. 40%.^46,47  However, why guns are owned and what kind of guns is very different. In Canada, only 5% of owners report owning them for self-defense. In the U.S., 72% of gun owners report owning them for self-defense. Also, about 12% of Canadian gun owners own a handgun; in the United States 72% own a handgun. ^46,47

Homicide in Indiana

In Indiana, homicide is more of an urban than rural phenomenon. Five of the ten largest cities with 24% of the state’s population accounted for 54% of all homicides in the state.⁴⁸   That urban homicides are more common than rural  was seen in a large study of all intentional firearm deaths from 1989-1999 in all 3141 counties in the United States. The counties were classified as either rural or urban. The most urban experienced 1.9 times the rate of firearm homicide as the most rural. The most rural experienced 1.54 the firearm suicide rate compared to the most urban. ⁴⁹

There are large differences in the homicide rate by race as well. Black Americans had a higher rate of homicide than whites in Indiana in 2016. There were 263 Black homicide victims which is 40 per hundred thousand Black citizens. The 186 white homicide victims were 3 per hundred thousand white citizens.⁴⁸  National data for 2016 were 18 per 100,000 Black homicide victims and 2.6 per 100,000 white homicide victims.^50,51 As a public health issue, homicide is much more significant for the Black population and more in Indiana than in the United States as a whole.

Black males are particularly at risk. Males are 87.5 % of Black homicide victims and homicide is the third leading cause of death for Black males. For whites, males were 71% of victims. The age of victims by race is different as well. 76% of Black male victims were 35 or younger. For white males, 41% of the victims were under 35. Firearms were used in 88% of Black homicides and 61% of white homicides.⁴⁸ The levels of homicide do not reflect high levels of firearm ownership by Black households. Nationally, 24% of Blacks compared to 36% of whites report owning a firearm.⁴⁴ No data exist specific to Indiana on gun ownership.⁴⁷

The difference of homicide rates and the concentration of homicides among young Black men has been the subject of considerable study. In Indianapolis, the Indiana University Public Policy Institute published a monograph in 2015  “Crime in Indianapolis” noting that while homicides and non-fatal shootings were at 20 year lows in the nation they were at four year highs in Indianapolis.⁵²  They have increased since that report. In 2018 the city had its highest number ever, 159.⁵³   The number was down slightly in 2019, but the Indianapolis Recorder reported the percentage of victims who were Black was up slightly from 73 to 75 in a city in which 30% of the citizens are black.⁵⁴

The Institute report posited that the behavior of criminal offenders result from the environment they are in, actions of the criminal justice system, and their individual behaviors. One aspect of the environment emphasized was the concentration of violence in small areas of the city. The Department of Public safety noted six focus areas of the city which comprise 4.7% of the city’s population but 28% of the fatal and non-fatal shootings. A suggestion was to focus efforts in these areas. The environmental factors this paper suggested addressing were integrating former inmates into the community, poverty, mental health issues, especially substance abuse,  unemployment, and education, particularly completion of high school. This paper did not focus on the role played by institutional racism in creating and reinforcing these disadvantages. It also did not specifically address that racism reflected in the actions of police that added to the alienation of communities of color from the criminal justice system. The criminal justice system should be a system the community could trust and turn to for support in confronting the homicide epidemic.

These complex factors underlying the epidemic of homicidal violence are not something on which I can claim any expertise. HCGV has focused more of our effort on factors relating to the behavior of obtaining and carrying firearms, especially handguns, that can be addressed through firearm regulation and can impact homicide rates.

Comparing the experience of Indianapolis with some other cities suggests that there are regulations that can make firearm less accessible and less likely to be carried by young men most at risk.  Some cities are having a great deal more success in curbing gun violence than are those in Indiana. Two cities that are best known for this effort are New York City and Boston, whose mayors joined together in 2006 to form Mayors Against Illegal Guns (MAIG) and focused efforts in their cities on reducing gun violence.

The following table shows changes in homicide rates in Boston, New York City, Fort Wayne, and Indianapolis in  2006, and 2017.

Table 5. Homicide Rates and per cent African American in the population

City	Homicide Rate 2006	Homicide Rate 2017	% African American 2010 Census
Boston	13.3	8.4	24
New York City	7.30	3.4	23
Indianapolis	17.5	18	28
Fort Wayne	8.03	14	15

Homicide Data from FBI UCR, Census from 2010 US Census

There are many differences between these cities, but not great differences in population by race. Boston and New York have more police, and better economies. These differences may play a part in why there were lower homicide rates in those cities in 2006, but are unlikely to account for the divergent rates over time, going down in Boston and New York City while staying high or going up in Fort Wayne and Indianapolis. Difference is policing policies and fire arm regulations may be places to look. HCGV has been focused on firearm regulation more than policing policies.

Both Boston and New York are able to pass regulations applicable within the cities only. Indianapolis cannot. Both Boston and New York have flexibility in granting carry permits. In New York City, only the police department can grant carry permits and they can limit their scope to only a home or business. In Massachusetts, local police departments interview people requesting a licenses to carry, do their own background checks and can restrict or even refuse to grant the license. This can be appealed in court. In Boston, you must show you have basic abilities to handle a handgun at a police range.

Both cities are in states which recognize the risk of unregulated gun sales. In Massachusetts, all firearm transfers except between family members go through a background check. New York also requires a background check for all sales. In New York, all handguns must be registered. In Massachusetts, all sales are registered, but owners are not required to update records if they sell the firearm. Both states require the reporting of lost or stolen guns. New York requires locked storage where children under 16 are present. Massachusetts requires locked storage of all firearms. Both states require firearms in cars that are not on the person of the licensed carrier to be in a locked storage container (not the glove compartment.)

The table below shows some of the benefits Massachusetts and New York associated  with their stronger laws.

Table 6. Indiana, Massachusetts, and New York strength of gun laws, firearm death rates, % gun ownership, percent firearms traced are from out of state

State	Strength of Gun Laws56	Firearm deaths per 100,00056	% gun ownership57	% of crime guns from out of state58
Indiana	D-	14.9	34%	34%
Massachusetts	A-	3.4	23%	79%
New York	A-	4.4	10%	83%

The presence of strong gun laws does not mean no one has a firearm. It does correlate with lower firearm death rates. Fewer crime guns from available from vendors or persons in state should translate to higher costs for crime guns.

What Indianapolis cannot do is pass firearm regulations because of Indiana’s pre-emption law that prevents the city passing any regulation on firearms. The state itself has no universal background checks, no registration of handguns, no safe storage requirements, and no restrictions on concealed carry licenses, and no requirement for a permit to purchase a handgun.

Programs the city has supported have mostly tried to deal with the pathway to crime that some youth follow to identify them and divert them, as well as attempting to break cycles of violence between groups. So far these have not impacted homicide rates significantly. Before the 2019 election, Mayor Hogsett signed on with Mayors Against Illegal Guns suggesting more focus on the role of addressing firearm access and concealed carry in the homicide epidemic.

Firearm regulation related to urban crime has three features:

Regulations need to focus on handguns. Because they can be carried concealed, they are the main choice for criminals. Because criminals are carrying them concealed, interactions between individuals and groups can immediately lead to homicidal violence.

The state needs to repeal the state pre-emption law so that cities can address handgun violence if the state will not. The need for this policy was recently reviewed in the Yale Law Journal.^58a

Keeping guns out of the hands of criminals

• Regulations that will slow the flow and increase the cost of firearms to ineligible users. Universal background checks on all handgun transfers and requirements to report lost or stolen weapons, along with requirements for weapons to be securely locked in the trunk when left in cars to reduce thefts, are all measures that have been used. In addition, limiting handgun purchases to one per month complicates life for traffickers. Required licensing for handgun purchasing and the registration of handguns in metropolitan areas should be implemented.

Reducing the carrying of handguns

• Keeping guns off the streets in cities by requiring training for concealed carry permits and allowing local police to refuse to issue them when sufficient grounds exist such as frequent arrests for violence or intoxication. Allowing police to limit the scope of concealed carry as well.

Goals for the urban homicide rate in Indiana.

• Halving the rate would put the city in the company of Boston and New York and save 130 lives a year, mostly Black young men.

Public Health measures related to homicides in Indiana

These measures are aimed at saving all lives, urban and rural, Black and white, that are lost to gun violence.

• Convince people that a firearm in the home, especially a handgun, is more likely to result in a homicide than to prevent one. If you have to have a firearm, then it should be required to be kept locked and accessible only to the owner or in direct control of the owner.
• Strengthen Indiana’s law on firearms in situations of domestic abuse to require removal of firearms when any violence has occurred.
• A recent study covered several years in which all persons arrested for homicide offenses in one county were given psychiatric evaluations. The highest rate of mental illness was substance abuse (47%) ⁵⁹.  A history of multiple arrests for intoxication or misdemeanor convictions related to substance abuse could be added to the list of disqualifications for firearm purchase in the state.
• Implement uniform background checks for all gun purchases or transfers.

IV. Firearms and self defense

The recent rewrite of the Constitution in the Heller decision to include the right to a weapon for self-defense to the Second Amendment’s right to weapons for a well-regulated militia would seem to indicate that firearms for self-defense are important to peoples’ safety. Already discussed are studies indicating firearms in the home are much more likely to be used in suicide or assault than for self-defense. Other questions are how often firearms are used by victims of crime and whether  statistics on firearm fatalities suggest defensive firearm use causes more justifiable fatalities than the firearm fatalities related to fatal accidents, suicides, or homicides between family members, intimate partners, and friends.

The Bureau of Justice administers a national crime victimization survey twice a year with a stratified sample of 50,000 or more households. Questions are asked as to whether any member of the household has been a victim 0f assault, burglary, larceny, motor vehicle theft, rape, or robbery  Victims are asked if they did anything to defend themselves. Two studies have examined this data for how often guns are used in self-defense. The first covered the years 1987-1980 and the second 2007-2011.

The first study looked at methods of self-defense reported by victims of rapes, robberies, and assaults.   For the period 1987-1990 victims reported using firearms in 0.83% of the incidents.⁶⁰ 

For the study covering 2007-2011, the authors looked at crimes in which there was personal contact with the offender whether or not the crimes were violent. They found very similar results; firearms were used in 0.9% of incidents. Males were more likely than females to use guns for self-protection (1.4% vs. 0.4%).  No guns were used for self-protection in the 300 sexual assault cases reported. About 4% of victims were injured after using a gun for self- defense, the same as were injured using any method. Most of the use was outside the home, and half was in non-violent crimes.⁶¹

How likely is a firearm to be used in a fatal accident, homicide, suicide, or justifiable homicide in self-defense?

The table below suggests just how unlikely a firearm will be used to kill in self-defense compared to how often it is used in a suicide, criminal homicide, or fatal accident. Since homeowners buying a gun are generally not professional criminals, homicides of persons in close relationship with the shooter are separated out from all homicides. These are the homicides most likely to start through arguments, circumstances least likely to result in a homicide in the absence of a firearm.

Table 6. Suicide⁶², Homicide⁶³, and Accidental deaths⁶² by firearm or other means in 2018

Cause of death	All	By means of Firearm	Other Means
Suicide	48,344	23,854	23,319
All Homicide	14,123	10,267	3,856
Homicide Wife by Husband	519	377*	142
Homicide Girlfriend by Partner	531	386*	145
Homicide between other family members, friends, and neighbors	1970	1420*	550
Justified Homicide by Civilians	268	238	30
Justified Homicides by Police	450	448	2
Accidental deaths *	167,127	458	166,669

*The FBI UCR does not specify means for these homicides. Numbers for firearm homicides are estimated from the overall 73% of all homicides by firearm.

The next table shows the relative likelihood of a firearm being used in a suicide, homicide of a friend, family member, or neighbor (separately for wives or girlfriends), or causing an accidental death compared to the likelihood of being used in a justified self-defense homicide.

Table 7.  Odds of a firearm being used in various fatal situations compared to being used in a justifiable homicide ^62,63

Justifiable Homicide	Wife’s homicide	Girlfriends homicide	Other family, Neighbor, or Friends Homicide	Accidental Death	Suicide
1	1.6	1.6	6	2	100

An additional source of data on self-defensive use of guns is the Gun Violence Archive (GVA).The GVA follows 7000 sources including law enforcement, other governmental sources, media, and commercial sources for all recorded incidents of gun violence in the United States.⁶⁴ One category is self-defense. For this category, they count all incidents whether or not an injury occurred. For the year 2018, the number was 1896 for self-defensive use. This number is 2% of the firearm deaths and injuries seen on average in the United States between 2010 and 2012 in Table 3 (94,425). ²⁸ For Indiana, in 2017, the Indsiana Mortality Rep[ort listed 604 firearm suicides, 369 firearm homicides, and 15 accidental firearm deaths.³  For that year, The Gun Violence Archive found reports of a total of 69 incidents in Indiana involving self-defense in which firearms were involved. Most involved self-defense of the home. There were 23 deaths and 29 injuries reported. The 23 deaths would be 2.3% of all firearm related deaths reported in the Indiana Mortality report, about the same as the percentage of accidental deaths, 1.5%. For advocates of concealed carry as a way to protect the public, there were just 3 reports in which a third party not involved in the crime used a firearm in defense of the victim. ⁶⁴

What are the odds of a gun owner’s weapon being used in a justifiable homicide compared to a suicide?

Fatal events are relatively unlikely to occur with the firearm of any individual gun owner in the United States. About 45 million US households (36% of 126 million) have firearms.⁴⁷ About 25% of the population, 0r 75 million are gun owners.⁴⁷ Most of them have their guns for self-defense.⁴⁷ In 2018, 23,854 firearm suicides would be one for every 1886 gun owning households and one for every 3,144 firearm owners; 238 justifiable homicides would be about one for every 189,000 gun owning households and one for every 315,126 firearm owners.

One website describes owning a gun as a kind of insurance. To quote from one website:  “Owning a gun for self-defense is like having fire insurance or health insurance. You don’t really think your house will burn down, but it might. You don’t really think you will have a catastrophic car accident, and huge hospital bills, but you might. You hope you will never need your insurance, but you have it just in case. The same goes for having a gun for self-defense. It is better to have it and not need it, than to need it, and not have it.” ⁶⁵  “Insurance” that is so much more likely to kill you or a family member is a bad policy.

Though evidence based on injuries, deaths, and confirmed media reports indicate a very small role for guns in crime prevention, gun advocates often claim critics are overlooking data on the thousands of lives saved and crimes prevented by gun owners. These claims are based on interview data which asked people if they had used a gun in self-defense. The percent answering yes was then extrapolated to the population as a whole. In a RAND analysis of this data, they note that in the National Self Defense Survey (NSDS) of Kleck and Gertz, the guns owners thought they had killed or injured 207,000 people a year, a number far in excess of all firearm deaths and injuries, almost all of which were from suicides or criminal homicides in any recent year.⁶⁶ Other estimates based on the NSDS survey have guns being used far more often than  was possible, for instance by more than 100% of burglary victims home when a crime was commited.⁶⁷

V. Does Gun Regulation Work to Reduce Gun Violence?

Several studies indicate firearm regulation reduces firearm violence.  In one review of firearm laws and homicides in all states, the authors conclude: “The strength of firearm legislation in general, and laws related to strengthening background checks (CBC) and requiring a permit- to- purchase a handgun (PTP) in particular, is associated with decreased firearm homicide rates”. ⁶⁸ A similar study of the impact of firearm laws on homicide and suicide deaths in the United States for the period 1991-2016 looked at changes over time in states that did or did not implement new gun regulations. They found that comprehensive background check (CBC) laws were related to a 14.9% decrease in firearm homicide rates; violent misdemeanor (VM) laws (laws that restrict firearm purchase or possession by persons convicted of violent misdemeanors) related to an 18.1% reduction; however, right to carry (RTC) laws for concealed carry permits (laws which restrict local authorities from denying permits to people passing a background check) were related to a 9% increase in homicides. ⁶⁹   This study did not include PTP laws. 

Changes in firearm fatality rates after changes in PTP laws have been studied in two states:  Missouri, which removed a long standing PTP law in 2007 and Connecticut, which instituted such a law in 1995. Revoking the law in Missouri was related to an increase in firearm suicides (16%). Instituting the law in Connecticut was related to a decrease (15.4%) in firearm suicides. Non-firearm suicide rates remained stable in Connecticut and increased by 4% in Missouri.⁷⁰ A study of homicide rates in Missouri found that repeal of the PTP law was associated with a 23% increase in firearm homicides with no change in non-firearm homicides. ⁷¹In a study of Connecticut, researchers found a 40% reduction in firearm homicides, with no change in non-firearm homicides after introduction of the law.⁷²   

Another study with a narrower focus was one on the relationship of firearm regulation and homicide in urban areas. This study considered the effects of right to carry (RTC), stand your ground (SYG), comprehensive background check (CBC), permit to purchase handguns (PTP), and violent misdemeanor laws (VM). As expected the SYG and RTC laws were associated with increased rates of homicides, 4% for RTC and 7% for SYG laws. PTP was associated with a 14% reduction in homicide rates. CBC and VM laws were both associated with unexpected increases in homicide rates.⁷³   The authors note that these laws were often passed in states that were experiencing an increase in homicides in the years preceding the passage of the laws. VM laws are narrow in scope aimed mainly at preventing intimate partner violence which they have been shown to do.⁷⁴ CBC laws may have little short term effect on homicide rates considering the ease of obtaining guns on secondary markets.

PTP laws force someone wanting a gun to have an interaction with law enforcement, which may offer a real deterrent, particularly to those in the business of trafficking guns from dealers to persons who cannot pass a background check. In the study on urban effects of regulations, the authors note that gun ownership rates had a bigger effect than regulation, increasing homicide rates by 37%. As this would generally be a continuous variable, the authors are unclear how they arrived at the 37% figure. ⁷³

Firearm regulations in one state can impact firearm homicide rates in surrounding states. A study compared firearm death rates from suicide and homicide by county from 2010 t0 2014, the state’s firearm regulation, and the firearm regulation of other states in the vicinity of the county. Stronger sate firearm laws were correlated with lower firearm suicide rates and lower overall suicide rates regardless of surrounding states regulations.  Strong firearm policies were associated with lower homicide rates and states with weak laws surrounded by other states with stronger laws had lower homicide rates. ^74a

A final study of interest compared firearm regulation around the world for its effects on violence. The authors started with a literature search for studies on the effects of gun regulation and gun fatalities during the period 1950 to 2014. After review, 130 studies met their criteria. They note that researchers looking at the same laws, for instance SYG laws and RTC laws, find opposite conclusions. However, they summarize that “Evidence from 130 studies in 10 countries suggests that in certain nations the simultaneous implementation of laws targeting multiple firearms restrictions is associated with reductions in firearm deaths. Laws restricting the purchase of (e.g., background checks) and access to (e.g., safer storage) firearms are also associated with lower rates of intimate partner homicides and firearm unintentional deaths in children, respectively.”⁷⁵

VI. Money and Guns

The firearm industry has been doing well recently. In April, 2019, The National Shooting Sports Foundation reported the industry had gone from $19.1 billion in 2008 to $52.1 billion in 2018. Jobs had risen from 166,000 to 312,000.⁷⁶

Of course, for society this needs to be balanced against the costs of firearm violence. Unfortunately, unlike automobile accidents and even domestic violence, there is no government agency tracking the costs of gun violence and little money available to support research. There is some data on hospital costs which indicate about $2.9 billion per year.⁷⁷   There are health care costs related to long term care and rehabilitation as well as mental health care for survivors and family members of victims.  There are also other direct costs of gun violence: increased policing costs, added incarceration costs from longer sentences for firearm felonies, and the cost to school systems, public event spaces, churches, and business in the continual need to upgrade facilities due to the threat of gun violence. Provision of items for school safety was measured as a $2.7 billion dollar a year industry in 2018, which does not include the costs of additional school safety personnel.^78,79

Much larger are the indirect costs of lost wages and productivity from premature  deaths and injury, estimated at $49 billion annually.⁸⁰   This burden is born by the families of firearm victims of suicide and homicide. Inner city communities suffer financially from the inhibition of economic activity related to high levels of gun violence. A recent congressional hearing put the total costs at $229 billion a year.⁸¹

Some make the argument that if Indiana enacted strict gun control measures, the industry would leave the state. If state firearm regulation is a key feature for the firearm industry, than it is surprising that  that of two states with almost the same population, the one with the much stricter gun regulation has more jobs and economic impact from the firearm industry. Massachusetts has 7,000 jobs  and total economic output of  $1.9 billion and Indiana, 5,500 jobs and economic output of $0.7 billion, according to the Firearm and Ammunition Industry Economic Impact Report of 2017.22,82

VII. Discussion

My initial impression that the presence of guns in households is of significance to the level of lethal gun violence has been confirmed for injury deaths, suicides, mass shootings, and homicides. In terms of the number of lives lost, firearm suicides and homicides are substantial public health problems for the whole population, and for some population groups homicides are of epidemic frequency.  The mass shooting phenomenon has social and economic costs far beyond the number of lives lost. The effects of mass shootings on society are akin to those of terrorism, consuming tremendous resources for what are rare events. The one category of firearm death that does not raise itself as a public health issue is the justified killing of people attempting crimes. In fact, this number is trivial, as is the number of crimes defended against with firearms.

I doubt much of this is new to people reading this report.  If one accepts that guns are such dangers, then the issue becomes what to do about it given the context of the present cultural attitudes and political realities of the United States. It is well known that most people would like to see more gun regulation. Also, it is well known that the firearm industry and some gun owners will fiercely oppose almost any regulation.

Several points to keep in front of people:

          Firearms do not make people safer; in fact, they do just the opposite:

Many who favor more regulation may also think guns in homes might be protective.  The facts are that having guns for self-defense is nearly useless for self-defense and increases the likelihood of being killed by a firearm.  Governor Pence’s statement to a recent NRA convention in Indianapolis “a home with a gun is a safer home” is simply false. Except in extreme circumstances such as making a living as a drug dealer or having had credible threats made against you, it makes no sense to have guns for self-protection. Having guns for hunting or target shooting carries the same risks as for self-defense, but owners are more amenable to risk mitigation such as safe storage, as it does not interfere with the purpose of having the weapon. For self-defense, gun advocates argue the need for the weapon to be available overrides any requirement for safe storage. If you want to defend yourself, you need to have the gun under your control all the time or it must be locked up for your safety and those around you. Facing a situation calling for shooting in self-defense is most unlikely during any lifetime. However stresses from life evens such as depression, marital conflict, or alcohol abuse happen commonly; ready access to a firearm dramatically increases the likelihood of a fatal outcome.  It is stupid and dangerous to keep a loaded handgun in the closet under some towels.

One website giving advice to women concerning firearms recommends firearms be kept in a safe room where you will huddle with your family during a home invasion. This website says this is a last resort and making your home safe with locks, lights, alarms, a dog, etc. should be in place first. The website recommends a shotgun over a handgun as easier and cheaper to learn to use and more intimidating than a handgun.⁸³ It is also less likely to be left lying around loaded or fall out of your pocket and less likely to end up as a crime gun if lost, stolen, or sold.

The recent increase in the number of households with firearms in response to the Covid-19 pandemic can be expected to increase the toll of firearm violence: suicides, homicides between family members and friends, and accidental firearm deaths.

          The firearm industry is a parasite on the economy:

The firearm industry accounts for about 300,000 jobs in manufacturing and more in distribution. As with industries like the tobacco industry and alcohol industry, the costs related to firearm production in terms of injuries, disability costs, mental health costs, and costs of protecting against gun violence are largely paid by taxpayers, rather than the producers or purchasers of the firearms (though many purchasers do pay with their lives). These costs are high and equal or outweigh any contribution of the firearm industry. The most significant cost is simply the lives lost each year to firearms that can be attributed to their unregulated widespread presence in society. Evidence from multiple sources indicates the majority of firearm suicides would not have occurred in the absence of a firearm. Many fewer households with firearms could save 10,000 of the 20,000 lives lost to firearm suicides in this country every year. If all cities in the United States carefully regulated handguns along the lines of Boston and New York City, 5000 or more lives could be saved. Since it is impossible to find offsetting contributions economically or in terms of saving lives, the gun industry is a major parasite on the American society.

          Gun Regulation does not mean taking your gun away from you:

Sensible gun regulation does not include removal of firearms. Even states that have banned the sale of assault weapons have grandfathered those owned before the law was passed.  They may require registration and only allow disposition through a registered dealer. Similarly, handgun restrictions relate to the carrying of handguns and restriction on clip capacity, not taking away guns. You can buy a handgun in New York City, which has the strictest regulations, as well as get a permit to carry if you have a particular reason. The NYPD strongly supports existing gun regulations as contributing to the safety of officers and the low homicide rates in the city. ⁸⁴

“The right to bear arms” is part of a larger social and political agenda:

Owning firearms has become politicized. Defending the right to own them has been elevated by some to the most important right people have, and taken on by many as a key aspect of their personhood. In gun advocacy rhetoric, there is reference to gun-owning as a defense against the state, clearly not the intention of the founding fathers. Some have incorporated into the right to bear arms the right to bear them openly to intimidate. Recently, protesters of public health requirements have shown up bearing firearms, as have some protesting police violence. One political party has incorporated politicized gun owners into its base, giving them total support.

Do firearm regulations work?

Measures of the impact of specific regulations on gun violence are real but modest. However, in concert, they can create a counter culture to the gun lobby to debunk the mythology of gun ownership for self-protection, so that fewer households own guns, particularly handguns, to me the most important goal of gun regulation. The results of this kind of revolution in attitudes can be seen in New York and Massachusetts.

What to do?

In Indiana, with control of both houses of the legislature and the governorship by Republicans, little progress has been made. The Indiana Red Flag law, passed following the shooting of police officer Laird, is one exception as it had no opposition from the gun lobby. The state also has laws that address access to firearms in situations of domestic violence and access to guns by children, but these need to be strengthened. Gun regulation advocacy groups have also managed to help block some proposed measures, such as permit less concealed carry and guns on public college campuses. They have also seen bills at least submitted to the legislature for CBC and other measures but these rarely get a hearing. 

I believe organizations such as HCGV should continue to get bills introduced for common sense gun regulation. Focusing on those related to domestic violence and protection of children may stand a better chance. One can argue that safe storage regulation that holds parents responsible could protect children at home as well as help keep guns out of schools. A number of states have closed the boyfriend loophole and passed stronger laws on relinquishment of firearms in domestic violence protective orders.

Continuing to advocate in letters to the editor and more effectively use social and broadcast media to bring across the broader message is important. For HCGV, I would consider developing an annual or semiannual report on gun violence in Indiana to be summarized and disseminated as a press release.

There is a long history of organizations that have come into existence to support sensible gun regulation. Prior to the 1970’s, the NRA was one of these, supporting many gun regulations, including those on carrying concealed weapons. Unfortunately, by 1980, the NRA was firmly against any and all regulation. Other groups favoring gun regulation have come into existence, often in response to particular acts of gun violence.   In 1974, the National Council to Control Handguns was founded by Dr. Mark Borinsky after he was robbed at gunpoint and nearly murdered. This later became Handgun Control, Incorporated and in 1981 Sarah Brady, whose husband had been badly injured in the attempted assassination of President Reagan joined the organization and eventually became the chairperson . This organization worked for years to get the “Brady Bill” passed which introduced background checks and waiting periods for gun purchases in 1993. The organization then became the Brady Campaign in 2000. Other organizations include the Million Moms March in 2000, Mayors Against Illegal Guns in 2006, Gabby Giffords and her husband’s Americans for Responsible Action in 2011 (now known as Giffords and the Giffords Law Center) was created after Gabby’s injuries in a mass shooting.  Moms Demand Action was created after the 2012 Sandy Hook shootings by Shannon Watts on Facebook while she lived in Indiana. Moms Demand Action later joined with Mayors Against Illegal Guns to become Everytown for Gun Safety.

Many states have organizations such as HCGV. Thirty two state organizations are affiliates of States United to Prevent Gun Violence which offers technical support and sponsors an annual meeting.  The Violence Policy Center and the Gun Violence Archive, nonprofit organizations which collect and analyze data on gun violence, have been important sources for this paper.

In addition to the Brady Law, the Assault Weapons Ban of 1994 was another milestone at the federal level. However, since 2000 there has been little progress at the federal level. However, there has been progress in many states. This paper mentions the wide variety of measures that some states have adopted.