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The Scope of the Problem: Gun Violence in the USA


Purpose of Review

To update current understanding of the extent and impact of firearm violence in the USA.

Recent Findings

In the past decade, rates of firearm injury have increased in the USA, both absolutely and in comparison to other high-income countries. Firearm homicides, firearm suicides, and public mass shootings have all been increasing. Firearm homicide rates remain highest for young non-White males in urban areas, and firearm suicide rates remain highest for older White males in rural areas. The burden of all these shootings falls not only directly on the victims themselves but also can impact their families, friends, and communities. These more indirect costs include medical care, grief, fear, hopelessness, and PTSD. The negative effects of exposure to firearm violence have been highlighted in the literature. Individual and community efforts to prepare for and prevent the shootings entail additional costs and burdens.


The scope of the US gun problem in 2019 is far greater than is indicated merely by medical costs and body counts.


In this chapter we discuss the scope of the firearm-related public health problems in the United States, focusing on the findings from the recent (2016–2019) scientific literature. We divide the discussion into two parts: the direct effects of firearm shootings (i.e., injury and death), and the more indirect effects (e.g., on medical care resources, ramifications of exposure to violence).

Direct Effects: Death and Injuries from Firearms

International Comparisons

Worldwide, it is estimated that, in 2016, over 250,000 people died directly from being shot: 64% were homicides, 27% were suicides, and 9% were unintentional shootings [1]. Six countries, all in the Americas, accounted for over half of these deaths (Brazil, the USA, Mexico, Columbia, Venezuela, and Guatemala). In the USA, by contrast to most other countries, firearm suicides outnumber firearm homicides.

In terms of firearm deaths, the USA is an outlier among high-income countries, and not in a good way. In 2015, the overall firearm death rate in the USA was 11.4 times higher than the rate in the 28 other populous high-income countries combined (e.g., Australia, Canada, Chile, Czech Republic, France, Germany, Italy, Japan, Republic of Korea, New Zealand, Slovak Republic, Spain, Sweden, Switzerland, the UK) [2••]. Over 91% of women killed by guns and 92% of youth (aged 15–24) killed by guns in all populous high-income countries were US women and US youth. Table 1 provides a comparison of the violent deaths to US 15–24-year-olds with similar aged young people from the other populous high-income countries combined.

Table 1 Violent deaths to 15–24-year-olds

In 2015, the homicide rate in the USA was 7.5 times higher than the homicide rate in the other 28 populous high-income countries combined, largely attributable to a firearm homicide rate that was 24.9 times higher. For US Whites, the firearm homicide rate was 12 times higher than the firearm homicide rate for the other high-income countries—and within the USA, the non-White firearm homicide rate was 5.7 times higher than the White homicide rate [2••].

International comparisons that focus on specific types of firearm violence are equally disturbing for the United States. For example, US rates of public mass shootings are extremely high relative to other countries [3••, 4••, 5, 6]. In addition, police in the USA are much more likely to be killed on the job, and to kill civilians, than police in comparable countries. For example, one comparison finds that in 2016 US police were killing civilians at 4.6 times the rate of Canadian police, 40 times higher than German police, and 125 the rate of police in England and Wales [7]. Guns are used in the overwhelming majority of police being killed by civilians and police killing civilians. “…(T)he dominant threat that police are responding to when they use lethal force is that of guns in the hands of their adversaries….the proliferation of concealable firearms in the civilian population is a major source of the singularly high rate of killings by police in the United States” [7 pp. 56–57]. Within the USA, empirical studies find that the major explanation for the differences across US states both in rates of fatal shootings of police and rates of fatal shootings of civilians by police is the level of household gun ownership in the state [8,9,10].

Deaths, injuries, and criminal victimization

In the USA, gunshot wounds killed almost 40,000 people in 2017 [11]. That represented an estimated national life-expectancy loss from firearms of 2.5 years for white Americans and 4.1 for black Americans [12].

In 2017 in the USA, there were 23,854 firearm suicides, accounting for 51% of all suicide deaths. There were 15,095 firearm homicides, accounting for 75% of all homicides. And there were 486 unintentional firearm deaths. Firearm homicide and firearm suicide rates have all increased over the past decade [11].

Rates of firearm suicide were highest in rural settings, much higher for men than women, higher for White than Blacks, and increased with age. The number of firearm suicides rose steadily from 16,599 in 1999 to 23,854 in 2017. Non-firearm suicides rose at an even faster clip, from 12,600 in 1999 to 23,319 in 2017.

Rates of firearm homicide victimization were highest in urban settings, were much for higher Blacks than Whites, were much higher for men than women, and peaked at age 20–24. Over 60% of all homicide victims in 2017 were in the 20-year age span 15–34. After a significant decline in the 1990s, the number of firearm homicides rose from 11,127 in 1999 to 15,095 in 2017, with almost all the increase occurring 2014–2017. Non-firearm homicides fell from 6160 in 1999 to 5031 in 2017.

Data on firearm fatalities are reliable, and the USA will soon add the final states into the National Violent Death Reporting System—a data system that provides rich circumstantial information on firearm and other violent deaths—making it a truly national system [13].

By contrast, data on non-fatal shootings are more suspect. For example, the CDC estimates that in 2015, there were about 85,000 non-fatal shootings; unfortunately, CDC point estimates of the number of non-fatal shootings cannot be used with any confidence (the 95% confidence interval for 2015 was 37,000–133,000). CDC estimates for 2017 were higher than for 2015, but these 2017 figures are no longer available on the CDC website as they were deemed “unstable.” Hospital billing data (e.g., Healthcare Cost and Utilization Project HCUP) are now often used to provide general estimates of rates of non-fatal shootings (75,000 in recent years).

Estimates of gun use in crime from the National Crime Victimization Surveys are that in 2017 there were over 400,000 violent crimes where the offender possessed, showed, or used a firearm [14]. This figure is an underestimate as it requires the victim to know that the perpetrator had a gun and many gun intimidations during intimate partner violence are not reported to the interviewers.

To summarize, on a typical day in 2017, guns were used in crimes more than 1000 times, there were probably 310 or more Americans shot, and over 100 died, including 65 by suicide and 41 by homicide.

Specific victims, places

Recent articles have focused on some specific types of firearm violence, victims, and places, including homicides of intimate partners [15] and of prostitutes [16], suicides among veterans [17], violent deaths of children [18], as well as shootings at schools [19] and workplaces. Here we briefly summarize workplace homicides.

A study of workplace firearm homicides (of the 500 workers murdered on the job in 2015, 79% were killed by firearms) found that non-robbery situations now account for almost half of these deaths [20••]. Arguments were the most common circumstance of the non-robbery workplace firearm homicides, typically customer-employee or employee-employee disputes. “While customers and co-workers who commit these crimes are often armed at the time of the argument, many are not and retrieve a firearm…Immediate and nearby firearm access plays a large role in argumentative workplace deaths. Limiting firearm access in the workplace is one possible way to prevent firearm workplace homicides” [20•• p. 8].

Indirect Effects

In this section, we discuss other aspects of the firearm-related public health problem that extend its burden beyond the physical injury to the victim. We first consider some of the ways these indirect effects can impact individuals, their families and friends, and the community at large. Many of these effects have received little study. Here we briefly describe them, as was done in Hemenway, 2011 [21]. We then review recent published studies that have explored some of these aspects in more depth.

Overall Costs of Firearm Injury

For the victim, getting shot may result in pain, suffering, lost quality of life, and psychological costs such as post-traumatic stress disorder. Trauma increases the future risk of psychiatric, emotional, behavioral, and health problems [22••]. In addition to PTSD, psychiatric problems include depression, anxiety, intrusive thoughts, sleep problems, and personality change. Emotional problems include anger, nervousness, withdrawal, loneliness, and despair. Behavioral problems include low academic performance [23], risky sexual behavior, substance abuse, delinquency, and violence. Finally, exposure to violence has been linked to such health problems as asthma, heart disease, and low birth weight babies.

The shooter also has costs—and there is always a person other than the victim involved in firearm assaults (including homicides) and often in unintentional shootings. The psychological costs to accidental killers are only beginning to be explored [24]. Intentional shooters are often caught, convicted, and incarcerated. The perpetrators’ life chances are severely diminished. The shooter may also be traumatized. Friends and family of the shooter as well as those of the victim may be devastated.

The community often bears the greatest costs. These include paying for many of the medical costs through Medicaid, general insurance premiums, and bad debt. For gun crime, there are the costs associated with criminal law enforcement, including the costs of police, district attorneys, judges, parole officers, and prisons.

Community members may be exposed to firearm violence—something that is common for firearm homicides, of which some 80% occur outside the home. Simply witnessing firearm violence can have many of the same long-term mental and physical health problems as being victimized.

Most important, there are large community costs from firearm assaults as people and institutions try to protect themselves from future shootings. For example, street firearm violence affects commercial and residential location decisions. Businesses do not want to locate in areas of high gun crime, tourists do not want to go there, and people do not want to live there. This leads to fewer jobs and flight from the neighborhood of higher-income people who can afford to leave. The loss of jobs, retail outlets, community social capital, and positive role models lead to neighborhood deterioration.

To avoid being shot, residents may change their behavior concerning recreation, shopping, leisure, and other activities. Children are not allowed to play outside, urban park space is unused [25], and residents are both less likely to go out at night and less likely to accept evening work. People live behind locked doors. Having fewer people on the street further reduces the safety of being on the street.

When people and institutions cannot avoid the danger, they often try to protect themselves from the danger (e.g., “target hardening”). Schools use metal detectors and practice lock-down drills [26]; police wear bulletproof vests. To protect themselves, juveniles may obtain guns and join gangs, which may lead to more firearm violence.

Two decades ago, two economists valiantly tried to put a single dollar value on the overall costs of firearm violence [27]. They asked a representative sample of Americans how much they would pay a year to reduce gun violence by 10% that year. They then extrapolated the sum to the entire population, multiplied by 10, and concluded that firearm violence cost Americans more than $200 billion a year. Whatever one thinks of this estimating method, given the rapid increase in public mass shootings, along with inflation and increasing population, the estimated number today would undoubtedly be substantially higher.

Some Specific Costs

Three types of indirect effects of firearm injuries and violence analyzed in the recent literature are (a) medical care costs, (b) effects of exposure to gun violence, and (c) the repercussions of mass shooting, particularly school shootings.

Medical Care Costs

Many recent articles examined the medical costs of treating gunshot wounds [28, 29••, 30]. Between 2006 and 2014, some 78,000 patients per year with gunshot wounds presented alive to the ED for firearm-related injuries; 37% were admitted to inpatient care; and 8% died in the ED or hospital [30]. If you can make it alive to the ED, your chance of survival is good. Not surprisingly—at least for data from two level-1 trauma centers—gunshot wound patients generally arrive more severely injured and require more operations, more ICU admissions, and longer hospital stays than other victims of interpersonal injury [31]. National medical costs of initial hospitalizations for firearm injury—about $750 million per year—are absolutely large, but small compared to overall US hospital expenditures. Medicaid pays about 1/3 and self-pay about 1/4 of the initial hospitalization bill [28, 29]. Ninety-day re-admission rates (sometimes to different hospitals) for firearm injuries are above 10% [32, 33].

Exposure to Guns and Violence

Exposure to guns and gun violence can have serious health consequences. Among other issues, recent articles have examined the “weapons effect” (i.e., simply seeing firearms may change one’s behavior) and have provided more evidence on the health effects of witnessing violence.

Regarding the “weapons effect,” a large series of psychological studies suggest that the mere presence of a gun may make the person more prone to desire to use a gun—in essence, that “the gun may pull the trigger”. A recent meta-analysis of 78 studies on this issue concluded that the evidence indicated that presence of a weapon increases (1) aggressive thoughts and (2) hostile appraisals of others’ intent [34••]. After accounting for publication bias and outliers, it was less clear whether the presence of weapons increase actual aggressive behavior.

Among youth, the mental health and behavioral impact of exposure or access to guns raises additional concerns. One recent cross-sectional study found that adolescents living in homes where a gun was present for protection had higher aggressive attitudes and behaviors than counterparts living in homes with no gun present [35]. No information was available on when the family had acquired the firearm. Another study examined families that had recently acquired firearms. That study found that the teenage children in those families were subsequently more likely to have increased depressive symptoms, with the link between in-home firearm access and depression more pronounced for female compared to male adolescents. The study found suggestive evidence that perceptions of safety at school comprised a possible mechanism linking in-home firearm access to adolescent depression [36]. While such studies do not necessarily indicate causation from guns to aggression and depression, depressed and aggressive adolescents are not those we would like to see have ready access to firearms. It is also disconcerting that another study found that about 10% of individuals who self-report angry or impulsive behavior also report possession of guns at home or carrying them outside the home [37].

Exposure to violence (e.g., high rates of violence in one’s community; parental domestic violence) is associated with multiple negative long-term consequence. A recent scoping review found 31 articles focused on the effects of youth exposure to firearm violence and concluded that “the behavioral and physical health consequences of youth exposure to firearm injury are consistently reported as high… Youth firearm injury exposure is clearly linked to high rates of post-traumatic stress symptoms and high rates of future injury” [38]. A recent study of children seeing or hearing gun violence found that over half reported being very or extremely afraid, sad, or upset as a result of the indirect gun violence [39]. Another study suggested that exposure to gunshots may reduce school achievement [23].

An interesting qualitative study asked 16 victims of gun violence to tell their story. Themes that emerged included the prevailing nature of everyday violence, feeling abandoned by the institutions of society, and evolving psychological effects. “The presence of gun violence in their neighborhoods has had an everlasting impact on their wellbeing” [22].

Effects of Mass Shootings

Many articles discussed various indirect effects of mass shootings, particularly school shootings. Evidence indicates that gun sales increase in the months immediately following mass shootings [40]. Shootings receiving extensive media coverage were associated with handgun purchase increases [41,42,43]. On the other hand, there is also some evidence that the deadliest shootings may have a negative impact on the stock prices of the manufacturers of the specific firearms used [44].

One article found a large spike in Google searches for “clean gun” and “buy guns” following the Sandy Hook mass shooting along with a significant increase in child accidental firearm deaths in those states with the largest spikes [45].

A review of 49 articles on the mental health consequences of public mass shootings concluded that these events are associated with adverse psychological outcomes in survivors and members of the affected communities. Suicides of friends and family of school shooting victims demonstrate the potential for profound and lasting suffering [46]. While less is known about the psychological effects of mass shootings on indirectly exposed populations, there is evidence that such events lead to increases in fears and declines in perceived safety [47].

With the increase in mass school shootings, there has been debate about the proper response by schools. Most schools now have active shooter drills, and many are considering bringing more guns into schools, such as by arming teachers. Not surprisingly, increasing the number of guns in school is quite controversial [39, 48, 49]. A literature review of current practices regarding school firearm violence prevention concluded that while hundreds of millions of dollars have been spent to harden schools, “none of the currently employed school firearm prevention methods have empirical evidence to show that they actually diminish firearm violence in schools” [50].

On a more hopeful note, evidence of an effective prevention policy comes from studies finding that banning large capacity magazines is associated with lower rates of rates of high-fatality mass shooting deaths [51••, 52].


While mass shootings receive much media attention, they account for only a tiny percentage of our firearm deaths. And the USA is an outlier in terms of firearm deaths compared to all the other high-income nations. Worse still, US firearm death rates have increased in recent years. The scope of our problem is far greater than suggested by merely counting dead bodies. These include financial, social, psychological, and physical health costs imposed on victims, shooters, families, friends, and communities throughout the nation. What has been missing is a societal response commensurate with the size of our firearm-related problems.


Papers of particular interest, published recently, have been highlighted as: •• Of major importance

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Hemenway, D., Nelson, E. The Scope of the Problem: Gun Violence in the USA. Curr Trauma Rep 6, 29–35 (2020).

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  • Firearm suicide
  • Firearm homicide
  • Firearm costs
  • Exposure to firearm violence
  • Medical costs
  • Weapons effect