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 . 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 , 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 . 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 , 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 ; 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 . 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 . 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 . 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 . 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 . 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 .
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” . 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 . Another study suggested that exposure to gunshots may reduce school achievement .
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” .
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 . 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 .
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 .
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 . 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 .
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” .
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].