Just as children share in the strengths and weaknesses of the families they live in, so do they share in the strengths and weaknesses of the societies in which their families live. One of the weaknesses of contemporary US society is its preoccupation with violence in general, and firearms in particular. For US children, the consequence of this is a level of firearm mortality and morbidity that is far higher than anywhere else in the world.
As child health-care providers and child advocates, pediatricians are, increasingly, called on to step in to treat and protect children who find themselves in the cross fire. Therefore, pediatricians must be as knowledgeable about this problem as they were about polio a generation or two ago. There has been a rapid expansion of interest in and knowledge about US pediatrie firearm injuries. Pediatricians can use that knowledge to help protect their patients . . . and their children. This article reviews what is known about the magnitude of the problem of firearm injury in the United States, risk factors for injury, and available prevention approaches.
THE PATHOPHYSIOLOGY OF FIREARM INJURIES
Prevention of firearm injury requires familiarity with the rudiments of ballistics and the biomechanics of firearm injury.1'5 The key concept is that firearms are designed to efficiently convey kinetic energy (ke) to a missile (generally a bullet), which transfers it to a victim according to the formula ke = '/zmf 2, where m is the mass of the missile and v is its velocity. If a bullet exits the body, the velocity that affects the amount of energy conveyed is the difference between the entrance and the exit velocities. Although the mass of the missile is small, the velocity with which it exits the firearm muzzle is high (hundreds to thousands of feet per second), and so the energy conveyed is very large.
The damage caused when a bullet enters tissue depends on several factors: the intrinsic strength of the tissue (eg, it requires a higher muzzle velocity to penetrate bone than soft tissue), the location of the penetration (more deadly damage is done if the brain, heart, or a major artery is hit than if a leg muscle or mesentery is struck), and the ballistic properties of the particular type of missile that is used. All bullets cause damage by direct contact (creating a permanent cavity) and by tissue crushing created by the traversing bullet's energy (which causes a temporary cavity). Contact injury predominates at lower muzzle velocities and crushing injury at higher muzzle velocities.
Although there are regulations in the United States controlling the design of many consumer products, there are none affecting the design of either firearms or bullets. The marketplace contains a large array of both types of products. The firearms can be divided for discussion along two parameters: the source of kinetic energy and the length of the muzzle. The velocity of the missile leaving a firearm is contributed by compressed air in airguns (also known as nonpowder firearms and BB guns) and exploding gunpowder in powder guns. Muzzle length is short in handguns (pistols) and sawed-off shotguns; it is long in riñes and shotguns. This article will concentrate on powder weapons (both handguns and long guns) because they cause most of the deaths and liië-threatening injuries. Readers are referred to other papers for a full discussion of airguns: the injuries they cause, their possible role in training children to use powder guns, and specific injury prevention approaches.6'10
MAGNITUDE OF THE PROBLEM
Three Different Circumstances of Injury
Any discussion of firearm injuries must include each of the major injury circumstances: assault/ homicide, suicide, and unintentional injury. The distinction is important because prevention must address risk factors for each of these. Figure 1 shows the pattern of firearm mortality, by age, for the three types of fetal injury. Firearm deaths become substantial in early adolescence and peak in early adult life. Homicide is the most common circumstance for fatal injury, followed by suicide; unintentional injuries, which often command the greatest media attention, are horrible but comparatively infrequent at all ages.1 '
The relative frequency of the different circumstances of firearm injury varies with the age of the victim. Among 1- to 9-year-old children, homicides are most frequent, followed by unintentional injuries. Among 10- to 14-year-olds, homicide and unintentional injuries are almost equally frequent, and account for three fourths of firearm deaths; the rest are due to suicide. Among the 15- to 34-year-old age group, homicides account for the majority of firearm deaths (just over half overall and 80% to 90% among blacks), and suicides account for the majority of the rest (38% to 45% overall, about 60% among whites).11
Figure 1. Firearm death rates by manner of death and age, for persons 1 to 34 years: United States, 1988. 11
Rapidly Rising Fatalities
Table 1 shows the alarming increase in firearm deaths that has occurred in recent years. Data from 1988, the last year fully analyzed in federal publications at this writing, are compared with 1985, the year contained in the Centers for Disease Control's last report to Congress on childhood injuries.12 For all circumstances, the number of deaths increased from 3089 in 1- to 19-year-old children during 1985 to 3873 during 1988, a 25% increase. The greatest rises were in the number of homicides, which went up 22% in 5- to 9-year-old children, 29% in 10- to 14-year-old children, and 54% in the 15- to 19-year-old age group. Fatality rates also rose most for homicide, up 33% for 5- to 9-year-old children, 38% for 10- to 14-year-old children, and 65% for the 15- to 19-year-old age group. For black males aged 15 to 19 years, firearm deaths more than doubled from 1984 to 1988. In 1988, firearm death rates were comparable in number to the sum of all death rates from natural causes for white males aged 15 to 19, and two-and-a-half times the death rates from natural causes for black males 1 5 to 19 years old.11
The scale of pediatrie firearm injuries in the United States is unique in the international community. A recent comparison of homicide deaths among males aged 15 to 19 years indicated the extent of this discrepancy.13 In 1987, there were 3187 firearm homicides in the United States (75% of all homicides in the 15- to 19-year-old age group), compared with 90 firearm homicides in 14 other developed countries combined (accounting for a mean of 23% of all homicides in those countries). The US rate was 21.9 per 100 000; among 20 other developed countries, the next highest rate was 5 (Scotland), and 13 countries had rates below 2.
Figure 2. Unintentional firearm mortality rates/100000 by gender and age group, 1988. a
Firearm deaths for all ages vary by region within the United States, with death rates being the highest in the South and West. Rates also vary substantially within states.'4 Pediatrie firearm deaths have been reported to be highest in rural areas.15 This is presumed to be caused by the accessibility of firearms (more firearms in rural areas thereby raising injury rates) and emergency medical services (less emergency medical service in rural areas, resulting in lower survival), but this has not been quantitated.
Sex and age are the strongest demographic risk factors for firearm fatality. As noted earlier, the problem is greatest for teens and young adults. Further, the problem is overwhelmingly one of males and is particularly severe for black males. For example, among the 15- to 19-year-old age group, the black male firearm homicide rate in 1988 was 67.9, compared with 7.1 in black females; among white males, the rate was 6.0, compared with 1.3 in females.11 Among black teen and young adult males, firearm homicide is, very simply, the leading cause of death. Race is almost certainly a proxy for low socioeconomic status in all of these epidemiologie patterns.16"17
The importance of males in the epidemiology of firearm injury is emphasized by recent findings that the presence of firearms in the homes of children and adolescents is correlated with the presence of adult males in the homes.18'19 Figure 2 shows that the strong male predominance is apparent even at the low rates of unintentional firearm injuries seen in the very young.20
Access to Firearms
Many bits of information argue that the most important risk factor involved in all circumstances of firearm death and injury is the accessibility of the firearms themselves.
Firearms are more lethal than the usual alternative: in one study, 60% of gun assaults were fatal, compared with 4% of knife assaults and <1% of blows and kicks.21 As a result, the same circumstances that may lead to violent acts are presumed to be less lethal in the absence of firearms than when firearms are present.
Possible Approaches to Reducing Pediatrie Firearm Injuries*
Firearm homicides generally affect teenagers, who become involved in arguments that escalate into fights. The assualts become homicides when a firearm, usually a handgun, appears. Recent surveys make it clear that teens have an easy time getting firearms. In a Seattle survey, one third of male high school juniors said they could easily obtain a handgun.22 In a national sample of high school students, 20% reported having carried a weapon in the previous 30 days, and 21% of these had carried a gun.23 Growing numbers of children are reported to carry weapons, including firearms, to school24; the available evidence suggests that these weapons often come from home.25 Other likely sources of the weapons include theft from homes and federally licensed firearm dealers (some of whom have been known to distribute firearms to "the street").
The concept that accessibility of firearms is critical to injury occurrence patterns is supported by a recent study of adolescent suicide victims, which demonstrated that suicide was more likely when firearms were present in the home.19 Presumably because adolescents have excellent fine motor skills, it did not seem to matter how the weapons were stored: locked and unloaded weapons as well as unlocked and loaded ones were used in suicides. While other methods appear to substitute for firearms among suicides of older individuals, this does not appear to be true for youthful suicides; it is inferred that youthful suicides are more impulsive and so more dependent on immediate availability of lethal means.26
Unintentional injuries generally occur in the homes of the victims, or of relatives or friends, generally during boyish play.27'28 It is reasonable to assume that such play would not be lethal in the absence of firearms. The weapon involved is usually a handgun, which is the type of weapon most often kept accessible and loaded, because it is in the home as a means of self-protection however illusory29) against feared crime and intruders. A recent survey18 suggests that only a relatively small proportion of the homes of children contain loaded handguns; the attributable risk associated with them must therefore be extremely large.
Whether or not it is the most decisive, the presence of the firearms in the environment is surely the most modifiable risk factor for firearm injury of children and adolescents. Prevention efforts must therefore focus on getting the guns out of the environments of children and adolescents.
In the United States, the vast majority of firearm injuries are caused by handguns, although more long guns are owned. This reflects the portability of handguns and the fact that many are kept or carried for protection, ie, ready to fire. Although in some circumstances, long guns appear to be as dangerous as handguns,19 handguns are the logical focus for efforts to reduce the majority of fatal and life- threatening firearm injuries.
Another logical focus is on weapons that allow many shots to be fired in a very short period of time. In prior centuries, firearms were extremely cumbersome to use. Over time, multiple-fire weapons and prefabricated bullets have facilitated firearm use for many purposes. However, until fairly recently, it was still necessary to reload weapons frequently and to depress the firearm trigger for each firing. Fully automatic firearms, which continue to fire selffeeding ammunition as long as the trigger is held down, have been banned from private ownership in the United States for a number of years. However, semiautomatic weapons, which accommodate moderately large self-feeding bullet supplies and fire each time the trigger is pulled at momentary intervals, are increasingly available, as both rifles and handguns. Much political controversy in the early 1990s has involved "semiautomatic assault rifles," which are favored by urban gangs and have been killing an increasing number of victims over the years. Most recently, semiautomatic pistols have been reported by urban trauma centers to be causing injuries with increasing frequency. Semiautomatic weapons merit particular attention because their operating characteristics allow them to cause exceptional lethality.
Each type of bullet has its own unique type of path through tissue, eg, with more or less tumbling, and these affect the extent of the ultimate injury. By international convention, bullets that can be used in war must be full metal jacketed because this type of bullet construction maximizes the chances that the bullet will exit the victim; therefore, victims who have not suffered fatal injury on impact are likely to be salvageable. Many bullets that are available for civilian use are not of this construction and are marketed to emphasize features that maximize the tissue damage that victims suffer (eg, magnum quantities of gun powder or soft deformable mushroom tips).
An important consideration in prevention planning is that bullets are consumables, so that regulatory or other interventions that impede bullet acquisition or affect bullet design might more quickly affect injury patterns than similar steps involving the firearms themselves.
Because of the high lethality of firearm injuries, primary prevention is the only logical approach. Efforts are warranted to reduce the frequency of violent interactions. Several pilot methods for training children and adolescents in nonviolent conflict resolution are under evaluation. Another approach is to attempt to reduce the lethality of violent interactions that do occur, and also of play and selfdestructive behavior, by reducing the use of firearms. Table 2 lists 17 possible prevention approaches, each of which has some potential to reduce firearm injury.30
The American Academy of Pediatrics (AAP) has reviewed the epidemiology of pediatrie firearm injuries, the prevention options, and the pros and cons of each option.31 Based on this review, it has developed a policy to guide pediatrie efforts to reduce firearm injuries. The guiding goal of the AAP policy is the removal of handguns from private homes, to protect both the children who may live in or visit those homes and the children's adults. The AAP is working with the Center for the Prevention of Handgun Violence in the development of educational materials for parents concerning the risks of handgun ownership and to dispel common fallacies: eg, that handguns protect families, which they do not,29 and that gun control is unconstitutional, which it is not.32 Further, the AAP has approved model state legislation to ban the manufacture, sale, and possession of handguns. This makes the AAP the only medical organization to call for such strong handgun control. (The American Public Health Association also has such a policy. )
The AAP's emphasis on restrictive legislation is based on several considerations. First, there is evidence that legal restraint on handgun access lowers both homicide and suicide rates. 26'33??4 Second, experience with other types of injury control has taught us that education alone does not suffice to optimize prevention strategies.35 Third, the longevity and lethal purpose of handguns will limit the potential for weapon design improvements to have a substantial impact on injury rates. Finally, the interests of children demand that the most effective approach be taken as quickly as possible. The AAP hopes that its emphasis on the needs of children will help to focus the populace on public health - rather than political - issues related to firearms.
Pediatricians can contribute to the public health effort that is needed to reduce pediatrie firearm injury in several ways. Primary care physicians can help families to understand the dangers of handguns in the home and can urge their patients' families to reduce or eliminate that danger. It is particularly important to educate parents of the extreme danger of having a gun in the home when someone in the household is at high risk for firearm use and injury. High-risk individuals include préadolescents and adolescents (especially boys), substance abusers, and those who are impulsive, prone to violent outbursts, or depressed.
Pediatricians can act as political advocates, initiating or supporting legislative efforts at local, state, and national levels. We can also continue to record the details of this latest epidemic, bearing witness to its devastation, clarifying its characteristics, and, perhaps within a generation, documenting its control.
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Possible Approaches to Reducing Pediatrie Firearm Injuries*