The Hidden Factor Lowering the Homicide Rate

Improvements in gunshot trauma care have lowered the homicide rate substantially, even as the gunshot injury rate remained constant

A few years ago I read an article about the war in Afghanistan, and improvements made to battlefield treatment of gunshot wounds. Improvements in treatment at battlefield hospitals there led to a substantial decline in death rates relative to prior conflicts. Fast forward to the present, and many of these techniques have made their way to hospitals throughout the country, greatly improving gunshot trauma care. The rash of mass shootings in recent years has actually resulted in less deaths than would be expected – this New York Times article describes in detail improvements in gunshot trauma care. This led me to a larger question – have improvements in trauma care lowered the death rate from gunshot wounds? If so, this could be lowering the US homicide rate by rendering gunshots less effective in killing victims.

I then looked at CDC injury and fatality data – how much have gunshot injuries risen in the US in recent decades, and how has the rise in deaths compared? If there were no change in healthcare quality, one would expect the ratio of gunshot injuries to deaths to remain constant – barring any major societal change in how or why gunshot injuries were occurring. The primary change in the nature of gunshot deaths over the last few decades has been the rise in suicides, which would raise the ratio of deaths to injuries. Improving care for gunshot wounds would reduce the ratio of deaths to injuries, as more injured patients would survive their wounds. [1]

While gunshot injuries rose 85% between 2001 and 2016, fatal gunshot wounds rose only 31%! On a per-capita basis, gunshot injuries have risen much faster than population growth, while gun-related fatalities have remained constant. This finding has a few implications: [2]

  • Progress in healthcare makes it seem like violence in the US has dropped more than it actually has – Americans are being injured by firearms at a higher rate than in 2000, but they simply die less often. Either perpetrators’ marksmanship has declined rapidly, or we have some great surgical advances to thank. 
  • US healthcare has in fact made substantial progress in reducing the death rate associated with firearms, as the survival rate for severe abdominal gunshot wounds has risen from 15% to 77%.
  • While the decline in violent crime from its peak in the early 90’s is real, it has been augmented by improvements in healthcare. With suicide now accounting for two-thirds of firearm deaths, further gains through healthcare will be hard to attain.

 

[1] If the rate of suicide by firearm rose relative to homicide by firearm (as appears to be the case in recent decades), we would actually expect the number of deaths to rise relative to the number of injuries – because most suicide attempts by gun are successful. Despite this trend, we see injuries rising faster than deaths – meaning ER docs and trauma surgeons are making a real difference!

[2] The raw statistics can be looked up on the CDC’s (primitive) website for the years 2001 and 2016: Fatal firearm injuries were 38,658 in 2016 (11.96 per 100,000) and 29,573 in 2001 (10.38 per 100,000), for an increase of 31% over the period. Non-fatal firearm injuries were 116,414 in 2016 (36.03 per 100,000) and 63,012 in 2001 (22.11 per 100,000), for an increase of 85% over the period.

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