1. Nelson, Roxanne


And the surge in violence doesn't show any signs of abating.


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Last year was the deadliest for gun violence in the United States in decades, and the trend appears to be continuing. Gun violence (excluding suicide) accounted for 15,448 deaths and 30,186 injuries in 2019, according to the Gun Violence Archive, which collects and validates reports of gun violence and crime incidents from 7,500 sources daily. In 2020, those numbers rose to 19,411 and 39,492, respectively. As of mid-August, 12,562 people died and 25,155 were injured this year as a result of gun violence.

Figure. Fans rush to... - Click to enlarge in new windowFigure. Fans rush to evacuate Nationals Park in Washington, DC, after three people were shot outside the stadium during the July 17 game between the Washington Nationals and the San Diego Padres. Photo (C) mpi34 / MediaPunch / IPX / AP photos.

"Some of the factors that have been identified are the surge in firearm purchasing, massive unemployment, and isolation," says Garen J. Wintemute, MD, MPH, director of the Violence Prevention Research Program at the University of California, Davis.


More firearms were purchased in 2020 than in any previous year since record keeping began in the late 1990s. A Washington Post analysis of federal data on gun background checks published in January revealed there were about 23 million firearms purchases throughout 2020, a 64% increase over 2019 sales.


The surge in gun violence doesn't show any signs of slowing, with the number of total casualties and the overall number of shootings leading to death or injury in the first five months of 2021 exceeding that of the same period a year earlier.


Yet, according to Kathryn Laughon, PhD, RN, FAAN, an associate professor of nursing at the University of Virginia, perspective is critical. "Violent crime has not gone up, and rates of violent crime are lower than in the 1980s," she says. "This is specifically about violent crime that is related to the use of guns, and what we know is that when there are more guns, there are more shootings." Research on gun violence has been stymied for years, so rigorous long-term data are lacking. "But we do have data that more thoughtful gun laws deter gun homicides," she notes.


Overall, gun violence is up, but it's not evenly dispersed, Wintemute explains, noting that it seems to be concentrated in major cities. He adds that "homicide and hate crime increased much more than other violent crimes." Homicides rose by about 30% in some of the largest U.S. cities in 2020, according to a report from the philanthropy Arnold Ventures early this year.



Researchers from the Violence Prevention Research Program looked at the association between firearm purchases and gun violence and published their findings in Injury Epidemiology in July. Their data show that the purchase of firearms soared during the first five months of the COVID-19 pandemic, along with gun-related violence. From March to July 2020, the researchers estimate there were about 4.3 million more background checks for firearm purchases (a proxy for firearm purchasing) than would have normally occurred-an 85% increase over the expected volume.


The findings also show there was a 27% increase in interpersonal firearm injuries and deaths between April and July 2020. This extrapolates to approximately 4,075 more injuries than would be expected for that time period. Yet, the researchers conclude, "At the state level, the magnitude of the increase in purchasing was not associated with the magnitude of the increase in firearm violence." They did find that the increase in firearm purchases may be a contributing factor in domestic violence gun-related injuries. Earlier work by these researchers, in which they looked at data from March to May 2020 only, found an association between firearm purchases and gun-related violence; but that study did not differentiate between domestic and nondomestic violence injuries.


"There were some similarities and differences between the two analyses," says lead author Julia Schleimer, MPH, a research data analyst at the University of California, Davis. "In both studies, we saw substantial increases in firearm purchasing and firearm violence nationally." Yet, she notes, "In the extended analysis, we did not find an association between excess firearm purchases and nondomestic violence at the state level."


The study period didn't include the period leading up to or following the presidential election in November. "Gun sales have continued unabated, and violence has remained at historic levels," says Schleimer. "However, we have not examined-nor has anyone else to my knowledge-the association between the continued surge in purchasing and violence after July 2020."


In their earlier research, published as a medRxiv preprint in July 2020, the investigators did not find a significant variation in this association in terms of baseline firearm ownership prevalence, socioeconomic status, racial residential segregation, urbanicity, or social distancing. "Our earlier analysis looked at whether the association between purchasing and violence varied by these characteristics, not necessarily whether purchasing itself was associated with these characteristics," Schleimer says. "What we know at this point is that there was considerable variation in the amount of excess purchasing across states. More research is needed to understand what factors drove those differences."


The association between firearm purchasing and domestic firearm violence in April and May 2020 occurred during the peak of physical distancing, the researchers note in their paper. This correlation could also be explained by other factors, including increased substance abuse or reduced access to domestic violence prevention and intervention services during those early months of lockdown. However, the second paper looked at a longer period of time, which included a summer filled with "increases in anxiety, grief, substance use, economic strain, disruptions to daily routines, high-profile instances of police brutality, and a national mobilization against systemic racism, which was accompanied by civil unrest." Each of these factors, alone or in combination, could play a role in firearm violence and thus diminish the role of gun purchasing. The updated study results thus suggest the importance of other contributing factors to firearm violence, say the authors, who emphasize the need for additional research.



Several bills are pending at the federal level, addressing different aspects of gun control. The Bipartisan Background Checks Act of 2021 (HR 8) would establish new background check requirements for firearm transfers between private parties. It passed the House in March and is now in the Senate. Another bill passed in March is the Enhanced Background Checks Act of 2021 (HR 1446). The Sabika Sheikh Firearm Licensing and Registration Act (HR 127) was introduced into Congress in January and would establish a process for the licensing and registration of firearms. It also prohibits the possession of certain ammunition and large capacity ammunition feeding devices. States have also introduced legislation, including Washington State, where several new firearm restrictions have been proposed.


"Fear outweighs all other reasons for purchasing firearms put together," says Wintemute. "There's the fear of being a victim, but also the fear that more restrictive policies might make it harder to buy firearms in the future."


Wintemute notes that more is needed than a focus on guns alone. "Perhaps the best reason for optimism is that we're looking beyond firearms," he said. "Federal and state initiatives, such as in New York and California, are explicitly tackling the social determinants of violence and not relying just on law enforcement or 'gun control' approaches."


In New York State, former governor Andrew Cuomo declared in July that gun violence is a "disaster emergency," the first such announcement in the nation. Cuomo outlined a comprehensive strategy that views gun violence as a public health crisis, one that will be addressed with both short-term and long-term solutions, including community-based intervention and prevention strategies to break the cycle of violence.


Nurses can also play an important role, especially in preventing gun-related injuries. "Asking about firearms in the home should be part of health history," said Laughon. "But nurses can also play a strong role on the policy level, and in lobbying for commonsense gun laws." In May 2018, the American Academy of Nursing (AAN) issued recommendations to help reduce gun violence, calling it a public health crisis. It also published recommendations in response to mass shootings. In a statement the following year, the AAN noted that it stands "ready to be a part of the solution and help shape policy to end this public health crisis. To do this, we must work together to shape policy at the federal level to prevent these needless tragedies from occurring."-Roxanne Nelson