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Guns do more than kill

Firearm injuries undermine mental, physical, and financial health, even for people who’ve never encountered a bullet.

Gun violence victim Lisa James gathers with friends and relatives of Avent Holston, who was shot and killed at the age of 27, on the second anniversary of his death in Newark, New Jersey, on October 28, 2021. 
Kena Betancur/AFP via Getty Images
Keren Landman, MD is a senior reporter covering public health, emerging infectious diseases, the health workforce, and health justice at Vox. Keren is trained as a physician, researcher, and epidemiologist and has served as a disease detective at the US Centers for Disease Control and Prevention.

In his speech last Thursday about the Robb Elementary School massacre in Uvalde, Texas, President Joe Biden spoke about a young student who’d averted the shooter’s attention by smearing her classmate’s blood on her face.

“Imagine what it would be like for her to walk down the hallway of any school again,” he said. “Imagine what it’s like for children who experience this kind of trauma every day in school, on the streets, in communities all across America.”

We don’t have to imagine that: We have data on what it’s like.

Between 11 and 62 percent of children who witness a mass shooting have post-traumatic stress, according to a 2021 review of the literature. The range is broad because different studies use different assessments for symptoms and study their participants over different time periods, among other variables.) The negative impact of firearm violence on children is so strong that some experts have advocated formally classifying it as an “Adverse Childhood Experience,” a distinction that would denote its proven negative effects on lifelong health.

Although every death causes pain to a circle of loved ones, shooting deaths appear to have a particularly terrible impact on the mental health of the families and communities where they occur.

Most of the research on grief responses following violent deaths (not exclusively limited to gun violence) suggests losing a loved one to violence makes bereavement especially intrusive and difficult. And gun violence seems to have a uniquely detrimental effect on the mental health of young people: In one survey, children in urban and rural areas were at higher risk for post-traumatic symptoms if they saw or heard gun violence — not necessarily in a school setting — even if they were also exposed to other types of harm, like physical abuse, bullying, or being a witness to family violence.

The costs of gun violence go well beyond deaths, and it’s not just witnesses and children who bear these costs. Shootings “have a ripple effect far beyond the person who was actually shot within a community,” said Megan Ranney, an emergency physician and researcher at Brown University’s medical and public schools who has studied firearm violence extensively.

Deaths from gun violence may be what shock us the most — and they should. But as health consequences of gun injuries go, deaths are only the tip of the iceberg.

In the US, the complications go well beyond the immediate loss of life and limb that occurs when bullet meets flesh. Gun violence is a public health nightmare that inflicts lasting damage on physical and mental health. Its devastation casts long shadows over time, intertwining with other determinants of health like education and community deprivation. Firearm injuries and deaths have downstream repercussions on the health of people who weren’t directly exposed to gunshots at all.

Understanding the broader health implications of these injuries could compel us to more urgent action.

“Part of the reason why violence is a public health problem is because of the significant and lasting health consequences for victims,” said Thomas Simon, who directs research priorities at the Centers for Disease Control and Prevention’s division of violence prevention. “The other reason it’s a public health problem is because it’s preventable.”

Waves of grief after gun-related losses contribute to mental and physical illness

Not all firearm violence is the same, and different types — suicides, homicides both intentional and not, mass casualty incidents, and law-enforcement-related — have different causes and different potential solutions. But regardless of its exact circumstance, each death due to firearm injuries has a durable and destructive impact.

When firearms injure or kill a person, hurt and loss radiate outward to affect concentric circles of people around them. Victims’ families and close friends sustain different harms than their communities and society at large — but the pain spreads far and wide in both predictable and surprising ways.

The innermost circle are those killed or injured by firearms. Between 2015 and 2019, more than 76,000 Americans survived gunshot wounds annually. In addition to coping with the long-term functional limitations resulting from their injuries, these survivors are at increased risk of chronic pain, psychiatric disorders, and substance abuse — and their families were also more likely to face challenges to their mental health.

In the next circle are the victim’s loved ones. When victims of gun violence die, grief and its aftereffects ripple outward, with sometimes startling effects on health and well-being.

Everyone who loses a loved one experiences grief, but there’s evidence that losing a loved one to gun violence hits harder. Although most of this research comes from outside the US, it’s still instructive: In the general population, around 2 to 7 percent of the bereaved experience complicated grief — a persistent and pervasive sense of loss accompanied by other emotional problems — as a consequence of a loss. That number is much higher — estimated between 12 and 78 percent — among people mourning loved ones lost to violent deaths (those figures are not limited to gun-related deaths, but gun deaths certainly fall in the “violent” category).

In the US, more than 45,000 people died of gunshot wounds in 2020. Each firearm-related death has the potential to pull this dark veil over the lives of the people it leaves behind.

Grief can impact physical health too. In the weeks and months following the loss of a loved one, grieving people are more likely to suffer from deteriorating physical health or death, much of it due to cardiovascular causes. Grief literally wears on the heart, as one recent, wrenching example showed: Two days after a teacher was killed in the school shooting in Uvalde, Texas, her husband died of a heart attack.

“If you develop very high levels of depression or post-traumatic grief, you’re much more likely to develop Alzheimer’s in later life, for instance, and more likely to pass away at a younger age than would otherwise be expected,” said Ashton Verdery, a Pennsylvania State University sociologist who has studied the health effects of bereavement.

For children, losing a loved one to gun violence leads to educational setbacks and mental health challenges

When children lose a loved one to gun violence, the long-term effects on their lives are often particularly profound. A recent Washington Post analysis estimates that more than 15,000 American children lose a parent to gun violence each year. Each of those children is likely to have lower educational attainment as a consequence of their loss. Education is strongly linked to health outcomes like chronic conditions and disability, so these losses are likely to lead to poorer health.

It’s not just that children’s grief disrupts their ability to focus on schoolwork. Deaths cause financial hardships. A child could lose their primary caretaker and provider, leaving them with an obligation to support their surviving family and choose work over education. Or it might not be a choice: The loss of a parent’s income may create insurmountable financial barriers to attending college, said Verdery.

Again, think of that number: At least 15,000 children lose a parent to guns every year. That’s 15,000 people whose lives — their financial and physical well-being — may be forever set on a different course.

But it’s not just the loss of a parent that can lead to worse outcomes for kids. Losing a sibling also lowers educational attainment for children — especially girls — and makes them less likely to reach adult milestones like establishing an independent residence, getting married, and having children of their own.

Gabriella Uriegas, a soccer teammate of Tess Mata, who died in the mass shooting at Robb Elementary School, cries as her mother, Geneva Uriegas, tries to comfort her as they visit a makeshift memorial outside the Uvalde County Courthouse in Texas on May 26.
Chandan Khanna/AFP via Getty Images

Communities with high rates of firearm injuries also suffer

The ripple effects of gun violence stretch well beyond those who lost loved ones, often affecting entire communities.

People who live, work, or attend school in communities with high rates of gun violence face health challenges of their own, even if they haven’t lost loved ones to firearms. Being exposed to gun violence leads to a variety of mental health issues, including problems with social function, anxiety, and depression. In part because chronic stress exposure impairs immunity and cardiovascular health, the ripple effects of gun violence also threaten physical health.

In Philadelphia, researchers conducted a study looking at reasons local children were coming to emergency rooms, and how close those children lived to sites of neighborhood shootings. They found that the closer children lived to places where people had been shot, the more likely they were to have a mental health concern.

Firearm injuries in schools can also lead to bad outcomes for the school-aged children exposed to it, even if they are not hit by a bullet. A recent analysis by the National Bureau of Economic Research found that exposure to school shootings led to increased absenteeism and reduced graduation rates and college attendance among students in Texas. Given the importance of education as a predictor of health, these outcomes likely contribute to a lower quality of life for young people over the course of their lifetimes.

Some of those effects hold even for students not directly exposed to school shootings, said Simon, the CDC researcher.

Before a pair of students killed 12 students, a teacher, and themselves at Columbine High School in 1999, about 4 percent of high school students nationwide said they had missed one day of school in the past month because they felt too unsafe to go, said Simon. “After Columbine — and this is nationwide — 10.2 percent,” he said, “and we’ve seen that percentage stay pretty high since then.” The latest pre-pandemic number was at 9 percent, he said.

In another study, adolescents in Los Angeles who expressed concern about school shootings — 40 percent of those surveyed — were more likely to later show signs of anxiety and panic or other mental health disorders.

Communities with high numbers of firearm injuries or deaths tend to have higher rates of anxiety and depression, said Ranney, the emergency physician and researcher.

“And then there’s this larger societal effect of a firearm injury,” she said. “There are also very real economic consequences for the larger society, whether it’s health care costs, lost work, or criminal justice costs.”

In 2018, the National Institute for Criminal Justice Reform tried to estimate the total cost per shooting to six American cities. In their calculations, the reports’ authors included expenses ranging from the cost of crime scene cleanup to the money spent on the law enforcement response; from the health care, legal, and incarceration fees to the revenue lost by taking both suspects and murder victims out of the general public. On the low end, a shooting leading to an injury in Mobile, Alabama cost the city an estimated $583,000. On the high end, Stockton, California was projected to lose as much as $2.5 million for each shooting homicide.

That’s money a city can’t spend on programs that improve the lives and health of its citizens. The City of Philadelphia’s controller’s office found that a single homicide reduced sale prices by 2.3 percent for homes within three-quarters of a mile (the vast majority of the city’s murders involve a firearm). The report estimated that lowering homicides by 10 percent for one year would increase the city’s property tax revenue by $13 million — several times the annual budget of many community health centers or food programs.

Identifying solutions requires acknowledging inequities in firearm injuries

The burden of all of these health effects is not borne equally by all Americans. Black Americans die from firearm injuries at rates higher than any other group, and nearly three times as high as white Americans. That means the grief, loss, and disadvantage following gun-related deaths fall disproportionately on Black families; the mental health symptoms that persist in communities after shootings affect Black communities more; the neighborhood divestment that’s both a cause and an effect of gun violence drains human and financial capital largely from Black neighborhoods.

That means there’s enormous potential for gun violence reductions to have far-reaching positive effects — beyond even saving lives — for the American communities that have long faced its worst inequities. Restorative violence-prevention programs rooted in Black communities’ strengths — and paired with reinvestment in depleted communities — hold promise for meaningfully reducing community shootings and improving educational and employment opportunities for residents. Over time, reducing gun violence in depleted neighborhoods could lead to reinvestment and renewal.

Programs to reduce school shootings by assessing students’ behavioral threats and intervening early are rare, but effective. Used more widely, they could broadly improve youth connectedness and mental health just by asking students to notice when their classmates are suffering.

Again, the public health crisis of gun violence stretches so much farther than school shootings, or mass shootings.

“Here in the US, we don’t really have one gun violence problem, we have at least four,” tweeted Thomas Abt, an expert and author on violent crime, which includes suicides, mass shootings, and domestic and community gun violence. Each requires different solutions, he wrote, but they all have one thing in common: They all depend on the easy accessibility of firearms.

That one area of convergence means that broadly reducing gun availability could have a big impact on both gun deaths and the long shadows they cast. While the impact of every gun-related death may reach far and wide, so can the impact of prevention.

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