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COMMENTARY |
The author is with the Children’s Memorial Research Center and the Departments of Pediatrics and Preventive Medicine, Fein-berg School of Medicine, Northwestern University, Chicago, Ill.
Correspondence: Requests for reprints should be sent to Katherine Kaufer Christoffel, MD, MPH, 2300 Children’s Plaza, Box 157, Chicago, IL 60614 (e-mail: kkauferchristoffel{at}northwestern.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONHOW US FIREARM INJURY...ENDEMIC VERSUS EPIDEMIC...FIREARM INJURIES AS AN...APPLICATIONS BEYOND FIREARM...References |
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There has been a transition in US firearm injuries from an epidemic phase (mid-1980s to early 1990s) to an endemic one (since the mid-1990s). Endemic US firearm injuries merit public health attention because they exact an ongoing toll, may give rise to new epidemic outbreaks, and can foster firearm injuries in other parts of the world.
The endemic period is a good time for the development of ongoing prevention approaches, including assessment and monitoring of local risk factors over time and application of proven measures to reduce these risk factors, development of means to address changing circumstances, and ongoing professional and public education designed to weave firearm injury prevention into the fabric of public health work and everyday life.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONHOW US FIREARM INJURY...ENDEMIC VERSUS EPIDEMIC...FIREARM INJURIES AS AN...APPLICATIONS BEYOND FIREARM...References |
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I propose that there has been such a transition: firearm injury data in the United States has indicated a change from an epidemic phase (from the mid-1980s to the early 1990s) to an endemic one (since the mid- to late 1990s). My aim is not to prove a hypothesis but to begin a discussion about whether such a transition has occurred and its potential significance for efforts to prevent firearm injuries. To that end, I (1) present evidence suggesting that firearm injuries in the United States have passed from an epidemic to an endemic and (2) review what is known about links between endemic and epidemic conditions—including models of endemic disease management—and consider how this information might be applied to firearm injuries. I conclude with a call to open a wide-ranging conversation about endemic conditions.
For the purposes of this discussion, endemic conditions are ones that are always present in an area, and epidemic conditions are ones that are rising and are well above historic levels. Both condition counts and rates are relevant (the former perhaps more for public awareness, the latter for public health reckoning).
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HOW US FIREARM INJURY PATTERNS HAVE CHANGED |
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TOPABSTRACTINTRODUCTIONHOW US FIREARM INJURY...ENDEMIC VERSUS EPIDEMIC...FIREARM INJURIES AS AN...APPLICATIONS BEYOND FIREARM...References |
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, which shows firearm death counts from 1910 to 2002, this stability is in sharp contrast to the rising tolls that were seen in epidemic periods (i.e., the 1920s–1930s, 1960s–1970s, and 1980s–1990s). The peak year of the most recent firearm injury epidemic was 1993, with a record 39595 gun deaths (15.4 per 100000). There was then a more than 25% decline in deaths to 28663 in 2000 (with a 34% fall in rates to 10.2 per 100000). Whereas gun deaths increased after 2000, reaching 30242 (10.5 per 100000) in 2002, the average 1% rise in rates from 1999 to 2002 was less than half the average 2.2% rise from 1987 to 1993; the largest single yearly rise was almost 7%, from 1989 to 1990. The death toll in 2003 was 30136 (10.3 per 100000).3
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shows the available data for the period 2000 to 2004. After 2000, the annual number of medically attended injuries was 58 000–64 000 (20.4–21.9 per 100 000).2 This pattern is consistent with the recent pattern for deaths.
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In the 1990s, when US public health efforts to prevent firearm injuries began in earnest, the situation was different: US gun deaths and injuries had been rising for close to a decade,4 and young people were dying at unprecedented rates.5 Although this was especially true in inner cities, suburban areas were also beginning to feel the lap of the rising tide of injuries.
Prevention strategies were dictated by the understanding that public health and government officials were dealing with an emergency. The factors guiding prevention work were therefore those that were most salient under epidemic conditions: meeting the immediate burden on the health system related to recent and looming deaths and injuries, dealing with the near-term social consequences of this burden (e.g., fear, grief, anger, short-term lost income), and creating opportunities for immediate benefits (even ones that might not be long lasting).
With these priorities in mind, the largest coalition of medical and allied groups working to prevent gun deaths and injuries, the HELP Network (1993–2006), originally named the Handgun Epidemic Lowering Plan, was formed. Prevention work focused on death counts, public and clinical education aimed at immediate change,6–13 experiments with removing guns quickly from communities through buy-back programs,14,15 and policy initiatives designed to bring quick and measurable changes (e.g., reducing rogue gun dealing by stiffening requirements for gun dealer licenses and taking tougher criminal justice approaches to areas with outbreaks of gun crime16–18). These efforts presumably contributed to falling rates of gun ownership,19 more focus on safe gun storage,20–24 and the development of improved approaches to collecting data on gun deaths.25–28
If it is true that firearm injuries have entered an endemic phase, prevention work may need to adapt to this altered situation. Experience with endemic health problems of other types may offer useful information about the differences between endemic and epidemic contexts.
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ENDEMIC VERSUS EPIDEMIC CONDITIONS |
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TOPABSTRACTINTRODUCTIONHOW US FIREARM INJURY...ENDEMIC VERSUS EPIDEMIC...FIREARM INJURIES AS AN...APPLICATIONS BEYOND FIREARM...References |
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First, a disease may be imported from an endemic area into an area where the disease is unknown, resulting in an epidemic. This is illustrated by the iconic introduction of smallpox into native populations in North America.
Second, endemic diseases always pose a risk of "epidemic flare"—that is, a sudden epidemic outbreak of the disease. Such concerns were evident after the 2004 tsunami and 2005 hurricane disasters. The immediate concern of disaster relief organizations is always rescue, followed by the establishment of vital services (food, water, and shelter). Quickly thereafter comes suppression of endemic disease to prevent epidemic outbreaks.
Third, endemic conditions exact an ongoing toll. Over years, total deaths in a region from endemic disease may well exceed those seen during an epidemic outbreak.29 The public health community therefore focuses resources on endemic diseases through immunization and other health promotion efforts intended to maintain low rates and to lower rates over time. Examples of noninfectious endemic conditions addressed in this way in the United States include adolescent pregnancy and injury from motor vehicles.
There is an extensive body of public health literature on the burdens associated with and management of epidemic and endemic conditions, and on the relationships between the two.30–41 The best-developed approaches for handling endemic and epidemic phases in an integrated way relate to influenza.
The US Department of Health and Human Services has an extensive program of influenza surveillance,42 as does the Communicable Disease Surveillance and Response program of the World Health Organization (WHO).43 These programs include designated preparedness phases and phase levels, which are based on objectively defined conditions and warrant specified actions. WHO’s plan recommends that national pandemic planning committees generate and implement control strategies, strengthen surveillance systems, engage scientific and medical experts, ensure the availability of needed supplies, address legal issues that may arise, and ensure effective communications with health professionals and the general public. The planning explicitly takes into account resource allocation based on pressing health needs and long-term, potentially disastrous health problems (e.g., for pandemic flu).44
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FIREARM INJURIES AS AN ENDEMIC CONDITION |
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TOPABSTRACTINTRODUCTIONHOW US FIREARM INJURY...ENDEMIC VERSUS EPIDEMIC...FIREARM INJURIES AS AN...APPLICATIONS BEYOND FIREARM...References |
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To further reduce ongoing firearm deaths and prevent or mitigate the next epidemic outbreak, an approach similar to that used for influenza might be considered. The approach would entail assessment and monitoring of local risk factors over time and the application of proven measures to reduce these factors. The approach would include the development of new means to address changing circumstances and ongoing professional and public education designed to weave firearm injury prevention into the fabric of public health work and everyday lives.
During the current endemic period, a challenging agenda could be undertaken without the visibility and sense of urgency present in an epidemic context. Such an agenda could include the creation of structures to establish firearm injury management phases predetermined and tied to local risk factors and conditions (such as gang violence; many isolated, elderly farmers; and high adolescent drug use), changing incidence rates (fluctuations in shootings per time interval or per population group), and similar activities to foster the creation of prevention planning committees (national, regional, and local). During the peak of the last epidemic outbreak of firearm injuries, those structures and procedures were needed but were not available. The evolving National Violent Death Reporting System58 can facilitate the needed work by providing data at state levels.
Over the next few years, efforts to prevent US firearm injuries might include the following initiatives.
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APPLICATIONS BEYOND FIREARM INJURIES |
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TOPABSTRACTINTRODUCTIONHOW US FIREARM INJURY...ENDEMIC VERSUS EPIDEMIC...FIREARM INJURIES AS AN...APPLICATIONS BEYOND FIREARM...References |
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Footnotes |
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Accepted for publication July 5, 2006.
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References |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
