In part one of a two-part series from the 2018 meeting of the American Public Health Association, PLOS Medicine Chief Editor Larry Peiperl discusses new evidence presented on racial disparities in firearm deaths in the United States
“Health Equity Now” is the theme of the 2018 meeting of the American Public Health Association. Areas of health disparity among subgroups include pregnancy outcomes, child health, rates of obesity, diabetes, infectious and non-communicable diseases, opioid overdose, and a dismayingly broad range of other conditions. In an opening address, US Surgeon General Jerome Adams noted that, as health disparities continue to widen, health equity is not attained just by providing individuals with what they need to succeed, but by establishing communities that foster health (session 2021).
Gun violence is a stark example of disparity at the community level, as evidenced by earlier data that was summarized in conference presentations. More than 300 people per day were shot in the US—about one-third of them fatally—during 2016, and children age 5-14 years in the US are more than 14 times more likely to die from firearms than children in other high-income countries. (D Hemenway, session 3016). Black people comprise 14% of the US population, but account for 59% of gun homicide victims (M Siegel, session 3161); the nationwide risk of dying from gun homicide is about 9 times higher for blacks than whites. This disparity is not only racial but also geographic in nature: a black individual living in Wisconsin has a 22-fold higher risk of being fatally shot compared to a white person (A Knopov, session 3161). Among black individuals age 15-34, handgun-related homicide is the leading cause of death.  Black people, armed or unarmed, are 3-4 times more likely than white people to be killed by police in the US. (A Mesic, session 3161).
A public health approach can be defined as making it easier for people to stay healthy and more difficult for them to get sick, and population-based actions to address root causes are generally more effective than interventions directed at specific individuals (D Hemenway, session 3016). In a series of oral presentations on laws to address firearm violence [Session 3161], three researchers from Boston University reported on new research on racial disparities in firearm deaths, with the aim of guiding upstream policy interventions.
- Michael Siegel presented a study of state firearm laws from 1991-2016 to explore whether different kinds of laws might have different effects on homicide rates on black populations compared to whites. The study found that laws regulating firearm purchases and possession (such as universal background checks and restrictions on concealed carry of firearms) were associated with lower homicide rates among both white and black populations, but that laws to remove guns from high-risk domestic violence situations and from individuals with a history of violent misdemeanors may have a greater impact among blacks. (He hypothesized that the latter finding may reflect inequitable conviction practices that affect black populations more than whites.)Siegel noted, however, that causality could not be inferred from the study design, in part because states with higher baseline homicide rates may be less likely to pass firearm laws. A similar theme recurred in other sessions: distinguishing between an effect of gun laws versus gun availability is difficult when states with stronger gun laws also have fewer guns. (D. Hemenway, session 4235) Further, the benefit of laws requiring background checks will depend on how effectively they can be enforced. A study by Jennifer Hernandez-Meier of the Medical College of Wisconsin (session 2065) found that around 40% of Wisconsin homicide suspects (and more than 30% of homicide victims) would have been legally prohibited from possessing firearms.
- Anita Knopov presented an analysis of the relationship between residential racial segregation and differences in firearm homicide disparities between racial groups across the US, using CDC data on race-specific homicide rates by state (1991-2015) together with census data on local racial dissimilarity. The analysis found that locations with more segregation showed even greater excess risk of homicide victimization of black people compared to white people, suggesting that firearm homicide is among the many adverse health outcomes in the US that are linked to structural racism.
- Aldina Mesic presented a cross-sectional study of racial disparities in police shootings of unarmed individuals. State-specific data on police shootings from the Mapping Police Violence Project were averaged over 2013-2017, and a 5-component index of structural racism (including residential segregation, incarceration rate, educational attainment, economic indicators, and employment indicators) was averaged at the state level over 2013-2015. After controlling for a variety of potentially confounding factors, including the black adult arrest rate, the study found structural racism to be a significant predictor of racial disparity in police shootings of unarmed individuals (but not of armed suspects), suggesting that structural racism, not just characteristics of individual police officers and victims, contributes to racial disparities in law-enforcement–related firearm deaths.
While none of these studies can prove causality, taken together they contribute to the evidence that entrenched racial dissimilarities (structural racism) contribute to disparities in firearm homicides, and that legal and policy solutions that fail to address these dissimilarities may inadvertently worsen the disparities.
Approaches to reducing gun violence in general are discussed in Part 2.
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