Americans Don't Really Understand Gun Violence

The massacre in Las Vegas this October earned a macabre superlative: the deadliest mass shooting in U.S. history, with 58 innocents killed and more than 500 injured. The outpouring of attention and support was swift and far-reaching. CNN published portraits of all 58 victims. A man from Chicago made 58 crosses to honor the fallen. Zappos offered to help pay for the 58 funerals. An anonymous man even paid for 58 strangers’ dinners in memory of those who died.

But what about the hundreds who were shot but didn’t die? A 28-year-old woman who was shot in the head at the concert is undergoing aggressive rehab after spending nearly two months in the hospital. A 41-year-old man is learning how to drive with his hands after he was paralyzed from the waist down. And many victims have relied on money raised through GoFundMe to support their medical care.

The hardships facing those gravely injured in Las Vegas represent a horrific microcosm of gun violence in America generally—horrible deaths provoke widespread reaction, while the wounds of many multiples more take their toll largely unnoticed, unnumbered, and unstudied.

Fatal gun violence is often categorized in ways that make it easy to track and study. That’s how researchers know that the murder rate in the United States has declined steadily over the past three decades. But what about gun violence that does not result in death? That is far trickier to measure. That’s because nonfatal gun violence has mostly been ignored.

As a result, policy makers, law-enforcement officials, public-health experts, urban planners, and economists are all basing their work on information that is unproven or incomplete. Without more data—without identifying who commits shootings, where, how, and against whom; without plotting their rise and fall, to correlate with potential contributing factors; without analyzing those questions on a national, regional, local, neighborhood, and individual basis—it’s impossible to tell which public policies and interventions could be most effective at reducing gun violence.

At least one recent study, published in the American Journal of Epidemiology, suggests nonfatal shootings have actually risen since the early 2000s. Based on what data does exist, they appear to constitute, by far, the largest portion of the country’s gun violence: Six out of every seven people who suffer a gunshot wound survive (excluding suicide attempts). Most of these injuries aren’t the result of mass-casualty events like the wrenching violence in Las Vegas or last month’s church massacre in Sutherland Springs, Texas; instead, they are the product of equally tragic incidents largely hidden from view.

“This country has a real challenge—an epidemic of firearm injury,” said Sandro Galea, the dean of the Boston University School of Public Health. He co-authored the Journal study with a team led by Bindu Kalesan, the director of the Center for Clinical Translational Epidemiology and Comparative Effectiveness Research at Boston University. “There’s a gulf of understanding on this issue,” Galea said.

Richard Aborn, the president of the Citizens Crime Commission of New York City, agreed. “Nobody’s ever focused on this,” he said. “That impedes us from understanding the gun-violence problem—and other, related activity.”

Largely ignoring nonfatal shootings means that Americans are both vastly underestimating and misunderstanding gun violence. Underestimating, because researchers are only barely beginning to measure the personal, familial, local, and societal costs of what Kalesan and others estimate are more than a million shooting survivors living in the United States; and misunderstanding, because nonfatal shootings can be quite different from those that result in death.

The dearth of research makes it near impossible to fully illustrate the realities of gun violence to the broader public. As of now, for example, nobody really knows how often people are shot by their intimate partners, how many victims are intended targets or bystanders, how many shootings are in self-defense, how such incidents affect community investment and property values, or how much it costs taxpayers to care for victims. In order to come up with their estimate of a million shooting survivors, Kalesan and her colleagues had to rely on imperfect data from hospital emergency-room reports.

As a result, survivors of gun violence are largely invisible, even to the people who work closely on the issue—including policy makers, academics, and medical professionals. According to Thomas Weiser, an associate professor of surgery at Stanford University Medical Center, Americans unwittingly turn a blind eye to gunshot victims’ medical needs, economic hardships, capacity for work, and ability to socially integrate. “We know very little about [gunshot]-trauma patients after they leave the hospital,” Weiser said.

Weiser warned Sarabeth Spitzer, a third-year medical student at Stanford University, that nonfatal gunshot injuries might be a bad research topic. Weiser told her that a combination of poor foresight, neglect, and a deliberate choking-off of funds had left the field with virtually no data and no analysis to work from. Plus, as with all gun-related matters, it’s a minefield of controversy, which can severely limit access to grants and other funding.

But Spitzer, a child of post-Columbine America, said the topic seemed a natural fit to her: For one thing, she intends to become a trauma surgeon. So she lobbied the university to help. Lucky for her, Stanford was willing to pay for a detailed national database of hospital care and payment data, which is why researchers now know, from a paper Weiser and Spitzer published in April, a great deal more about the costs of hospitalization for gunshot victims. “We took a straightforward question—of cost data and insurance—that remarkably didn’t have an answer,” Weiser said. Their study found over $700 million dollars a year just in post-emergency-room hospitalization costs—borne primarily by Medicaid and other government sources, or by victims themselves. Just 21 percent of the gunshot patients had private insurance.

These costs can be filed under what Aborn calls the “closet consequences of nonfatal shootings.” They are not insubstantial. Another paper prepared by Kalesan and her team, which is still under peer review, finds that the hospital readmission rate for gun injuries is higher than for automobile accidents. Other research reveals that victims of nonfatal shootings are quietly carrying enormous physical and psychological burdens. Kalesan has been interviewing gunshot survivors for a study on the long-term effects on both the wounded and their families. One of her subjects, a woman who was shot in the arm during a workplace incident 15 years ago, recently told Kalesan, “I’m still waiting for my old self to come back.” Another man was shot in the head while standing in the street; he has a traumatic brain injury and can speak only three words. His mother cares for him full-time; they live on $650 a month in government benefits.

At the University of Toronto, Jooyoung Lee is working on a similar project, writing a book based on his research tracking shooting victims in Philadelphia. Lee has observed, particularly among those shot by hollow-point bullets, that recurring pain can drive shooting victims to opioid addiction. That, in turn, can push them into dangerous situations and risky behavior as they try to feed their habit, which can lead to more trauma, incarceration, or medical intervention—all of which only compound a single gunshot’s effect on an overburdened health-care and criminal-justice system.

Kareem Nelson, the founder of Wheelchairs Against Guns in New York City, a nonprofit aimed at protecting kids from bullying, gangs, and gun violence, speaks of the tremendous strain on caregivers, most often mothers and grandmothers with limited time and resources. “Families are already struggling” in neighborhoods with gun violence, he said. “So, when a child gets shot, a mother has to go through hoops. It’s really, really hard.” Again, a single gunshot’s effect is compounded, especially when both victim and caretaker are removed from the job force and stripped of their economic productivity. Some initial research is also starting to assess the effects that all shootings—not just homicides—have on neighborhoods, from economic development to property values to the quality of life for those who live there.

“There” means places such as Mosby Court in Richmond, Virginia, and Copeland Street in Boston’s Roxbury neighborhood. From outward appearances, the two seem more different than they really are. Mosby Court is a low, sprawling public-housing development, with wide streets and lines of laundry drying in the afternoon sun. Copeland Street’s aging four-floor-walkup apartment buildings and three-level converted condos squeeze next to one another, casting shadows on foreboding entryways. But they are kindred communities. In early April, each neighborhood suffered the nonfatal shooting of a young black child innocently walking in their neighborhood: a 7-year-old girl in Richmond, a 6-year-old boy in Boston.

“In the summer, we all sit out here enjoying the weather,” said Kieth Miller, who was sitting on the gray steps of his Copeland Street building, the same building where that 6-year-old boy lives. But the stoops and a park on the street were empty on that sunny April weekday afternoon. The shooting had occurred a few days earlier, as the boy walked to the corner store with his father, the intended target. “Nobody wants to be out now,” Miller said.

This is the gun violence Donald Trump bemoaned during his presidential campaign—he framed it, as many Americans do, as a problem exclusive to black communities. African American parents, he said, “have a right to walk down the street of your city without having your child or yourself shot.” But it is a sentiment that runs counter to available data: Kalesan’s study, covering 2001 to 2013, shows nonfatal-assault victimization rates declined among African Americans and increased significantly for whites. The likelihood of a white person getting shot by an assailant and surviving rose 40 percent over those 12 years, while the likelihood for black Americans remained fairly steady; fatal shootings declined slightly for both races over that time.

If they so choose, Trump and Attorney General Jeff Sessions have an opportunity to push forward a major project to close the data gap and potentially inform evidence-based approaches to gun violence: the Panel on Modernizing the Nation’s Crime Statistics. Assembled by the National Academies of Sciences, Engineering, and Medicine, at the request of the Bureau of Justice Statistics and the Federal Bureau of Investigation, the panel issued a book-length report last year on the need to change current crime definitions and classifications. It highlighted nonfatal shootings as a priority. “The nation as a whole lacks reliable measures of shootings,” the authors wrote.

The second part of the report, with specific recommendations, is expected to be published next year. But the research community fears the likelihood of its implementation has declined drastically with the departure of the more supportive Obama administration. Those fears grew when FBI Director James Comey, a key cheerleader for the crime-statistics effort, was fired in May.

Current FBI Director Christopher Wray did not respond to inquiries about the project. Nor did the White House press office. But the researchers I spoke to see the president and his attorney general, Jeff Sessions, as disinterested in numbers-driven approaches to crime and violence. Their fears are grounded in the administration’s hostility to data and evidence-based policymaking on everything from climate change, to the effects of voter-ID laws, to animal welfare. Perhaps the most analogous example is the National Commission on Forensic Science, which was established by the Obama administration to advise the Justice Department on the best use and practices of DNA, ballistics, and other forensic sciences in solving and prosecuting cases. The commission was developing uniform standards for forensic testimony, but Sessions discontinued the body, and its plan for forensic standards, in early April.

“If you had asked me three years ago, I would have been more optimistic,” Janet Lauritsen, a professor at the University of Missouri, St. Louis, and the panel’s chair, said. Now? Well: “You have to have an appreciation for facts and a budget to implement it.”

The roots of the gun-research problem go back nearly 100 years. In 1929, when federal law-enforcement officials unveiled the country’s first standardized method of tracking crimes, they divided assaults into just two categories in the inaugural Uniform Crime Reporting Handbook: simple (usually a misdemeanor) and aggravated (often a felony). Serious urban crime plagued cities, but it was a wholly different time. On the one hand, it was the year of the Saint Valentine’s Day Massacre in Chicago, when gangsters associated with Al Capone killed seven men, five of whom were members of a rival gang; on the other hand, the UCR handbook explained that shooting at or into trains should not count as a violent crime because “they are usually offenses of malicious mischief by children.” Because of the widespread adoption of the UCR’s criteria, police departments to this day fail to report shootings as separate, countable crime statistics; instead, an unknown number of shootings are lumped in with all the other aggravated assaults, like stabbings, pool-cue beatings, or attacks with a bat.

“The shooting data has been problematic from the start, and that’s because of this aggravated-assault category,” Lauritsen said. “That legacy has been around for 90 years.”

Newer reporting systems—gathered through law-enforcement associations, victim surveys, health-care providers, and independent organizations such as the Gun Violence Archive—have all published useful data, but each is operating piecemeal. Taken together, these data collections don’t come close to a complete and direct accounting of gun violence—unlike, say, incidents of cancer, which are rigorously tracked with robust federal funding.

The study Kalesan and her colleagues published earlier this year in the American Journal of Epidemiology concluded that nonfatal gun violence was rising as of 2012. They used data from the National Electronic Injury Surveillance System, a network created by the Centers for Disease Control and Prevention and the Consumer Product Safety Commission that relies on a sampling of hospital emergency-room reports.

However, the study’s findings aren’t infallible. The National Electronic Injury Surveillance System has been criticized as incomplete for how its data is compiled—changing the specific hospitals sampled and not accounting for shooting causes that are reported as “unknown.” A few months after the study’s publication, a rebuttal appeared in the Journal from researchers at Duke University’s Sanford School of Public Policy and the University of California, Davis. After adjusting for purported flaws in the National Electronic Injury Surveillance System, they found that the rate of nonfatal shooting assaults rose for a few years starting in 2003, but then declined to almost exactly where it started.

This much is certain: Nonfatal shooting assaults are a major, persistent public-health problem. And without more thorough data collection on gunshot victims, the information that’s available to the public will be imperfect at best—and deeply flawed at worst.

Without modernized crime statistics, researchers simply cannot answer questions like: Who pulled the gun? Did he or she deliberately fire it? Who, if anyone, was struck? What happened to the victim? The case information collected by hospitals is not typically coded for any connections to the case information collected by law enforcement, so it’s almost impossible to match victims to any arrested perpetrators or seized firearms, which would yield a trove of useful data—criminal histories, relationships between victims and shooters, socioeconomic status, weapon types. Some police departments do carefully track shootings, but most keep that data internal. In New York City, for example, police track nonfatal shootings rigorously, Aborn said, starting from when victims walk into an emergency room with a gunshot wound. “We really like to unpack shootings,” he said. “It’s almost an epidemiology approach: understanding what’s causing the disease. Without that data, it’s very hard to do that kind of analysis.”

But other cities can’t tell you how many people are shot in their own jurisdictions, said David Kennedy, the director of the National Network for Safe Communities at the John Jay College of Criminal Justice. That includes many of the biggest cities in the country. When the Major Cities Chiefs Association routinely surveys its members for violent-crime data, only 40 of its 69 member agencies are usually able to provide the number of nonfatal shootings. And when The Baltimore Sun tried last year to compare lethality rates for shootings, it found that only half of the country’s 30 biggest cities even keep that data.

Researchers and analysts tend to go where the data—and the funding—is. Over the years, that has meant looking at homicides, not at nonfatal shootings—because murders are sufficiently rare and well documented to provide reasonably comprehensive information. That gap widened after Congress passed the Dickey Amendment in 1996, which, along with accompanying budget cuts to the CDC, effectively took the federal government out of the business of funding gun research. Though it was ostensibly designed to prevent federal backing of biased anti-gun propaganda, the National Rifle Association-backed law has had a huge chilling effect: Since, academics found themselves with little hope of attracting funding, many of them steered clear of gun-violence research.

Former President Barack Obama tried, with limited success, to reverse this course. He directed the CDC to resume financing the small amount of gun-related research that is allowable under the Dickey language, but little has happened. The money has mostly gone to maintaining the CDC’s database on fatalities.

Nongovernmental research funding has made up some of the difference—but it tends to go to policy-oriented work in line with the funder’s mission or to splashier topics like mass shootings.

Perhaps it’s not surprising then, given the barriers, that those few who do specialize in researching nonfatal shootings tend to be disproportionately passionate about the topic—which often translates into personal support for stricter gun-control measures. That makes them easy targets for gun-rights groups looking to attack them for bias. This past December, Doctors for Responsible Gun Control called for Kalesan to be fired, citing her social-media posts as evidence of anti-gun animus. Her co-author, Galea, was placed on a “watch list” of professors with a “radical agenda” for his gun-violence op-eds in The Boston Globe. Kalesan and Galea say they don’t have any financial conflicts of interests to disclose when they publish on gun control.

Indeed, gun-control groups aren’t in the habit of funding research on a significant scale. Though they’ve tried to close some of the data gap—the nonprofit Gun Violence Archive, for example, now catalogues shooting victims through media and law-enforcement reports—they don’t have industry-sized piles of money to toss around. With limited resources, most organizations concentrate on lobbying for and against legislation rather than on funding research to undergird their arguments.

Significant drives for federal gun-control legislation tend to come after widely publicized tragedies like the Pulse nightclub, Sandy Hook, and Gabby Giffords shootings. Indeed, Democrats resurrected their gun-control push immediately after Las Vegas and again after Sutherland Springs. To be sure, it may be politically savvy to push for reform when the nation appears to be united against gun violence. But the legislative measures most often put forward are things like assault-weapons bans and the use of terror watch lists for background checks. Those bills may resonate with many Americans, but they have no connection to the vast majority of shootings. Most gun violence is not a mass-media event. It takes place one shot at a time, on city streets and rural properties, with non-assault weapons, usually between people who know each other. A woman shot during the Las Vegas massacre may share similarities with one shot by her partner, but there are too many variables to treat both events as if they were the same—or as if regulation to prevent one kind of violence would likely stop the other.

Most shootings also never result in an arrest, according to FBI assessments, but news-making mass shootings rarely go unsolved. Those perpetrators typically die or get arrested at the scene, or soon after. The hundreds who put bullets in other people every day, however, are far less likely to be apprehended. Unlike homicide cases, there are rarely elite detectives and prosecutors investigating nonfatal shootings, just overtaxed precinct detectives with little authority to commandeer the resources of patrol officers, crime-scene specialists, or testing labs.

Worse, according to many advocates I spoke to, nonfatal shootings are too often viewed as occurring among criminals, drug dealers, and drug users—none of whom summon much sympathy from policy makers or law enforcement. What’s more, state resources to help those victims, including therapy, relocation assistance, and compensation funds, often go only to those who were not involved in the commission of a crime at the time of the shooting, like innocent bystanders. This effectively sends the message that those injured while engaging in a drug deal, carrying an unlicensed weapon, or starting a fistfight don’t deserve help.

That’s a shame, Lee said, because that’s often exactly when both criminals and victims are most in need of the help those services provide. “A lot of times it’s a turning point in their life path,” he said. “By denying them funds, the state is essentially denying people those opportunities.” There is, Lee said, “a perception by police, by politicians, by health-care providers, that they are guilty in their own demise. That has a lot of implications on the care and treatment they can receive afterward.”

Thea James was working in the Boston Medical Center trauma unit on Patriots’ Day in 2013 when Boston Marathon bombing victims arrived. James, the associate chief medical officer and the director of the Violence Intervention Advocacy Program, also had several young men freshly admitted from that weekend’s spate of gun violence. Her staff didn’t blanch when a bombing victim lashed out verbally at a nurse’s innocent cheery greeting. “We understand that is a manifestation of trauma,” James said. “But if one of my [shooting victims] said that, [nurses would] be calling public safety.”

Instead of getting the help and sympathy that other victims of violence receive, black men in urban areas in particular are penalized, James said. When they act out, refuse to cooperate, or clash with people, authority figures yell at them, manhandle them, and further marginalize them. But “that’s not bad behavior—it’s a manifestation of their trauma,” James said.

James’s program is one of more than 30 in a national network that provides help to shooting victims, from mental-health counseling to job-training programs. Most, like hers, are at urban trauma centers that see the bulk of a city’s shooting victims and where population density justifies their existence. Gunshot victims in rural areas rarely get such interventions.

“We grab them while we have them, and we start developing a relationship with them,” she said. “They just have to say yes.” Three-quarters of them do, and accept some post-hospitalization assistance from the program.

Some 175 shooting victims a year end up at Boston Medical Center, the Boston University-affiliated hospital in the city’s downtown, according to James. Almost all shooting victims will suffer some psychological trauma, James said, impairing their ability to navigate a life that, in most cases, was already difficult. It’s worth pausing to consider what this means. Each year in Boston, 200 or so people return home from the hospital after having been shot, adding their trauma to a small number of already troubled neighborhoods. And Boston is a relatively low-violence city.

The national conversation on gun violence often includes mental health—but usually in the context of preventing the next mass-murder, not in ameliorating the daily struggles and stressors that are exacerbated in crowded, impoverished neighborhoods. Joao DePina, for example, believes that his brother, Michael DePina, would be alive if better mental-health interventions were available. Michael was shot to death at age 29 in 2014, in what Joao believes was the end of a back-and-forth set of shootings with a rival. On the surface, it fits into a 20-year narrative of retaliatory gun violence in Boston’s Cape Verdean community. But Joao, a longtime peace activist who is now running for city council, said it had more to do with long-standing mental-health problems stemming from Michael’s difficult childhood in the foster-care system. “He had a lot of anger and animosity,” he said. “He couldn’t control those things.”

Reverend James Wilkins, a pastor in Richmond, understands. “My granddaughter survived but has a brain injury,” Wilkins said. She was 11 when she went outside to ride her scooter five years ago; she took a 40-caliber bullet to the back of the head. Now 17 years old, she doesn’t have the full use of some parts of her body, but she gets good grades and after working her first job earlier this year, she is focusing on her studies.

Wilkins, a former street criminal who did time himself, saw a second tragedy in the man who shot his granddaughter—a 22-year-old just out of prison at the time. “He was in a dark place, crying out, with anger and pain,” he said. “I was one of those. I grew up in a prison household. The only role model you know is a man in jail telling you to hold down until he comes back.”

“That 15-year-old kid who gets a gun and pulls the trigger,” Nelson said, “that’s a person who needs some help.”

The National Network of Hospital-Based Violence Intervention Programs plans to develop a database from member programs like James’s to provide data on interventions and outcomes. If that data proves that James’s program works, perhaps she won’t have to keep scrambling for her $750,000 budget. Over the program’s 10 years, she has seen funding come and go from the city of Boston, a federal Shannon Grant, the Robert Wood Johnson Foundation, the 2009 economic-stimulus fund, the Boston Public Health Commission, the Department of Justice, the Massachusetts state budget, and various private donors.

A little farther south on the gray Boston University School of Medicine campus, Kalesan does her gun research in her spare time, off the clock from her day job running the Center for Clinical Translational Epidemiology and Comparative Effectiveness Research. Her hope of getting funding for her gun-related studies has turned to despair.

“I trained to be a pharmaceutical trialist,” Kalesan said. When she did that work, funders “would hunt us down to give us money.”

Lee is fortunate enough to have a book deal to write up the research he conducted over two years in Philadelphia, when he had a foundation-paid fellowship at the University of Pennsylvania and a small government grant. He has had more luck getting funded for his sociological studies of street rap than for his gun research.

Nevertheless, bit by bit, they and others are contributing to a body of evidence that could help change how the country and its policy makers respond to gun violence. At the current pace, however, that will take many years—and many, many more victims.