November 2023

Issue Brief by Eileen Salinsky

By Eileen Salinsky, Program Advisor, Grantmakers In Health

Firearm injuries are a serious public health problem, killing more than 47,000 Americans each year and becoming the leading cause of death for children and teens in the United States in 2020 (Simon et al. 2022; Goldstick et al. 2022). Given the impact and complexity of this health crisis, Grantmakers In Health (GIH) hosted a first-ever preconference session focused on firearm violence in advance of the June 2023 GIH Annual Conference on Health Philanthropy. Session speakers briefed partners on the causes of gun violence and provided an opportunity for health funders to learn more about potential solutions through a public health lens. This Issue Brief provides highlights of the meeting’s proceedings and previews GIH’s plans to convene a funder learning collaborative on firearm violence prevention to continue the peer learning and sharing that began at the preconference session.

Understanding Firearm Violence in the United States

Following welcoming remarks delivered by GIH’s President and CEO, Dr. Cara V. James, preconference participants heard presentations from a panel of experts conducting research on the nature and causes of firearm violence in the United States, including:

Firearm Injuries: Data to Drive Prevention

The loss of life caused by firearm violence is staggering and requires a public health response. In 2021, an average of 57 lives were lost to firearm homicide and 72 to firearm suicide each day (Simon 2023). Dr. Simon kicked off the speaker panel with a presentation that described the toll firearms have taken on the nation’s public health in terms of morbidity and mortality. Dr. Simon stressed that firearm violence is a public health crisis and described the public health model of prevention which includes: (1) defining and monitoring the problem, (2) identifying risk and protective factors, (3) developing and testing prevention strategies, and (4) assuring widespread adoption of evidence-based solutions. While the criminal justice system has a role in responding to firearm violence, public health approaches are critically needed to advance prevention.

Unfortunately, firearm violence has increased sharply in recent years, and racial disparities are widening. During the COVID-19 pandemic, the firearm homicide rate in the United States reached its highest level since 1994—from 2019 to 2020, the overall firearm homicide rate increased 34.6 percent, from 4.6 to 6.1 per 100,000 persons (Kegler et al. 2022). The largest increases occurred among non-Hispanic Black or African American males aged 10–44 years and non-Hispanic American Indian or Alaska Native (AI/AN) males aged 25–44 years. The firearm homicide rate among Black males aged 10–24 years was 20.6 times as high as the rate among white males of the same age in 2019, and this ratio increased to 21.6 in 2020. The overall firearm suicide rate remained relatively unchanged from 2019 to 2020 (7.9 to 8.1); however, in some populations, including AI/AN males aged 10–44 years, rates did increase. Conditions of poverty are associated with firearm deaths. Counties with the highest poverty levels had firearm homicide rates 4.5 times as high and firearm suicide rates 1.3 times as high as counties with the lowest poverty levels (Kegler et al. 2022).

These tragic trends continued into 2021, with both firearm homicide and suicide rates increasing 8 percent relative to 2020, equating to nearly 9,000 more lives lost in 2021 compared to 2019 (Simon et al. 2022). When analyzed by intent, suicide accounted for the majority of firearm-related deaths in 2021 (53.9 percent), followed by homicide (42.9 percent), unintentional deaths (1.1 percent), legal intervention/police shootings (1.1 percent), and undetermined intent (0.9 percent) (CDC 2023).

While firearm-related deaths garner much public attention, nonfatal firearm injuries are even more prevalent. Assaults account for the majority of nonfatal firearm-related injuries based on data from hospital emergency department visits (78.2 percent), followed by unintentional injuries (17.5 percent), self-harm (3.3 percent), and legal intervention/police shootings (0.8 percent) (HHS 2022). These differences in the distribution of nonfatal firearm injuries by intent relative to fatalities largely reflect the lethality of firearm-related suicides. Approximately 90 percent of firearm suicide attempts end in death, compared to only 4 percent of all suicide attempts not involving a firearm (Conner et al. 2019).

Like firearm-related mortality, rates of nonfatal firearm injuries have also increased sharply in recent years. Relative to 2019, emergency department visits for firearm injuries during 2020, 2021, and 2022 were 37%, 36%, and 20% higher, respectively (Zwald et al. 2023). Even as total rates of emergency department visits plummeted when the COVID-19 pandemic was declared in March 2020 and people avoided exposure to health care settings, visits for firearm injuries rose sharply.

The Centers for Disease Control and Prevent (CDC) provides a wide variety of resources to support research, surveillance, and interventions to prevent firearm violence. Dr. Simon highlighted several of these resources, such as the Advancing Violence Epidemiology in Real-Time (AVERT) initiative, which provided funding to 12 state health departments as part of a competitively funded effort to obtain surveillance data in near-real time on emergency department visits for nonfatal firearm injuries and Resources for Action to help states and communities take advantage of the best available evidence to prevent violence and suicide. These strategies include interventions for helping those at greatest risk, addressing locations associated with the highest risk, and addressing the underlying conditions that contribute to risk and disparities.

Dr. Simon concluded his presentation by stressing the existing firearm violence prevention research gaps. He described the types of questions being addressed with CDC’s research funding, including research focused on understanding the modifiable risk and protective factors and the most effective prevention strategies for the populations and settings at greatest risk.

Structural and Societal Determinants of Health and Firearm Violence

The social determinants of health—the conditions in which people live, work, play, and access care—have a highly influential impact on health outcomes, including firearm death and injuries, quality of life, and health inequities. Dr. Buggs began her presentation by reviewing the World Health Organization’s definition of violence and the Social Determinants of Health and Health Equity Framework. Her description illustrated how this definition of violence includes actions that lead to group-level deprivation and highlighted how the conditions of people’s lives are mediated by structural and societal determinants of health inequities. Socioeconomic and political context related to governance, macroeconomic policies, social policies, public policies, culture, and societal values have a profound influence on people’s socio-economic position. This position (defined by social class, gender, ethnicity, racism, education, occupation, and income) largely dictates the material circumstances of people’s lives (i.e., the social determinants of health) and plays a role in shaping behavioral, biological, and psychosocial factors related to health outcomes.

Low-income and marginalized communities face a constellation of health threats that interact to influence both vulnerability to and burden of disease. Dr. Buggs introduced the concept of syndemics: the clustering due to contextual and social factors of multiple and adversely interacting disease states within populations (Lemke et al. 2021). This increased disease burden and vulnerability reinforces macro-level factors, creating a reinforcing loop that perpetuates disparities and inequities. Dr. Buggs emphasized that violence prevention must focus on preventing both inter-personal violence and structural violence (i.e., systems, policies, and practices enacted by those with power to advantage some groups while depriving others of meaningful opportunities for meeting basic needs critical to safety and health) (Buggs et al. 2023).

The large racial disparities observed for firearm death and injuries in the U.S. are a result of historical and contemporary structural violence that negatively affects victims of violence and the broader communities exposed to violent events. Dr. Buggs shared maps of the distribution of shootings in Baltimore, MD and Louisville, KY that show how firearm violence is spatially concentrated in racially segregated neighborhoods. For these highly affected neighborhoods, firearm deaths are just the “tip of the iceberg” for understanding traumatic harm. Firearm assaults outnumber deaths by more than 2:1 (Kaufman et al. 2020). Surviving victims require ongoing care and healing to address the physical, emotional, and psychological effects of firearm violence. In highly impacted communities, large numbers of people who are not directly victims themselves have firsthand exposure to violence, spatially proximate exposure, secondary experiences of firearm violence, and anticipatory concerns about firearm violence. The negative health effects of witnessing or experiencing violence include psychiatric, emotional, behavioral, and physical impairment (Kravitz-Wirtz et al. 2022).

The racial segregation and socioeconomic disadvantage that characterize communities highly impacted by violence is the product of a long and continuing history of structural racism. Dr. Buggs shared maps of Baltimore, Detroit, Oakland, and Sacramento that demonstrate how discriminatory redlining policies from decades ago have left a legacy of racism that continues to influence racial segregation, income, and health disparities in those communities today (Mehranbod et al. 2022).

Racial segregation, income inequality, and firearm violence are highly correlated. Dr. Buggs described research documenting that redlined communities have significantly higher rates of firearm injury and people living in communities with socioeconomic disadvantage have an increased probability of involvement in and exposure to community firearm violence (Schleimer et al. 2022). Insecurities in basic needs such as food, housing, and financial resources at the individual, household, and community levels are independently and jointly associated with the increased risk of violence exposure and involvement. The impact of food insecurity on predictors of violence has been noted even when food insecurity occurred years prior (Slopen et al. 2010). Concentrated disadvantage and needs insecurities may contribute to interpersonal violence by affecting cognitive functioning, stress levels, conflict, and mental health problems. When experienced during childhood, basic needs insecurities and concentrated disadvantage may also serve as risk factors for exposure to violence in the home—an adverse childhood event that increases the risk of future violence exposure and involvement (Buggs et al. 2022).

Firearm violence must be addressed through a racial equity lens. Equity-oriented interventions encompass a broad range of community violence intervention strategies, such as individualized wraparound social services (e.g., housing/financial assistance, legal services, therapeutic services, grief/trauma counseling, substance use disorder treatment, and job training), hospital-based violence intervention programs, community (“street”) outreach, violence interruption and crisis management, and case management and transformational mentoring (Buggs 2022). Place-based interventions include vacant lot remediation, dilapidated building demolition, home façade renovation, increased lighting, tree planting, and investments in low-income housing improvements (Gobaud et al. 2022).

Broader efforts to increase equity and decrease income inequality also reduce firearm violence. State and local-level social spending on social and public health services is associated with decreases in homicides, the earned income tax credit was found to reduce firearm violence, and the low-Income housing tax credit program reduced violent crime (Kim 2019; University of Washington 2021; Freedman and Owens 2011). Increasing women’s economic self-sufficiency has been found to reduce the risk of intimate partner violence. Other equity-driving policies include participatory budgeting, voter enfranchisement, greater support and economic opportunity for formerly incarcerated people, universal basic income, and policies that decriminalize and support individuals experiencing substance misuse, mental illness, and poverty (Buggs et al. 2022).

Dr. Buggs concluded her remarks by stressing the importance of centering the voices and experiences of those most impacted by the problem and increasing the representation of those voices and experiences in research, policymaking, and practice leadership. The people most impacted by firearm violence must be driving efforts to identify, implement, and evaluate solutions.

Trends in Firearm Ownership and Purchasing

The proportion of households and individuals reporting gun ownership has increased in recent years, after years of decline in the 1980s and 1990s and a relatively stable rate in the 2000s. Dr. Crifasi began her presentation by sharing longitudinal trends in gun ownership, both household ownership and personal ownership. In 2021 35.2 percent of households and 24.5 percent of individuals reported gun ownership, reflecting a 13.5 and 19.5 percent increase respectively relative to 2016 (31 percent of households and 20.5 percent of individuals in 2016) (Davern et al. 2023). Comparatively, in 1980, 47.3 percent of households and 28.1 percent of individuals reported gun ownership. Recent personal ownership rates have risen for both males (9.5 percent increase) and females (32.4 percent increase) since 2016 (Davern et al. 2023).

Declines in household gun ownership relative to historical levels are largely due to the decline in people who own guns to hunt. In 1977, 31.6 percent of households included a household member who hunts, compared to 14.1 percent in 2021 (Davern et al. 2023). The belief that guns are necessary for defense has replaced hunting as the dominant reason why people own guns. A Gallup survey conducted in October 2021 found that 88% of gun owners counted protection against crime as a reason for owning a gun, while 70% counted target shooting and 56% counted hunting as reasons (Gallup  2023).

The relatively small increase in the percentage of households and individuals reporting gun ownership in recent years obscures the significant increase of firearms in communities, as gun purchases appear to have increased dramatically over the last two decades. Dr. Crifasi shared data from monthly checks reported to the National Instant Criminal Background Check System (NICS) which generally serves as a proxy for gun purchases. These background checks averaged just 1,632,692 per month in 2012, compared to 3,239,723 per month in 2021, with notable spikes in monthly checks throughout the COVID-19 pandemic (FBI 2023). Yearly NICS data indicate that background checks increased 325 percent from 1999 to 2021. Data on firearm manufacturing during this period show that the largest increase in gun production occurred for pistols and rifles, with the production of revolvers, shotguns, and other types of guns remaining relatively stable.

Rates of firearm homicides and suicides are correlated with rates in NICS checks. Dr. Crifasi described how firearm homicides have increased in tandem with NICS checks, with sharp rises in both occurring between 2019 and 2021. During this period, firearm homicides increased 43 percent, while yearly NICS checks increased 37 percent. The relationship between NICS checks and firearm suicides shows a similar, though less highly correlated, trend with an 8 percent increase in suicides during this timeframe.

Rates of firearm deaths vary widely by state, and these variations appear related to both gun ownership and gun safety policy. Dr. Crifasi shared data on firearm mortality (homicides, suicides, and other) in 2021 by state (Davis et al. 2023). She described how states with higher rates of gun ownership and relatively lax gun safety policies related to purchasing and storage requirements (e.g., Mississippi, Louisiana, New Mexico, Alabama) have higher rates of firearm deaths than states with lower rates of gun ownership and stronger gun safety laws (e.g., Massachusetts, Hawaii, New Jersey, New York).

Funder Perspectives on Firearm Violence Prevention

Following presentations from these experts in firearm violence prevention, Dr. James facilitated a panel discussion among four funders who are currently investing in firearm violence prevention. Panelists included:

  • Tracy Costigan, Senior Director, Robert Wood Johnson Foundation,
  • Tim Daly, Program Director, The Joyce Foundation,
  • Scott Moyer, President, Jacob & Valeria Langeloth Foundation, and
  • Jessi LaRose, Director of Strategic Initiatives, Missouri Foundation for Health.

Panelists were asked to respond to the following discussion prompts:

  • Why has your foundation decided to invest in firearm violence prevention? Although their journeys differed, all of the foundations represented on the panel concluded that investments in firearm violence prevention are critical to achieving their respective missions. For the Langeloth Foundation, The Joyce Foundation, and Missouri Foundation for Health, this commitment is explicitly reflected in strategic priorities or initiatives focused on firearm violence prevention. For the Robert Wood Johnson Foundation, significant investments in firearm violence prevention are embedded in the organization’s broader mission of building a Culture of Health rooted in health equity. As Dr. Simon’s presentation clarified, the enormous toll of firearm violence on public health and the racial disparities inherent in these outcomes demand a response from funders seeking to improve health and advance equity.
  • How would you describe the current focus of your organization’s partnerships and investments in firearm violence prevention? While the specific focus of individual foundations varied, collectively the panel highlighted partnerships and investments addressing (1) research to better understand both the nature of firearm violence and the effectiveness of violence prevention interventions and polices, (2) program support to accelerate the adoption of evidence-based community violence interventions and test innovative approaches, (3) power-building to elevate the voice of affected communities, (4) narrative change, and (5) policy change efforts to influence access to firearms, reform criminal justice systems, and encourage public sector investments in community-based prevention efforts, research, and other public safety solutions.
  • Where are there gaps in philanthropic engagement? What should funders new to this space focus on? Given the long history of underinvestment by public and private funders, there are myriad opportunities for philanthropy to fill gaps in the field of firearm violence prevention. Additional investments are needed in research, community-led interventions, power-building, narrative change, policy implementation, and policy advocacy at federal, state, and local levels. Firearm injuries affect all communities, in both urban and rural areas, creating a need for funders of all kinds to engage on the issue.Funders can direct their investments to strategies that best align with their own competencies, funding priorities, and geographic focus.  Firearm violence prevention is highly intersectional with links to many of the issues health funders have already prioritized, including health equity, behavioral health, intimate partner violence, and children’s health. Funders can pursue multiple “on-ramps” to firearm violence prevention that align with and complement existing grantmaking portfolios.
  • What risks have you encountered in advancing this work and how have you managed these risks? Perceived risks related to firearm violence prevention efforts, while often overblown, frequently emphasize the reputational risks of engaging on a “controversial” topic or the operational risks of investing in an unfamiliar area. Firearm violence prevention has been politicized, but adopting an evidence-based, public health orientation helps to minimize divisiveness for philanthropies seeking to engage on this issue. Panelists encouraged other funders to spend time educating their own boards about how firearm violence affects the communities they serve and to consider the broad range of possible intervention strategies in need of investment. Some investments (e.g., policy advocacy) are likely to be viewed as riskier than others (e.g., research), allowing funders to make grantmaking choices that match their own risk tolerance levels. Collaboration with more experienced funders, through informal relationships or formal collaboratives like the Fund for a Safer Future and the Partnership for Safe and Peaceful Communities, was cited as a valuable way to learn about the firearm violence prevention ecosystem and identify high-yield opportunities to advance the work.

    Opportunities for impact do exist. Some funders view firearm violence as an intractable problem, and this misguided belief distorts perceptions of risk. Progress has been made on firearm violence prevention and philanthropic investments have been instrumental to these advances. Research, policy development, advocacy, legal scholarship, and evaluations funded by philanthropy have had a meaningful impact on both policy and practice, such as the adoption or strengthening of Extreme Risk Protection Order laws in 21 states, the passage of the Bipartisan Safer Communities Act, increased funding for proven community violence intervention strategies, and local efforts to build community resiliency in the wake of tragedies.

Participants met in small groups following the panel discussion and shared perspectives, challenges, and information needs from their own grantmaking organizations. Many of the participants were already supporting firearm violence prevention, however a significant number were not active in this work. Some of these funders were considering future investments, while others attended to build their own knowledge. Regardless of current levels of investment, participants said they valued the opportunity to network with their peers and indicated a desire to continue building relationships and engaging in peer learning.

Building on the energy and momentum that emerged from the pre-conference session, GIH is pleased to announce the creation of a Learning Community designed to (1) facilitate a cohort of funders investing in firearm violence prevention to promote shared learning and collaborative problem solving, (2) provide guidance and support to funders new to or considering investments in firearm violence prevention by highlighting effective strategies and offering technical assistance through a network of experienced colleagues, and (3) raise the visibility of firearm violence prevention within the field of health philanthropy and encourage additional investments in related interventions. Funded by The Joyce Foundation, The Kresge Foundation, the Jacob and Valeria Langeloth Foundation, the Missouri Foundation for Health, and the Roots & Wings Foundation, the Learning Community will provide valuable opportunities for collaborative learning. Stay tuned for information on how you can inform and participate in Gun Violence Prevention Learning Community activities!

References

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Buggs, Shani. Community-Based Violence Interruption and Public Safety. Arnold Ventures, July 2022.

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Davern, Michael, Rene Bautista, Jeremy Freese, Pamela Herd, and Stephen L. Morgan. “General Social Survey 1972-2022.” NORC at the University of Chicago, 2023. Data accessed from the GSS Data Explorer website.

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