By Dean Ana V. Diez Roux, MD, PhD, MPH

According to the New York Times, there were 214 mass shootings (defined as 4 or more people shot) in the United States this year alone; 1,500 dead in mass shootings since 2009; at least 15 mass shootings since 2012 in which “authorities said the gunman was able to obtain weapons legally.” These are just a few facts pulled from news stories this past weekend. These facts are no surprise, we have become used to them, and even expect to hear them restated yet again, each time another mass shooting occurs. It is also not surprising to see how these mass shootings often intersect with racism and homophobia: the racist killing of Black people by a white supremacist in a supermarket in Buffalo just this past month, anti-Asian killings in Dallas just a few weeks ago, the anti-Latino immigrant killings in an El Paso shopping center in 2019, the antisemitic killings in a Pittsburgh synagogue in 2018, the shooting of 49 people at a gay nightclub in Orlando in 2016 and so many others. Just a few days ago in the latest horrific shooting, the killing of 19 children and 2 adults at a school in Uvalde Texas, their heartbreaking photos of smiling faces on the front pages of newspapers across the world.

And yet horrible as they are, these killings are only the tip of the iceberg and represent only a very small percentage of the deaths caused by gun violence in the United States every year. In 2020, according to the CDC 45,222 people died from gun-related injuries in the U.S. These deaths include gun murders (43%) and gun suicides (54%). In 2020 nearly 8 in 10 murders involved a gun and this proportion was the highest since at least 1968 when CDC began tracking these numbers. The total gun deaths in 2020 represented a 14% increase from the year before, a 25% increase from five years earlier and a 43% increase from a decade prior. The increase was observed for both gun murders and gun suicides although the percent increase was larger for gun murders than for gun suicides. Reliable estimates of U.S. gun ownership are difficult to obtain but it has been suggested that there may be more than 300 million guns in circulation in the United States resulting in the largest per capita gun ownership rate in the 230 countries studied. In another horrifying twist, gun sales surged during the pandemic.

The gun death rate varies dramatically across U.S. states, ranging from a low of 3.4 deaths per 100,000 in Hawaii to a high of 28.6 per 100,000 in Mississippi in 2020. But differences across countries are even more dramatic. The U.S. was 20^th in gun death rates among 195 countries and by far the highest by much among comparable high income countries (in 2016 the age adjusted firearm death rate per 100,000 people was 10.6 in the United States compared to 2.1, 0.6 and 0.3 in Canada, Spain and the United Kingdom respectively). Many of the countries that ranked high on the list are small countries and therefore the absolute numbers of deaths were not nearly as high as those observed in the United States: among the 195 countries only Brazil had more deaths from gun violence than the U.S. In an even more striking fact, according to the most recent CDC data for 2022 firearms have now become the leading cause of death among young people in the U.S. largely as a result of an increase in firearm homicides. Not surprisingly, and in an illustration of how the interrelated systems of racism, inequality and a commercial system that promotes unfettered access to guns generate health inequities, firearm deaths show dramatic disparities: Black young people aged 0-19 years experienced a 40% increase in firearm deaths between 2019 and 2020 and in 2020 Black adolescent boys (aged 15-19 years) died by firearm homicide at a rate that was 21 times higher than white adolescent boys.

I know, this is no surprise, we have heard and seen these types of statistics so many times before. And yet as I write them, as I look them up to make sure I am being accurate, I am horrified again by what these statistics show. Yes better data, more studies of “gun safety,” more policy analyses can help. But we do not need these things to take action. The descriptive data are obvious and powerful: if we want to stop this the first thing we must do is limit access to guns and take guns off the street. I am not naïve about this. I know that this apparently simple intervention, something that many other countries do or have done has been incredibly difficult in the United States (and some argue may even be impossible) because of the way in which government works in the United States and because of an incredibly powerful gun lobby. But it still remains the right and obvious thing to do. We must also address all the other complex problems in our society that contribute in direct and indirect ways to violent deaths including racism and inequality and the social and economic systems that sustain them. But in the case of gun violence there is one obvious and simple fact: gun deaths cannot occur without guns, guns kill and having a gun facilitates the killing of people. Let’s address that and then move on to everything else too.