American Journal of Public Health | April 2007, Vol 97, No. 4626 | Commentaries | Peer Reviewed | Christoffel
Firearm Injuries: Epidemic Then, Endemic Now
| Katherine Kaufer Christoffel, MD, MPH
There has been a transi-
tion 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 pub-
lic health attention because
they exact an ongoing toll,
may give rise to new epi-
demic outbreaks, and can
foster firearm injuries in
other parts of the world.
The endemic period is a
good time for the develop-
ment of ongoing prevention
approaches, including as-
sessment 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 edu-
cation designed to weave
firearm injury prevention
into the fabric of public
health work and everyday
life. (Am J Public Health.
IN THE UNITED STATES,
firearm injuries are off the front
pages, just a few years after they
were identified as one of the lead-
ing problems facing the nation.1
Within the firearm injury preven-
tion community, discussions about
why have focused on the early-
21st-century US political land-
scape. The factors discussed have
included a shift in the focus of vio-
lence prevention to terrorism
since September 11, 2001, and
opposition by the Republican pres-
idential administration to firearm
regulation. Although these factors
are surely relevant, it is necessary
to consider whether the epidemi-
ology of firearm injuries may have
changed in ways that have pro-
moted the shift in public attention.
I propose that there has been
such a transition: firearm injury
data in the United States has indi-
cated 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 oc-
curred and its potential signifi-
cance 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 epi-
demic to an endemic and (2) re-
view what is known about links
between endemic and epidemic
conditions—including models of
endemic disease management—
and consider how this informa-
tion 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 discus-
sion, 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 condi-
tion counts and rates are relevant
(the former perhaps more for
public awareness, the latter for
public health reckoning).
HOW US FIREARM INJURY
There has been substantial sta-
bility in US firearm deaths since
annually; rate=9.8–10.2 per
100000 population).2As seen in
Figure 1, 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
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
Data on nonfatal firearm in-
juries are much less available
than are data on fatalities.
Figure 2 shows the available
data for the period 2000 to
2004. After 2000, the annual
number of medically attended
injuries was 58000–64000
(20.4–21.9 per 100000).2This
pattern is consistent with the re-
cent pattern for deaths.
These flat trends mean that the
current level of US firearm in-
juries has become routine to the
general population, most of whom
are not victims of gun violence. In
this context, reduced public atten-
tion to firearm injuries is not diffi-
cult to understand.
In the 1990s, when US public
health efforts to prevent firearm
injuries began in earnest, the sit-
uation was different: US gun
deaths and injuries had been ris-
ing for close to a decade,4and
young people were dying at un-
precedented rates.5Although this
was especially true in inner cities,
suburban areas were also begin-
ning to feel the lap of the rising
tide of injuries.
Prevention strategies were dic-
tated by the understanding that
public health and government offi-
cials were dealing with an emer-
gency. The factors guiding preven-
tion work were therefore those
that were most salient under epi-
demic conditions: meeting the im-
mediate burden on the health sys-
tem 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 im-
mediate benefits (even ones that
might not be long lasting).
With these priorities in mind,
the largest coalition of medical
April 2007, Vol 97, No. 4 | American Journal of Public Health Christoffel | Peer Reviewed | Commentaries | 627
FIGURE 2—Nonfatal firearm injuries in the United States from 2000 to 2004.
FIGURE 1—Firearm deaths in the United States from 1910 to 2002.
and allied groups working to pre-
vent 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 clini-
cal education aimed at immedi-
ate change,6–13experiments with
removing guns quickly from
communities through buy-back
programs,1 4,15and policy initia-
tives 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 ap-
proaches to areas with outbreaks
of gun crime16–18). These efforts
presumably contributed to falling
rates of gun ownership,19more
focus on safe gun storage,20–24
and the development of im-
proved 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.
Public health work is charac-
terized by adaptation to ever-
changing conditions—for example,
the changing antibiotic resistance
of pathogens, lifestyle changes
that alter disease and injury pat-
terns, and natural and man-made
disasters. How public health
work adapts depends, in part, on
whether the target condition is in
an epidemic or endemic phase.
The following are 3 salient dan-
gers associated with endemic
First, a disease may be im-
ported from an endemic area into
an area where the disease is un-
known, resulting in an epidemic.
This is illustrated by the iconic in-
troduction of smallpox into native
populations in North America.
Second, endemic diseases al-
ways 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 hurri-
cane disasters. The immediate
concern of disaster relief organi-
zations is always rescue, followed
by the establishment of vital ser-
vices (food, water, and shelter).
Quickly thereafter comes sup-
pression 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.29The public
health community therefore fo-
cuses resources on endemic dis-
eases through immunization
and other health promotion ef-
forts 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 en-
demic conditions, and on the re-
lationships between the two.30–41
The best-developed approaches
for handling endemic and epi-
demic phases in an integrated
way relate to influenza.
The US Department of Health
and Human Services has an ex-
tensive program of influenza sur-
veillance,42as does the Commu-
nicable Disease Surveillance and
Response program of the World
Health Organization (WHO).43
These programs include desig-
nated preparedness phases and
phase levels, which are based on
objectively defined conditions
and warrant specified actions.
WHO’s plan recommends that
national pandemic planning com-
mittees generate and implement
American Journal of Public Health | April 2007, Vol 97, No. 4 628 | Commentaries | Peer Reviewed | Christoffel
control strategies, strengthen sur-
veillance systems, engage scien-
tific and medical experts, ensure
the availability of needed sup-
plies, address legal issues that
may arise, and ensure effective
communications with health pro-
fessionals and the general public.
The planning explicitly takes into
account resource allocation
based on pressing health needs
and long-term, potentially disas-
trous health problems (e.g., for
FIREARM INJURIES AS AN
All 3 of the major risks associ-
ated with endemic conditions
apply to firearm injuries.
• Endemic conditions are mobile.
As the world’s leading gun pro-
ducer and exporter, the United
States needs to consider its role
in preventing the adverse
health consequences of gun in-
jury from spreading. The
spread of gun deaths and in-
juries to countries that have
low rates of both—such as En-
gland (0.3 deaths per 100000
population in 1999) and Japan
(0.1 deaths per 100000 popu-
lation in 1995)—should be
• Endemic conditions can flare up
as epidemics. We have learned
much over the past 20 years
about the factors that promote
gun injury. These include easy
access to guns (especially hand-
guns),46,47the introduction of
new weapon models,48gang
and drug turf wars,49,50domes-
tic violence without escape op-
tions,51,52and depression in ado-
lescents53and elderly men.54,55
It is likely that if several of these
factors again surge, rates of gun
injury will again rise. In addition,
there are probably “unknown”
factors that could drive a rise in
gun injuries (such as the intro-
duction of semiautomatic pistols,
which was a wild card in the last
epidemic outbreak). Develop-
ment of a repertoire to monitor
and respond to known risk fac-
tors is all the more important
given the likelihood of such an
• Endemic conditions cause much
suffering. Gun deaths and in-
juries continue to afflict fami-
lies and communities in the
United States, where there
were 147488 shooting deaths
from 1999 to 2003. The bur-
den is particularly heavy for
families that suffer from de-
pression, communities wracked
by drugs and gangs, and states
and rural areas with high gun
To further reduce ongoing
firearm deaths and prevent or
mitigate the next epidemic out-
break, 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 es-
tablish firearm injury manage-
ment phases predetermined and
tied to local risk factors and con-
ditions (such as gang violence;
many isolated, elderly farmers;
and high adolescent drug use),
changing incidence rates (fluctua-
tions in shootings per time inter-
val or per population group), and
similar activities to foster the cre-
ation 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
System58can facilitate the
needed work by providing data
at state levels.
Over the next few years, ef-
forts to prevent US firearm in-
juries might include the following
• Health departments could
strengthen their monitoring of
deaths and nonfatal injuries to
guide prevention planning and
ensure that an outbreak is
• Health departments could
begin to monitor risk factors
that are likely to contribute to
future epidemic outbreaks of
firearm injuries and to develop
response repertoires for those
factors to prevent outbreaks
• Public health and medicine could
begin to institutionalize firearm
injury prevention methods, in-
cluding initiating processes to act
on changes in injury patterns and
educating health professionals on
how to include gun injury pre-
vention in routine history-taking
and health-promotion counseling.
This would be a change from
epidemic-born prioritization of as-
sessing and reducing immediate
• US injury prevention profes-
sionals could become more in-
volved in international public
health work aimed at reducing
violence from small arms. This
work is led by the International
Action Network on Small
Physicians for Prevention of
Nuclear War (through its
Aiming for Prevention cam-
paign, which addresses small
arms by fostering public educa-
tion, medical education, and
move would be a change from
the exclusively domestic focus
on US public health work re-
lated to firearm injuries.
The notion of addressing pub-
lic health problems in both epi-
demic and endemic phases is ap-
plicable to many conditions, both
infectious (e.g., HIV infection61)
and noninfectious (e.g., motor
vehicle injuries, obesity). Lessons
from influenza control can be
applied broadly. Although they
would not translate directly to
noninfectious conditions, it
would not be hard to adapt them
to firearm injuries.
About the Author
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.
Requests for reprints should be sent to
Katherine Kaufer Christoffel, MD, MPH,
2300 Children’s Plaza, Box 157, Chicago,
IL 60614 (e-mail: kkauferchristoffel@
This commentary was accepted July 5,
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