What would society be willing to pay to eliminate this $3.1 billion a year medical cost?  It turns out that two of the authors of that JAMA article tried to estimate it in a previous article in the Harvard Health Policy Review, which I wasn’t aware of when I made my previous posting.  According to their article, Duke professor Peter J. Cook and University of Chicago Professor Jens Ludwig believe the number was perhaps as high as $100 billion in 1998 (or $125 billion in my back-of-the-envelope estimate of 2008 dollars).² Here’s there logic:  in a 1998 study conducted by the National Opinion Research Center, the thousand US households surveyed were, on average, willing to spend an additional $239 dollars each to reduce gun violence by 30% in their state.  Do a little math using 2008 dollars³ and 2008 households⁴ and get:

$34 billion.  How do we get to $120 billion?  The above calculation reflects what the US households would be individually willing to pay to reduce gun violence by 30%.  Assuming a linear increase in willingness to pay to reduce by 100%, the Cook and Ludwig suggest the tab looks like this:

(In fairness, I have some concerns about this extrapolation.  Saying I am willing to spend $239—or $303 in today’s dollars—to reduce gun violence by 30% does not necessarily mean I’m willing to spend $1,010 to eliminate it completely.  And certainly, as the authors point out, there may be some real costs to eliminating gun violence by 100% that a linear extrapolation will not account for, even if I were willing to pay for it.  Nevertheless, if the precise figure is wrong, surely the scale is not.)

Add to this $113 billion the roughly $10-20 billion annually in costs attendant to suicides and gun-related accidents and you land somewhere between $123 billion and $133 billion—call it $125 billion in nice round figures.  That’s a big number no matter how you look at it:  it roughly equals the combined annual budgets for the US Department of Health and Human Services and the US Department of Education, or somewhat more surprisingly, the combined annual budgets of the US Department of Homeland Security, Department of Energy, Department of Justice, Department of Agriculture, Department of Transportation, and NASA.⁵  (By the way, think this is an abstract comparison?  Perhaps, but remember:  we pay for all of these government agencies, so we already perceive their value, just as we perceive a value in reducing gun violence.)

If all this talk of big numbers is giving you a headache, the good news is there are simpler and more cost-effective solutions than seeking the American peoples’ collective budgetary allocation for half again as many federal agencies as they’re already funding.  Take a look at simple and effective programs like Speak Up! and Ask!, both run by my friends at PAX, which seek to eliminate school gun violence by encouraging kids to speak up if they know of something which might happen (in the case of Speak Up!) and encourage parents to ask if the houses at which their children are playing contain guns (in the case of Ask!).  These are fabulously cost-effective programs, and their results (here and here) are speak for themselves.

1. Philip J. Cook; Bruce A. Lawrence; Jens Ludwig; Ted R. Miller The Medical Costs of Gunshot Injuries in the United States JAMA. 1999;282(5):447-454.
2. Philip J. Cook; Jens Ludwig; The Costs and Benefits of Reducing Gun Violence Harvard Health Policy Review. 2001; Vol 2, No. 2.
3. http://www.westegg.com/inflation/infl.cgi
4. Day, Jennifer Cheeseman, Projections of the Number of Households and Families in the United States: 1995 to 2010, U.S. Bureau of the Census, Current Population Reports, P25-1129, U.S. Government Printing Office, Washington, DC, 1996
5. http://en.wikipedia.org/wiki/United_States_federal_budget

According to this study, lifetime medical costs alone of gunshot injuries range as high as $79,927 per incident (New York State lifetime medical cost for treating self-inflicted non-fatal injuries). That’s in 1994 dollars. Adjusting for inflation, that number would be $113,348. But adjusting for the increase in medical care costs over the past 14 years, that number would now be a shocking $160,448. Other costs are not quite so high, but nevertheless disturbing: the average lifetime medical cost in New York State for all types of gun injury (again in 1994 dollars) was $34,420 (that’s $47,448 in today’s dollars, or $69,096 at today’s medical costs).

In the study year, there were some 134, 445 gunfire-related injuries in the US. (By my calculation, that’s approximately five injuries per 10,000 US residents.) The authors estimate that these injuries cost some $2.3 billion per year in 1994 (that would be $3.2 billion in today’s dollars, or $4.6 billion at today’s healthcare costs). And that’s just the medical costs. Investigation, prosecution, incarceration: all of these costs are separate and no doubt substantive.

But wait, you say. Crime rates are down since their peak in the mid-’90s. Surely we are spending less now than we used to be, right? Although I want to go find more recent data, I contend, in the absence of that data, that we are spending as much or more annually now than we were then. Why? Other data, in this case from the FBI, indicates that although the homicide rate has stayed fairly stable since 2000, the rate of homicide by gun or explosive weapon has increased dramatically:

Oh, and one last thought. Think this is all somebody else’s problem? I mean, after all, it’s not like you are paying for this medical care, right? Wrong. 49% of these costs are born by the government (read: your tax dollars), and another 18% are paid by private insurance (read: higher insurance premiums). Directly or indirectly, you are footing the bill for 67% of the medical costs of gun violence. That’s $3.1 billion of your money we spend per year.

The critical development: whatever might have happened was averted because somebody tipped off police. Of course, it’s often difficult to prove a negative (but not impossible!). Nevertheless, the facts so far made public in this case are compelling enough for me to draw the conclusion that the arrest averted a potential tragedy.

Media Credit: Vanessa Sanchez / Daily Lobo

For every community which organizations like Speak Up! serve there are numerous others in which the threat of student gun violence remains unaddressed. But the promise is tremendous: in 80% of all school violence, someone other than the perpetrators knew about it in advance. Therein lies the opportunity: to save lives by notifying authorities before it’s too late. This time, it worked.

from the CeaseFire website

Thus Kotlowitz’s article about Slutkin’s epidemiological approach to violence struck a chord. In the epidemiology of disease, there is always an “index case“—the first case on record. In violence, there is a precipitating event. And, just like an epidemic, the intensity of transmission amplifies throughout the population: a particularly vociferous antagonist can result in tens of crimes, never mind an asymmetric number of shootings and homicides. Enter CeaseFire, an organization which seeks to interrupt violence at its first, most critical step: what epidemiologists would cause “index case transmission”—when the first victim becomes motivated aggressor.

And, just as public health deals with the results of infection (i.e., sick people who become patients), so the results of unchecked transmission of the disease of violence are higher crime rates, an ever-increasing rate of youth-involved gun violence within the otherwise fixed homicide rate, and an exploding prison population. As my colleague Pascal Levensohn recently summarized, the prison population of the US might as well be its own nation. They are the victims of a disease just as surely as were the nineteenth century’s leper colonies: shunned by society, the very definition of “out of sight, out of mind.”

Fortunately, organizations like CeaseFire and PAX, about which I wrote previously in “A PAX on Gun Violence”, understand that ostracism of those infected with this disease isn’t the answer. Recognizing that the ounce of gun violence prevention created by these worthy organization is worth far more than its proverbial pound of cure (actually, that was Benjamin Franklin), both PAX and CeaseFire appear to understand that nipping violence in the bud requires intervention before the disease spreads.

About a year or so ago, I was lucky enough to meet Dan Gross, the co-founder and CEO of PAX, a New York-based organization which has developed two truly innovative programs which reduce gun violence long before anybody ever fires a weapon. A former advertising executive, Dan found his life changed forever when his brother became the innocent victim of gun violence himself: his younger brother Matthew was critically wounded in the now infamous 1997 shooting on the observation deck of New York’s iconic Empire State Building. Leaving his lucrative advertising career behind, Dan has since become first the leader of PAX and then the creator of two important programs.

One of these programs, Speak Up, addresses the reality that many school shootings are avoidable. According to the US government, over 1,000,000 students take some kind of weapon to school at least once a month. Moreover, over 80% of school attacker tell someone of their plans before they execute them. In other words, in four out of five cases, friends of the perpetrators−often themselves students in the very schools which will later fall victim to gun violence−have heard rumors, threats, innuendo, or otherwise have reason to suspect the perpetrators may turn to guns to settle their grievances. Although it seems obvious that a “hotline,” reminiscent of suicide prevention hotlines, should be created for kids to report such threats anonymously, it turns out not to be quite so simple. There are both legal and procedural complications inherent in accepting anonymous tips regarding minors. Enter Speak Up! Thanks to a 24/7 hotline at 866-Speak-Up and numerous educational and support materials, students now have a safe an anonymous resource on which they can rely. Perhaps equally importantly, PAX has spent the time and money to develop a carefully-calibrated protocol which is endorsed by national law enforcement and educators’ organizations.

The second program, called ASK, encourages parents to ask if the homes which their children visit to play contain firearms. Why? Because a shocking 1.7 million children in the US live in homes with weapons which are both loaded and unlocked. In 2003, nearly eight children and teens were killed by firearms every single day. And in 2004, a horrifying 37 children and teens were injured by firearms every single day. With 40% of children living in households containing firearms, it’s not unreasonable for parents to ask: “Are there any guns where my children are playing?” (As aside: neither I nor, it seems, PAX, have any objection to properly licensed and secured—i.e., locked—firearms. This is not a gun control issue. This is a safety issue.) This year, on June 21st (the first day of summer), communities nationwide will recognize ASK Day, a day to focus on asking a simple question which can save kids’ lives.

If you have a moment, browse over to the PAX website and learn a little bit more. Find out how you can help. Every time these two PAX programs succeeds in reducing an incident of gun violence—even if that eliminates an opportunity for a ShotSpotter-assisted arrest—I, for one, will feel our society has taken a step in the right direction.

Gun violence has become not only the tool of murderers but the tool of intimidators, and thus it is becoming all the more prevalent. One city in which our technology is deployed, for example, suffered 100 murders last year. There were another 300-500 people wounded by gunfire. But in that same city, over that year, we detected more than 3,000 incidents of gunfire. All of this in a city in which it is illegal to fire a weapon outdoors within city limits (unless, of course, one is at a licensed shooting range). It is safe to assume this approximately one-in-ten ratio is not the result of preternaturally poor aim on the part of those shooting the weapons. Nor is it anything to be happy about. As these data indicate, guns are fired illegally just as often for purposes other than to kill someone. So one need not only be concerned about murders and hard-core felons. We also need to worry about the people who fire guns for the sake of intimidation, to “mark territory,” or simply because it’s fun.

The solution to our nation’s gun violence problem does not lie solely in technology such as ShotSpotter. Naturally, as the company’s CEO I am inclined to recommend the technology as a reliable mechanism to reduce gun crime (in fact, ShotSpotter systems have been proven to reduce gunfire and violent crime), but that’s not the point of this posting. The sad reality is that, by the time ShotSpotter finds out about a crime, society as a whole has missed the opportunity to prevent that crime from happening in the first place. Around the office, we can occasionally be heard saying that ShotSpotter can’t help put the bullets back in the gun. Nor can we stop the gun from being fired. But what if somebody could? Therein lies a tremendous opportunity.

The next post in this series: capitalizing on that tremendous opportunity