 Good afternoon. I am David Clark and I am chair of the American Bar Association Standing Committee on Gun Violence. We hope you will find this program today presented in conjunction with the office of the mayor of Philadelphia to be timely and useful. With gun violence continuing to be such a terrible problem in our country, much worse here than in the rest of the developed world, people continue to ask what, if anything, can be done about it. You know, I grew up in a home with guns, hunting from an early age in a rural state and I understand the issues and we must find a way to investigate and discuss the problems that we're having in this country. And that's what we hope to do and to discuss possible solutions. This program is designed to review the problem of gun violence in America from a public health perspective and to consider what can be done about it, taking into account the requirements of the Second Amendment. Certainly, some important considerations are what impact does the Second Amendment have on measures designed to reduce injuries and deaths from guns. Is the Second Amendment a complete bar to all measures to reduce gun violence, as some would say? Or does the Second Amendment, as defined by the court's interpretations, allow reasonable laws and regulations designed to reduce gun violence, even if they affect or limit gun ownership, possession or use? What have the courts, including the Supreme Court, said about this? And what has been done here locally in Pennsylvania and in Philadelphia to combat gun violence and what further can be done? These are some of the things we will examine and we hope to advance the discussion of in the time available this afternoon. And thank you for braving the traffic. I understand there's some things going on in the city that have backed things up quite a bit, and so there will be people trickling in, and we appreciate your efforts to get here today. As the program schedule and the speaker's biographical sketches indicate, we have distinguished speakers, first on public health issues, then on the law, including the Second Amendment, then on what has been done locally, with a panel discussion following each set of speakers. To keep things moving along, we will take questions only in writing. We have handed out cards for your questions. If you need another or some more, let us know and we will hand out some more. We will collect those at the before each of the panel discussions and give them to the moderator. We'll have people at the end. If you pass a question down to the end of your row, either aisle, we will collect them there. With that, I give you Rich Negrin, the managing director and deputy mayor of Philadelphia, and we appreciate your being here today. It turns out that it is a big day in Philadelphia. They have budget hearings, and as I understand it's not just budget hearings. It's a big deal. That's part of the reason I understand for the traffic perhaps downtown, but we have Mr. Negrin. There's a piece on his background outside, and it will be followed by Jim Silkinet, who's president of the American Bar Association, and a partner in the New York law firm of Sullivan and Worcester, and they will give us some introductory remarks. Mr. Negrin. I'm a half of Mayor Nutter in the great city of Philadelphia. First of all, welcome to Philadelphia. What better place to have this conversation than right here in the cradle of liberty, where many of our rights, most of our rights were obviously created. The circumstance that David was talking about is, if there's a state of the union in Philadelphia, today is that day, where the mayor gets to stand up and give his budget address around his priorities for the 2015 fiscal year budget. So you can imagine there are people with all kinds of interest around what's going to be in that budget and what's going on, and they all want to have their say. So we're getting a great deal of protest and different things going on around Philadelphia. There was actually much quieter than it was last year, which was a little spooky. I kind of expected, you know, you build yourself up for these, and the mayor actually gave the speech this morning, just about an hour and a half ago, totally uninterrupted, which was the first time that's happened in a long time. So I was pretty worried about that. I know David's worried about that happening right now during this speech, right? At some point today, there could be some of that activity, and that's what, you know, free speech and what Philadelphia and the city of Brotherly Love is all really about. I want to give Dave a round of applause. Let's congratulate him for what a great program. As we talked about the possibility of bringing this here, obviously to a great place like Philadelphia and the Constitution Center, I could not have imagined such an impressive agenda throughout the day. Some of the best, most talented scholars on this subject are going to be here in Philadelphia, and I'm incredibly, incredibly proud of that. I want to, besides welcoming you generally, I want to talk just briefly, just for two minutes, about two aspects of, because we have so many experts in the room, you guys know more on this issue than I do. I want to talk about two aspects of the gun violence issue that often doesn't get discussed. The first one is the cost of violence, and I want to describe what I mean by that. And maybe it's because today's budget day, and I'm thinking about, you know, a four and a half billion dollar city budget here in Philadelphia. You know, one third of that budget is for public safety. Think about that. One third of four and a half billion dollars here in Philadelphia going to combat violence and public safety. Think about that. And it's not just about that shocking number for me. It's about the opportunity cost that we don't talk about a whole lot. That's the cost of violence that I'm talking about. You know, we're going to have another several police classes because we have to get our police numbers. Every day we're losing 25 to 30 police officers to retirement. Six thousand police officers for a city of this size is way too small. So we're constantly fighting and fighting to keep those numbers up in light of what's happening to our changing workforce. When we look at the investments that we're making on public safety, every dollar spent on public safety is a dollar that we can't spend on our children. Every dollar spent on trying to combat this issue is a dollar we can't spend on poverty, on opportunity, on workforce development. We don't talk about that a lot, right? That's the cost of violence. We've done some great things in Philadelphia and I'm incredibly proud. You know, a new law enforcement strategy, great programs like focus deterrence, Philly Rising Community, you know, really a community neighborhood initiative improving quality of life, taking community policing to a whole new level, winning awards around innovation in terms of what we're doing in our neighborhoods. A 40% reduction in homicides since this administration took office. The lowest numbers around homicides and crime since 1968 here in Philadelphia. And that's all great news. That's all positive. But here's some of the stats that I think are still there that we still have to talk about. In 2013 here in Philadelphia, guns were used in 3,000 robberies, 2,200 aggravated assaults. In 2013 here in Philadelphia, adult shooting victims over 1,000, 1,050 here in Philadelphia. Folks who died as a result of that, 189. In Philadelphia, juvenile shooting victims last year alone, 78, nine of them died. Guess what? We've got some of the best trauma centers in the entire country. There are five critical, highly rated trauma centers in Philadelphia that save lives every single day, better than most cities. Those numbers would be far worse if our doctors weren't experts in saving their lives and treating gunshot wounds. Here in Philadelphia, the US Army sends their doctors to learn how to deal with traumas and violence because of what we've experienced here in Philadelphia. So despite the progress that we've made, there's a lot of work that's left to do. But I want you to think about that cost today as we talk about these issues. It is easy sometimes in an environment as sort of pristine and as beautiful as the Constitution Center to forget the real cost of what we're talking about today. And that's why I want to close briefly with the second phase. The first one obviously is the cost of violence. The second one is really the faces of violence and the faces of our victims that it's easy to forget. We've got mothers in charge here that I know you'll be hearing from Dorothy later. They feel this viscerally in their soul because they've experienced this personally. I want to talk to you about some of our stories in Philadelphia. Just a year and a half ago, a dispute that began on Facebook, something stupid amongst kids, resulted in an adult shooting a carload of children inside of a car, killing two of them, right? That's the gun violence that happens in Philadelphia. Just last year in Logan, a two-year-old girl, I want you to imagine this, at a block party, 200 people present. A dispute arises amongst people who are at the block party. So you know everybody has to know who they are right in the Logan section. That two-year-old girl, Toddler, caught in the crossfire, shot in the abdomen. Not one person came forward, 200 people present. We solve our problems with gun violence still too often, despite our numbers. And that's a huge issue. And those are real stories. That little girl was in the hospital for nearly two and a half months trying to save her life and her organ functions for the rest of her life. And she still has a long, long recovery. A two-year-old girl. I was so outraged as the mayor was as well. There was a big cover of the Daily News where we said, speak up. You know, that is just unfathomable to me that a child will be injured like that as a result with people that you know, know who did it and don't come forward, right? That's part of the conversation here as well. So let's make sure we remember that. I want to close by talking about a 13-year-old boy whose father was murdered by a MAC-10 submachine gun. You know, our officers are outgunned in Philadelphia, right? Since the assault weapons ban has gone away. The MAC-10 that you could buy at a gun show that really has no legitimate sporting purpose. You guys know what gun that is. Really short submachine gun with a long clip. Easily adapted to be made, you know, a machine gun, not just a couple rounds. And someone drove past in a drive-by and shot that 13-year-old's father on a Sunday morning. It was the first time that father was going to see his son play football, Pop Warner. And they never got there because he was shot dead. And that 13-year-old held him in his arms as his father died right there in the street. I was that 13-year-old. That was me many years ago. This issue is real for me. It's personal for me. Guns like that have no place in our society. Think about those issues, think about those victims, think about the cost of violence. And let's have a great discussion. Thank you very much. Most gun owners are responsible and law-abiding. They use their weapons for hunting, like I did growing up in Kansas, for sport for other lawful purposes, protected by the Second Amendment. But as we have learned from mass shootings in Columbine, Aurora, Sandy Hook, and a number of other locations, this is not always the case, and which is why we are gathered here today. We may not be able to prevent every shooting, but I believe we have an obligation to try to do more to stop gun violence in this country. Since the Kennedy Administration, the American Bar Association has promoted policies to reduce gun violence and advance public safety through greater enforcement of existing gun laws and in adoption of reasonable gun regulations as allowed by the Second Amendment. The first ABA policy related to gun violence was adopted in 1965, supported amending federal law and a number of important respects to address interstate sales of firearms through formerly unregulated mail order purchases, including the rifle used by Lee Harvey Oswald to kill President Kennedy. These reforms were later enacted as key provisions of the Gun Control Act of 1968, the principle federal law regarding firearm sales transfers and possession, which those provisions are still operative today. As a national voice of the legal profession, the ABA has been and should be at the table for important conversations that involve our nation's laws. But the ABA should also be at the forefront of discussions about strategies to reduce gun violence across a wide range of disciplines, including many that are going to be represented and discussed here today. Our goal this afternoon is to examine the current state of the law and the undeniable violence we see in our cities. We are proud to include local voices that are less often heard, including voices from the local faith community here in Philadelphia. We hope today's discussion will begin a conversation on ways that we can all come together to reduce gun violence endemic to our communities. Gun violence is a difficult and oftentimes emotionally charged topic, but I hope that we can use this common place as a starting point for a fruitful discussion. Conversations on this issue, like the one we are having today, are very important for the sake of those we have lost through gun violence for those left behind and out of respect for the long tradition of responsible gun ownership in this country. Today's event is one of many discussions the ABA is convening around the country on this set of topics. We hope to engage all perspectives as we move forward towards common sense policies that work to prevent gun violence and protect our second important Second Amendment rights. So thank you for joining us today. I look forward to engaging with all of you in the discussion. Thank you. Thanks to the ABA and to President Silkenit for its leadership on this issue. We're very grateful and thrilled to be here. So it's my job once my first slide appears. There we go. Well, do we go? All right. To provide a brief overview of guns and public health. And so, as David said, I teach at Johns Hopkins and co-direct the Center for Gun Policy and Research. So what do we mean by a public health perspective on gun violence? Well, one thing we mean is to consider all different kinds of deaths from gunfire, homicide, suicide, accidents, and all of the different kind of victims. And Dr. Susan Sorensen will talk about one kind of victim, victims of intimate partner violence, but we consider all different kinds of victims. We focus on prevention, trying to prevent these deaths from happening in the first place rather than primarily on punishing the perpetrators. Not that that's unimportant, but the public health perspective tends to emphasize prevention. We consider the important role of the vector that is the firearm. If this were malaria, we would consider the role of the mosquito or the virus, but here it's the firearm. We design, implement, and evaluate interventions, and we tend to take multiple approaches using many different disciplines. So one of the things that we ask ourselves is, what are the relative risks and benefits of guns? And it's important to acknowledge that guns do have benefits associated with them, not just the recreational benefits that David mentioned, but guns can be protective. They are used in self-defense. How often that happens, the estimates vary a great deal from relatively small numbers to much higher numbers, and there's even more maybe controversy about whether some or even many of those defensive gun uses are in fact socially desirable, or are they undesirable, some high-risk person or criminal defending himself or herself against another person. And we balance those things against the risks, that is the public health burden, and that's primarily what I'm going to be talking about. Another way of flavoring, if you like, that risk-benefit equation is this advertisement from Beretta some years ago, saying that a gun will, in this case, in the home environment, will tip the odds in your favor. If that's accurate, then probably there are some kinds of things that we wouldn't choose to do. If, on the other hand, the data suggests otherwise, as some of our panelists will cover, then maybe there are important things consistent with the Second Amendment that we need to do to reduce the risks associated with guns in the United States. So those guns out there are associated every year. This is the pie chart of gun deaths in 2010 with 31,000 gun deaths in the United States, 31,000. And maybe it surprises at least some of you that the largest share of those deaths in yellow, more than 19,000, are actually suicides. There are still 11,000 homicides, but 19,000 suicides. And that's why Dr. Matt Miller from Harvard will be presenting on that precise part of the problem. So I'll say less about suicides as we go forward. If you, instead of looking just at a one-year snapshot, if you look over time, in this case from 1962 to 2010, you see that we're relatively fortunate, if you want to say that, in that gun deaths over the last few years at least haven't been going up. We've been relatively stable at about 30,000 deaths. It's obviously far too many, and we need to be thinking about ways to reduce that number. But if you look back only a few years, we had almost 40,000 such deaths, 25% more, in 1993. And so it's critically important in addition to trying to reduce those 30,000 deaths and make sure that we don't wind up back in the bad old days of 1993 when we had 40,000 deaths. So it's, again, critical to understand what works and what doesn't to prevent these kinds of deaths and to make sure we don't, God forbid, wind up worse than we are now. Similarly, again, if you look over time at the homicides, the recent peak, again, was in 1993, pushing 20,000 homicides, again, compared to the 11,000 that we have now too many, but certainly we don't want to be back in a world where we have that many homicides, gun-related homicides, every year. Here are the unintentional deaths or what you might more colloquially call the accidental deaths. And there the chart looks very, very different. There we've had massive success over time. Again, we're down to about 600 unintentional or accidental deaths every year, compared with well more than 2,000 if you go back some number of years. For my money, we haven't fully explained that decline. It's an impressive success story. There are a number of possible explanations, but I don't think we've really nailed it down. If you saw this kind of chart for a chronic disease, for an infectious disease, and we didn't know the reason, we can be sure that we would be flooding research centers with funding to try to answer that question. But one of the reasons, again, for my money that we don't have a clear answer is that we haven't devoted the kind of research funding that's proportional to the nature of the problem. So as the saying goes, the deaths are the tip of the iceberg and the non-fatal injuries are important as well for every fatality in 2012. We had about two and a half non-fatal, firearm-related injuries more than 80,000 and then more than 400,000 violent crimes that occur with a gun every year. So how many guns are there? Again, this is my job to give you the sort of big picture background. Our estimate, and I'm sad to say that it's an estimate because we don't, for the most part, register guns in the United States the way we register cars. You can't just count up if you want to know how many guns there are in the U.S. You can't just count up the number of registrations. We have to engage in estimates. And in fact, this estimate of 300 million guns in civilian hands comes from a survey that comes out of the Harvard Injury Control Research Center and Matt Miller's group. Of that 300 million guns, again, maybe it surprises you that the majority of those are long guns. That is hunting guns, rifles and shotguns. Only about 40%, roughly speaking, are handguns and that translates to about a third of U.S. households that have at least one gun in them. That number has been going down over the years and that's something else that we could talk about. Now, despite the fact that handguns are 40% of the U.S. gun stock, if you look at the share of firearm-related homicides, so now we're talking about gun homicides, the share of gun homicides that are committed with a handgun, is approaching 90%. So even though they're not the majority of all guns, they're the vast majority of the homicides with guns and that figure has been very, very stable over time. When we talk about a gun homicide problem in the U.S., we're largely talking about a handgun problem. Now, for other kinds of gun deaths, like suicides and accidents, the picture might be a little bit different. But for homicides, we're largely talking about a handgun problem. We heard the importance of considering the cost of gun violence. Estimates here too vary some. A recent estimate is about $170 or so billion when you add up all of the different costs, not just the medical costs, but the kind of opportunity costs that the former speaker was mentioning. And if you divide that by the number of guns out there, you get around $600 for every gun in the U.S. and the guns that are out there are not carrying that cost. That, as an economist would say, that's an externality that's being pushed onto all of the rest of us. So the reason that, again, I'm so pleased that the ABA has taken such wonderful leadership on this is that law is such an important and effective tool for gun violence prevention. Whether we're talking about legislation, which Julie left which in the next panel we'll talk about, or litigation, which John Lowy in the next panel will talk about, or even regulation, although regulation at the federal level is tough to come by. So let me just give you a quick example from an area that I work on about how law can be an enormously powerful, but unfortunately underutilized, I would argue, tool. And that has to do with the regulation of gun dealers. So it's important to ask yourself, where are the guns that are being used in crime? Where are they coming from? And I think people don't fully appreciate that basically every gun that ultimately winds up in private hands, even the private hands of someone who ultimately uses that gun in crime was first sold by a licensed gun dealer, a federally licensed gun dealer. Really the only exceptions are those guns that were stolen directly from the dealer or stolen directly from the manufacturer. That's the bad news. Further bad news is that, really, we have most gun dealers, most of the 50,000 gun dealers in the U.S. are businessmen who want to follow the law and do follow the law. But we have a small number of gun dealers, the best research, which is not new anymore, but suggests that about 1% of those 50,000 dealers, or around 500 dealers, sell more than half of the guns that are ultimately traced to crime and recovered by the police. So one thing you could do about that is to have better licensing and oversight of gun dealers. Make sure that we focus on those small number of problem gun dealers. I mentioned that gun dealers are federally licensed, but states could license gun dealers as well. So let me ask you all a question. How many U.S. states license the person who cuts your hair, the cosmetologist? Out of 50 U.S., I won't make you, this is not my classroom, I promise, I won't call on you. The answer is all of them. So 50 U.S. states license cosmetologists. How many U.S. states license the person who sells your gun to you? The answer is 18. And why is that important? I mentioned that gun dealers have to be licensed at the federal level. Well, if they're licensed at the state level, we can have a lever to pull at the state level if we engage in adequate oversight and inspection of those dealers to maybe take their license away if they're not doing the right thing. And criminals do get their guns from licensed dealers sometimes, even directly. This is data that was produced at my center with the help of Dr. Kate Vities who's here and Daniel Webster showing that 11% of people who are in prison and who used a gun in their most recent crime, 11% got the gun directly from a licensed dealer. This doesn't even count the people who got it indirectly from a dealer. So, again, what can law ultimately do about this? So research that we've done suggests that if a state does have strong dealer regulation, that is, if it does license gun dealers and engage in some of these other things that you see here, record keeping rules, inspections, in fact, does regular inspections of those gun dealers, that you can have much lower levels of a measure of gun trafficking. That not surprisingly, if you send the message to these dealers that we're looking out to make sure you're following the law, more of them will ultimately follow the law. So, again, that's just one example of many more that will come today of how law can be an enormously potent tool. And again, why it's quite appropriate, I would argue, for the ABA to be part of this. But, of course, as you'll hear from Dean Chemerinsky later on, laws have to be constitutional. It's appropriate in our democracy, of course, for laws to comport with the Constitution. But it also just makes good strategic sense. You certainly do not want to be spending a lot of your political capital advocating for a law that ultimately the courts have to strike down. So no one wants that, the gun violence prevention groups, at least of all. So let me conclude by saying that I hope I've persuaded you, if you weren't already, that guns do pose an unacceptable public health burden, but that we can do something about it. Sometimes there's a sense of hopelessness about this issue. And I hope today's group, although it will talk about the obstacles, will give you a sense of hope that we have had successes and we can have more in the future, especially if we bring multiple disciplines together. Public health, law and medicine, law enforcement is enormously important. Public policy, psychology, sociology. And as long as we're careful to avoid violating protected rights. And I'll finish by saying that a year ago we brought together a group of scholars to produce the book that is on the left there. And just today, actually, hot off the presses, we have an update to that book, chapter writers producing information about what's happened over the past year. And both of these for free are attainable on the Center for Gun Policy and Research's website. So thank you very much. Good afternoon. And being based here in Philadelphia, I'm going to borrow from Mayor Nutter and welcome you to the city of brotherly love and sisterly affection. We're glad to have you here. And that's what I'm going to be talking about today. Love and affection gone horribly wrong. Because when we think of guns, we think of in the street, we think poverty, we think men. And less often do we think about guns in the home and how they're used in the home. And this topic is a bit different as well because it's not just some amorphous individual or stranger, but it's a specific known person who is a risk to another specific known person. In my short time today, I'm going to figure out the slides. In my short time today, I am going to talk to you about a few key points. One is that there are several solid specific policies that are in place. The implementation enforcement of these policies is uneven. And the evaluation of these policies is difficult, but it's promising. Also to tell you why these things are important for women's health and safety and to close with a few suggestions that might provide some room for improvement. You all may have heard of prohibited purchasers and possessors, the 1968 gun control act specified that convicted felons, people who had renounced their citizenship, people who were dishonorably discharged from the military were not allowed to purchase or possess a firearm. In 1994, with the Violence Against Women Act, they added persons who were under certain domestic violence restraining orders. Those restraining orders by federal law were those in which the person who was to be restrained, to be kept back from to protect the other person was somebody who had had the chance to appear at a hearing and defend him or herself. So a judge had said, this person is a specific risk to this person and we're not going to let that person have a gun, which makes sense. In 1996, they then added what was called the Lautenberg Amendment and it added misdemeanors. Felons were already prohibited purchasers and possessors. They added misdemeanors of domestic violence because it's really hard to get an aggravated assault, a felony charge, in a case in which there are intimate partners. Even the injuries are the same as if it's strangers, it's really hard to get an ag assault charge conviction. As of 2008, 13 states had laws that went beyond the federal law, usually by expanding the class of victims to include dating persons and such. Also in 2008, President George W. Bush signed into law the NICS Act. It provides resources to states, not an unfunded federal mandate, to improve the amount and quality of information about domestic violence that is submitted for use in the national instant check system. That has helped. In some ways, purchase is easy because it has to do with people going, getting a gun and acquiring one. Possession, which involves either the person relinquishing a gun or a gun being seized in its removal, is more of a challenge. There's law enforcement resistance to this for a variety of reasons. As of 2004, work that was done by Yann Vernick, our first speaker, 18 U.S. states had laws authorizing police to remove guns when responding to a domestic violence incident. So at the scene. 16 U.S. states had a law allowing courts to order the guns removed when a restraining order was issued. 17 states had both laws, and 26 states had neither law. I'll encourage you to look at the law center to prevent gun violence's website. In 2008, they reported similar numbers, and they just updated their website with this information, or this information on their website, I should say, just a few weeks ago. The laws themselves are not uniform. In Pennsylvania, for example, in 2005, the law that was enacted here authorizes, but it does not require the removal of guns at the scenes. And if so, it's limited to the gun that was used in that incident. A person could have an entire arsenal on the wall, but it's only the gun that was used to threaten or used against the person that could be removed. And then also as of 2008, about 18 states had laws about removing the guns or ammunition at the scene. And some research that we did found that public support for this is really high. In fact, there's much greater support for removing guns at the scene of a domestic violence than there is for arresting the perpetrator in a scene of domestic violence. So, as I mentioned, implementation and evaluation. There are challenges to the evaluation, largely because there's uneven implementation and enforcement. The laws vary from jurisdiction to jurisdiction. And also because, luckily, there's a low base rate of intimate partner homicide. The few evaluations that have been done to date, and there have been just a few, ones by Victor and Mercy, Dugan et al. and Zeolian Webster, they have found modest effects which is a good positive step with things that are this uneven in implementation and enforcement. So some of these policies may have promise. I'll talk more about that towards the end. But why are these things even important and why are they important for women's health and safety? Well, as we can see, good news, like other forms of homicide, intimate partner homicide in the United States is down. It's down substantially in the past 30 years. The risk of homicide is highest in intimate partner homicide when the woman is trying to end the relationship. When she's doing exactly what we tell her to do, which is to leave. So what we do see, and we separate it out by gender, is that intimate partner homicide is dropped radically for men and somewhat less so for women. And men's intimate partner homicide by guns have dropped by over 80%. Their non-gun homicides have dropped by about half. And for women, their intimate partner homicides by guns have dropped by about 40%. So let's take a look at those numbers. I pulled the data from the FBI for the most recent years available. And from 2006 to 2011. As you can see, I'll just walk you through this chart. The bars on the left for each year, because we have 2006, 7, 8, 9, 10, and 11 at the bottom. The bars on the left side under each year are by an intimate and what weapon that person used. On the right are strangers by all lethal means. So you can see on the left side, that red bar is the handguns that have been used. The darker blue bar is long guns, and then the lighter blue bar, there's the ones that are a gun, but it was unspecified what type. And so we've confirmed here, something that was noted first about 25 years ago, that women are about two and a half times as likely to be shot and killed by their husbands or another male intimate, as they are to be shot, stabbed, strangled, bludgeoned to death or killed in any other way by a stranger. And among abused women themselves, because this is just the general population, but if we look at abused women, and who have a chronic history of being abused, even after taking into account a range of victim suspect, abuse and incident characteristics, abused women are over five times more likely to be killed by their abuser if the abuser has access to a gun. So we've been looking at and talking about fatalities. Now let's look at what we in public health call non-fatals. And we'll see that firearms are used to coerce as well as to kill. From a survey that was done in the late 1990s, we found that about three and a half percent of the women in the United States had had a partner threaten them with a gun. And slightly under one percent had a gun used against them by an intimate partner. This is the entire population of the United States. And as public health folks, you might look at these percentages in shrug, but the numbers themselves suggest otherwise. So calculating these out for our 2012 estimates, it's the latest population estimates to do, that means about 4.3 million women, adult women, alive in the United States today, had been threatened with a gun by their intimate partner. And about 850 of the adult women had either been shot or shot at by their husband or someone who they, at least at one time, loved. That's roughly every adult woman in Boston, Denver, New Orleans, who's celebrating Mardi Gras these days, and in Sacramento. So again, these are estimates from a representative sample of community residing adults. Battering an ongoing multifaceted type of violence is different and coercive control is at its core. So I'm going to tell you a little bit about a survey that we did of 417 residents of 67 battered women's shelters. And we found on the left side of these bars is a general population. On the right side are those who were the residents of the shelters. And we can see that guns, both long guns, any gun at all, and handguns are far times, are far more common in the homes of women where there has been battering. So it's almost three times more common, so a weapon is used. And in about two-thirds of the homes with one or more handguns, the partner used the gun against the woman. Over 70% had threatened to shoot or kill the woman, and 5% had actually shot or shot at her. What we also found interesting is that if a firearm had been used against her, there had been many, many different types of weapons used against her, over eight, compared to about four for those who had not had a gun used against them. Which to me, I take that if you beat a woman, if you want to coerce a woman, you don't have to do that if you have a gun. You don't have to beat her. You don't have to use other weapons. The gun and its presence and the threat of its use can get her to do what it is an abuser wants her to do. So just to reiterate the key points that I had, there's several very solid specific policies in place. Implementation and enforcement is uneven, but the challenging evaluations that need to be done have shown promising results. Guns are important to women's safety and health, and there's room for improvement. And with that, I'm going to offer a few closing thoughts. One is we might be able to say a bit more in a few years, because with Obama's executive actions of last January, he ordered the Centers for Disease Control to begin conducting research on gun violence. They had basically stopped doing that for a long time. The Institute of Medicine at the request of the Centers for Disease Control developed a national research agenda and research priorities in record time. Since then, the National Institutes of Health, National Institute of Justice have issued calls for proposal to fund more research in this area. The Centers for Disease Control have yet to act. But perhaps we will have more to say. Also, I think what's important is I've talked about these specific laws that are specific to intimate partner violence, but there are other laws that are important too. For example, when people say, stand your ground laws, what do they think? I think Trayvon Martin in Florida, right? George Zimmerman. There's another Florida case that's not Trayvon Martin, but Marissa Alexander. In 2010, her husband was after her. He was pushing her. He refused to leave. He was threatening her and such. She fired a warning shot into the corner of the room by the ceiling. She was arrested. And in 2012, she was convicted and sentenced to 20 years. And that was for threatening, seeing that shot as a threat to her husband and her two children. September 2013, appeals court threw that out because the jury had been told she had to prove beyond a reasonable doubt that he had abused her. So it sort of shifted what the focus of the trial actually was. Well, on Monday of this week, the Florida State Attorney said that she will retry the case and seek the maximum sentences and will ask that these, if convicted, the sentences be served consecutively, which would be 60 years and essentially give this woman a life sentence. No one was killed. No one was hurt. So we have to talk about how these stand-your-ground laws are being implemented. Another thing we might want to look at is internet sales. Zina Houghton had a restraining order against her husband, but he got a gun online from an online dealer. And those sales are not required to have a background check. He shot and killed her and three others at a spot and then wounded several others and then killed himself. In October 2013, like many other people who have been touched by gun violence, her brother was moved to action and Elvin Daniel presented a petition of 60,000 signatures to Congress. So these are just some of the other things that are now and current that we can also look at and consider and trying to make the world safer and marriage is not as bad for some. Thank you. My name is Matt Miller from the Harvard Injury Control Research Center. It's an honor to stand here before you. One year ago, this past January, at the invitation of my friend, colleague, and co-panelist, John Vernick, I spoke at the Johns Hopkins University in an assembly convened in the wake of the Sandy Hook massacre where Adam Lanza killed 20 little children and eight adults beginning with his mother and ending with himself. Today's conference is animated by the memory of those children and adults as well as by the memory of many others who have died outside of Sandy Hook before and since by gunfire. It's worth making an observation about what was typical and what was atypical about that fateful day in December. That more children and adults died by gunfire in the United States that day than in any other high-income nation is typical. That an assault-type weapon was used to kill them is not. That children died in one place all at the hands of a single person is not typical. What is far more typical is that young men, especially young men of color, are being killed one by one in obscenely disproportionately large numbers here in this country every day. But for our nation as a whole, as has been said, the number of people who die by gunfire every year at their own hands by suicide outnumbers the number of people who are killed by other people with guns by almost two to one. There are almost twice as many people who are dying by gunfire at their own hands as are dying by gunfire at other people's hands. And if what we're thinking about here today is the total of lethal firearm violence, we have to think about suicide as well. In this country there are over 300 million guns in civilian hands. Over half of all suicides are firearm suicides and a third of all homes contain firearms. So we can't really have a conversation about preventing suicide in the United States without having a conversation about household gun ownership. And when we talk about suicide and guns, and this is the take-home message, the risk is not only assumed by the gun owner, it's also imposed on every other household member. This is like cigarette smoking, except in this case, as opposed to secondhand smoke, the imposed risk is at least as great in relative terms as the assumed risk. And the data that I will run through this afternoon will give you some insight into possibly why that's the case. Okay, well, there you have a picture of the United States. Everyone recognizes that. And when I talk to grand rounds to psychiatric audiences, I first show them this slide and they recognize, yes, that's the slide of the United States and there's variation indicated in the rate at which suicide is distributed. In fact, rates vary more than three-fold, which is much, much more variation than you see for almost any other cause of death, any other leading cause of death. And when I ask them, why do you think rates vary like that? The first response that I usually get is, oh, I didn't know that, that's interesting. And then the next is, well, there must be more depression or other mental illness or substance abuse. In those places where suicide rates are much higher than in other places. That turns out, in fact, not to be the case. I guess you can't read my mind when I want the slide to change. So, there you go. Okay, so this is a slide, one among several I could have shown you, that depicts suicide rates increasing at the state level as you go from the left to the right of the graph. What you see below that is this tremor of a line that doesn't really change that much. It's basically a little bit of noise that goes right across all 50 states. What that represents is the amount of serious psychological distress that is reported by people who live in each of the 50 states. It doesn't vary. People who live in Montana are a lot more likely to die by suicide than people who live in my state, Massachusetts, but they're not more likely to have serious psychological stress. They're not more likely to have depression. They're not more likely to think about suicide, planned suicide, or even attempt suicide. So how can we have more variation in rates at which people are dying by suicide across these 50 states than we have for almost any other leading cause of death when the rates at which people are suffering to the point that they make attempts is pretty uniform? How can that be? If I was showing you a slide of motor vehicle crashes and I told you there are more motor vehicle crash deaths in Montana than in Massachusetts, you would probably say people just drive faster on the roads in Montana because we have a lot of cities in Massachusetts. And that would be true. The rate at which people are getting into crashes is not that different, but the rate at which they're dying in crashes is higher. The same is true when you think about intentional injury, whether you're talking about homicide or suicide. The rate at which people are dying in their attempts is higher in the United States when they live in states, as it turns out, not surprisingly, given the talk in states where gun ownership is more prevalent. So what we see here is the distribution of methods used in fatal versus non-fatal suicidal behavior. As you can see, slightly more than half of all suicide deaths are by firearms. When you look at non-fatal attempts, the vast majority, four out of five, are poisonings and the other 15% or so are cuttings. The likelihood of death with poisoning or cutting is less than 5%. The likelihood of death if you shoot yourself is over 90%. This little picture up in the right-hand corner is one from a movie by Ames called The Powers of Ten and it's meant to remind me to tell you that there are ten times as many non-fatal self-harm as there are suicides. One out of ten acts proves fatal because most acts are with pills or cutting, but nine out of ten acts with firearms prove fatal and that's an important concept to bear in mind. Okay, so here we have seven states that gave us data to look at the distribution of suicide by method in relation to household gun ownership. I'll show you this slide. I'll show you one of 50 states as a plot because it really makes the point pretty clear. What you see here is that Vermont and Maine and New Hampshire have much higher gun ownership rates than do New Jersey, Massachusetts and Rhode Island. The rate at which people are dying, look in the last column, by non-firearm suicide is about the same whether you live in the high gun or the low gun states. But when you live in a high gun state, rates at which people are dying by firearm suicide is a lot higher and that's what drives the overall rate of suicide. That's why you can have similar rates of attempts across the 50 states and huge variation in the rate at which people are dying by suicide. Here's a scatter plot and it's sort of in felicitous that the color I've chosen in the left lower corner is green in case you're colorblind. But when I show these slides, the axes are sometimes hard to read and there's one of these that doesn't go with the other as the Sesame Street diddy goes. There's one of these that really doesn't fit and I think you can all see that it's this one here in the lower corner, the green one. The other two show a clear pattern of increasing rates of whatever the y-axis is as you move across the x-axis. Is this gonna... Okay, there we go. So here, no pattern. This is the relationship between gun prevalence in a state and the rate at which people are dying by non-firearm suicide, just what we saw in the other slide. This slide is the relationship between gun prevalence, household gun prevalence, and the rate at which people are dying by firearm suicide. Very tight correlation. The net effect is a tight correlation between gun ownership and rates at which people are dying by suicide across the 50 states. Okay, this is a somewhat self-aggrandizing slide because it's work that I did with a student of mine that basically runs regressions and tries to account for differences in rates at which people attempt suicide. What you can see here, probably the clearest example here, this is the relationship between the rate at which people are dying by suicide with guns and suicide attempt rates. As you could have seen, you could imagine from what I've said previously, there is no correlation between rates at which people are attempting suicide and rates at which they're dying because people are attempting at the same rate basically everywhere. And what determines what drives what causes higher rates of suicide in high gun areas or in households with guns is the presence of guns. Okay. This slide is a simple depiction of the toll of suicide in this country in the high gun versus the low gun states. So you've seen regression analyses and correlation coefficients and scatter plots and rates, but this is the number of people who are dying in high gun compared to low gun states to illustrate the real toll that we're talking about. Okay. So the high gun states have the same population as the low gun states. We took the states with the lowest gun ownership and we added them up and the states with the highest gun ownership and added the population up and just got an aggregate that balanced the total population. So all you have to look at are the numbers of people who are dying. So let's look at all adults. In the high gun states, there were over 7,000 firearm suicides and there were 4,000 non-firing suicides. In the low gun states, there were 1,600 firearm suicides and about the same number of non-firing suicides. The net effect, the net result, more than 5,000 more people are dying in the high gun states compared to the low gun states over this, excuse me, two-year period. It's a lot of people. Okay. So what do we know about these guns? We know that guns are much more likely to result in death when used in an attempt than any other commonly used method. We know that most of these come from people's homes. These are not guns that are by and large illegally trafficked. They're guns that have been in the homes for a long time and they're not guns that are bought with the intent of killing oneself. We know that because not only the gun owner but everyone else in the household is put at risk. And we've talked about the 300 million guns in civilian hands. Okay. So why would making it harder for people to gain access to a gun reduce the likelihood that they're going to die by suicide? Wouldn't somebody serious enough about killing themselves to use a gun, find another equally, equally lethal way to die by suicide? Well, you wouldn't have the variation in rates of suicide that I've shown you and you wouldn't have differences in suicide rates in gun owning compared to non-ongoing homes in the same neighborhood if that were the case. It's not an unreasonable hypothesis. If someone serious enough, if I truly have intent that serious enough to kill myself with a gun, wouldn't that intent persist long enough for me to find another equally lethal way? The answer, the empirical answer to that reasonable speculation is no. We wouldn't have the patterns that we'd do if that were the case. And so what's the rationale? There are three well-established clinical observations and then one additional observation that helps undergird the idea that making it harder for someone to reach for a gun in a moment of suicidal impulse can save the life not only in the short run but in the long run. And those are that many suicidal acts, especially among younger people are impulsive. Two, suicidal crises are often ephemeral. Three, people who survive even nearly lethal suicide attempts have a very good prognosis with respect to whether they're going to die by suicide or not. I'm a physician. I trained as an oncologist. And the type of patient that I most hoped for in a clinic was a young man like Lance Armstrong who had testicular cancer because the likelihood that that could be cured even in its wide metastatic state was better than 90%. Well, that's the prognosis that people have when they've attempted suicide seriously. They have as good a prognosis as not dying by suicide as Lance Armstrong had to survive his cancer. And this method-specific case fatality rate means what we've said before guns are a lot more lethal than other culturally acceptable, commonly used methods here in the United States. There are lots of what are called case control studies, individual level data that cooperate both in direction and magnitude, the kind of information that I've shown you at the level of states and cities. And these studies have controlled lots of different factors and you basically get, this is a meta-analysis, there's a strong relationship between living in a home with a gun and the likelihood you're going to die by suicide because you're more likely to die by firearm suicide without any difference in the rate which you're likely to, the likelihood at the risk of non-farm suicide. All right, so here's one of the many studies that was done, this by Art Kellerman back in 92 and what you can see is it, whether you have a handgun or a long gun, you're at increased risk for suicide if you live in a home with a gun. The way you store a gun matters. If it's not loaded, if it's locked, it's better than if it's not locked. There's this hierarchy of risk that's consistent with the exposure to guns, the likelihood of being exposed to guns and that's particularly true when you're thinking about kids. This is a study of five to 19-year-olds who lived in homes with guns and the question was, does the way you store it make a difference? The answer is it does. If you store it more safely, the kid is less at risk but even a safely stored gun is at higher risk than not having the gun at home and it does by a considerable amount. The question has come up often and it's relevant to the litigation in trials about firearm ownership and the relationship between guns and suicide. Well, maybe gun owners are different from non-gun owners in ways that put them at higher risk for suicide. Again, a reasonable proposition is not one that stands up to empirical scrutiny. Gun owners are no more likely than non-gun owners to have depression, anxiety disorder, you name it. That doesn't distinguish them. Sure, they're different. They bought guns but they're not different in any way that we know is related to the risk of suicide. Okay. The time series analysis that I have up there simply says if you look what happened in the mid to late 1990s in the United States, what we know is suicide rates dropped because firearm suicide rates dropped in tandem with declines in firearm ownership over that time period. Non-farm suicide rates did not change. The net effect was a decrease in suicide rates, especially among younger people of almost 30% over that time period. And studies that we've done using panel data have sort of have corroborated that or at least have demonstrated that controlling for various other factors. The other thing to note is over that time period the rates at which people were reporting depression or suicidal ideation and making suicide attempts also didn't change. So you see over time the same sort of pattern that I mentioned across space at the beginning of the talk. Here's a slide from the New Yorker back this past December. And when I saw this, it made me think yes, this looks like a homicide. But the data are just so much better when it comes to suicide. I wish we could save some and apply it because it's actually a lot harder to do the research on homicide to studies involving homicide. The data are overwhelming, they're incontrovertible. But we're forgetting about the toll. The gentleman who spoke earlier so movingly about his father dying in his own arms, it's a very powerful statement. And there are spokespeople for those who die in homicidal though mostly disenfranchised. There aren't the same stories for people who died by suicide and yet the toll is enormous. All right, what are we doing? Are we acting on what we already know? Well the short answer to that is no. This is a study of psychiatrists and they were asked do you talk to your patients who are suicidal about the risk of having a gun in the home? You can see only one out of five talk to their suicidal patients about having a gun in the home. This is a study that we did in emergency departments where we asked attendings and nurses and residents did they speak to people who came in with suicidal behavior about whether they had a gun in the home? Well if they had a gun, if they said they had a plan with a gun then two out of three spoke with them. I don't know why the other one or the other three didn't. But if they had a plan with something else and they were suicidal but it didn't involve a gun only one out of five talked about having a gun. That's the strongest risk factor that you can do anything about. All right. We asked in the same survey people what did they think would happen? There are more than a thousand people who died by gun suicide every month. What would happen if it was impossible for that person to get a hold of a gun during a suicidal impulse? And these are physicians and nurses and residents. Oops. And as you can see two out of three nurses two out of five physicians said that most or all of the people who died by firearm suicide would have found another equally lethal way. Most are all. About 20% about 30% of the general population thinks that not a single life could be saved. So that's the mindset that we are up against in thinking about the role of firearms and suicide. Two more slides. Suicide can be prevented without necessarily doing anything about underlying mental illness. Means restriction is in fact the strongest approach that has the greatest potential to immediately and largely reduce rates at which people are dying by suicide in this country. There's no generic antagonism between trying to attend to people's suffering and making it more likely they're going to live through that suffering by putting distance between them and their gun. And we're not doing it nearly enough. This final slide is a picture of Ulysses bound to his ship's mast. It epitomizes an action that anticipates sort of actuarial risk and takes steps to avoid calamity. This metaphor works as an illustration of the kind of enlightened self-interest that health professionals should strive to have their patients consider and deed act upon. The metaphor may work as well more broadly as an illustration of societal actions that integrate science into public health policy. Preventing suicidal behavior and the suffering that leads to suicidal acts has been extremely difficult. But we can save lives still both in the short run and in the long run by enabling the kind of enlightened self-interest that Ulysses' choice exemplifies. After all, Ulysses survived where others perished, not because he was less compelled by the sirens' calls towards death, but because he recognized his potential incapacity to resist those calls and took steps to avoid disaster. Thank you very much. It doesn't involve changing any laws, but it's simply implementing them. It can be done in an administrative level. They say, okay, we are now going to report all of our restraining orders and our domestic violence, misdemeanor convictions to the National Instant Check System. There are a number of states that still don't do that, don't have the capacity to do that, haven't done that similar with mental health records and it does not require any new law on any level, but simply an agency saying, okay, we're going to do it. Pennsylvania did that and quickly went from very, very few to over a quarter of a million mental health records in the National Instant Check System within the space of a few days last year. We can do the same thing with restraining orders and domestic violence, misdemeanor convictions, and that would be a good start that does not involve legislation and dealing with elected officials and their hesitance in terms of addressing some of those issues. So that's one thing. Matt, any other solution you did get in, a group of them at the end there, for example, you mentioned the gun storage, do the safe storage laws make a difference? Are there studies? There are studies and there's a suggestion that they may, but most of the, we're not going to legislate our way towards huge reductions in suicide through direct legislation, but legislation or action more broadly can have an educative role. If it helps shift the way people think about what responsible behavior is, storing guns safely, for example, if legislation supports that sort of social shift, then I think you're going to see there'll be a much greater chance that people are going to, people's lives will be saved. You have other possibilities like smart gun technology. You can pull the trigger or release the bullet. You've protected the other people in the home. So there are, but getting physicians and other healthcare workers and people like you in the audience to recognize that suicide is preventable, that the evidence is extremely powerful and that it's not inevitable that somebody who's going to attempt this is going to die, just getting those ideas out there and having discussions about helping people make enlightened decisions in their own enlightened self-interest will probably be the surest way to reduce the toll. Can I jump in on safe storage also for a second? So in the late 1980s, Florida, not known as your most rabidly anti-gun state, became the first state in the country to adopt what's called a child access prevention law. That's a law that says that if you do have a gun in your home, you have to store it safely so that young children can't gain easy access to it. Since Florida enacted its law, 17 more states have enacted these CAP child access prevention laws, 18 states. And the research shows pretty substantial reductions in accidental shootings among children. And as Matt says, more modest reductions among children are not going to safe store our way out of the teen suicide problem. But safe storage can have an important effect on both child accidents and maybe even a modest effect on teen suicides. Definitely. Safe storage certainly can. And the extent to which the law actually affects that is really hard to pin down. When we did a study where we asked people, did they think they lived in a state which had that Jan mentioned and almost everybody thought they lived in a state that had those sort of laws. And there was no correlation with thinking that you lived in a state like that and actually on the individual level how you stored your gun. But again, there may be something about the way these laws are promoted and the way it induces certain type of societal norms that could shift behavior. And that's part of the role of legislation I would imagine. Let me add one more here that a couple of people have written from the audience Jan Vernick or anybody else can pitch in. Has anything been done to address or even shut down the 1% of firearm dealers that are leading to over 50% of the crime gun sales? Great question. Yeah, actually some cities have done wonderfully innovative things. They've used their crime gun tracing data the data associated with the guns that are recovered from police then they get traced and you figure out which dealers are selling them. They've figured out which are their problem dealers and a handful of cities have done very innovative things. They've done undercover sting operations of those dealers to catch them illegally selling their guns. Once they've caught them doing that they've brought lawsuits and maybe John Lowey will talk about this also. Lawsuits against those dealers and research that we've done has shown that the cities who do that well Chicago, Detroit, New York City that target those problem dealers, sting them and sue them seem big changes in illegal gun trafficking and changes in the number of their crime guns that are coming from those precise dealers. So yes, there absolutely are enforcement strategies that can work. Jan, you had mentioned not spending the resources you mentioned to decline in certain types of gun accidents or deaths and indicating that this were a disease. We would be studying it a lot more. We haven't been putting the resources. Someone specifically asked, do you know why the Center for Disease Control has not done more, why it stopped studying gun violence? Well, so it's a story that takes place beginning around the mid 1990s. The CDC had been studying not just the number of gun deaths but risk factors for gun deaths and had been looking at gun policy and very explicitly the National Rifle Association felt that that research was inappropriate. They lobbied their friends in Congress and Congress took money away from CDC's budget and redirected it the precise amount they had been spending on guns. They redirected towards other things and they introduced a rider in CDC's annual appropriations that says that CDC can't use money to lobby for gun control. Now, they couldn't lobby for gun control even before that but the action of calling this attention to it and forcing CDC officials to come to Congress and testify ultimately wound up as a chilling factor. Now, as Susan mentioned, we have good reason to hope that that's changing. President Obama in an executive action in 2013 instructed federal agencies that fund research to begin funding research on gun violence prevention. Again, CDC commissioned the Institute of Medicine to recommend to it what the major areas of gun violence prevention funding ought to be and we're hopeful that that money will become available soon.