County of Santa Clara
Santa Clara Valley Health & Hospital System
Public Health Department
Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 1 of 10 County Executive: Jeffrey V. Smith
110756
DATE: May 24, 2022
TO: Board of Supervisors
FROM: Sara H. Cody MD, Health Officer and Public Health Director SUBJECT: Interim report on the study on public costs of gun violence
RECOMMENDED ACTION
Under advisement from October 19, 2021 (Item No. 35): Receive interim report from the Public Health Department relating to the implications of the study on the public costs of gun violence.
FISCAL IMPLICATIONS
This report is informational only and will not impact the County General Fund.
REASONS FOR RECOMMENDATION
On January 28, 2020, the Board approved a framework, work plan, timeline, and resources required for the Public Health Department (PHD) to develop a report on the cost of gun violence. On October 19, 2021 (Item #35), the PHD updated the Board of Supervisors on the Cost of Gun Violence Study (“Study”). This report provides the Board with information specific to the Public Cost of Gun Violence Study. As a companion to this report, the Office of the County Counsel has provided the Board with a confidential off-agenda memorandum.
The magnitude and impacts of gun violence are extremely complex, and it is not easy to fully understand its true toll on society. The healthcare system, criminal justice system, and other public sectors bear the most direct and tangible monetary impact of gun violence. Indirect and intangible costs of gun violence are typically captured through established metrics and benchmarks such as lost income and lost quality of life. Costs can also include the vast array of prevention and intervention efforts in response to gun violence across different public sectors. Gun violence also impacts human lives in ways that are not as readily measurable, such as family members lost to shootings or suicide, people who witness shootings, or children who grow up in an environment of gun violence. Aside from direct and indirect costs, individual and community-level trauma resulting from these incidents lasts throughout the life course and even extends across generations, with social and economic consequences in neighborhoods, communities, and society.
Attachment D
Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 2 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
This report provides certain preliminary findings from the Study and PHD’s preliminary recommendations arising out of the Study. Because the contractor conducting the Study only recently obtained the last data set for the Study, the costs for criminal justice data and comparison data are still being calculated. PHD expects that the Study and an initial draft report will be completed by June 2022. After PHD reviews and finalizes the report with the contractor, PHD anticipates that it can return to the Board in August 2022 with the final report and a final set of recommendations.
Preliminary Findings from Current Gun Data
The Public Cost of Gun Violence Study is intended to provide information on the complexity of the economic impacts of gun violence. Quantitative data sources include a variety of existing data sources, such as firearm sales, health and hospital data, death data, firearm charges and sentencing data, service utilization and staffing data, victim compensation data, and population survey data. The preliminary findings include a summary of trends, and a subset of cost analysis.
Firearms present in Santa Clara County
• In 2021, about 550,000 guns were owned by Santa Clara County residents. • From 2017 to 2021, county residents registered an average of 28,000 guns annually.
Nonfatal Firearm Injury Related Emergency Department (ED) Visits • The annual nonfatal firearm injury-related ED visits more than doubled during the past decade. The number of visits increased from 60 in 2011 to 156 in 2020. The age- adjusted rate of visits increased from 3.4 per 100,000 people in 2011 to 8.8 in 2020. • Nine in ten (90%) of the nonfatal firearm injury-related ED visits were among males. • Nonfatal firearm injury-related ED visits disproportionately impacted Latino residents.
During 2016-20, nearly 6 in 10 (57%) nonfatal firearm injury-related ED visits were among Latinos, who account for only 1 in 4 residents (25%) of the county. • A higher proportion of nonfatal firearm injury-related ED visits were among young adults. During 2016-20, nearly 2 in 3 (65%) of the nonfatal firearm injury-related ED visits were among adults ages 18 to 34 years old.
• Unintentional/accidental firearm injuries (77%) were the most common cause of nonfatal firearm injury-related ED visits during 2016-20. o The accidental firearm injury-related ED visits increased five-fold from 2011 (n=22) to 2020 (113).
Fatal Firearm Injuries or Firearm Deaths
• From 2001 to 2020, 1,494 county residents died due to a firearm-related injury. • Firearm deaths among county residents stayed relatively stable during the past decade. • The most common cause for firearm deaths among county residents was self-inflicted firearm injuries (suicide). During 2001-20, 6 in 10 (60%) firearm deaths were due to Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 3 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
self-inflicted firearm injuries, followed by assault/homicide (34%), and legal intervention (4%).
• During 2016-20, 9 in 10 (89%) firearm deaths were among males. • A higher percentage of firearm deaths were among adults ages 18 to 34. During 2016- 20, 1 in 3 (34%) firearm deaths were among county residents ages 18 to 34, followed by 1 in 4 deaths among 45-64 (26%) and 65 and older (24%) age groups, respectively. • During 2016-20, nearly 6 in 10 (57%) firearm deaths were among Whites residing in the county, followed by Latinos (28%), Asians (16%), and African Americans (6%).
Estimated Costs for Firearm Injuries and Deaths
• During 2016-2020, the average annual costs related to nonfatal firearm injuries and deaths were nearly $1.2 billion. The cost estimate represents medical, criminal justice, mental health, lost wages, quality of life, emergency services, and employer-related costs.
• Quality of life costs (82%, $951 million) accounted for the largest share of the cost estimates for firearm injuries and deaths during 2016-20. • Forty four percent of the estimated costs related to firearm injuries and deaths were due to self-inflicted firearm injuries/ suicide. The average cost associated with self- inflicted firearm injuries/ suicide was $516 million in a year from 2016-20. • Average costs for assault related firearm injuries and deaths were $512 million in a year during 2016-20, accounting for another 44% of the estimated total costs related to firearm injuries and deaths.
• The County of Santa Clara incurs costs of $72 million annually due to firearm incidents at the County and City level. This estimate includes public costs from the following sectors: medical, mental health, emergency services, police, and criminal justice. It excludes the costs of incarceration in state and federal prisons, as well as costs to the private sector.
Preliminary Recommendations
Gun violence is preventable. Public Health approaches to prevent gun violence include a multitude of strategies directed towards both addressing risk factors and increasing protective factors. Elected officials, government entities, community-based organizations, neighborhoods and communities, individuals, and gun manufacturers and dealers all play a role in working together to prevent gun violence. Prevention Institute conducted a series of key informant interviews and stakeholder engagement meetings to identify concerns related to gun violence, current actions regarding gun violence prevention, and policy recommendations to include in further action planning. The following preliminary recommendations include possible actions for the County and city elected officials and County and city departments, community-based organizations, advocacy groups, and residents based on stakeholder engagement meetings held between February and May 2022.
Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 4 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
Implementation of some of the recommendations will require additional investment and commitment from the County leadership and departments, and key local stakeholders.
POLICY AND ADVOCACY RECOMMENDATIONS
Recommendation #1: Encourage the adoption of gun safety policies and practices to ensure gun safety for gun owners and the broader community. Advancing a culture of gun safety would require establishing more robust and evidence-based gun safety policies and practices. One example of such policies is safe storage ordinances requiring firearms to be stored with a locking device or in a locked container, unloaded, and separate from ammunition. Another example is the adoption of policies that require gun owners to report or more promptly report the loss or theft of their firearm.
Recommendation #2: Direct the Administration to utilize Racial Equity Impact Assessment tools1 to evaluate the County's policy position on guns and advocate for more equitable gun violence prevention policies at the county, state, and federal levels.
A Racial Equity Impact Assessment (REIA) is a systematic examination of how different racial groups can potentially be affected by a policy decision or action. It is used to identify unintended or disproportionate negative consequences that may fall upon historically disadvantaged racial groups, in order to mitigate harm and promote greater equity. In the context of gun violence, a REIA can be used to reduce victimization, and minimize arrests and incarceration. Typical questions in a REIA include: What types of racial disparities could potentially result from the policy’s design and implementation? Who are the specific communities that will be impacted by the policy?2 The use of REIA is relatively new in the U.S, but adoption is on the rise among counties and cities. The City of Seattle has been using Racial Equity Analysis in its policy development and budget planning since 2012. Other regions, such as King County, WA, and St. Paul, MN, have also either adopted or are close to adopting racial equity assessment in their policy and program planning process.3 Gun violence prevention policy advocates have a renewed awareness of the potential for racial bias in developing and implementing gun violence prevention policies. Intertwined with the legacy of systemic racial discrimination in the United States, there are continuing disparities in enforcing and implementing firearm restrictions. Gun violence prevention researchers urgently recommend racial equity impact assessments for all gun violence policies.4
RECOMMENDATIONS TO INCREASE PROTECTIVE FACTORS THAT
ADVANCE EQUITY
1 Johns Hopkins Center for Gun Violence Solutions, Racial Equity Impact Assessment Tool for Gun Violence Prevention, https://efsgv.org/racialequity/
2 Racial Equity Framework for Gun Violence Prevention, The Educational Fund t o Stop Gun Violence, https://efsgv.org/wp- content/uploads/EFSGV_REIA_Framework.pdf
3 Racial Equity Impact Assessment, Race Forward: The Center for Racial Justice Innovation, https://www.raceforward.org/sites/default/files/RacialJusticeImpactAssessment_v5.p df 4 Swanson, JW. The color of risk protection orders: gun violence, gun laws, and racial justice. Journal of Injury Epidemiology Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 5 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
Recommendation #3: Adopt and replicate community-centered, place-based approaches to gun violence prevention in neighborhoods facing concentrated disadvantage/concentration of risk factors for gun violence. A history of racially discriminatory practices such as redlining and other inequitable investments has created communities of concentrated disadvantage where risk factors for gun violence are high. In these places, gun violence can be prevented by strengthening the economic health, built environment conditions, social environment, and civic infrastructure of neighborhoods and cities.
An increasing body of evidence for place-based strategies is prompting the federal, state, and local jurisdictions to adopt this approach. Community-centered, place-based approaches include resident engagement and neighborhood action planning; culturally rooted, community-based violence prevention and intervention; community health worker programs; resident-led healing and trauma-informed neighborhood projects; and campaigns for educational equity and affordable housing/anti-displacement. Effective models exist in the county and across the state and can be replicated in neighborhoods experiencing high rates of gun violence.
Recommendation #4: Expand partnerships with ethnic behavioral health service providers to strengthen community-based crisis intervention, de-escalation, and mobile mental health crisis care, and improve policies and protocols to separate people in crisis from access to firearms. Community-based crisis interventions and mobile teams would offer targeted interventions to individuals and groups in need, wherever they are, including at home, work, or elsewhere in the community. Mobile crisis units already exist in various locations within Santa Clara County. This recommendation would strengthen the County's focus on expanding community-based crisis intervention and mobile teams among specific ethnic populations and geographic areas most impacted by gun violence. This strategy would consist of multi-disciplinary teams represented by trained, licensed providers, local community-based programs, community members, and people with lived experiences as part of the crisis continuum of care, especially among communities of color. This strategy would also seek to reduce police officer-involved injuries, reduce arrests of individuals with mental illness, minimize officers' use of force, increase diversion of mentally ill individuals from the criminal justice system, and enhance their access to mental health and other prevention services addressing social determinants of health. Also, California’s Red Flag Law and Gun Violence Restraining Orders (GVRO) provide mechanisms to prevent gun harm in instances of a mental health crisis. This recommendation would also include robust community education messages to communities about warning signs and how to activate these life- saving mechanisms through GVROs. Interjurisdictional and intersectoral coordination would yield tremendous progress on this front.
Recommendation #5: Increase partnerships between cities, school districts, and the County to expand community-led social, recreational, behavioral, educational, and employment-related supports for young people experiencing exclusion from opportunity. Many opportunities for young people exist, yet there is a small segment of the county's youth whose social, recreational, behavioral, educational, and employment-related needs remain unmet. These young people are more likely to suffer from poor mental and Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 6 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
behavioral health and have a higher risk for gun violence perpetration and victimization. Too often, these disadvantaged young people are met with punitive responses rather than opportunities that build their protective factors. Supportive options should be explicitly designed with input from this population to emphasize safe, stable, and nurturing connections and environments, with attention to cultural and community fit.
RECOMMENDATIONS TO STRENGTHEN GOVERNMENT AND COMMUNITY-
LEVEL COORDINATION AND DATA SYSTEMS
Recommendation #6: Establish a gun safety data workgroup to guide the development of a data-to-action dashboard. The data workgroup would be represented by County departments, city agencies, and community-based organizations involved in gun violence prevention efforts. A workgroup could develop a centralized data platform to track the impacts of gun violence locally and progress on gun violence prevention. The complexity of multiple data systems involved in tracking the actual cost of gun violence, disparate data collection systems and processes across various service delivery systems, and lack of non- governmental contributions of data as part of the entire data to action planning process present challenges in fully understanding the extent to the impact of gun violence.
To fully understand the prevalence and impact of gun violence, all these data sources need to be analyzed and reviewed together. Governmental and non-governmental agencies would be encouraged to make more data publicly available in the spirit of transparency and to support data-driven decision-making. Data sharing agreements would permit the inter-departmental sharing of de-identified record-level data that allow for continuous analysis along the spectrum of gun violence and comprehensive summarization of data. A centralized data platform consisting of data contributions from all relevant agencies and constituencies would track the impact of gun violence locally and inform joint prevention efforts related to gun violence.
CHILD IMPACT
The recommended action may have a positive impact on children. This report provides preliminary options for policy and system recommendations that protect children from exposure to gun violence. Nationally, the number of firearm deaths surpassed motor vehicle traffic accident deaths among children ages 0-19 years and is the leading cause of injury deaths in this age group. Aside from being physically harmed by gun violence, children are also impacted by the presence of gun violence in their environment. The recommended actions outlined in the report would limit access to unauthorized gun possession among youth and provide options for investment in programs and services to enhance protective factors among youth most at risk for gun violence exposure.5
SENIOR IMPACT
Seniors are negatively impacted by harm to families and communities in which they live.
During 2016-20, despite occupying a smaller percentage of total firearm deaths in the county,
5 Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, WONDER, Multiple Cause of Death, Injury Mechanism & All Other Leading Causes, 2018-20. Ages 1–19. Accessed on May 2, 2022.
Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 7 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
seniors ages 65 and older have the highest age-specific rate of firearm deaths. Rate of suicide with a firearm was highest among residents ages 65 and older as well.6 The recommended actions would positively impact seniors by limiting unsafe access to firearms among unauthorized users, expanding crisis mental health services, and providing options for investment in programs and services to develop protective factors among seniors most at risk for gun violence exposure.
SUSTAINABILITY IMPLICATIONS
The recommended action would have no sustainability implications.
BACKGROUND
Gun violence is a public health crisis and has become a leading cause of premature death that affects many communities and families daily, whether through suicide, domestic violence, community violence, or other forms. Through a public health approach, violence is preventable across all types of gun-related injuries and death.7 Each day, over 110 Americans are killed, and over 200 Americans are injured by a firearm.8 According to the CDC, 2020 was the deadliest year on record for gun violence, accounting for the death of 45,222 people in the country. This death count represents a 14% increase from the year prior and a 25% increase from five years prior.9 For California, in 2020, there were 3,449 deaths reported due to firearm.10 Gun homicides are leading the rise in homicides overall, and the use of firearms is rapidly increasing in other crime categories such as robbery and assault.11 Such evidence of the steady and alarming trend calls for urgent public action.
The PHD executed a contract with the Pacific Institute for Research and Evaluation (PIRE) and the Prevention Institute to partner with the PHD to conduct the cost of gun violence study and develop a framework for reporting the results. PIRE performed the economic analysis in collaboration with the PHD. The Public Cost of Gun Violence Study analyzes the societal cost of gun violence, utilizing a peer-reviewed framework for costing gun violence developed by PIRE.12 This framework consists of an economic analysis of direct out-of- pocket costs across the continuum of public services and employer responses associated with injury and death and indirect cost data following an event. Direct costs include police, emergency response, hospital-related expenses, healthcare claims, family mental health services, court, criminal justice, and employer costs. Indirect costs include victim loss of wages and the estimated value of lost quality of life.
6 Santa Clara County Public Health Department, Vital Records Business Intelligence System (VRBIS), Data as of 7/1/2021 7 EFSGV, Public Health Approach to Gun Violence Prevention, https://efsgv.org/learn/learn-more-about-gun-violence/public- health-approach-to-gun-violence-prevention/
8 Centers for Disease Control and Prevention, National Center for Health Statistics, WONDER Online Database, Underlying Cause of Death. https://everytownresearch.org/report/gun-violence-in-america/ 9 Pewresearch.org https://www.pewresearch.org/fact-tank/2022/02/03/what-the-data-says-about-gun-deaths-in-the-u-s/ 10 Centers for Disease Control and Prevention’s WISQARS Fatal Injury Reports ( http://www.cdc.gov/injury/wisqars/fatal.html) 11 Public Policy Institute of California, 2021, https://www.ppic.org/blog/gun -deaths-drive-californias-largest-ever-rise-in- homicides/
12 Miller, T. R., & Cohen, M. A. (1997). Costs of gunshot and cut/stab wounds in the United States, with some Canadian comparisons. Accident; analysis and prevention, 29(3), 329–341. https://doi.org/10.1016/s0001-4575(97)00007-9.
Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 8 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
Several County departments are engaged in gun violence prevention efforts ranging from individual-level interventions to organizational, community, and population-level actions.
These efforts are highlighted below. The summary is not an exhaustive list, but rather an illustration of the work that spans across multiple sectors, from behavioral health and public health to criminal justice and law enforcement.
Current County Department Efforts to Address Gun Violence • County Public Health Department
o Violence Prevention Program - community-driven and upstream violence prevention
▪ East San Jose PEACE Partnership –a place-based, community-led collective impact model represented by residents and community organizations working together to address the root causes of violence. ▪ We All Play A Role – a place-based strategy for violence prevention – by building resilience, trust, and other protective factors at a community level.
o Healthy Cities Program – Healthy Cities Dashboard
▪ The Healthy Cities Dashboard recognizes and encourages city municipalities to adopt evidence-based policies that promote health and equity. This dashboard highlights safe gun storage, suicide prevention, and community-based crisis response policies.
• County Behavioral Health Services
o Suicide Prevention Program promotes firearm safety among county residents through public awareness campaigns that promote gun safety, safe storage practices, and suicide prevention for firearm owners. The program developed multimedia communication resources to spread suicide prevention messages online, radio, and at community events.
o Mobile Crisis Response Teams screen and assess crisis situations over the phone, and intervene wherever the crisis occurs. Teams consist of licensed clinicians and therapists with training and expertise in crisis response. This team provides immediate response and delivers crisis intervention services at locations throughout the County.
• County Probation Department – Neighborhood Safety/Services Unit (NSU) o NSU currently operates in two neighborhoods in Santa Clara County (located within East San Jose and Gilroy). NSU employs a holistic range of strategies that include gun safety and gun violence prevention through education and awareness-raising, activation of safe community spaces and improving the built environment, partnering with schools, improving housing conditions, and economic development.
• County Sheriff's Office
Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 9 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
o Collects firearms from individuals who are subject to temporary and permanent restraining orders.
o Delivers the Voluntary Firearm Relinquishment Program and education efforts to reach residents outside of buy-back events.
• County District Attorney's Office
o The Crime Strategies Unit (CSU) was created in October 2016 to study crime in Santa Clara County and develop cross-disciplinary and multi-jurisdictional solutions. Its role is to coordinate, promote, and assist with County-wide gun enforcement initiatives:
o Gun-Related Intelligence Program (GRIP)
▪ Identifying shooters and crime-drivers for vertical prosecution and follow- up
▪ Coordinating with Federal Partners on adoption candidates ▪ Facilitating weekly coordination meetings with investigators and prosecutors to solve crimes and file cases more quickly in gun crimes o Analyst Support
▪ Preparing declarations for court and prosecutors regarding high-risk gun offenders
▪ Drafting and disseminating weekly analysis of all gun crimes in the County for local Law Enforcement discussion and action plans o Education Campaign – regional training of police, prosecutors, and community groups on GVROs, Firearms techniques, and Firearm Violence Trends o Priority Gun Offenders
▪ Identifying repeat offenders for vertical prosecution, high bail requests, and investigatory action in collaboration with county law enforcement agencies
o Gun Prosecutors
▪ Newly Added positions who work exclusively to prosecute shooters, gun traffickers, and priority gun offenders in collaboration with GRIP ▪ Review hundreds of search warrants and large-scale support investigations of gun crime drivers
o Crime Lab Firearms Unit
▪ Universal and timely use of firearms imaging technology and the National Integrated Ballistic Information Network (NIBIN) network to identify guns used in multiple crimes (evidence-based strategy) through analyzing firearms evidence
Board of Supervisors: Mike Wasserman, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian Page 10 of 10 County Executive: Jeffrey V. Smith
Agenda Date: May 24, 2022
▪ Identification and analysis of fully automatic machineguns, "Ghost Guns," and specialized assault weapons
o Prohibited Persons Enforcement
▪ Family Violence Unit (FVU) – Prohibited Persons Gun Relinquishment hearings and analysis in every arraigned case
▪ GRIP/CSU review and identification of armed prohibited persons, through the APPS list and weekly review of hundreds of gun arrests, facilitation/coordination of safe apprehension of offenders and recovery of firearms
o Gun Buy-back Events
▪ In collaboration with city police departments, the Community Prosecution Unit has organized around 12 events over the last ten years and has removed 7,000 unwanted guns from the public.
o Gun Safety and Violence Prevention Workgroup
▪ Began as part of the East San Jose PEACE Partnership, this workgroup is led by the Community Prosecution Unit and serves as a space for district attorneys, law enforcement, city violence prevention programs, behavioral health, public health, and advocacy groups to share information and collaborate around gun harm reduction and prevention.
STEPS FOLLOWING APPROVAL
The Clerk of the Board is requested to notify Colleen Singh-McGuire, Public Health Department, upon completion of Minute Traq processing.
LINKS:
• References: 107857 : 107857
• References: 99826 : 99826
ATTACHMENTS:
• Cost of Gun Violence Report_Board Presentation_5.24.22 (PDF)