The massacre at Robb Elementary in Uvalde, Texas, resurfaced many troubling facts about America’s exceptional propensity for gun violence. But perhaps one of the most disturbing is that firearms are now the leading cause of death among Americans ages 24 years and under.

While guns have long been a fixture of American life, the emergence of firearms as the leading killer of young people is a relatively new phenomenon.

For years, cars held that distinction. But over the past two decades, motor vehicular deaths involving Americans between the ages of 1 and 24 plummeted, cutting the rate by nearly half. And sometime in the late 2010s, those two lines — deaths by car and by firearm — crossed paths on the graph of leading causes of death for young people.

In 2020, the most recent year for which data was available, firearms killed 10,186 young people, the highest number in two decades.

Centers for Disease Control and Prevention

(It’s worth noting that motor vehicular deaths increased in 2020, the first year of the pandemic. That said, firearms also saw a jump, and remained the biggest cause of death for young people.)

Based on a recent analysis of Centers for Disease Control and Prevention (CDC) data published in the New England Journal of Medicine (NEJM), the chart on one level tells a tragic story: lives taken too soon. But it also highlights how policy action can move the needle on saving lives — and how policy neglect can deepen a preventable tragedy. The article received some initial attention when first published in April, but its findings have reemerged in various American media outlets following the massacre in Uvalde. It’s easy to see why the comparison is striking a chord: The youngest members of our society are dying from the most American of public health problems.

While the Uvalde massacre has occasioned the latest round of national introspection on guns, the American tragedy of gun violence goes well beyond such incidents. One of the NEJM article co-authors, Lois Lee, a professor of pediatrics and emergency medicine at Harvard Medical School, told me that mass shootings with at least several deaths are unfortunately just the tip of the iceberg. “Mass shootings like [Uvalde] actually only account for less than 1 percent of pediatric firearm deaths. … Most firearm deaths are not from mass shootings, but from homicides (62%) and suicides (33%),” Lee said.

Even as firearm deaths among the young have risen, motor vehicle deaths have declined by about half since 2000. Although traffic violence continues to kill many children and has markedly increased in the pandemic, the decades-long decline is nevertheless a hard-fought public health milestone built on research, safety measures, and regulation. This included adopting harm reduction principles in traffic safety policy: People are going to drive cars regardless, the thinking goes, so why not focus on making it as safe as possible?

The current rate of young Americans being killed by firearms is not an inevitability; it is a policy choice. In their analysis of this CDC data, Lee and her co-authors argue that the same approach to reduce motor vehicle deaths among young people can and should be applied to guns.

How America made cars safer but not guns

The decline of motor vehicle deaths in America over the past two decades is part of a broader trend that began in the 1960s. Ralph Nader’s seminal 1965 exposé, Unsafe at Any Speed, catalyzed an auto safety movement that culminated in the creation of the National Highway Traffic Safety Administration (NHTSA), which set up the infrastructure for automobile safety.

From the 1970s onward, the NHTSA would maintained a database on motor vehicle-related deaths, make research investments, and provide safety certifications for cars on the market, incentivizing auto companies to adopt safety procedures. The work of the NHTSA and civil society groups like the Insurance Institute for Highway Safety helped usher in a new era where safety features like seat belts and airbags became standardized. All of this, along with measures like universal state licensing of drivers and registration of cars, led to the decline in youth and overall American motor vehicle mortality. The CDC would eventually tout this decline as one of the country’s biggest public health achievements of the 20th century.

And as Lee recounts in the NEJM article, that progress continued into the 21st century. In 1998, frontal airbags became mandatory in all cars and trucks sold in the US. Other improvements like automatic emergency braking, blind-spot detection, side airbags, and rear-facing cameras also contributed to an improved auto safety landscape. “What we’ve seen is more than a half-century of efforts to make the automobile safer,” said Mitchell Moss, a professor of urban policy and planning and director of the Rudin Center for Transportation at New York University.

If cars went one way with safety, guns went the other. Guns are one of the only consumer goods whose safety is not regulated by any government agency. Gun manufacturers are also very insulated from lawsuits, and perhaps consequently, have little incentive to design safer guns, such as “smart guns” that would only be operable by the users they are registered to. As Moss said, “We really have a Wild West approach to the manufacture of weapons in this country.”

To top it all off, federal research about guns, gun violence, and gun safety was also basically frozen for over 20 years until 2020 due to an NRA-backed measure known as the Dickey Amendment. “We don’t even have a true, real-time national database to understand what is going on with firearm injuries and deaths,” Lee said. “We have a lack of infrastructure, a lack of researchers, and then a lack of knowledge to even know what are the things we can do to mitigate or certainly decrease firearm injuries and deaths.”

Contrast that with cars. When looking at the public health achievement of reducing motor vehicle deaths, safety improvements of cars and the introduction of driver-specific regulations paved the way, says Kerri Raissian, a professor of public policy at the University of Connecticut. “The federal government incentivized the uptake of certain safety actions (by tying interstate money to the legal age of driving, for example) and states enforce road rules,” she wrote to me in an email. “It’s an achievement in terms of the outcome and coordination it took to get us here.”

To be sure, the number of car deaths is still unacceptably high — a recent report from the International Transport Forum, which is affiliated with the Organization for Economic Co-operation and Development (OECD), found that the US in 2020 had more road fatalities per 100,000 people than every other OECD country.

In fact, traffic fatalities likely reached a 16-year high last year, with pedestrian deaths in particular rising by 59 percent since 2009. This could be partly attributed to how cars have gotten safer for drivers and passengers, but not for anyone else. The auto industry makes and promotes larger and more dangerous SUVs that are much more likely to kill pedestrians in crashes. SUV sales have also gone up sharply in the last decade, now making up half of all car sales in the US. Despite the increase in pedestrian fatalities, the NHTSA has declined to adopt safety tests other countries use to protect pedestrians.

That said, cutting back on overall deaths and mitigating injuries should be — and has been — the overriding policy goal, and that’s what’s led to results, Lee says. “It’s unrealistic given the numbers of cars on the road and the vehicle miles driven or ridden per person that we would ever get to zero,” she said. “And mitigating injuries or deaths is just the tip of the iceberg. There are many greater injuries that require hospitalizations.”

For legal, cultural, and political reasons, guns, like cars, are inextricable from American life. But if that is the case, it’s all the more reason that we need to try to implement whatever strategies possible to reduce harm. Moss said it plainly: “We’re not going to eliminate the car from American life,” and the same truism can be applied to guns. “I think what’s happened is we have normalized the deaths of children. We’ve become too accepting of this.”

As Vox’s Marin Cogan has written, “To do nothing is to endorse an intolerable status quo.” And even if federal action is not coming anytime soon, there is still plenty that can and has been done at the state level that can successfully decrease the rate of gun violence. Lee also pointed to a study she and her colleagues did that showed the enactment of laws requiring the safe storage of firearms away from children led to a reduction in child homicides, suicides, and unintentional deaths. Furthermore, there is solid research, both domestically and abroad, showing that regulations like licensing can curb firearm deaths of all people, not just youth.

“When a child is killed, you are losing the rest of their life as a member of society, as a member of their family, as a member of their community,” Lee said. “And the repercussions of that in some way will never go away.”