# Have Americans Become Less Violent Since 1980?

The US homicide rate hit 10.2 per 100,000 in 1980, fell to 4.4 by 2014, then spiked to 6.5 in 2020. This looks like a story about violence rising, falling, and rising again. The actual story is simpler and worse: homicidal violence tripled in the 1960s and 70s. After adjusting for medical improvement, there is no clear statistical signal that it ever came back down. What changed was not the violence but how often it killed people.

# Deaths vs. attacks

The homicide rate measures deaths. Deaths from gunshot wounds depend on two things: how many people get shot, and how many of those people die. Medicine affects the second thing. The homicide rate doesn't separate them.

If you get shot in the abdomen today, you have about a 92% chance of surviving. In 1960, you had about a 70% chance. In 1900, about 13%. The prognoses for other penetrating trauma wounds also improved, though this varies by wound location: head shots remain almost uniformly fatal regardless of era, while extremity wounds were highly survivable even a century ago. Abdominal wounds are a central case of an injury that kills you without good care and doesn't with it.

[Harris et al. (2002)](https://people.umass.edu/zguo/iraqi%20war%20/murder%20and%20medicine.pdf) estimated that without post-1960 medical improvements, the US would have had 50,000–115,000 homicides per year in the late 1990s instead of the observed 15,000–20,000. But Harris presented this as a single-year counterfactual, as though merely to say that things were worse than they looked in 1999.

We have two standard measures of the trend in serious violence: the homicide rate and the aggravated assault rate. Both are distorted. The homicide rate is distorted by improving medicine, which makes the same number of attacks produce fewer deaths over time. The aggravated assault rate is distorted by changing reporting and classification practices: expanded reporting and definitional drift inflated the count through the early 1990s, while CompStat-era downclassification pressure may have deflated it afterward. To thread the needle and satisfy my own curiosity, I hacked together a third trend line by dividing the medical improvement out of the homicide rate. The resulting point estimates aren't very meaningful (this is not a literal count of attempted murders). But the *trend* is less distorted than either alternative, because it starts from hard death counts and adjusts using clinical data that doesn't depend on crime reporting.

# The vanishing decline

I put together [some interactive charts](/assets/files/murder_medicine.html) illustrating this adjusted trend line. The adjusted trend tells a different story than the raw homicide rate: the 1965–1980 increase is steeper than the raw numbers suggest.

The raw homicide rate fell 57% from the 1991 peak to the 2014 trough. After adjustment, the firearm-lethality-adjusted rate fluctuates in a band from roughly 15 to 18 per 100,000 from 1980 through 2020, with no statistically discernible downward trend: an at-best-ambiguous decline of about 10% from the 1980 level, well within the noise of year-to-year variation.[^variance] The "great crime decline," attributed to lead abatement, legal abortion, broken windows policing, and approximately a hundred and twenty other causes, is roughly the same size as the improvement in trauma surgery over the same period.

[^variance]: This is a claim about the adjusted series as constructed: the year-to-year variance swamps the apparent trend. A separate question is how sensitive the adjusted series is to assumptions about denominator drift in the FBI data. If recorded firearm assaults were inflated by reporting improvements, the adjustment overcorrects and the true decline is larger. The convergence with the independent clinical proxy for 1964–1985 (within 10%) constrains how large this effect can be for that period, but does not eliminate it, and the two series diverge more widely after 1985.

The post-2014 homicide spike is almost entirely explained by increasing weapon lethality rather than increasing attacks. (On the post-2014 lethality reversal, see the [Council on Criminal Justice's 2025 report](https://counciloncj.org/trends-in-the-lethality-of-crime/).)

# Two different ways to divide out the medicine

About three quarters of US homicides involve firearms: roughly 60% in the 1960s, rising to about 80% by 2021.[^firearmshare] Knives, blunt objects, and fists make up the rest. The survivability of knife wounds and beatings has improved too, but not nearly as dramatically. This is primarily a story about what happens when you get shot.

[^firearmshare]: FBI Supplemental Homicide Reports via [BJS](https://bjs.ojp.gov/content/pub/pdf/htius.pdf). The firearm share was 57% in 1964, crossed 65% in the early 1970s, and has been 73–80% since the mid-1990s.

If you know how much more survivable a gunshot wound is today than it used to be, you can divide that improvement out of the observed homicide rate to get a trend line that isn't suppressed by medical progress:

> adjusted(year) = observed(year) × baseline_lethality / current_lethality(year)

I use two independent data sources for the lethality curve.

**Data source 1: Overall firearm lethality from crime statistics.** [Harris et al. (2002)](https://people.umass.edu/zguo/iraqi%20war%20/murder%20and%20medicine.pdf) calculated the ratio of firearm homicides to (firearm homicides + firearm aggravated assaults) using FBI data. This ratio dropped from 15.5% in 1964 to 5.4% in 1999. Harris used this to estimate a counterfactual homicide count for a single year. I use the same lethality curve as an input to the adjustment formula above, applied continuously across 1964–2020. This is the orange line in Chart 1 and the purple line in Chart 3.

This data source has a known problem: the denominator, FBI-reported aggravated assaults, has been inflated over time by changes in reporting practices and definitions unrelated to actual violence, which makes the lethality ratio decline look larger than the actual improvement in survival. [Andresen (2007)](https://utppublishing.com/doi/10.3138/cjccj.49.2.185) replicated the analysis for Canada using attempted homicides instead of all assaults and found no lethality decline at all. The Harris data uses *firearm* assaults specifically, which should be more robust to reporting drift than all aggravated assault, since there's less ambiguity in whether a shooting occurred than in whether a bar fight qualifies as "aggravated." But just to be sure, I also use a second data source that doesn't depend on crime reporting at all.[^1]

[^1]: Eckberg (2014) challenged Harris using the National Crime Victimization Survey instead of UCR data, finding stable lethality 1973–1999 rather than declining. [Scott Alexander cites this](https://www.astralcodexten.com/p/record-low-crime-rates-are-real-not) as evidence against the medical-suppression thesis. But Eckberg's "lethality" is a chimera: homicides from vital statistics divided by assaults from a survey of 240,000 people (yielding roughly 1,000 aggravated assault victims per year). That's a ratio of two quantities measured by completely different instruments with different biases and coverage. Harris at least uses numerator and denominator from the same system, so some systematic biases cancel. Meanwhile the NCVS can't disaggregate by weapon type, can't measure homicide at all (dead people don't answer surveys), and assault (albeit not specifically aggravated assault) is the worst-recalled crime in the survey. In fairness, my own adjustment also mixes data sources (vital statistics deaths adjusted by clinical surgical case fatality rates), but the adjustment factor comes from a different *kind* of measurement (hospital outcomes for a specific wound type) rather than a different survey trying to measure the same population-level count with different biases.

**Data source 2: Abdominal gunshot wound survival from clinical literature.** Hospital data on the mortality rate for abdominal gunshot wounds provides a lethality curve independent of crime reporting. Overall gunshot mortality blends abdominal, thoracic, head, and extremity wounds with very different survival profiles; the abdominal series is not measuring that. Abdominal GSW mortality is valuable as an available like-for-like proxy for medical capability generally: the rate of improvement in trauma care's ability to save people with a specific wound type.

The chart uses seven anchor points, interpolated linearly:

- **1900:** 87% mortality[^anchor1900]
- **1918:** 45% mortality[^anchor1918]
- **1960:** 30% abdominal GSW mortality[^anchor1960]
- **1988:** 12% abdominal GSW mortality[^anchor1988]
- **1995:** 9.5% abdominal GSW mortality[^anchor1995]
- **2010:** 11% abdominal GSW mortality[^anchor2010] (*higher* than the 1990s, reflecting worsening injury severity: more shots per victim, higher caliber, more critical-region hits)
- **2020:** 8% mortality[^anchor2020]

[^anchor2020]: Extrapolated from the TQIP trend (11% in 2010 to 9.4% in 2014). No post-2014 national abdominal-specific series is available.

Corroborating data not used as anchors:[^corroboration] Memphis overall assault lethality 11.4% in 1935, 5.5% in 1960, 3.2% in 1985 (Giacopassi et al.); Vietnam-era KIA ratio fell from 29.3% (WWII) to 19%, with helicopter medevac cutting wounding-to-surgery time from 4-6 hours to 35 minutes (1968-1975).

[^anchor1900]: Civil War abdominal GSW mortality was 87% per [Barr et al. 2023](https://pmc.ncbi.nlm.nih.gov/articles/PMC10513126/), and persisted through the [Spanish-American](https://ajronline.org/doi/10.2214/ajr.174.5.1741233) and [Boer](https://pmc.ncbi.nlm.nih.gov/articles/PMC1570575/) Wars despite aseptic technique, because antibiotics and blood transfusion did not yet exist.

[^anchor1918]: WWI forward hospitals [reduced military abdominal wound mortality from 65% to 45%](https://pmc.ncbi.nlm.nih.gov/articles/PMC1421143/). Since this improvement mainly corrected the military's inferior hospital access, 45% approximates civilian practice of the same era.

[^anchor1960]: [Wilson & Sherman 1961](https://pubmed.ncbi.nlm.nih.gov/13698874/), "Civilian Penetrating Wounds of the Abdomen," 494 cases at a single hospital. Pre-EMS, pre-trauma systems, but with antibiotics and blood banking.

[^anchor1988]: [Demetriades et al. 1988](https://pubmed.ncbi.nlm.nih.gov/3421760/), 300 consecutive abdominal GSW cases at an urban Level I trauma center. Found 88.3% survival (11.7% mortality).

[^anchor1995]: Consensus across multiple 1990s series, cited by [multiple papers](https://www.sciencedirect.com/science/article/abs/pii/S0020138399002478) as the standard figure for abdominal GSW mortality at trauma centers during this period.

[^anchor2010]: [ACS Trauma Quality Improvement Program](https://pubmed.ncbi.nlm.nih.gov/32380348/) national database, 16,866 abdominal GSW patients (2010-2014). Found 11% mortality in 2010 declining to 9.4% by 2014. The 2010 figure is higher than the 1990s consensus, consistent with worsening injury severity (more wounds per victim, higher caliber) partially offsetting continued improvements in care.

[^corroboration]: The estimates are synthesized from scattered military and civilian series, not a single longitudinal dataset. [Barr et al. 2023](https://pmc.ncbi.nlm.nih.gov/articles/PMC10513126/), "'Through and Through' History," reviews GSW management from the 14th century to the present and is the best single overview. [Giacopassi et al. 1992](https://doi.org/10.1177/0022427892029004002) examined Memphis police homicide files at 25-year intervals, corroborating the mid-century improvement. The Vietnam-era killed-in-action ratio fell from [29.3% in WWII to 19% in Vietnam](https://achh.army.mil/history/book-vietnam-orthovietnam-ch01/).

Between the anchors, the chart interpolates linearly. The steepest improvement is 1900-1918, followed by 1960-1988 (Vietnam-era surgical advances, 911/EMS, regionalized trauma).

Before 1966, American ambulances were predominantly operated by funeral homes, which seems like a conflict of interest.[^ambulances] Two men would arrive with a stretcher and no medical equipment; treatment happened at the hospital or on the embalming table. The 1966 Highway Safety Act set the first federal standards for emergency medical care, and most funeral homes exited the business.

[^ambulances]: See the [National Academy of Sciences 1966 report](https://nap.nationalacademies.org/catalog/9978/accidental-death-and-disability-the-neglected-disease-of-modern-society) "Accidental Death and Disability: The Neglected Disease of Modern Society," which documented the state of emergency medical services and prompted the Highway Safety Act.

I guess if multiple members of your family got shot, you'd pay a lot of attention to trauma medicine. Both my grandfathers had serious heart attacks, so I grew up paying attention to heart attack propaganda: call 911 immediately, because the patient needs to reach the hospital within sixty minutes of symptom onset. That's how I learned about the "golden hour." But the golden hour didn't come from cardiology. It came from people getting blown up in Vietnam.

Helicopter medevac in Vietnam cut the time from wounding to surgery from 4–6 hours (the Korean War average) to about 35 minutes, and the killed-in-action ratio fell from 29.3% in WWII to 19% in Vietnam. The combat medics who developed these techniques became the model for civilian EMTs; the first standardized EMT training program was published in 1967, and the military's helicopter evacuation model was directly adapted into civilian trauma centers in the early 1970s.

Around the same time, the US government declared war on cancer, drugs, and Vietnam, all three of which still exist despite billions of dollars poured into their respective wars. What made trauma deaths different? I think there are two answers. First, in the war on cancer, progress looks hard to distinguish from grift on 1 year timelines, while rushing someone to the hospital in 1 hour rather than 2 seems verifiable at lower levels of fidelity, like 30 minute pizza delivery. Second, there's money to be made in illegal drugs, but gunshot wound mortality wasn't a revenue stream for anyone involved in the process except the undertakers, and it was never a large percentage of their revenue, so there was no institutional resistance to actually solving the problem. Oh, and the Vietnamese fought back.

While the abdominal series reflects these improvements, it does not capture changes in injury composition: if the average shooting victim in 2020 arrives with more wounds to more body parts than in 1970, the abdominal CFR overstates the population-level rescue effect. The firearm lethality data (Data source 1) implicitly captures this because it measures deaths per assault incident, not deaths per wound type. For this reason, the firearm lethality curve is the primary data source; the abdominal GSW curve is a secondary confirmation of the trend.

Plugging this curve into the same adjustment formula gives the green line in Chart 3 and extends the picture back to 1933 (before FBI data begins) using vital statistics homicide rates.

This adjustment is an upper bound. Some fraction of homicide victims (those with instantly fatal head wounds, those dead on scene before any care is possible) die regardless of the era's medical capability. If 10–15% of homicides are medically invariant, the true adjustment for recent decades is roughly 60–80% of the displayed values.

Where the two adjustment series overlap (1964–2020), they track closely for the first twenty years, then diverge. Both series agree on two things: the steep rise from 1964 to 1980, and a wobbly plateau rather than a clear trend in either direction post-1980. They disagree on the shape of the wobble.

From 1964 to 1985, the two adjusted series track within 10% of each other,[^sameshape] notably close given that one depends on FBI crime reports and the other on clinical surgical outcomes, with no shared data. From 1986 to 1999, the abdominal series shows a spike (peaking at 1.5× the firearm series around 1990) then returns to parity by 1999. That's the problem with independent sources, but if we can find out why they diverge, the we can decide how to interpret the divergence.

[^sameshape]: From 1964 to 1985, the ratio of ABD-adjusted to FL-adjusted rates stays within 0.975–1.098. From 1986 to 1999, the ABD series spikes to 1.49× FL at 1990, then returns to 1.02× by 1999. Post-2000 the ratio drops below 1.0, hitting 0.72 at 2010 (as abdominal mortality ticked back up with worsening injury severity), then crosses back above 1.0 around 2016 and reaches 1.32 by 2019.

During the crack era, the shift from revolvers to higher-capacity semiautomatic pistols and from smaller to larger calibers meant more wounds per victim and more multi-region injuries, exactly what the abdominal series isn't tracking. [Webster et al. (1992)](https://pubmed.ncbi.nlm.nih.gov/1596170/) documented this at a DC trauma center: mean entrance wounds per patient rose from 1.44 to 2.04 between the pre-crack and crack periods.

The abdominal series measures survival from a specific wound type and keeps dropping as medicine improves; the firearm lethality ratio measures deaths per shooting incident and captures the worsening injury severity that the abdominal series misses. When injuries get more severe, the firearm fatality ratio rises even as the medical loss curve keeps falling. (This is also what seems to have happened in 2020.)

After 2000, the series diverge in the opposite direction.

The abdominal series has lower temporal resolution (fewer anchor points, so it can't track short-term movements) and noisier anchors (some are single-center case series, others are multi-center or consensus figures, and they span different eras of trauma system organization). The firearm lethality series is more trustworthy for year-to-year movements. The abdominal series is useful as a check that the overall direction is real and not an artifact of assault-count contamination.

# The homicide-assault ratio

The adjustment formula isn't the only evidence that medicine is suppressing the homicide trend.

If violence were declining at the same rate as reported homicide rates, the ratio of homicides to aggravated assaults should be roughly constant: the same attacks should produce deaths at the same rate. Instead, the ratio fell by a factor of 3.5, from about 59 homicides per 1,000 aggravated assaults in 1960 to about 17 per 1,000 in 2000, where it roughly stabilized.[^haratio]

[^haratio]: Computed from [FBI UCR](https://ucr.fbi.gov/crime-in-the-u.s) homicide and aggravated assault rates: 5.1 homicides and 86.1 aggravated assaults per 100,000 in 1960 (ratio 59.2 per 1,000); 5.5 and 324.0 in 2000 (ratio 17.0 per 1,000).

Part of this reflects expanded assault reporting. In the early 1960s, most police departments kept paper records and relied on victims to walk into a station. The rollout of 911 systems in the late 1960s and 1970s made reporting easier. (I guess that explains why there was a lot of only slightly dated 911 propaganda around when I was growing up in the '90s.) Police professionalization and computerized records meant more incidents got written up. Domestic violence, largely ignored by police before the 1980s, began generating assault charges. And the legal boundary of "aggravated" drifted outward: the FBI classifies pepper spray, Tasers, and BB guns as dangerous weapons for UCR purposes. [O'Brien (2003)](https://www.sciencedirect.com/science/article/abs/pii/S0049089X03000145) documented the broader pattern, arguing that long-term UCR increases in assault rates reflect reporting and recording improvements rather than actual increases in violence. But even generous estimates of reporting drift account for perhaps half the 3.5× decline in the ratio. The remainder is consistent with the medical improvement thesis: the same number of serious assaults producing proportionally fewer deaths over time.

After 1994, the reporting drift may have reversed direction. The NYPD's CompStat system, introduced that year, held precinct commanders accountable for index crime numbers, creating institutional pressure to make those numbers go down. One way to do this legitimately is better policing; another is to reclassify borderline felony assaults as misdemeanors, which don't count in the index. [Eterno and Silverman (2012)](https://books.google.com/books/about/The_Crime_Numbers_Game.html?id=Fg3tTqt9I5IC) documented this practice extensively. In NYPD data from 2000 to 2009, felony assaults fell 42% while misdemeanor assaults fell only 9%, a divergence hard to explain without systematic downclassification.[^compstat] CompStat spread to most major US police departments during this period.

Recorded aggravated assault fell roughly 30% from the early-1990s peak to the early 2000s. A reclassification rate of 3 percentage points per year, compounding through a ratchet effect where each year's downclassified baseline becomes the next year's starting point, would account for the entire recorded decline. The true contribution is probably smaller, but it need not be large to meaningfully affect lethality ratios.

The Harris firearm lethality data uses specifically *firearm* aggravated assaults as its denominator, not all assaults. A shooting is inherently less subject to reporting drift than a borderline bar fight that might or might not get classified as aggravated. Under [UCR rules](https://ucr.fbi.gov/crime-in-the-u.s/2019/crime-in-the-u.s.-2019/topic-pages/offense-definitions), any assault involving a firearm is classified as aggravated by definition, regardless of injury; simple assault explicitly excludes incidents involving firearms. A precinct commander under CompStat pressure can downgrade a borderline bar fight from aggravated to simple, but cannot do the same with a shooting. The firearm assault count is still subject to changes in reporting completeness (whether the incident gets a report written at all), but not to the felony-to-misdemeanor reclassification that Eterno and Silverman documented. This means the Harris firearm-specific lethality ratio is substantially more robust to CompStat-era distortion than the all-assault ratio discussed above.

[^compstat]: Eterno and Silverman's data on the felony/misdemeanor assault divergence is from *The Crime Numbers Game* (2012), drawn from NYPD non-index crime data obtained via lawsuit in 2010. An [independent audit](http://thenewyorkworld.org/2013/07/03/compstat/) commissioned by Commissioner Kelly confirmed that "misclassification of reports may have an appreciable effect on certain reported crime rates." Similar practices have been documented in [Atlanta, Baltimore, Dallas, New Orleans](https://clcjbooks.rutgers.edu/books/crime-numbers-game/), and agencies in the UK, Australia, and France.

ETA 8 Mar 2026: A few days after publishing this, I figured out a likely explanation for why homicide and aggravated assault diverged so much. Between the late 1970s and the early 1990s, aggravated assault grew noticeably faster than the medically adjusted homicide trend, and then declined during the following period in which medically adjusted homicide was flat. This seems to contradict not only the hypothesis of a single crime trend, but the hypothesis of a single violent crime trend. The explanation is incentives. Some aggravated assaults are really attempts to kill someone, others aren't. Expanded reporting (and more willingness to construe previously neglected categories like domestic violence as aggravated assault) functionally increased the penalties for trying to beat someone up severely but not kill them (or any other marginal aggravated assaults), while leaving the effective penalty for trying to kill someone unchanged. Eventually people noticed and were deterred from marginal aggravated assaults, while there was no change in homicide behavior because there was no change in homicide deterrence.

# Everything behind locked glass

Property crime, car theft, robbery, and survey-measured victimization all declined after 1990. Scott Alexander makes this case in detail in [Record Low Crime Rates Are Real, Not An Artifact](https://www.astralcodexten.com/p/record-low-crime-rates-are-real-not), arguing that these parallel declines confirm the homicide decline was genuine. Doesn't the coherence across categories suggest the homicide decline was real too?

These categories are consistent with a decline in some forms of criminal activity, and nothing in the medical adjustment contradicts that. But observed crime rates reflect prevention expenditure and enforcement thresholds, not just underlying criminal intent. A pharmacy with nothing behind locked glass is not the same crime burden as one with the same shoplifting rate but everything behind locked glass. A city that stops prosecuting thefts under $950 has fewer recorded thefts without anyone stealing less. As Scott himself [acknowledges](https://www.astralcodexten.com/p/crime-as-proxy-for-disorder), the relationship between recorded crime and the experienced burden of disorder is loose. It's unclear how much recorded crime trends in property categories reflect changing behavior versus changing measurement.

Shootings are the category least subject to this. They get reported regardless of policing philosophy or prosecution thresholds, and you can't reduce them by making everyone walk around in bulletproof glass display cases.[^2]

[^2]: If would-be shooters are emboldened by the lower probability of a murder rap, the lower expected penalty could even increase the rate of shootings, making the medical adjustment conservative rather than aggressive. This is probably most relevant to those who shoot people as part of some other vocation such as robbery. True amateurs, who kill from causes like anger, on the other hand, could even be discouraged by the lower probability of the closure provided by the death of one's enemy, or they could try to inflict more severe wounds.

# Fewer young people, more violence per young person

The US population aged 15–29, the peak offending demographic, shrank from 27.4% of the population in 1980 to about 20% in 2020, a 27% decline.[^demographics] This age group commits roughly half of all homicides ([BJS, 1980–2008](https://bjs.ojp.gov/content/pub/pdf/htius.pdf)), so the demographic shift alone predicts about a 14% decline in homicide rates, all else equal.

[^demographics]: US Census Bureau, population by age via [FRED](https://fred.stlouisfed.org/series/SPPOP1529TOZSUSA).

The raw homicide rate fell 36% from 1980 to 2020, well beyond what demographics explain. But the firearm-lethality-adjusted rate shows no decline. After removing the medical artifact, the age-adjusted rate of lethal-intent violence *increased* above 1980 levels, peaking around 2005.[^ageadjusted]

[^ageadjusted]: I estimate the age-adjusted trend using the per-young-person (15–29) rate rather than a formal age-standardization across all cohorts. The 30–44 age group, responsible for another 30% of homicides, also shrank, from about 22% to 19% of the population over the same period. A formal adjustment accounting for both cohorts would likely show an equal or larger increase in underlying violence.

What's more, the US incarceration rate went from 220 per 100,000 in 1980 to 744 per 100,000 in 2010, a 3.4× increase.[^incarceration] By 2000, roughly 3.5% of all 15–29-year-olds were locked up, versus 0.8% in 1980. So you had a smaller crime-prone population, vastly more incarceration, and vastly better medicine, and the adjusted rate still went up. The underlying propensity toward lethal violence increased substantially during the "great crime decline."

[^incarceration]: [BJS Prisoners Series](https://bjs.ojp.gov/library/publications/prisoners-2020-statistical-tables). Total incarceration (state + federal) per 100,000 US residents.

Most of the literature explaining the great crime decline is explaining the wrong thing. The question is not "why did Americans become less violent after 1990?" but "why did Americans become so much more violent after 1965, and why haven't we stopped?"

___

# Caveats

Pre-1933 data is unreliable due to incomplete death registration, so the adjusted series starts at 1933. The ideal additional check would be a long-run national series on nonfatal firearm injuries (ED visits, hospitalizations) independent of crime reporting; no such dataset currently exists at the national level. CDC's WISQARS nonfatal injury data begins only in 2001 and the CDC itself flags it as unreliable for firearm injury trend estimation.

The adjustment is most informative for the US specifically. Homicide declined in Western Europe too, roughly 33% from 1990 to 2020, and Europe didn't have the same trauma care revolution in gunshot survival, which might seem to undermine the medical-artifact thesis. But American and Western European homicide operate in fundamentally different regimes. American homicide rates are roughly 8× higher than Western European rates and dominated by firearms (75% of US homicides); European homicide is knife-dominated and occurs at rates so low that a handful of incidents per year visibly moves a small country's statistics. The medical artifact is roughly proportional to the share of violence involving firearms multiplied by the improvement in gunshot survival; both factors are much smaller in Europe. Western European countries also share enough economic integration, demographic trends, and cultural shifts that their "independent" declines are more like one data point measured several times than several independent replications. European trends tell us essentially nothing about the size of the American medical artifact.