Confronting the small arms pandemic:
Unrestricted access should be viewed as a public health disaster
Neil Arya
BMJ 2002; 324: 990-991: April 27, 2002.
Physicians throughout the world bear witness to the terrible consequences of small arms as weapons of war and violence. But do we truly understand the impact and the epidemiology of the small arms pandemic, and can we devised effective strategies for prevention as we have for other major public health issues?
The capacity for collecting consistent, reliable, and relevant data for evaluation is limited by various cultural, economic, infra-structural, and logistical factors even in countries of the Global North and in non-war situations. Nevertheless, we have some solid data of the magnitude of the problem and indicators suggestive of approaches to solutions.
The US for instance, has more than 28,000 deaths per year from small arms -- accidents, suicides, and homicides -- by far the highest rate in the developed world (1). In that country firearms are the leading cause of death in the age 15-24 category, slightly ahead of motor vehicle accidents, and are the third leading cause of death in the under-15 age group (2). While the US murder rate without guns is roughly equivalent to that of Canada (1.3 times), its murder rate with handguns is 15 times the Canadian rate (3). Countries with similar cultural, economic, and ethnic makeup but with widely different gun possession rates also had widely differing firearm death rates, roughly correlating with the percentage of households with guns (4). For example, Britain's firearm death rate is about 0.3/100,000 while the US rate is 11.4 (5). Households with firearms are three times more likely to have murders and five times more likely to have suicides (due to all causes) than similar households without firearms (6,7). These data suggest that firearms' deaths may be preventable, by controlling supply and possession.
Data from the Global South is less clear, especially in conflict situations. In many post-conflict countries in Central America and Africa, only a tiny percentage of guns are registered, estimates of the total in circulation vary widely, and reporting of casualties may be affected by fear of authorities. Small arms nonetheless were unarguably the primary cause of death in war situations in the 1990’s, believed to cause about 300,000 deaths per year(8). Together with the estimated 200,000 people die each year from firearms in non-conflict situations these deaths represent about a quarter of the 1.8-2.3 million deaths due to violence in a typical year in the 1990s (9,10). The victims are often the youngest and healthiest members of society. Male combatants are the major perpetrators and direct victims of small arms violence, but in many conflicts non-combatants -- disproportionately women and children -- account for a large proportion of direct casualties and may also suffer the psychological and social burdens of increased domestic violence.
Impacts have also been evaluated in economic terms. Small arms purchases account for perhaps US$10 billion each year, a relatively small proportion of the roughly $850 billion spent on military forces annually worldwide (11). Yet the economic consequences can be far greater. In Colombia, violence primarily related to small arms has been calculated as costing up to 25% of the country's GDP (12).
Unless weapons are removed when hostilities end, casualties may not be substantially reduced. In the mid 90s in Afghanistan, for example, Meddings and the ICRC found a decline in the rate of weapons-related injury before and after a particular region came under uncontested control of only 20-40% when weapons remained in circulation (13).
Supply-side strategies such as buyback and amnesty schemes have been tried in countries such as the UK and Australia. In response to massacres at Dunblane and Port Arthur, those countries tightened regulations, the former banning handguns and the latter semi-automatic rifles. British citizens voluntarily turned in 250,000 weapons, while the Australian buyout program netted 750,000. Law enforcement officials in both countries affirm the effectiveness of these measures in reducing damage to these weapons.
Many say that a supply side approach alone is inadequate and various demand side measures to reduce impact have been proposed. Awareness building and educational programmes to promote cultures of peace; international norms that stigmatize the possession of guns and programmes to reintegrate former combatants into local society and to provide real economic opportunities have all been postulated to reduce harm from small arms, but are more difficult subjects of study. In Mozambique, a unique project: Tools for Arms combines supply and demand side approaches. The buyback of weapons, the metal of which is turned into art, provides compensation for gun owners, giving them new economic opportunities.
International humanitarian law may be applied to restrict weapons that cause damage disproportionate to war aims. Whole classes of weapons could be banned from civilian possession, just as landmines and other indiscriminately harmful weapons have been banned from military and civilian use. While it appears that to prevent harm due to small arms, North and South, combat and non-combat, restrictions and regulation of licit weapons are necessary, this has been fiercely opposed by highly-organized, wealthy and influential groups such as the National Rifle Association, which act both nationally and internationally. It is thought that the failure to reach meaningful agreement to control illegal manufacture and trafficking in small arms produced at the recent UN Conference on the Illicit Trade in Small Arms and Light Weapons was partly as a result of the lobbying efforts of these groups.
Public health models could be used to evaluate the effectiveness of each of the aforementioned approaches. International Physicians for the Prevention of Nuclear War (IPPNW) has used the public health paradigm to call for the abolition of nuclear weapons and to support the global ban on landmines. With the convening of an international medical conference on small arms this September in Helsinki, IPPNW announced its intent to campaign for policies that can reduce firearms-related deaths and injuries as part of its war prevention mission.
The conference drew more than 200 participants from six continents. These experts addressed the gaps in our knowledge, proposed areas for future research, and pondered educational and advocacy strategies. This was the first time that physicians, WHO and ICRC researchers, social scientists, peace activists, government representatives, and students came together to address the small arms issue from a public health perspective.
The next steps will be to determine relevant data on which to base recommendations for policy change and community action; to coordinate and standardise databases and collection methods in order to integrate research in the Global North and South; to heighten awareness about the public health and social consequences of small arms among local, national, and international policy makers; and to inform our professional colleagues, our students, and the public about the multiple causes and the devastating consequences of small arms violence.
We hope to further these initiatives at the IPPNW Congress in Washington, DC from May 1-5 and at the 6th World Congress on Injury Prevention and Control in Montreal from May 12-15, 2002.
References
1. Center for Disease Control Atlanta 2001 preliminary 2000 figures on website http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf
2. Centers for Disease Control and Prevention. Rates of homicide, suicide and firearm related death among children-26 industrialized countries. MMWeekly Report 1997;46:101-105.
3. Cukier W. Firearms regulation: Canada in the international context. Chronic Diseases in Canada April 1998.
4. Goldring N. Bridging the gap: light and major conventional weapons in recent conflicts. Toronto, Ontario: International Studies Association. 1997.
5. Christoffel, K., Cukier, W. Toronto/Chicago Nation Status Reports on Violence and Firearms-Safer-Net and the HELP Network 2001. Also see website www.ryerson.ca/SAFER-Net
6. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. New Eng J Med 1992;327:467-472.
7. Kellermann AL, Rivara FP, Rushforth NB. Gun ownership as a risk factor for homicide in the home. N Eng J Med 1993;329:1084-1091.
8.Project Ploughshares. Armed Conflicts Report 1996. Waterloo, Ontario: Institute of Peace and Conflict Studies. 1996.
9 Cukier W. Firearms/small arms; finding common ground. Canadian Foreign Policy 1998;6:73-87.
10. Reza A., Mercy JA, Krug E. Epidemiology of violent deaths in the world Injury Prevention 2001; 7:104-111
11. Boutwell J, Klare MT. A scourge of small arms. Scientific American June 2000:48-53.
12. Vieira, OV Ryerson Polytechnic University. Workshop on international small arms/firearms injury surveillance and research. Toronto. June 18, 1998.
13. Meddings D. Weapons injuries during and after periods of conflict: retrospective analysis. BMJ 1997;315:1417-1420.
Neil Arya is a family doctor in Waterloo, Ontario and is President of Physicians for Global Survival, the Canadian affiliate of International Physicians for the Prevention of Nuclear War, the recipient of the 1985 Nobel Peace Prize.