• firearms
• homicide
• suicide
• international policy

This journal often publishes papers on gun injury, almost all of them American. Readers on other shores could be forgiven for asking if the topic concerns them, given the sharp disparities in firearm related mortality. For example in the United States, 4% of the world population possesses 50% of the planet's privately owned firearms^1,2; America's gun death rate stands head and shoulders above those of 35 similar high and upper middle income nations.³ Of the 35, 29 suffer less than half the firearm related death rate in the United States.

Despite a recent spike in drug related shootings in a handful of cities including London, a resident of England or Wales remains 26 times less likely to die by gunshot than an American. In Japan, the risk of gun death is at least 100 times lower than in the United States.

Yet America is far from alone in suffering high rates of firearm related mortality. Close competitors include Mexico, South Africa, Colombia, Estonia, and Brazil^3,4—nations with whom Americans rarely see themselves in the same league.

As the World Health Organization, the Small Arms Survey and others push out the fringes of research into gun death, it seems clear that worse is to come. In scores of less wealthy countries the toll has barely been measured—entire societies which lack the resources to accurately count injury deaths, let alone centralise data on method or intent.

In South Africa, where firearm mortality overshadows all other external causes of death, and whose data collection is among the most effective in the Global South, only one third of unnatural death records are available for analysis.⁵ Even that fraction is perforce an estimate. The current discussion of inadequacies in United States firearm related health data⁶ highlights the comparative transparency (and excellence by world standards) of American gun death and injury statistics.

That said, best estimates show that gunshots cost us 500 000 lives each year, worldwide. Of these, 300 000 people die in regional conflict and 200 000 in interpersonal violence and suicide.⁷ The majority of victims are non-combatants, many of them women and children. Where estimates are available, non-fatal firearm related injuries are said to number three for every gun death.⁸

Gun injury has been labelled a “disease” (American Medical Association, International Red Cross), a “public health emergency” (Centers for Disease Control), an “epidemic” (US Surgeon General), and a “scourge” (UN Secretary General, the Vatican).

The global proliferation of small arms increases both the lethality of violent encounters and the number of victims. With 639 million firearms in circulation worldwide,⁹ guns increasingly transform minor disputes into shootings and make it easier for children to become killers. In Papua New Guinea, intertribal disputes once settled with bows, arrows, and machetes are now fought out with firearms. Across great swathes of Africa and South Asia, child soldiers are enabled with AK-47s, exploited by adult combatants, their lives ended or distorted, their weapons still available for banditry and domestic violence even if peace does arrive.

No community seems immune from this pandemic of gun violence. It overwhelms health services and undermines personal security, economic development, good governance, and human rights.

And the involvement of the public health community will be crucial to any solution.

The emergency room is no place for geopolitics or for blame. To a trauma surgeon delving into gunshot wounds in Pretoria, London or Islamabad, it matters little if the weapon was fired by a terrorist/freedom fighter, by a mobster, a soldier, or an angry husband. Nor does it matter if the gun was military in appearance or had previously been used only to shoot pigeons. Whether the gunshot is by accident, suicide, crime or conflict, the damage done to the victim, the family, and wider society is remarkably similar.

Public health professionals are ideally placed to act as lynchpins for firearm related policy swings in their own countries. When guns are discussed and regulated matter-of-factly as vectors of injury, ideological barriers can be moved aside, much as they were in the prevention of HIV/AIDS.

Then the healing—and even more importantly, the prevention—can proceed.