By Beryne Odeny (Washington University in St. Louis, Department of Surgery) and Julia Robinson (PLOS Global Public Health) The first in-person CUGH…
By guest contributors Rashi Jhunjhunwala, MD MA; Arturo Cervantes Trejo MD MPH DrPH; Pablo Tarcisio Uribe-Leitz MD MPH; John Lindsay-Poland, Keith Martin MD PC; Stephen Hargarten MD
What’s the Problem?
When investigating the epidemiology and impact of infectious disease outbreaks, researchers examine all characteristics of biologic injury, evaluate and address elements of disease, and seek efficient prevention strategies and responses. The success of these interventions is rooted in utilizing evidence-based public health strategies, political support, multisectoral participation, adequate funding, and community engagement. Despite overwhelming evidence of the impact of firearm-related violence and injury, why doesn’t this tragic humanitarian problem lead to a similarly coordinated response?
By the Numbers
Each year, firearm-related violence is responsible for tens of thousands of deaths, debilitating injuries, and economic and social losses worldwide. Between 2010 and 2020, firearms caused almost two million fatalities. In 2016, according to the Global Burden of Disease Report, close to 60,000 people younger than age 24 died from firearm-related wounds delivered through either intentional or unintentional acts. This violence disproportionately affects Latin America. The same 2016 report showed that about 35% of worldwide firearm-related deaths occurred in only five countries: Brazil, Colombia, Guatemala, Mexico, and Venezuela. Despite these estimates, agencies cannot determine the exact number of deaths from bullets, and much less is known about the non-fatal number of disabling firearm wounds. Moreover, humanitarian crises in Mexico, Central America, Colombia, and Brazil are exacerbated by violence due to the wide availability of firearms. In 2018, of Guatemala’s 3,227 homicides, 80% were committed with firearms. In 2019, 71% of Mexico’s 34,582 homicides were committed with firearms, as were 73.1% of homicides in El Salvador and 73% in Honduras. In response to this violence, families, particularly from Central America, are fleeing for safety in increased numbers, either heading for the US border or being internally displaced. The scope of this complex problem has multiple downstream implications for safety, security, and immigration.
Gun Violence and the Epidemiological Triad
The gun violence prevention community can learn from infectious disease initiatives. The same principles of public health sciences can be applied to the prevention of injuries from bullets and guns. The designation of public attention and resources for infectious diseases has been facilitated by the epidemiological model of infectious disease causation as well as a public health model of disease management. Both the epidemiological triad of host, agent, and vector/environment and the public health approach of defining the problem, identifying risk and protective factors, developing prevention strategies, and ensuring adoption can be used to frame and address the pandemic of firearm violence.By utilizing the disease model and public health sciences, we can test, implement, monitor, and evaluate programs and policies that address the following: 1) high risk behaviors (host), 2) agent of disease (bullets) 3) vector of disease (firearms), 4) and high-risk environments that facilitate violence (physical, social, and policy environments).
Dr. Rodrigo Guerrero took this approach 30 years ago in Cali, Colombia to address the high volumes of homicide and firearm-related injury at the start of his 1992 Mayoral term. Dr. Guerrero mapped out where and when homicides were likely to occur, creating a visual representation of the problem, its perpetrators, and risk factors for higher incidence of violent behavior. He found that many deaths occurred over the weekend, and victims were likely to be intoxicated. This prompted restrictions on alcohol sales as well as limitations on when firearms could be legally carried. While these policy changes faced challenges from certain sectors, evaluation of their effects revealed a dramatic drop in hospital admissions for violent injury.
From Evidence to Policy
Investment in and broad uptake of evidence-based programs such as this are effective in reducing gun violence. Research is critical to provide policymakers with data to form a path forward which addresses gun violence in a manner that can garner broad support. This can only be undertaken with increased financial investment. In the United States, after more than 20 years of funding neglect, Congress allocated $25 million US dollars to two US federal agencies (CDC and NIH) to study gun violence in 2019, and recommended $50 million in FY2022. These steps allow for further delineation and understanding the full burden of disease.
Next, we must create, implement, and evaluate policies and programs that can prevent and intervene in host and environmental factors that contribute to violence. In 2012 when Dr. Guerrero again became Cali’s mayor, the preponderance of violent deaths had shifted from interpersonal disputes to organized crime. Increased social inequality also contributed to environmental facilitators of violence. This example shows the complexity of the factors that lead to violence. One neglected driver of the massive amount of gun violence in Latin America is firearms trafficking and exports from the US. The recent lawsuit by Mexico against US gun manufacturers, which accuses the companies of marketing weapons directly to drug cartels, indicates that some nations are prepared to start holding gun companies accountable for the damage their products cause.
But there remain large gaps of knowledge about firearms across the Americas that require investigation. We need to better understand which factors increase demand for weapons (e.g. organized crime linked to trafficking of drugs, people, wildlife and other illicit markets, as well as social conditions that promote violent behaviors), which contexts reduce their flow (e.g. strong governmental oversight) and reduce demand (e.g. addressing the social determinants of health such as increasing opportunities for youth in their local contexts). With regards to guns themselves, greater attention to legal sales and illicit trafficking of this vector and its flow through borders and communities can provide contextual evidence of where this violence is most often taking place.
Leaders of civil society across sectors must collaborate in efforts to stem the uncontrolled transfer of guns to Latin America, invest in gun violence research, and develop and strengthen the implementation of programs and policies that address firearm violence. These efforts would benefit from deploying evidence-based public health principles that have been proven to stop the spread of infectious diseases to address the pandemic of firearm violence. We must be collectively fearless in speaking out and demand that this neglected global health pandemic threat be comprehensively addressed, as we have for COVID-19, malaria, dengue, and zika. Our future depends on it.
About the Authors:
Rashi Jhunjhunwala MD MA is a general surgery resident at Beth Israel Deaconess Medical Center and Chief Fellow at the Program in Global Surgery and Social Change at Harvard Medical School. Her clinical interests are in trauma surgery and critical care, and her research interests are in the ethics of global surgery and surgical care delivery, disparities in surgical access, and health equity and anti-racism training and education. Twitter: @rashijjw
Arturo Cervantes Trejo MD MPH DrPH is a professor and chair of public health at the Faculty of Health Sciences, Anahuac University Mexico, and active member of the Violence Prevention Alliance of the World Health Organization. He is also a member of Stop US Arms to Mexico, a project of Global Exchange. Twitter: @ahaukine
Tarsicio Uribe-Leitz MD MPH is a faculty member at the Program in Global Surgery and Social Change at Harvard Medical School, Instructor in Surgery at Harvard Medical School, Investigator at the Center for Surgery and Public Health at Brigham and Women’s Hospital, and a PhD candidate in Epidemiology at the Technical University Munich. Twitter: @TatoUribeLeitz
John Lindsay-Poland is a writer, activist, researcher and analyst focused on human rights and demilitarization, especially in the Americas. He has written about, researched and organized action for human rights and demilitarization of US policy in Latin America for 30 years. He coordinates Stop US Arms to Mexico, a project of Global Exchange. Twitter: @johnlp3; @stopusarmstomx
Keith Martin MD PC is a physician who, since September 2012, has served as the founding Executive Director of the Consortium of Universities for Global Health (CUGH) Twitter: @keithmartinmd
Stephen Hargarten MD, MPH, is a Professor of Emergency Medicine at the Medical College of Wisconsin, (MCW). He currently serves as the Senior Injury and Policy Advisor for the Comprehensive Injury Center at MCW. He is the founding Dean of Global Health at MCW and the former chair of the Emergency Medicine Department. Twitter: @HargartenSteve; @GVPAmericas