Firearms have overtaken car crashes as the main cause of premature deaths due to trauma in the US since 2017, finds research published online in the journal Trauma Surgery & Acute Care Open.
In 2018 men made up more than 85% of premature firearm deaths, with firearm suicides highest in older white men, and firearm homicides highest in young black men.
Firearm deaths, however, have been steadily increasing over the past decade, and the researchers wanted to find out if these have become the leading cause of premature death associated with trauma.
They analysed data from annual National Vital Statistics Reports (NVSR) for the years 2009 to 2018, the latest year for which data were available, and death certificates for each of the US states.
These firearm deaths were further stratified according to age, gender, injury intent, and geographical region—North, South, Midwest, and West—and compared with those for car crashes.
During the study period, the total 10-year cumulative years of potential life lost for car crashes and firearms added up to 12.9 million and 12.6 million, respectively.
But firearm deaths surpassed those of car crashes as the leading cause of traumatic death in 2017, with 1.44 million years of potential life lost compared to 1.37 million.
This trend continued into 2018, with 83,037 more potential years of life lost attributed to firearms than to car crashes.
Between 2009 and 2018, the annual percentage change in firearm deaths increased by 0.72 every year, while the annual percentage change in car crash deaths fell by 0.07 every year.
Analysis of injury intent showed that firearm suicides increased throughout the 10-year study period. They accounted for 18,735 trauma deaths in 2009, rising to 24,432 in 2018, and a parallel increase in potential years of life lost, rising from 571,720 to 741,869 in 2018.
Firearm deaths inflicted by the police or other law enforcement agents in the line of duty remained relatively static, with 333 deaths in 2009 and 539 in 2018.
Men made up most of the 38,929 firearm deaths in 2018, accounting for 33,258 (85+%).
A breakdown of ethnicity showed that firearm suicides were highest among white men in 2018, comprising nearly half (49%) of total firearm deaths, with those among the over 45s 46% higher than among the under 45s. Firearm homicides were highest among black men, comprising 18% of all firearm deaths.
Cumulatively, white men lost a total of 4.95 million potential life years due to firearm suicide over the 10 year period, equal to more than a third of the total for all firearm deaths, and more than double the figure attributable to firearm homicide: 1.7 million.
Black men lost the most potential life years due to homicide: a cumulative total of 3.2 million, compared with 0.4 million due to firearm suicide. Most firearm homicide deaths were among 15-24 year olds.
While the cumulative figure of potential years of life lost due to firearm homicide was lower among black men than those attributable to firearm suicide among white men, the younger age at which black men died increased the total for each death.
White women lost a total of 1.3 million potential years of life to firearm deaths throughout the study period, over half of which were firearm suicides.
Firearm suicides among women increased by 31.5% over the 10 year period; homicides rose by just under 10%. Black women lost more potential years of life to firearm homicide than to firearm suicide.
Regionally, the South had the highest cumulative total of potential years of life lost due to firearms (5.7 million), followed by the Midwest and the West. The Northeast had the lowest cumulative total: 35,789 years of life lost.
Official data show that in 2018 there were over 3 million registered firearms in the South, with Texas and Florida the two states with the highest number of registrations in the US.
The researchers acknowledge that the current average life expectancy in the US is 78.7 years, rather than 80, which they used for their calculations.
Nevertheless, the trend in premature trauma deaths associated with firearms is clear, they point out. The US alone is estimated to have 393.3 million firearms compared with 16.8 million in Mexico and 12.7 million in Canada.
They conclude: “Suicide is responsible for the most [years of potential life lost] due to firearm deaths, and continues to increase in the U.S. at an alarming rate. The predominant populations that are affected by firearm deaths are older white males secondary to suicide, and younger black males secondary to homicide.
“More resources should be redirected and allocated to these at-risk populations to decrease this potentially preventable cause of death and years of life lost.”
Firearm violence is a pressing public health issue that is growing on a global scale. Mortality from firearms contributes more than 250,000 deaths each year worldwide, yet firearms still hold a massive commercial industry, with over 1 billion weapons in circulation as of 2017 [1, 2]. 857 million of these firearms are in civilian hands; an estimate that has increased by 32% from 2006 .
Even as research on non-communicable diseases and injuries (NCDIs) continues to progress, the burden of firearms on global mortality has received less attention. In fact, research, reporting, and prioritization of firearm violence is often concentrated in high- income countries (HICs), despite this issue affecting all populations globally.
Given the increasing importance of firearm violence, this commentary aims to restate the impact of firearms on health using selected research on the burden of firearm violence. It will demonstrate how politics, globalization, and spread of culture and ideals influence firearm violence on a global scale, and recognizing the diversity in definitions of the term “global health,” provides three definitions to demonstrate how firearm violence ought to be framed as a global health issue [3–5]. The need to recognize firearm violence as a global health issue is important to support prioritizing research and creating sound interventions, especially in low- and middle- income countries (LMICs).
The impact of firearm violence
Injury and mortality rates from firearm violence, high-risk populations, causal factors, and societal issues which impact the rates of firearm violence are available from the Global Burden of Disease (GBD) data (Table 1). However, globally civilian populations share a majority of the burden of firearm violence; only 10% of mortality from firearms occurs in conflict situations [3, 6].
Mortality from firearms is also disproportionately concentrated in LMICs in South America, in addition to the United States; the GBD data from 2017 estimates that 50% of mortality from firearms occurred in countries that make up just 10% of the global population . Worldwide, populations see similar patterns of firearm mortality; in every country, death rates are higher for men than women, and often the highest risk is among 20- to 24-year-olds. The majority of firearm deaths globally are in fact as a result of homicides .
Mortality and Disability from Firearm Violence in 2017 (per 100,000)a
|Global Mortality and Disability|
|Type of Violence||Prevalence||Mortality||YLDs||YLLs||DALYs|
|United States Mortality and Disability|
|LMIC Mortality and Disability|
YLDs Years lost due to disability, YLLs Years of life lost due to premature mortality, DALYs Disability adjusted life years.
Overall, fatality from firearm violence in the US has not decreased in over a decade. This is even as homicide risk is decreasing and suicide risk increasing over time; around 70% of homicides and 50% of suicides in the US involve firearms . A disproportionate amount of these homicides are concentrated among black males; while white males have the highest risk for suicide by firearms, which also starts in younger populations and contributes to more than half of firearm mortality.
At-risk populations also differ geographically in the US; suicide rates are 54% higher in rural areas while homicide rates are 90% higher in urban centers. Given these types of statistics, the US is an outlier in mortality from firearms as compared to other nations worldwide.
The GBD data separates firearm violence into three categories- deaths from firearms, unintentional injuries from firearms, and self-harm from firearms . Collectively, mortality from these three categories contributes to over 250,000 preventable deaths per year, and over 46,000 Disability Adjusted Life Years (DALYs) lost (Table (Table1)1) .
Mortality from firearms is also significantly higher in LMICs; those in Central and South America, most notably Guatemala, Venezuela, and El Salvador, have mortality rates significantly higher at around 40 per 100,000 deaths as compared to the global average of 6 per 100,000 . 2400 per 100,000 DALYs are lost from physical violence in these countries, compared to a global average of 171 per 100,000 .
Firearm violence also places a substantial burden on healthcare systems, economies, and societies around the world. In 2010 alone, the societal costs of firearm violence totaled $164 billion, the equivalent of 1.1% of the gross domestic product (GDP) of the United States in that same year. The 2015 Global Burden of Armed Violence report noted that almost USD 2 trillion could have been saved in a decade if the global homicide rate had been decreased from 7.4 to 3 deaths per 100,000; this is the equivalent of 2.64% of global GDP from 2010 .
Factors that influence global firearm violence
The global political landscape directly influences firearm violence, particularly in LMICs . The dynamic between high-income and low-income countries around the world also shapes the burden of firearm violence as policies, trade, and globalization worsen the problem. For example, extensive supply chains and the import of arms from HICs like the United States to other countries around the world highlight the importance of considering firearm violence as a global health issue .
More recently, the COVID-19 pandemic caused a surge of more than 90 million USD worth of firearms being exported to LMICs, particularly in Asia . As scholars begin to better understand the private industry’s role in firearm violence, it is clear that such expansions in trade, supply chains, and marketing of arms on a global scale are contributing to the burden of firearm violence worldwide.
The global war on drugs has also extensively impacted the burden of firearm violence. In Mexico, government efforts to crack down on drug trafficking organizations resulted in an escalation of drug-related violence . In addition, the political influence of HICs (such as the United States) has contributed to this issue, taking into account increasing drug consumption, loose firearms regulations, and regimes which are reportedly key actors in the drugs trade .
In fact, the political climate in HICs like the United States has the influence to shape how firearm regulations are interpreted, and enacted, in LMICs around the world. Most recently, the Mexican government has sued gun manufacturers in the United States for facilitating the trafficking of weapons with their negligent practices . Roughly 70% of the trafficked firearms in Mexico come from the U.S., and 17,000 homicides can be linked to these weapons annually. The estimated damage of these trafficked weapons in Mexico is nearly 2% of the country’s GDP, which they will seek in the lawsuit, aiming to reduce further homicides in Mexico .
Additionally, globalization plays a role in increasing firearm violence as dynamics between HICs and LMICs change over time. Increases in foreign imports around the world have escalated competition within arms markets to produce higher performing weapons that can fire multiple types of ammunition, increasing both the accessibility and lethality of firearms . Increasing globalization has also been found to promote the openness of trade and weaken public authority, making small arms ownership more likely . The demand for small arms in HICs, which are responsible for the majority of the manufacturing and trading of these weapons, has caused the proliferation of small arms in LMICs as they are recycled down the “economic ladder.”  While research shows that attempting to limit globalization would not stop the trade of firearms, it is critical that the public health community more closely studies the movement of arms from HICs to LMICs .
Researchers have also suggested that “gun culture” from HICs (like the United States) has been “sold” to LMICs through various forms of media. In India, a country with historically low gun ownership rates, globalization has caused rates to increase . In the city of Shivpuri, a program was sponsored which fast tracked the firearm permit process for men who were undergoing vasectomies, noting that this program allowed men to trade one aspect of their masculinity for another . The shifting ideals surrounding the policies and accessibility of firearms caused by globalization has drastically impacted LMICs, a critical consideration for public health professionals as they begin to target this issue .
Finally, foreign policies can have an impact on arms trade and firearm violence in LMICs. In 2006, the United States was the only nation to dissent from the UN vote to implement stricter standards using an international arms trade treaty . Traditionally the US policy positions on firearms have weakened efforts to further international agreements and gun control policies, and have particularly affected Latin America, as loopholes in laws have allowed for a consistent flow of arms across the US and Mexico border . Alternatively, in the 1990s, the United States suspended arms exports to Paraguay until they were able to improve arms policies, illustrating how foreign policy can influence firearm violence in both positive and negative ways .
It is also clear that local policy can be successful in reducing violence; in 2021, Colombia introduced gun carrying restrictions in the cities of Bogotá and Medellín. Within 6 years, these cities saw a 22.3% reduction in firearm violence (adjusted for the standard annual reduction in control cities) . Given this research, it is critical that global and local policy focuses their efforts on combating firearm violence.
Firearm violence is a Global Health issue
As the body of research on firearm violence continues to grow, the public health and medical communities have shifted towards treating firearm violence not only as a preventable condition but also akin to an “infectious disease.”  Individuals who are more susceptible to firearm violence typically share various common exposures; like traditional disease epidemics. The environment, social networks, socioeconomic status, and education all influence the prevalence of firearm violence among communities and individuals .
This shift in knowledge has informed a variety of public health interventions aimed at decreasing the burden of firearm violence. However, to strengthen these interventions, it is critical that firearm violence be framed as a global health issue. As is evident from the factors which shape firearm violence, this issue takes place on a global scale, affecting the world’s most vulnerable populations. Politics, globalization, and the spread of culture and ideals through multi-media sources around the world has all contributed to the spread of firearm violence, which must be addressed by the global public health community [8, 12, 13].
Firearm violence also fits within the numerous frameworks and definitions proposed for ‘global health.’ In 2008, United Kingdom launched a 5-year strategy to target global health issues, defined as “health issues where the determinants circumvent, undermine or are oblivious to the territorial boundaries of states, and are thus beyond the capacity of individual countries to address through domestic institutions.” [3, 17]
Firearm violence is certainly a global health issue by this standard, in urgent need of research, attention, resources, and intervention. It is also beyond the capacity of individual nations to address this through domestic institutions; many countries are struggling to achieve a social and health system in which firearm violence is no longer a cause for mortality, and due to the effects of globalization, it will take interventions in every country to curb the transfer of firearms between HICs and LMICs .
Koplan defines global health as “an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide.”  Reducing mortality from firearm violence is an area of critical research and practice and has direct health and equity implications. By better understanding patterns of violence in at-risk populations around the world and synthesizing current research on successful interventions, this knowledge can be used to develop strategies to reduce the burden of firearm violence on individuals, communities, and economies.
Scholars also state that for an issue to be considered a global priority, it should have four tenets: a global conceptualization of health, the synthesis of population-based approaches, the central concept of equity in health, and a cross-sectoral, interdisciplinary approach . Firearm violence fits well within this conceptualization of global health; while all countries experience varying degrees of burden on their economies, healthcare systems, and populations as a result of firearm violence, globally it affects everyone and therefore warrants solutions rooted in research, evidence-based policy, and interventions. Given the applicability of firearm violence to the current definitions and frameworks for global health, the need for transnational solutions to firearm violence, and the ways in which firearm violence is influenced by global politics, it is apparent that given its vast impact on the health of world populations, firearm violence is a global health issue [8, 12, 13].
reference link : https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8506468/
More information: Firearms: the leading cause of years of potential life lost, Trauma Surgery & Acute Care Open, DOI: 10.1136/tsaco-2021-000766