 |  |  |  |  |  |  |  |  |  |  |
| |||||||||||
|
 | |
| |
 | |
Categories of Health ImpactsHealth impacts can be grouped into direct effects and indirect effects, as below. Distinctions should be made between externally or objectively measurable effects, such as physical injury, and subjective effects, such as fear and stress. Such effects can be assessed through both quantitative and qualitative data. Direct health effects of arms: e.g. death, injury, disability, mental and emotional consequences, fear and stress Indirect effects on individuals: e.g. forced displacement, kidnapping, forced recruitment, sexual assaults, torture, reduced access to health services, infectious disease, malnutrition Effects on health services: e.g. depletion of health resources, cessation of health services, destruction of health infrastructure, targeting of health personnel Health effects in terms of personal and societal costs: e.g. potential life years lost, potential productivity lost, reduced personal mobility, reduced family income, decreased development. Research Challenges, Tools, and TechniquesComprehensive surveillance of injury and mortality includes collection of data on factors such as the nature of injury, cause of death, make and origin of the weapon, circumstances of the event, and victim/perpetrator relationship. Surveillance of indirect health effects, including mental trauma and social costs, must identify suitable indicators for measurement. Data can be collected from various sources:
Conference participants agreed that collecting and handling data entails many challenges. First, data provided is often unreliable and inconsistent. Second, agencies differ in definition of terms and research methods. Third, geographic coverage of the data is not complete, with an urban bias in many countries, and a higher-income bias internationally. Fourth, there are some cultural aberrations in reporting. For example, in some Latin American countries, suicides are under reported while accidental deaths are over-reported. Lastly, language groups differ in their definition of terms. For example, in the Spanish language, the term "homicide" is often used to describe involuntary manslaughter as well as intentional homicide or murder. Examples of comprehensive injury surveillance projects in South Africa and Wisconsin, USA illustrated the additional logistical challenges that research projects must also overcome. Most notably, research is resource intensive and requires a long-term commitment of funds and effort. Research projects require the involvement or approval of multiple agencies with differing agendas, some of whom may initially be suspicious of the goals of the project or deny access to researchers. A lack of detailed information on the make and origin of firearms used in injuries presents a barrier to research. In disorganized settings such as poor countries in humanitarian crises, additional logistical challenges may include dynamics such as the following, described for the Congo DR: Territory may be divided and controlled by warring parties, researchers may be suspected of espionage, health infrastructures may be ruined and their data rendered invalid, and communication and transport may be lacking (by road, air, telephone, etc.) A significant body of research exists in low-income states and war-affected regions that is of high quality but poor presentation. Researchers lack the resources to refine and distribute it and so it fails to reach the mainstream international medical journals and indexes. Recommendations For Research
Analysis of Risk FactorsTrends in Injuries From Small ArmsCollected data are useful for analyzing trends, whether on a global or local scale, and for focusing policy interventions. Data can be analyzed to identify trends for risk incurred by whom, when, where, and from what type of weapon. For example, the South African National Injury Mortality Surveillance System showed the following patterns of risk:
Though comprehensive aggregate national data are unavailable for disorganized settings, more localized studies provide insights into trends. ICRC studies in Cambodia that inquired into the combatant or civilian status of the weapon-injured person led to the finding that civilians were being targeted not only by artillery and mortar fire in combat, but also by handguns used in interpersonal disputes unrelated to combat. Further study in Cambodia showed that in the absence of a post-conflict disarmament program, the rate of gun injury did not decrease significantly after the cessation of armed conflict. Conference participants described studies of varying scale in Brazil, Bangladesh, Cambodia, Finland, Honduras, Canada, and Uganda. Categorizing Risk FactorsVarious models were used to analyze risk. An "ecological" model presents several levels of society where risk factors can be identified. In parentheses are examples of the qualities associated with high risk.
Discussion from the conference suggests that the societal level can be further broken down into:
Identifying Key Risk FactorsResearch studies that compare countries, cultures, and households that are similar for all but one variable, and research that compares a region before and after modification of a variable (e.g. through legislation ), help to illuminate the importance of specific risk factors. Availability Availability of firearms, or access to them, is described by some as the "universal" risk factor, or the one which is critical in all forms of gun violence regardless of the context. Many studies have suggested that access to firearms increases the lethality of violence, raising the probability that an act of violence will result in death. Others have shown that reducing access to firearms also reduces the frequency of acts of violence by showing that the "substitution" effect - the resort to alternate tools of violence in the event of blocked access to firearms - is inconsistent at best. In discourse about small arms, efforts to address the availability of small arms are called "supply side" efforts. Human insecurity Human insecurity, or the lack of protection by other means, is viewed as the root motive for the ownership and use of small arms. Such insecurity can arise from many causes, including:
In small arms discourse, efforts to address the human insecurity leading to arms use are called "demand side" efforts. Social acceptability Social acceptability includes attitudes, cultural beliefs, and behavioral factors. Various types of social acceptability apply: a) "cultures of honor,"
or vendetta cultures (e.g. codes to avenge dishonor with violence, reciprocal
violence. Includes honor killings of women, inter-gang killing) Efforts to address the social acceptability of arms use are also called "demand side" efforts. Identifying Groups Vulnerable to Direct and Indirect Health Burden From Small ArmsAlthough young males are effected directly by gun violence in greatest numbers, other groups are at high-risk for specific types of armed attack, or bear a great deal of indirect burden from small arms violence. a) Women Women are targeted for specific types of violence, such as sexual attacks. Compared to men in some studies, women are more likely to be attacked by someone they know. They bear the brunt of economic burden when spouses and children are killed, and shoulder a great deal of the challenge of maintaining social and community cohesion. b) Children Children are at risk of being forcefully recruited as child soldiers, exploited sexually, or kidnapped to exact ransom from families. Children are especially affected by psychological trauma given their early stages of mental development, and inherit the societal legacies from mass violence. c) Refugees and internally displaced persons (IDP's) Refugees may arrive at camps bearing arms used in a previous context, but are sometimes scapegoated unfairly as a source of weapons by host communities. They may bring their political differences to the new site and have conflict with fellow refugees or their host community. Without income sources, they may resort to selling arms to members of the host community, even if their camp is at risk of being targeted. Refugees often suffer from associated health problems of malnutrition and infectious diseases. Internally displaced persons are not protected by international conventions on refugees. There is no international coordinating mechanism or organization to defend the rights and interests of IDPs. As such, they suffer many of the same problems as refugees, and are particularly susceptible to state predation, collapse, or repression. Recommendations
Prevention Through Policy and ProgramsLinking Evidence to Policy and Programs Information from public health research and analysis does not directly lead to evidenced-based decision-making. Instead, preparatory work is required to find audience with policy-makers, develop their acceptance for public health input, and overcome the reflexive retort, "Don't confuse me with the facts. My mind is already made up." Effective preventive action, whether in policy advocacy or field programs, requires knowledge, a mobilized constituency or popular base, and clear, precise objectives. It is widely accepted that there is some level of legitimate use of small arms for military, law enforcement, and civilian professional and personal purposes. In addition, small arms are present at every level of society, and their use is not easily controlled by legislation alone. Thus, in general terms, to reduce injury from small arms does not call for a ban, but wise norms and regulations on appropriate possession and use. Norms and regulations are needed to establish criteria and enforce the appropriate: 1) acquisition, possession, carrying and use of small arms, 2) supply, trade, and transfers of small arms, 3) penalties for violations of the above norms. Such norms need to be operative at international and national levels through treaties and legislation, but must also function at the level of the community, family, and individual through cultures, beliefs, and norms for responsible behavior. Research among pastoralist clans in the Horn of Africa, for example, observed intra-clan use of small arms as closely regulated by indigenous clan codes and penalties, although, by contrast, inter-clan violence remained a major problem. Policies and Programs to Mitigate Risk Factors For Small Arms InjuryAvailability, or "supply" of small arms Measures to reduce access to small arms are focused on reducing the lethality of violence but not necessarily its frequency. Limitation of access is possible at several levels:
Preventing diversion and misuse: realities of supply both legal and illicit Recent global negotiations at the United Nations produced a legally-binding agreement on controls of non-state, illicit firearms production and transfer (Firearms Protocol, UN Convention Against Transnational Organized Crime), and a politically-binding statement on the control of illicit arms transfers (Program of Action, UN Conference on the Illicit Trade in Small Arms and Light Weapons in All its Aspects). Both are important steps, but recent research shows that state authorized, legal transfers constitute the major source of supply, and the number of small arms producing countries increased to 64 in the 1990's, including high and low income countries. Arms are an instrument of political power, employed for diplomatic, strategic, and economic reasons. The world's most powerful governments are also arms producers. For this reason, in order to engage a serious debate on policies of legal arms transfers, an unprecedented mobilization of credible information and political constituencies is required. Existing international law describes norms and responsibilities for states engaged in legal arms transfers, but such norms need to be clarified, observed and enforced. One such effort, a campaign for a Framework Convention on International Arms Transfers led by the Arias Foundation and other NGOs, seeks to clarify existing international law and its application to human rights and humanitarian concerns. Human insecurity and social acceptability, or "demand" for small arms Work to reduce demand for small arms may involve traditional humanitarian, social development, and education projects, but includes a focus on understanding and addressing the specific reasons for weapons possession and use in a community or culture. Such work aims not only to reduce the lethality of violence, but its frequency as well. Efforts to address human insecurity include initiatives for economic development, education, security sector reform, human rights protection, good governance, and effective justice systems. Efforts to address social acceptability include surveys of attitudes, engaging with cultural traditions, and public education. Example of interventions addressing both supply and demand risk factors The organization Viva Rio, based in Rio de Janeiro, Brazil, combines a public health approach with community-based organizing to impel policies and programs to reduce small arms violence.
The projects of Viva Rio have had success in reducing risk factors for gun violence, including a zero-injury rate for the high-risk favela during its first project year, government-sponsored public events of weapons destruction, and national legislation. Evaluation A crucial component of public health intervention is the process of evaluation of effectiveness. In advance, the complex web of risk factors must be assessed, including cultural attitudes toward weapons, levels of human insecurity, etc. For example, efforts at weapons collection may be ineffective where human insecurity and demand for arms is very high. Increasing resources for law enforcement may fail without addressing issues of corruption in the force and mistrust in the community. Following intervention, research of results and evaluation of methods is necessary. Recommendations For Prevention1. Combined, Focused Action on Supply and Demand Factors Rather than debating the primacy of supply versus demand factors, materials presented in the conference suggest that both types of factors should be addressed simultaneously. "Supply side" efforts reduce the presence of lethal weapons and create an environment more conducive to demand reduction work. "Demand side" efforts reduce the dependence on and market for small arms and thereby create an environment more conducive to reducing supply. To achieve focus for local action, proper public health analysis should identify the salient risk factors for a specific area and tailor policy to address those factors. The previous example about Viva Rio illustrates such a combined approach. Global coordinated action on both supply and demand factors is possible. 2. Set Norms and Regulations Appropriate to Health Concerns Norms and regulations from the international to the local level define boundaries of responsible use of small arms. Health professionals play a crucial role at multiple stages in renegotiating those boundaries to enhance health and safety. a. Reframe the debate The problem of small arms is fundamentally a health and humanitarian problem. Law enforcement and national security strategies are not sufficient to ensure effective prevention of injury and death. A paradigm shift must be engaged to view the problem as a health issue, i.e. an epidemic, to be managed urgently with public health and humanitarian expertise. b. Advocate measures to allow sufficient access to data Public health research requires access to relevant data kept in records of law enforcement, military, and other agencies. Linked data systems and informative serial numbers applied to automobiles have been instrumental in efforts to research and reduce traffic accident injuries in the United States. A similar system of transparency, with data-sharing and standardized marking, is necessary for small arms and their associated injuries. c. Question the norm / shift the burden of proof Descriptive epidemiological information coming from conflict areas can call into question whether policies of arms transfer and military intervention are actually helping their ostensible intended beneficiaries. As occurred with the issue of landmines, credible, non-exaggerated medical research may ultimately put the burden of proof on military and government authorities to document why a particular use, transfer, or type of weapon is necessary. d. Propose higher standards / better enforcement of existing norms Public health and medical organizations can inform local, national, and international advocacy efforts for legislation to restrict arms transfer and use based on considerations of health and human security. Existing international law, including humanitarian and human rights law, provides an initial basis for such considerations, but measures must be clarified, elaborated, and enforced by the international community. Ongoing education and development work can help to redefine norms for responsible and ethical use of weapons at the cultural and individual level. e. Monitor and evaluate progress An effective, coordinated medical and public health network for research and analysis can provide accurate monitoring of efforts to reduce the health impacts of small arms. Such a network can evaluate progress and setbacks in the field based on rates of health impact, and can play a "watchdog" role by alerting attention to cases where policy measures are ineffective or counter productive in reducing injury and death on the ground. Helsinki Conference Links:
|
Aiming
for Prevention: International Medical Conference on Small Arms, Gun Violence and
Injury