Between 1990 and 2016, firearm deaths were more common outside war settings
Between 1990 and 2016, firearm deaths were more common outside war settings

than within in all but one year.
than within in all but one year.

In 2016 alone, there were 251?000 such deaths.
In 2016 alone, there were 251?000 such deaths.

When a quarter million people die per year by use of firearms,
When a quarter million people die per year by use of firearms,

that is an enormous public health problem and crisis that we should really address
that is an enormous public health problem and crisis that we should really address

and of course acknowledge that the risks vary tremendously across nations.
and of course acknowledge that the risks vary tremendously across nations.

Global Burden of Disease Investigators from the University of Washington's Institute
Global Burden of Disease Investigators from the University of Washington's Institute

for Health Metrics and Evaluation have estimated trends in global mortality
for Health Metrics and Evaluation have estimated trends in global mortality

from firearms between 1990 and 2016.
from firearms between 1990 and 2016.

The researchers measured cause-specific deaths by age, sex, location,
The researchers measured cause-specific deaths by age, sex, location,

and year for 195 countries, and evaluated the relationship between gun ownership
and year for 195 countries, and evaluated the relationship between gun ownership

and access and gun injury deaths.
and access and gun injury deaths.

Overall, there was good news: during the 27 years,
Overall, there was good news: during the 27 years,

the global rate of firearm deaths decreased at an annual rate of 0.9%,
the global rate of firearm deaths decreased at an annual rate of 0.9%,

primarily driven by a decrease of 1.6% in suicide rates.
primarily driven by a decrease of 1.6% in suicide rates.

But trends differed by country, age group, and other variables.
But trends differed by country, age group, and other variables.

Two patterns were especially noteworthy.
Two patterns were especially noteworthy.

First, gun deaths were highly concentrated.
First, gun deaths were highly concentrated.

In 2016, six countries in the Americas accounted for more than half of all firearm deaths.
In 2016, six countries in the Americas accounted for more than half of all firearm deaths.

These countries hold only 10% of the world's population.
These countries hold only 10% of the world's population.

And there was another notable example of geographic concentration.
And there was another notable example of geographic concentration.

If you look at the countries with the highest rates of firearm homicide in 2016,
If you look at the countries with the highest rates of firearm homicide in 2016,

they're concentrated in Latin America and the Caribbean.
they're concentrated in Latin America and the Caribbean.

These countries have something in common: many have been identified as drug producing
These countries have something in common: many have been identified as drug producing

or transporting by the US Department of State.
or transporting by the US Department of State.

And this has repercussions beyond firearm deaths.
And this has repercussions beyond firearm deaths.

Having criminal organizations heavily armed and often far better armed than law enforcement,
Having criminal organizations heavily armed and often far better armed than law enforcement,

it really, really leads to a set of conditions that not only elevate violence
it really, really leads to a set of conditions that not only elevate violence

but generally make it hard for a country to move forward in ways
but generally make it hard for a country to move forward in ways

that advance public health and safety.
that advance public health and safety.

In these countries, firearm deaths were driven by homicides, in line with a global pattern
In these countries, firearm deaths were driven by homicides, in line with a global pattern

where homicides exceeded suicides, and unintentional deaths.
where homicides exceeded suicides, and unintentional deaths.

But in 67 countries in 2016, mostly in Europe, high-income North America and Australasia,
But in 67 countries in 2016, mostly in Europe, high-income North America and Australasia,

suicides dwarfed homicides, which is the second important pattern.
suicides dwarfed homicides, which is the second important pattern.

Take the United States: Much of our discussion about gun violence in the United States and what
Take the United States: Much of our discussion about gun violence in the United States and what

to do about it does not recognize that for every homicide with a firearm, there are two suicides
to do about it does not recognize that for every homicide with a firearm, there are two suicides

with a firearm, and, importantly, as public health professionals,
with a firearm, and, importantly, as public health professionals,

we recognize that these are preventable deaths.
we recognize that these are preventable deaths.

And preventing these deaths could have a big impact globally.
And preventing these deaths could have a big impact globally.

In 2016, the US had only 4% of the global population, but in that same year,
In 2016, the US had only 4% of the global population, but in that same year,

it had 35% of global firearm suicides.
it had 35% of global firearm suicides.

While some of our policies connect to both of those kinds of risks, both for homicides
While some of our policies connect to both of those kinds of risks, both for homicides

and suicides, there are other strategies that may be very specific and unique
and suicides, there are other strategies that may be very specific and unique

to suicide reduction that we have not fully examined and invested in.
to suicide reduction that we have not fully examined and invested in.

One thing that many people in public health are beginning to talk about is ways
One thing that many people in public health are beginning to talk about is ways

to change a culture, in essence, about holding firearms from individuals when they're going
to change a culture, in essence, about holding firearms from individuals when they're going

through some crisis that might elevate their risk for suicide.
through some crisis that might elevate their risk for suicide.

So just as a friend or a family member, as a caring thing to do about someone's safety,
So just as a friend or a family member, as a caring thing to do about someone's safety,

would say, let me get you, let me drive you home because you've had too much
would say, let me get you, let me drive you home because you've had too much

to drink, you do the same thing with saying,
to drink, you do the same thing with saying,

let me hold your guns while you're going through this divorce.
let me hold your guns while you're going through this divorce.

Let me keep your guns after you just lost your job and are very distraught.
Let me keep your guns after you just lost your job and are very distraught.

We also talk about this as what physicians can do in their role in counseling patients
We also talk about this as what physicians can do in their role in counseling patients

and their families to reduce access to firearms to lower suicide risk.
and their families to reduce access to firearms to lower suicide risk.

But, in my opinion, it's a much bigger public health challenge to really change a culture
But, in my opinion, it's a much bigger public health challenge to really change a culture

about firearm access and suicide.
about firearm access and suicide.

It is the thing that is leading to the greatest number of firearm deaths in our country.
It is the thing that is leading to the greatest number of firearm deaths in our country.

Whenever we've had big breakthroughs in public health,
Whenever we've had big breakthroughs in public health,

it's always been a combination of policy and cultural change.
it's always been a combination of policy and cultural change.

And this global data set is a lens through which researchers can better compare nations
And this global data set is a lens through which researchers can better compare nations

and examine how the interaction between policies and culture affect firearm death rates.
and examine how the interaction between policies and culture affect firearm death rates.

A final takeaway is about gun ownership.
A final takeaway is about gun ownership.

How does access to firearms influence patterns of homicide and suicide?
How does access to firearms influence patterns of homicide and suicide?

The study in question here is consistent with other studies
The study in question here is consistent with other studies

that look at other units of analysis.
that look at other units of analysis.

Sometimes those units of analysis are household, sometimes they are communities,
Sometimes those units of analysis are household, sometimes they are communities,

sometimes they're cities, states, and now across countries.
sometimes they're cities, states, and now across countries.

We see a fairly consistent relationship, when you control for other factors,
We see a fairly consistent relationship, when you control for other factors,

the more firearms there are, the greater the risk for both firearm homicide and suicide.
the more firearms there are, the greater the risk for both firearm homicide and suicide.

But this finding doesn't address the complex set of factors
But this finding doesn't address the complex set of factors

that affect whether owning a firearm might result in a lethal outcome.
that affect whether owning a firearm might result in a lethal outcome.

People in public health and people who study epidemiology and risk as it relates
People in public health and people who study epidemiology and risk as it relates

to firearms mostly think about it in terms of relative risk: the more guns,
to firearms mostly think about it in terms of relative risk: the more guns,

the more deaths there are with respect to homicides and suicides in particular.
the more deaths there are with respect to homicides and suicides in particular.

But I think what's lost in that, however, is absolute risk.
But I think what's lost in that, however, is absolute risk.

In the United States, for example, roughly one in three homes will have at least one firearm,
In the United States, for example, roughly one in three homes will have at least one firearm,

and the vast majority of those homes with firearms, nothing bad will happen.
and the vast majority of those homes with firearms, nothing bad will happen.

It's when other risk factors are coupled
It's when other risk factors are coupled

with firearm ownership that the excess risk is formed.
with firearm ownership that the excess risk is formed.

And these risk factors can be found in any country.
And these risk factors can be found in any country.

Each population has some people who are more impulsive, have more anger problems,
Each population has some people who are more impulsive, have more anger problems,

have more mental health problems, a variety of other things,
have more mental health problems, a variety of other things,

that could otherwise make them more impulsive to harm themselves or someone else.
that could otherwise make them more impulsive to harm themselves or someone else.

And sometimes it has to do more with context.
And sometimes it has to do more with context.

Infrequently do we acknowledge the substance abuse component of this,
Infrequently do we acknowledge the substance abuse component of this,

and specifically alcohol, that comes into play, that elevates both homicide risk
and specifically alcohol, that comes into play, that elevates both homicide risk

and suicide risk, and you mix a firearm into that mix of alcohol abuse,
and suicide risk, and you mix a firearm into that mix of alcohol abuse,

any violence that's directed at others or oneself becomes highly lethal.
any violence that's directed at others or oneself becomes highly lethal.

So the more firearms there are, the more likely it is
So the more firearms there are, the more likely it is

that they will end up in high-risk contexts.
that they will end up in high-risk contexts.

But these contexts vary globally.
But these contexts vary globally.

And this variation underpins both the global disparities in firearm deaths
And this variation underpins both the global disparities in firearm deaths

and effective ways to reduce them.
and effective ways to reduce them.