“There can be no keener revelation of a society's soul than the way in which it treats its children.”
Firearm fatalities and children—2 terms that, in combination, evoke grief and disbelief, and cause our heads to shake. As medical providers, along with the mothers and fathers, grandparents and cousins, aunts and uncles, teachers, coaches, and best friends, we who take care of children and young adults with traumatic injuries will never understand this phenomenon. Why? We live in a “civilized” society and are responsible for the most vulnerable in our midst; why do we have to keep asking this question?
In Canada, we can be proud that we have a society that generally respects this responsibility with policy makers that have put societal safety ahead of individual “rights.” Canadian gun control policies are strong but not perfect. For the past decade,1 firearm-related fatalities in Canada have dropped or at least stayed relatively stable, depending on the age group considered.1 For those under 15, an average of 7 Canadian children sustain fatal gunshot wounds every year, both intentionally and unintentionally.1 This is a far cry from the increasing US average of now over 1 child a day (443 under the age of 15 in 2015),2,3 but it is still 7 children too many. Alarmingly, this number jumps 16-fold to 115, when we consider our youth aged 15 to 24, of which half are self-inflicted and half are due to homicide. This number similarly pales next to the 6883 American youth who died from firearm injuries in 2015 alone,2 almost two-thirds as homicide, but it is still too many. Although gun-related suicide has been slowly declining in Canada, it claims 3 times more Canadian lives than homicide per year; 587 Canadians (all ages) in 2014, at last count.1 As access to firearms, both legal and illegal, has now indisputably been associated with increased risk of suicide and homicide, this reflects a need for further research in prevention and concrete interventions (limiting acquisition, counseling families, and enhanced means of enforcing mandatory safe storage) to eliminate access to firearms for those at risk for self-harm and violence to others.4–6
Canada's firearm mortality rate is 4.3-fold lower than the United States, but we still rank fifth in firearm mortality rates amongst 23 Organization for Economic Co-operation and Development countries while taking second place for firearm-related homicides.7 Our Australian colleagues have shown that these fatality rates, amongst all subpopulations, can be even lower; Australia ranks 16th for overall firearm mortality rates and shares the third lowest firearm homicide rate with 8 other countries. Their reaction to the deadly 1996 Port Arthur massacre, to bring in strict policy limiting availability and access to semiautomatic firearms, stringent background checks with prolonged pre-acquisition waiting periods, and an intense gun-buy-back program reflects the mindset of putting the well-being of their society ahead of individual rights to “bear arms.” Since the enactment of these laws, concurrent to an already dropping rate of firearm deaths in that country, there was an additional significant reduction in firearm-related suicides and homicides due to mass shootings (≥5 deaths per event), from 13 events between 1979 and 1996 to 0 since.7 Although similar in many values and societal perspectives, the chasm between Canada's and Australia's firearm injury rates is striking.
How much further can Canada evolve to strive towards lower firearm mortality rates with gun control policies? Many would purport that our policies are too strict and infringe upon individual conveniences and freedoms. However, haunting memories of the 1989 Ecole Polytechnique massacre that took the lives of 14 women and injured 14 more, the horrific scenes of Sandy Hook elementary school in which 20 children and 6 adults were gunned down, and now the fresh wounds of Las Vegas (58 dead, 546 injured), Texas (26 dead, 20 injured), and LaLoche, Saskatchewan (4 killed, 7 injured) tell us that, at the least, we should not allow any weakening of the policies and principles that we currently have. Can we do better? As trauma care providers, we admit that we are not the experts in firearm control. However, we are the experts that face the horrors of children and youth who die in our emergency departments and operating theatres from firearm injuries, and then must explain “why” to their mothers and fathers. Surely, as a country, we can do better.
Perhaps, we draw an analogy to Canada's Road Safety Strategy8 with a vision of “Towards Zero,” which focuses on the more than 1800 Canadians dying every year on Canada's roads with the message and spirit that “life and health can never be exchanged for other benefits within society?” Commitments have been made at all levels of government and in the private sector to reduce this number to 0 by 2025 through improved awareness and collaboration amongst stakeholders, enhanced legislation and enforcement, improvements in safety infrastructure, research support, and the evaluation and leveraging of technology and innovation. On average, over 750 Canadians are killed by firearms every year1; that is only 2.5 times less than deaths on our roads. We must apply the same principles to strive for a “Vision Zero” for these Canadians as well, and should congratulate our governments for moving this issue forward with dedicated support and “a plan.” Recent announcement of federal funding to bring together stakeholders addressing gun violence and gang activity is laudable. But this report should be actionable and should not overshadow the roughly 80% of firearm deaths not related to violent assault.9
As Canadians, we pride ourselves on looking beyond our borders to societies in need: “global health.” As healthcare professionals, many of us travel to far lands to participate in medical and surgical missions, often focusing on the most vulnerable in these populations—children. In developing countries, children bear the burden of congenital anomalies with little access to surgical care, and often lack the necessities of life such as clean water, food, and shelter. Canadians can pride themselves on their contributions to building infrastructure, such as wells and schools, and bringing medical and surgical expertise to give these children and youth a better chance for a healthy and happy life. What then should we do when we are faced with the knowledge that south of our border, on average, 7 children are seriously injured and over 1 are killed every day by guns, and that 90% of all children, worldwide, who die from the barrel of a firearm live in the United States.2 Over 100 Americans (all ages, on average) die by guns everyday; this number now surpassing death from motor vehicle crashes.3 By no means does this belittle the hardships faced by millions living far from our borders, including refugees and those caught in conflict and persecution. But what do we do about the families we consider our neighbors?
No longer can we just shake our heads at the horrific shooting massacres that dominate our airwaves and preoccupy our minds and those of our children. No longer can we nervously speak about violence “that is not in our backyard,” hiding behind perceptions that Canada is “better” or expressing sorrow that that is “their” reality. As we would with any society in crisis (our neighbors being no exception), we have an obligation to speak up for those who cannot have their own voices heard, especially children. As those who treat injured Canadians of all ages, we have an obligation to ask “what can we do to help?”. If we are most effective participating in research that will help target evidence-informed interventions to reduce the risk of firearm deaths, research that may be stifled secondary to political fear, then we should work with our American colleagues to do this.10 Additionally, we can join the voices of our colleagues, and advocate with evidence-informed arguments for a safer and more responsible societal approach to gun control.5,6,10 This is a public health crisis that demands our attention.
We care about our Canadian children and youth, but we live in a global world and cannot be silent bystanders when our most precious and vulnerable are at risk. It is our professional responsibility, as caregivers to those who are injured, to speak up and be heard. We must be willing to work with all levels of government to advocate for surveillance, funding, and execution of strong and translatable research, and implementation of evidence-informed policies around not only firearm control, but mental health, suicide, and violence. We need to support each other and our American colleagues in their efforts to advocate for research, and effective and sensible firearm control measures that put the rights of children and society ahead of the rights of individuals.5,6,10 We must advocate for our political leaders to do the same with their counterparts south of the border, and to work diligently and passionately towards preventing unnecessary loss and suffering by “preventing the bleed,” because every life, Canadian and other, is precious.11
2. Centers for Disease Control and Prevention
. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: http://www.cdc.gov/injury/wisqars
. Accessed December, 2017.
3. Grinshteyn E, Hemenway D. Violent death rates: the US compared with other high-income OECD countries, 2010. Am J Med
2016; 129: 266–273.
4. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms
and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med
5. Snider CE, Ovens H, Drummnond A, et al. CAEP position statement on gun control. Can J Emerg Med
6. Canadian Paediatric Society. The Prevention
of Firearm Injuries
in Canadian Youth
; 2017. Available at: https://www.cps.ca/en/documents/position/youth-and-firearms#ref31
. Accessed December, 2017.
7. Chapman S, Alpers P, Agho K, et al. Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev
8. Canadian Council of Motor Transport Association. Canada's Road Safety Strategy; 2025. Available at: http://roadsafetystrategy.ca/files/RSS-2025-Report-January-2016-with%20cover.pdf
. Accessed December, 2017.
9. Public Safety Canada. Major ner Federal Funding and Summit to Tackle Gun Violence and Gang Activity; 2017. Available at: https://www.canada.ca/en/public-safety-canada/news/2017/11/major_new_federalfundingandsummittotacklegunviolenceandgangactiv.html
?wbdisable=true. Accessed December, 2017.
10. Bauchner H, Rivara FP, Bonow RO, et al. Death by Gun Violence—A Public Health Crisis. JAMA Ped
11. Maa J, Masiakos PT, Elsey JK, Warshaw AL. Prevent the Bleed: How Surgeons Can Lead the National Conversation About Firearm Safety Forward. Ann Surg
2017; doi: 10.1097/SLA.0000000000002638. [Epub ahead of print].