BALLISTIC TRAUMA: A PRACTICAL GUIDE THE INTERNATIONAL SMALL ARMS SITUATION: A PUBLIC HEALTH APPROACH by Neil Arya and Wendy Cukier INTRODUCTION Whether emergency room physicians, trauma surgeons, psychiatrists, pediatricians or family doctors, physicians throughout the world bear witness to the terrible consequences of small arms on human health. A physician stemming a bleed in the chest of a gunshot victim is not concerned with whether the shooting was a suicide, an accident or a homicide, whether it took place in a conflict-situation or in peacetime, or whether the perpetrator was a gang member, a soldier, a non-state actor or a law-abiding gun owner. What matters to the physician is whether bullet struck bone, whether bone shattered, whether metal and bone splinters punctured vital organs or blood vessels, or severed the spinal cord – in short, whether the patient will survive and if so, what his or her future health will be 1 . Medical treatment has advanced in the last decade, but physicians have long recognized that preventing death and injury, in times of war 2 or peace 3 , can produce more significant benefits than an exclusively treatment-based approach. Public health approaches to the small arms issue are based on evidence and science and involve various disciplines of expertise, including epidemiology, but also psychology, sociology, criminology, economics, education and medicine. A harm-reduction approach begins with the premise that the weapons, by their very nature, are designed to kill, harm or threaten other beings in a particular context. Given the accepted utility of legal firearms in society, the goal is not typically a ban, as was the case with antipersonnel mines, but regulation or “harm reduction”. A public health approach to injury begins with a careful analysis of the epidemiology and etiology of the injury, focusing on the causal factors which produce the injury. The injury prevention model examines the interactions between the environment (both physical and social), the host (the victim), the agent (the firearm) and the vector (the ammunition). The focus is on understanding the causal chain and breaking the chain at its weakest link with “fact-based” interventions 4 . Interventions may address the underlying factors which give rise to violence, for example, programs to improve the social and economic conditions which give rise to violence. Interventions may focus on reducing the severity of violence - efforts focused on supply of weapons, for example which attempt to control exports or access to small arms. Finally, interventions may focus on "treatment", on trauma care, on rehabilitation and reintegration. 5 This model is a useful one for understanding the problem of small arms and the approaches to reducing their negative effects on health. This chapter will consider: 1) Basic Concepts