C International Epldemiological Association 1998 Printed in Great Britain International Journal of Epidemiology 1998;27:214-221 Firearm-related deaths in the United States

and 35 other high- and upper-middle-income countries EG Krug, KE Powell and LL Dahlberg Background The Forty-Ninth World Health Assembly recently declared violence a worldwide public health problem. Improved understanding of cross-national differences is useful for identifying risk factors and may facilitate prevention efforts. Few cross-national studies, however, have explored firearm-related deaths. We compared the incidence of firearm-related deaths among 36 countries. Methods Health officials in high-income (HI) and upper-middle-income countries (UMI) with populations greater than one million were asked to provide data using ICD-9 codes on firearm-related homicides, suicides, unintentional deaths and deaths of undetermined intent, as well as homicides and suicides for all methods combined. Thirty-six (78%) of the 46 countries provided complete data. We compared age-adjusted rates per 100 000 for each country and pooled rates by income group and geographical location. Results During the one-year study period, 88 649 firearm deaths were reported. Overall firearm mortality rates are five to six times higher in HI and UMI countries in the Americas (12.72) than in Europe (2.17), or Oceania (2.57) and 95 times higher than in Asia (0.13). The rate of firearm deaths in the United States (14.24 per 100 000) exceeds that of its economic counterparts (1.76) eightfold and that of UMI countries (9.69) by a factor of 1.5. Suicide and homicide contribute equally to total firearm deaths in the US, but most firearm deaths are suicides (71%) in HI countries and homicides (72%) in UMI countries. Conclusions Firearm death rates vary markedly throughout the industrialized world. Further research to identify risk factors associated with these variations may help improve prevention efforts