Association between firearms and mortality in Brazil, 1990 to 2017: a global burden of disease Brazil study

The global burden of diseases, injuries, and risk factors study (GBD) estimated the occurrence of 251,000 firearms deaths globally in 2016, resulting from homicides, suicides, and unintentional causes [1]. Half of these deaths occurred in six countries: Brazil (43200), the USA (37200), Mexico (15400), Colombia (13300), Venezuela (12800), and Guatemala (5090). Thus, Brazil accounted for about one-sixth of all firearms deaths [1]. There are large global differences in rates, ranging from 0.2 deaths per 100,000 inhabitants in Singapore in 2016 to 39.4 deaths per 100,000 in El Salvador during the same period [1], which may be partly explained by differences in socioeconomic standing, inequalities, cultural perspectives, and availability of weapons [2]. High rates of gunshot homicide are concentrated in the Americas, in a belt that runs from Mexico to Brazil (including the Caribbean). The region has been associated with drug cartels as well as the manufacture and sale of firearms and their illegal trade [3‐5]. The illegal trade in firearms is one of the main determinants of the complex problem of interpersonal violence [2, 6, 7].

Global studies indicate that high mortality rates from violence by firearm are intrinsically related to greater availability of weapons [1, 8]. Other factors associated with firearm mortality are the caliber of the firearm, which determines the lethality of the weapon [9]; the existence of groups linked to the drug trade, arms, theft of goods, and control of territories; and the consumption of alcohol and drugs [10‐13]. A study shows that in Australia, after the law that banned possession of weapons and the campaign for the voluntary return of arms, in 1997, the number of deaths from firearms was reduced and collective massacre by firearms no longer occurred [14]. In 2000, the South Africa Firearms Control Act was approved, prohibiting the possession of weapons except under specific conditions. Law enforcement studies have pointed out that there was a 13.5% reduction in rates of violent deaths per year after the arms control law; more than 4500 deaths were prevented in five South African cities between 2001 and 2005 [15].

In 2003, the Brazilian Congress approved the Disarmament Act, which expanded regulations on the registration, possession, carrying, and sale of firearms and ammunition, and was also defined by the voluntary return of firearms and ammunition [16]. In 2005, there was a referendum to ban the marketing of firearms and ammunition. After strong lobbying by pro-firearms groups, including congressmen, ruralists, and the armaments industry, the marketing of firearms and ammunition remained legal, with restrictions [16]. In January 2019, the new Brazilian government published a decree amending the rules and expanding the possibility of possessing weapons in homes and commercial establishments throughout the country [17].

Access to firearms is a necessary precondition for firearm injury to occur [1], making it important to monitor the new measures in Brazil. Thus, this study aims to analyze the trend in mortality by firearms by age and sex, for states, and nationally for Brazil, and the association between these deaths and indicators of possession and carrying of weapons.

Figure 1 and supplemental table 1 show that firearms deaths increased from 25,819 (95% uncertainty interval [UI] 24,750.3–28,736.1) to 48,493 (42,750.8–50,042.4) from 1990 to 2017, with a stable age-standardized mortality rate of 17.5 (16.5–19.8) to 21.5 (18.6–22.6) per 100,000 and an increase in firearm homicides from 14.8 (14.4–20.4) per 100,000 in 1990 to 20.4 (17.7–21.1) per 100,000 in 2017. Suicides involving firearms decreased from a mortality rate of 1.7 (1.4–2.3) to 0.7 (0.5–1.1) per 100,000, and unintentional firearms deaths decreased from 0.9 (0.8–1.0) to 0.4 (0.4–0.5 ) per 100,000.

The firearm-related death rates per 100,000 inhabitants were higher in males than females in 2017. Homicides were concentrated in young males aged 20–24 (rate = 105.8 per 100,000), 25–29 years (rate = 84.3), and 15–19 years (rate = 82.2). The rate of firearm deaths among males aged 20–24 years old was 20.35 times higher than that among females in the same age group, for whom it was 5.2 deaths per 100,000. Rates declined with increasing age. Suicide and unintentional firearm deaths were also higher among males; rates of firearm-related suicide increased with age, reaching higher rates among the elderly (Fig. 2a and b). Rates of firearm death were higher among males than females in 2017, not just at the national level but in all Brazilian federation units (Fig. 3).

Figure 4 shows the evolution of the medians of the rate of firearm homicides and rate of total violent deaths by firearms in each group of federation units according to the rate of voluntary return of firearms in the period 2000–2017. The group of Brazilian federation units with the highest firearm collection rate (median = 7.5, interquartile range 3.5–12.5) showed reductions in the rate of total violent deaths by firearms (annualized percent change—APC = −1.5) and firearms homicides (APC = −1.6) throughout the period. Brazil saw its most significant reductions in these causes of death between 2003 and 2005 (APC of −9.0 and −9.1), coinciding with the beginning of the implementation of disarmament measures. In the following years, mortality rates from these causes continued to decline, although with lower intensity (APC = −0.1; −0.4). The group with the lowest firearm collection rate (median = 2.0 per 100,000, inhabitants, interquartile range 0.5–4.5) experienced a trend of increasing death rates (APC of 3.3 and 4.1 for total violent deaths by firearms and firearm homicides, respectively) from 2000 to 2017, although there was a deceleration in firearm homicide rates (APC = 1.4) in the post-implementation period of the disarmament statute (2003–2005). In 2017, federation units with the highest voluntary return of firearms to the authorities exhibited lower rates of violent deaths due to physical violence (20.8) and all firearms injuries (22.5) than federation units with low voluntary return (26.7 and 28.3 due to physical violence and all firearms injuries, respectively).

Figure 5 compares the relationship between age-standardized mortality rates due to firearms and SDI level by the Brazilian state. In the period from 1990 to 2004, mortality rates increased in most federation units; federation units with low and low-middle SDI showed higher and increasing rates, while federation units with high and high-middle SDI presented lower rates and also increasing rates. In the period from 2005 to 2017, after the beginning of the voluntary return of firearms to the authorities, the pattern reversed, with great declines in the federation units with better socio-demographic status (high and high-middle SDI); the decline was more rapid in Rio de Janeiro, São Paulo, and the Federal District, while increases occurred in lower SDI federation units, but not as quickly.

Table 1 shows that an increase in the composite index of firearms seized or collected (b5) was associated with a reduction in firearm deaths in the subgroup of vulnerable females, children, and the elderly (r = −0.269, p = 0.005). An increase in the rate of voluntary return of arms (b1) was associated with a reduction in unintentional firearm deaths (r = −0.364, p < 0.001). An increase in SDI was associated with a reduction in the total firearm death rate (r = −0.266, p = 0.008), firearm homicide rate (r = −0.266, p = 0.008), and unintentional firearm death rate (r = −0.316, p = 0.001). SDI subgroup level (low, low-middle, high-middle, and high) was correlated with the rate of firearm deaths for almost all specific causes of firearm deaths; however, low SDI federation units were associated with lower total rates of firearms deaths (r = −0.366, p < 0.001) and rates of firearm homicides (r = −0.391, p < 0.001), but with the highest unintentional rates of firearm deaths (r = 0.471, p < 0.001). The final models produced in the multiple linear regression analysis for each outcome that presented statistical significance were (i) total violent firearm deaths in the vulnerable subgroup (females, children, elderly) from 2005 to 2016 (p = 0.004, R² = 0.089); (ii) unintentional firearm deaths (p < 0.001, R² = 0.144); (iii) total violent firearm deaths (p = 0.008, R² = 0.060); and (iv) firearm homicides (p = 0.008, R² = 0.060) in the period 2013–2016 (Table 2). Details of rates of total violent deaths related to firearms and firearms homicides and rates of voluntary return of firearms in Brazil are available in supplemental table 2 and 3. The graphical and statistical analysis of the residues assures the adequacy of the model, taking into account the regression assumptions (supplemental figure 1).

In 2017, there were more than 45,000 deaths from firearms in Brazil, and more than half were among males between the ages of 15 and 29 years. From 1990 to 2017 there was an increase in firearm homicides and a reduction in suicides and accidental deaths by firearms. Homicides increased in most federation units, and the highest rates were observed in the federation units of Alagoas, Sergipe, and Rio Grande do Norte. The federation units with significant reductions in rates were Rio de Janeiro and São Paulo. In the period 1990 to 2004, firearms death rates increased in most federation units. In the period from 2005 to 2017, after the voluntary return of firearms to the authorities, the pattern reversed, with large declines in the federation units with the highest SDI; while firearms death rates in federation units with low SDI also declined, though not so rapidly.

Analyses showed that firearm death rates in the vulnerable group (women, children, the elderly) decreased with increases in voluntary return of firearms to the authorities and with increases in SDI.

Brazil stands out as one of the most violent countries in the world. It ranks first in absolute number of deaths by firearms and sixth in firearms mortality, behind several countries in Central America and the Caribbean, with death rates from firearms per 100,000 inhabitants such as those in El Salvador (43.1), Venezuela (42.1), Guatemala (29.6), Honduras (23.5), Jamaica (23.5), and Colombia (22.4). Previous research has suggested that such high firearms mortality rates may be associated with trafficking of drugs such as cocaine, illegal markets, and homicides [10, 22].

Controlling the possession of firearms is an important constraint on the occurrence of injury and death by firearms. In Brazil, high rates of possession and carrying of firearms and young males living in areas with poor socio-demographic conditions are strong facilitators of the occurrence of such deaths [23]. Prior research has found that restricting the availability and use of firearms can significantly reduce firearm deaths [14, 15]. However, monitoring and evaluating these interventions is still a challenge in Brazil due to a lack of information that would make it possible to establish baselines and monitor weapons nationally and in critical areas. In addition, the entry of illegal weapons is not measured. Estimating the total number of weapons held by the civilian population is a challenging task that has yielded inaccurate and unreliable results. It is a challenge to account for the number of weapons circulating in the country among civilians, since not all weapons are legally registered, and methods for estimating the number of illegal firearms in circulation, smuggled into the country, or in the possession of militia or traffickers are inadequate [2]. The lack of quality information makes it difficult to accurately estimate firearm availability and thus does little to subsidize public security policies and interventions.

Firearms collection may have reduced homicide rates. Federation units with higher rates of firearm collection decreased their rates (São Paulo, Rio de Janeiro, Distrito Federal, others), while federation units with lower rates of firearm collection experienced an increase in firearm homicide rates. Similarly, positive outcomes have been observed in countries that applied regulatory measures for the use of firearms, such as Australia [1, 2, 14], South Africa [15], and Colombia [24, 25]. Japan, which banned the possession of firearms and rifles in 1945, stands out as having one of the lowest firearm homicide rates in the world, at 0.03 per 100,000 inhabitants [1]. A 1997 study investigating the impact of these measures on indicators of violence found that state gun control laws in the USA had a much smaller effect on firearms than socioeconomic variables did [21]. This study did point out that systems of law vary widely between states, and if there were a more uniform arms control law in the USA, the impact could have been stronger [21].

In Brazil, authors have pointed to the importance of voluntary arms collection measures in reducing firearm deaths [2, 26, 27]. The reduction of firearm homicides in the last decade in São Paulo and of suicides in the state of Rio de Janeiro may be associated with firearms delivery programs created through the Disarmament Act [26, 27]. Cerqueira [2] has argued that fewer weapons lead to less crime, and therefore disarmament policies can reduce violent crime. Brazil’s experience of a reduction in firearm deaths and hospitalizations following firearm control and restriction legislation in 2003 supports this argument [26].

Control of the use of firearms by civilians may reduce certain rates of violence in Brazil. For every ten weapons taken from circulation, it has been estimated that more than two lives have been spared [24]. Concern over firearm violence and death in Brazil has led to changes beyond national legislation. In 2013 at the United Nations, Brazil and 60 other countries signed the Arms Trade Treaty to regulate the international arms trade in order to reduce the number of firearms diverted to illegal trafficking. This regulation, which Brazil has adhered to, is important because the country’s arms industry is the fourth largest exporter of light weapons in the world, according to the Small Arms Survey. It is ahead of countries such as Israel, Austria, and Russia. According to the Brazilian Army, which was responsible for controlling exports from 2005 to 2010, Brazil exported 4,482,874 firearms [8] and sold them to countries in Africa and Asia. The Brazilian gun industry moves approximately $100 million a year [8].

Our study also shows the impact of SDI on the reduction of homicides and accidental deaths, which can be explained by the multi-causal nature of violence and by the intimate association between poverty, social inequalities, family disintegration, and domestic violence, as well as by the absence and/or precariousness of social policies and public security and in the existing barriers to access to justice [12, 28, 29].

Suicides were more frequent among the elderly and in federation units of the south and southeast regions, particularly in the state of Rio Grande do Sul, whose population contains a higher percentage of elderly people. Suicides have been declining in the country, but other countries have also observed concentrations of suicide among their elderly populations [1].

Globally, deaths from firearms are higher among males than females [1], and higher among young adults than other age groups. This pattern occurs in Brazil and is associated with social and economic inequalities [1, 28]. The main victims of firearm violence are young, poor, less-educated, black, unemployed, or inhabitants of the outskirts of the cities, which are generally degraded areas with low cohesion and social support [28, 30]. Previous research has also found that young adult males have greater exposure to high-risk situations such as alcohol abuse, drug trafficking, and drug use [31], and are more likely to have criminal records [8, 32]. Prior studies point to the association between illicit drug use and homicide [22, 31]. Other factors associated with firearm violence are lack of investment in public security, police violence, and conflicts over land disputes and areas of agricultural frontiers [33].

Federation units in the north and northeast regions contributed most to the increase in homicide. From 2000 to 2015, upward trends in homicide rates in the country were at the expense of growth in small and medium-sized municipalities [34]. Situations such as clashes over agrarian issues and territorial conflict over assignment of indigenous lands and quilombolas have led to increases in violent deaths [35]. Organized crime and disputes between armed factions have increased violence in northeast federation units like Ceará and Rio Grande do Norte [36].

Many Brazilian cities bordering other countries, such as at the triple border of Brazil, Paraguay, and Argentina, have become critical territories for violence, as they serve as entry corridors for drugs and weapons [28, 30]. This may explain the increase in rates of firearm mortality in border federation units such as Paraná and Acre. In contrast, lower rates are observed in Southeastern federation units [28] like São Paulo and Rio de Janeiro, which can be explained by greater investments in public security as well as social policies, economic improvement, employment, and income in these regions [28, 37].

Although firearm mortality rates were much higher among men than women, Brazil also has notably high rates of femicides, murders of females because of their gender, ranking fifth in the world for rates of these occurrences. Female murder victims follow a similar profile to male victims as being young, black, single, less educated, and/or murdered due to their status as a woman [38].

It is therefore essential to monitor the United Nations Sustainable Development Goals (SDGs), which advocate a new model for global development that prioritizes peace [39]. Brazil is a signatory to the goal of “peaceful and inclusive societies for sustainable development, providing access to justice for all, and creating effective, accountable, and inclusive institutions at all levels” [39]. The SDGs are the first universal structure to make explicit the connection between violence, conflict, and development, stating that “development that cannot be achieved without peace and security is unsustainable.” It has among the indicators to be measured intentional killings and direct deaths from conflicts [39]. The SDGs thus demand an unprecedented global shift in attention to reducing violent deaths as a means of facilitating global development [39].

Contrary to the commitment of the SDGs [39], Brazil’s federal government relaxed regulations on the possession of weapons in the country in January 2019 [17]. Therefore, it is essential moving forward to monitor the increase in the possession of weapons by the civilian population and the possible increase in violent deaths in the country.

This study had several limitations. One limitation is that data on the number of circulating weapons are not available, necessitating the use of proxy measures; however, these indicators depend on the performance of the public security system in reducing the occurrence of violence. In order to circumvent this limitation, a group of indicators that together represent an approximation of the number of circulating weapons, in particular a composite index, the voluntary return of firearms, and illegal carrying of firearms, as described in the methods [27]. Since this is an observational study, inference on causal relations is always limited and subject to confounding by unmeasured factors. Strong cultural pressures to avoid legal implications of homicide and the stigma associated with suicide homicides and suicides may be misclassified as unintentional firearm injury deaths [40], specially when intent is not clear. This fact can also impact the garbage code redistribution process of undetermined intention deaths, specially in states where SIM present lower quality of causes of death.

This study concludes that Brazilian federation units with more weapons collected reduced their mortality rates, confirming the importance of the disarmament statute approved in 2003. Public policies of disarmament of the civilian population should be reinforced since they can reduce the number of violent deaths in Brazil and other Latin American countries. Rigorous measures to combat smuggling and illegal commerce of arms, as well as reliable registration of the available firearms, are also useful and necessary measures. It is essential to monitor the Brazilian government’s policies aimed at facilitating access to firearms in the country and how they could impact rates of firearm mortality.