Firearm violence presents a compelling test of the unfinished agenda of the Ottawa Charter for Health Promotion.
Adopted in 1986, the charter identified peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity among the prerequisites for health. It also recognised that promoting health requires action by governments, communities, health systems and other sectors of society.
Four decades later, gun violence is undermining many of those conditions across the world.
South Africa illustrates the challenge starkly. It has among the world’s highest homicide rates, and firearms account for a substantial proportion of killings. Behind these deaths is a much wider burden. Gunshot injuries can require emergency care, complex surgery, blood transfusions, intensive care, rehabilitation and long-term support. Survivors may live with permanent disability, chronic pain and psychological trauma. Families absorb bereavement, lost income and caregiving responsibilities. Communities experience fear, disrupted schooling, constrained economic activity and weakened social cohesion.
A global challenge
But this is not only a South African problem. Firearm violence is a global public health challenge, although its scale and character vary considerably between countries and regions. Globally, firearms account for almost half of homicides where the mechanism of killing is known; in the Americas, they account for approximately three-quarters. Firearms are also implicated in suicide, intimate-partner violence, accidental injury and lifelong disability.
This is why gun violence cannot be understood only through the lens of policing and criminal justice.
Police, courts and effective law enforcement are indispensable. But when a preventable cause of death and injury repeatedly sends people to trauma units, creates disability, damages mental health, disrupts families and communities and consumes substantial health resources, it is also a public health concern.
The distinction matters because public health asks questions that begin before the shooting.
Criminal justice necessarily asks: who committed the offence, and how should the law respond? Public health adds: Who is most at risk? Where are shootings concentrated? How are the firearms being obtained? What circumstances make violence more likely? Which interventions reduce that risk? And what can be changed before another person is shot?
We would not confront a cholera outbreak by treating those who become ill, while ignoring the source of contamination. Prevention requires us to look upstream. The same principle applies to firearm violence.
The factors that drive gun violence are not identical everywhere. They can include firearm availability, illicit trafficking, diversion from lawful possession, weak regulatory systems, unsafe storage and failures of enforcement. These interact with wider conditions such as inequality, gender-based violence, organised crime, alcohol misuse and social exclusion. Their relative importance differs by setting, which is precisely why good data and locally grounded prevention matter.
From framework to prevention
The Ottawa Charter offers a useful framework for action even 40 years later.
Building healthy public policy means recognising that decisions about firearm regulation, licensing, safe storage, tracing and diversion have consequences for population health.
Creating supportive environments means reducing exposure to violence in the places where people live their daily lives: homes, schools, workplaces, transport systems and public spaces.
Strengthening community action requires communities to be partners in prevention rather than merely recipients of interventions. Survivors, local organisations, health professionals, educators, researchers, government and civil society all bring knowledge necessary to understand and prevent violence.
Developing personal skills includes strengthening conflict resolution, positive parenting and youth development, while recognising that individual behaviour cannot substitute for effective institutions and safer environments.
Reorienting health services means moving beyond the treatment of gunshot wounds. Health systems can contribute through injury surveillance, prevention, trauma-informed care, rehabilitation, mental health care and support for survivors and families.
South Africa also offers an important lesson for the wider world. Research has associated stronger implementation of the country’s Firearms Control Act with substantial reductions in firearm homicide. The significance of that experience is not that South African legislation provides a template that can simply be exported. Countries differ in their laws, institutions, cultures, firearm ownership and patterns of violence.
The transferable lesson is more fundamental: firearm deaths can be prevented through deliberate public policy, but legislation is only as effective as the institutions that implement it.
That means reliable licensing systems, enforcement, safe storage, tracing, controls against diversion, credible data and institutional accountability. It also means understanding how legally held firearms enter illicit markets and ensuring that prevention reaches communities carrying the greatest burden of violence.
The wider lesson is that firearm violence is not inevitable.
Public health has repeatedly demonstrated that preventable death can be reduced when societies identify risks, generate evidence, change environments, regulate hazards and invest in prevention. We apply this reasoning to infectious disease, road injury, tobacco and other threats to population health. Firearm violence warrants the same seriousness.
Forty years after Ottawa, gun violence exposes unfinished business in health promotion. The question is no longer simply whether health systems can save people after they have been shot. It is whether governments and societies are prepared to act on the conditions that make shootings more likely and on the evidence about what can prevent them.
Success must therefore be measured by shootings prevented, lives saved, disabilities avoided and communities made safer, and not only by trauma care delivered, firearms recovered, crimes investigated or perpetrators prosecuted.
Preventing gun violence is not only a criminal justice responsibility. It is a public health imperative – in South Africa and across the world.
