A hospital-based survey of small arms injuries in a community in Nigeria

Inyang, UC[1], Ofoegbu, CKP[2]

[1]Dept of Orthopaedics and Traumatology, University of Uyo Nigeria
[2]Dept of Surgery, University of Ilorin, Nigeria

ABSTRACT
Background: Some reports on small arms from Nigeria have been published, most of which are retrospective studies.
Objective: To present a 12 month prospective survey of small arms injuries with a view to adding to the body of knowledge on this subject.
Methods: A prospective study and analysis of all patients admitted for gunshot injuries (GSI) at the University of Uyo Teaching Hospital, Uyo Nigeria between September 2010 and August 2011. Data collected include: age, sex, occupation, whether GSI was intentional or unintentional, type of gunshot, circumstances surrounding the injury, sites of injury (single or multiple) and the eventual outcome.
Results: There were 64 patients in all, 61 males and three females (M: F=20:1).Peak age was 21-30 years, predominantly students by occupation (21, 32.8%), 53(82.8%) were intentional while 11 (17.2%) were unintentional. There were nine high velocity GSI while 55 (86%) were low velocity GSI. Armed robbers fired 30 victims (46.9%) while students' cultists fired eight (12.5%). The regions were single in 45 (70.3%) while 19 were multiple (29.7%). The lower extremities were involved 19 times, head and neck nine, upper extremities nine, chest four, abdomen and pelvis four where single site injuries occurred. There were seven deaths, three of whom had abdominal GSI, two in the extremities from exsanguination and one multiple regions GSI including the abdomen.
Conclusion:  This study has highlighted the male and armed robbery factor in intentional gunshot injuries and these calls for strategies to ensure safer communities.

Key words: Small arms, Gunshots, Injuries

INTRODUCTION
Small arms proliferation and its consequences have become a global problem. There are about 639 million small arms in circulation worldwide (more than one weapon to 10 people) accounting for 300,000 deaths in armed conflict and 200,000 deaths from homicides and suicides annually1.Forty seven of the 49 biggest conflicts in the 1990s were fought with small arms[1]. Fifty nine percent of these weapons are legally in civilian hands and 57 people are killed by small arms per hour[2]. Small arms are responsible for up to 90% of the world's combat related killings and for approximately 100% of the world's murders and violent crimes2.  Nigeria has had more than 40 violent clashes in the past four years and most were executed with small arms.
Some authorities have labeled small arms as the real “weapons of mass destruction”.[2] The system being awash with this vast number of small arms presents with a multitude of negative effects including loss of lives and destruction of property worth millions of naira, displacement of people (or refugees) especially women and children, feeling of insecurity and suspicion, destruction of democracies and retardation of socio-economic development and loss of foreign investment.
This prospective study was done to obtain our perspective of the problem as the patients presented to the teaching hospital setting in Nigeria. Most of the studies on small arms injuries from Nigeria are retrospective studies.
Patients and Methods
A prospective study of 12 months from September 1, 2010- August 31, 2011 of all patients admitted for gunshot injuries (GSI) at the University of Uyo Teaching Hospital, Uyo, Nigeria was done.
Data collected pertained to age, sex, occupation, whether GSI was intentional or unintentional, velocity of gunshot (high or low), circumstances surrounding the injury, site of GSI (single or multiple) and eventual outcome (alive, dead). There was no autopsy done as this is very difficult in our environment due to some religious and cultural reasons.
The data was analysed using Microsoft Excel software

Figure 2:   Causes of Small Arms Injuries
Figure 3:    Causes of Intentional Injuries

Figure 4:   Distribution of Single Site Injuries

RESULTS
A total of 64 patients who sustained gunshot injuries (GSI) presented during the period under study. There were 61 males and three females (M: F=20:1).The age range was between 13- 60 years (mean-31.3 years, standard deviation-10.91). The peak age group was 21- 30 years (24 patients). Figure 1 shows the distribution of the patients by age. The victims represent a cross section of the society with 32.8% (21 patients) being students, 15.6 %( 10 patients) being artisans and 14.1 %( nine patients) being traders. Table 1 is the distribution of the patients by occupation. The intent of injury was established in the 64 patients with 53 being intentional (82.8%) and 11 being unintentional (17.2%).Armed robbers were responsible for 30 of the GSI accounting for 46.9% of the total and 56.6% of the intentional injuries. Fifteen (23.5%), 11(17.2%) and two (3.1%) patients were shot on the highways, home and in trading shops respectively. Armed robbers also shot a member of a local vigilante group for crime control on patrol and a policeman during a shoot out with policemen. Intentional injuries were inflicted by the police on suspected criminals; during communal clashes, also during clashes between rival political groups and during disputes about landed property. Student-cultists fired at eight patients (12.5%), six being intentional and two unintentional from stray bullets. Figure 2 shows the circumstances that caused injuries from small arms.
There were 11 unintentional injuries comprising mainly of two GSI by policemen (at a police checkpoint and a security guard mistaken for an armed robber) and the two GSI by cultists mentioned above. There were also two unintentional GSI from hunting accidents with a hunter mistaking his colleague to be the prey.  Figure 3 shows the circumstances leading to intentional injuries. Fifty- five (86%) patients had low velocity injuries with small arms while nine (14%) had high velocity injuries. Forty-five (70.3%) patients sustained injuries to a single anatomical site while 19 (29.7%) had GSI to multiple sites. The lower limbs were hit 19 times, head and neck nine, upper limbs nine, chest four and abdomen and pelvis four times for those who sustained single site injuries.  Figure 4 shows the anatomical distribution of injuries to a single site while Table 2 shows the distribution of the multiple injuries.
Thirty-nine (60.9%) patients were discharged while seven (10.9%) died. Seventeen (26.6%) patients discharged against medical advice while one was transferred to another health facility. Three of the patients who died had abdominal GSI, two in the extremities and one at multiple sites including the abdomen.
Haemorrhage as a cause of death was present in six of the seven deaths. Table 3 shows the causes of death.
In our environment, males dominate in the use of small arms. Our male: female ratio of 20:1 is also reported by other authors worldwide.[3, 4, 5, 6, 7]   Some reasons have been adduced for this to include response to perceived threat and resistance posed by the male (as distinct from the seemingly passive nature of the females)[5] and the fact that males by nature are more exposed to forces of violence.[8] The peak age in our study was between the 21-30 years age group; the age when men are strongest and most active.[4, 5] It may also be because this is the age group that is most unemployed.
Most of the GSI in our series were intentional (82.8%) with the aim to injure or kill. These were mainly fired by armed robbers but this may also be due to the pervading culture of violence in our polity where might is perceived to be right. Other studies from Nigeria confirm that most of the injuries from small arms are intentional with figures above 75%.[3, 5, 8] The involvement of the different anatomical sites of the body also attests to this severe culture of violence.[5]
A large proportion of small arms used in our community are low velocity weapons. Our figure of 85.7% correlates with other findings of 79.7%3 and 92.2%.8 High velocity weapons have a minor proportion but 47% of injuries in Lagos; the most industrialized city in Nigeria was of this variety.[4] The wars in the West African sub region (Liberia, Sierra Leone, and Cote d'Ivoire) have been implicated as the source of the small arms.[13] This is because of trade liberalization, transportation and the open border policy between the countries in the sub region. Another factor is that the security agencies (police, customs, and immigration) are ill equipped and this makes it very difficult to counter the well equipped, organized and sophisticated criminals that engage in small arms trafficking.

Armed robbers fired a significant proportion of the shots in our study (46.9%). This is also reported by other authors (57%, 77%).[3, 5, 8] Many youths are involved and this may be due to the high level of unemployment, frustration and hopelessness amongst this category of people.[5] There is also an increasing bankruptcy of moral values, indiscipline and corruption in our polity, which the frustration among the youth feeds on. The reasons stated above may also explain why higher institution cultists are a significant proportion of those who use small arms in our environment (12.5%). Another reason is said to be the incessant closure of our higher institutions.[5]
The unintentional injuries (17.2%) were mostly from shots fired by hunters and policemen. Other studies reported similar findings (9%8 and 10.9%5). Some of the victims in our study sustained injuries from clashes between supporters of rival political parties in the state. In the period up to the elections in April, 2011, armed thugs were used by politicians to intimidate, injure and kill opponents. Many politicians organized private armed groups for this purpose. Some were also injured from communal clashes which have been a recurring decimal in our polity.  Youths from different ethnic or religious affiliations fight each other using small arms as weapons. Assassinations have also become a part of the culture of violence with some high profile victims. Sadly, most of these assassins are never apprehended, further worsening the insecurity in the polity.
Single injuries were sustained in 70.3% of patients with the lower extremities being the most common site. This correlates with the intent to maim and not to kill although it can be argued that victims are demobilized initially to ensure their capture and are eventually killed. Figures between 15.7-29% were reported by other studies.[3, 5, 8] It has however, been suggested that lower extremity injuries are most common because the aim is to demobilize and not to kill and may also be due to indiscriminate shooting by armed robbers to scare people away.[8] Three of the seven deaths in our study had an abdominal component of injuries. Abdominal injuries from firearms are associated with a high mortality rate. In the study by Dogo et al, four of the five patients that died from abdominal trauma sustained gunshot injury.[9] The fact that haemorrhage is a major factor in the death of the victims is linked to the parlous state of our health care system which some workers have also commented upon.[10, 11, 12]
The United Nations has been in the forefront to combat the menace of small arms worldwide, outlining measures to be undertaken nationally and internationally and passing resolutions to affect these. These include the United Nations Security Council Resolutions 1397, 1460 and1467 (Nov 20, 2001, Jan 30, 2003 and March 18, 2003 respectively).[13] some regional agreements have also been reached and these include;
European Union code of conduct on arms export(June 8, 1998), ministerial declaration for continued concerted action [on Small Arms] in the Great Lakes Region and the Horn of Africa (August 8, 2002) which was  signed by Burundi, Congo (DRC), Djibouti, Ethiopia, Eritrea, Kenya, Rwanda, Sudan, Tanzania and Uganda; and moratorium on importation, exportation and manufacture of light weapons signed by Economic Community of West African States (ECOWAS) at Bamako, Mali in November 1996.[13] The problem with these resolutions and agreements is that there are loopholes that criminals can take advantage of and  they are not binding with inexact and indecisive implementation.[13]
Some measures have been suggested for national governments to curb this menace and these include; ensuring strict discipline, civilian oversight and adequate training amongst the police and armed forces. This, it is said would reduce deaths by this sector.[13] Others are, barring the formation of civil militias and not permitting local communities to partake in law enforcement functions unless under strict oversight; ensuring that adequate laws are enacted and used to punish the misuse of small arms by private people, addressing the socioeconomic problems associated with poverty, corruption, illiteracy and youth unemployment,[13] development of border communities with provision of basic amenities, establishment of a national arms registry to regulate, monitor and control the use of small arms in Nigeria,[13] education and enlightenment campaigns for the citizenry on the need to develop a culture of peace and institution of better conflict resolution methods.[13]

CONCLUSION
GSI is a predominantly male problem, with armed robbery as the main cause. The intentional nature of GSI calls for strategies to ensure safer communities both at home and at school where students' gangsters is a second major cause of GSI. Despite the low velocity nature of GSI, it could still be fatal with abdominal injuries having the worst case-fatality ratio. Further research is needed to document the economic costs of GSI in the community.

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