South Africa

Gun violence: What it costs the body, and our country

By Sebastian Van As 20 March 2014

Surviving gun violence is costly – not just to the body, but to society as a whole. Between one and four people survive an incident of gun violence for every person shot and killed in South Africa, and treating the country’s gunshots has been costed at approximately 4% of the National Health Budget: R6 billion annually. Yet surviving a gunshot wound is no mean feat. By SEBASTIAN VAN AS.

A recent article by Margie Orford describes the three bodies present when Oscar Pistorius shot and killed Reeva Steenkamp on 14 February 2013: Pistorius, Steenkamp and a third body – the intruder Pistorius claims he was shooting.

While the court decides whether the four shots Pistorius fired through the locked bathroom door were meant for Steenkamp or this intruder, the fact is that the body behind the door stood little chance of surviving four gunshots. While emergency medical intervention reduces the chance of a gunshot patient dying, the most important factors in surviving a gunshot are the ‘ballistics’ (bullet type, speed and size) and where the person is shot; that is the bullet tract through the body. Many firearm injuries to the brain and central nervous system are lethal on impact, while injuries to the heart and lung often lead to death within minutes.

Trauma surgeons see the immediate impact of trauma – car accidents, stabbings and shootings – on the human body daily; often the body of a gunshot survivor looks the least damaged. A small, round hole is the only external evidence of the massive internal damage caused by a bullet resulting from three processes. First, the bullet crushes all structures along its tract, complicated by a process called cavitation, where soft tissue (either elastic tissue such as abdominal organs – liver, spleen and kidneys, or inelastic tissue – the brain is particularly susceptible) collapses inwards with the permanent cavity being the resultant defect. Secondly, energy transfer occurs during retardation of the bullet, which may cause damage outside the bullet tract; bullets are classified as low speed (handgun) or high speed (AK47 machine gun), those with greater speed will dissipate more energy and cause more tissue damage. Thirdly, if the bullet (or shell) hits a bony part in the body, it often disintegrates and fragments of bullet and bony splinters scatter through the surrounding tissue, causing further damage.

Assuming a person survives the initial impact of a bullet and receives trauma care in time; the fact that a gunshot injury is an open wound in itself signals complications due to the risk of infection resulting from the bullet forcing dirt and pieces of bone or debris deep into tissues. Very often resultant infections are life-threatening; this is because the efficacy of antibiotics is diminished due to poor blood supply resulting from tissue damage.

Bullets wounds through the head, lungs, heart, major blood vessels or bowel will all be lethal if patients are not taken to theatre for an emergency operation. In addition to emergency surgery, typically a patient with a gunshot injury will undergo several operations to repair the injury in stages, a prolonged stay in intensive care followed by a lengthy stay in a general ward allowing for physical and occupational therapy. After being released from hospital a gunshot out-patient usually faces months more of rehabilitation – placing a tremendous burden on their family.

Compared to other injuries, complex gunshot patients, on average, consume more resources: Patients need more surgery, more intensive care, more blood transfusions and more long-term rehabilitation than patients with other injuries.

Surviving gun violence is expensive. In addition to the medical expenses listed, economists have identified five other costs associated with gun injuries: public programme costs (police, paramedic and ambulance transport costs); mental health care costs; productivity losses (the costs associated with not being able to undertake paid and unpaid work. Also included are earnings lost by family and friends caring for the injured person; as well as the productivity lost by employers through the absence of the injured person); administrative costs (which include disability and social grant claims, legal and court fees); and quality of life costs (where a monetary value is placed on the cost of individual and family pain, suffering and lost quality of life).

In the USA in 2011, patients were treated for gun injuries at an average cost of US$52,000 (R550,000) per patient, while the average health costs in the first year of a traumatic spinal cord injury range from US$311,000 to US$953,000.9 (R3,500,000 to R10,000,000). Treating gunshots in South Africa has been costed at approximately 4% of the National Health Budget: R6 billion annually.

Between one and four people survive an incident of gun violence for every person shot and killed, which means that between eighteen and 72 people survive an incident of gun violence every day in South Africa. In a developing country like South Africa, the vast majority of gunshot survivors are uninsured, so rely on government assistance – and thus taxpayers – to cover costs incurred.

As the world’s media focuses on Oscar Pistorius’ murder trial, the spotlight is turned on violent crime in South Africa. Our Constitution grants all South Africans the right to be free from all forms of violence, a right that is violated when someone is shot. For too long South Africans have viewed violence and associated injuries as an intrinsic part of life in South Africa. This need not be; violence can be prevented. It is the duty of governments, communities and individuals to make this difference. One practical step is to support legislation that controls who own what gun for which purpose so only people that are fit and proper are granted the responsibility of handling a lethal weapon. DM

Professor Sebastian van As is Head of the Trauma Unit at the Red Cross War Memorial Children’s Hospital and President of Childsafe South Africa (

Photo by REUTERS/Thomas Peter


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