Global Health Challenges Social Analysis 76: Lecture 16

Harvard University Initiative for Global Health

Global Health ChallengesSocial Analysis 76: Lecture 16


Burden of Injuries

Road Traffic Accidents

Suicide

Homicide


Injuries are a major cause of the burden of disease and Injuries are a major cause of the burden of disease and have a disproportionate impact on young adults, have a disproportionate impact on young adults, particularly males. particularly males.

Concept of injuries as a legitimate area of concern for Concept of injuries as a legitimate area of concern for public health and for health authorities in countries public health and for health authorities in countries is relatively new. is relatively new.

Many of the drivers of injury mortality and potential Many of the drivers of injury mortality and potential solutions are not in the narrow purview of health solutions are not in the narrow purview of health systems and require broader solutions and systems and require broader solutions and coalitions. coalitions.

Injuries


Distribution of 5.2 Million Global Injury Deaths, 2002

Road traffic accidents

23%

Poisonings7%

Falls8%

Fires6%

Drownings7%

Other unintentional

18%

Self-inflicted injuries

17%

Homicide11%

War3%


Burden of Injuries


Suicide

Homicide



Road Traffic Accident CPD (0-80), 2002

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

EMR B

EUR B

AFRO D

AFRO E

SEAR B

EMR D

EUR C

SEAR D

AMR B

AMR D

WPR B

AMR A

EUR A

WPR A

Males Females


Road traffic accidents in different societies vary Road traffic accidents in different societies vary substantially in the mix of deaths from drivers, substantially in the mix of deaths from drivers, passengers and pedestrians. passengers and pedestrians.

Although the nature of death is often not recorded, a Although the nature of death is often not recorded, a number of studies suggest that a large fraction of number of studies suggest that a large fraction of deaths in developing countries are in pedestrians deaths in developing countries are in pedestrians and/or passengers. In high-income countries, the and/or passengers. In high-income countries, the majority of deaths are in drivers. majority of deaths are in drivers.

Driver, Passenger, Pedestrian Mix





In most but not all higher income countries, there is a In most but not all higher income countries, there is a characteristic epidemic curve of road traffic characteristic epidemic curve of road traffic accidents. accidents.

With development the exposure to road traffic accident With development the exposure to road traffic accident death, whether as a driver, passenger or death, whether as a driver, passenger or pedestrian, increases as total miles travelled pedestrian, increases as total miles travelled increases.increases.

At some threshold level of income per capita, societies At some threshold level of income per capita, societies begin spending resources to reduce the risks per begin spending resources to reduce the risks per mile travelled resulting in a decline in risk, even mile travelled resulting in a decline in risk, even though exposure continues to increase.though exposure continues to increase.



Road Traffic AccidentsAge-standardized death rate (per 100,000)

0

10

20

30

40

50

60

70

80

1950 1960 1970 1980 1990 2000

Year

AS

DR

(p

er 1

00,0

00)

Australia

Greece

USA


1. Factors influencing exposure to risk

2. Factors influencing crash involvement

3. Factors influencing crash severity

4. Factors influencing post crash injuries

Risk Factors





Decreasing exposure – mass transport systems, land-use Decreasing exposure – mass transport systems, land-use policies, trip reduction (e.g. work at home), increasing policies, trip reduction (e.g. work at home), increasing legal age for use.legal age for use.

Road design – speed limits, road engineering, road Road design – speed limits, road engineering, road networks, speed bumps, traffic calming, identification networks, speed bumps, traffic calming, identification and intervention for high-risk crash sites.and intervention for high-risk crash sites.

Vehicle design – seat belts, airbags, daytime lights, vehicle Vehicle design – seat belts, airbags, daytime lights, vehicle crash worthiness, audible seatbelt reminders, variable crash worthiness, audible seatbelt reminders, variable speed limitation devices, alcohol interlocks.speed limitation devices, alcohol interlocks.

Compliance with road safety –speed cameras, enforcement Compliance with road safety –speed cameras, enforcement of alcohol laws, mandatory child seats and seatbelt laws, of alcohol laws, mandatory child seats and seatbelt laws, bicycle and motorcycle helmet laws and enforcement.bicycle and motorcycle helmet laws and enforcement.

Intervention Strategies



Since 1960s, developed countries have developed and Since 1960s, developed countries have developed and tested a range of strategies to reduce the risk of tested a range of strategies to reduce the risk of RTAs.RTAs.

Why have these technologies and strategies not Why have these technologies and strategies not diffused to developing countries? Is it a question of diffused to developing countries? Is it a question of cost? Is it a question of problem recognition and cost? Is it a question of problem recognition and policy priority? policy priority?

In regions such as EUR B or EMR B with middle to high In regions such as EUR B or EMR B with middle to high levels of income, it is extraordinarily difficult to levels of income, it is extraordinarily difficult to understand why effective technologies have not understand why effective technologies have not been adopted. been adopted.

Key maybe the shift from ethos of personal Key maybe the shift from ethos of personal responsibility to social responsibility for road traffic responsibility to social responsibility for road traffic accidents.accidents.

RTAs in Developing Countries


Burden of Injuries


Suicide

Homicide


Suicide death rates are about 3-6 times higher in males Suicide death rates are about 3-6 times higher in males except in a belt running from South Asia through except in a belt running from South Asia through China where risks are nearly equal. China where risks are nearly equal.

Suicide rates rise with age except recently in countries Suicide rates rise with age except recently in countries where young male suicide has risen dramatically.where young male suicide has risen dramatically.

In many high-income countries, suicide rates in older In many high-income countries, suicide rates in older adults have been dropping over the last 50 years.adults have been dropping over the last 50 years.

Highest rates are for males in Eastern Europe and the Highest rates are for males in Eastern Europe and the Former Soviet Union. Former Soviet Union.

Suicide Patterns


0.0

02

.00

4.0

06

.00

8P

rob

ab

ility

of

de

ath

1950 1960 1970 1980 1990 2000Year

M 19-39

F 19-39

M 40-59

F 40-59

M 60-79

F 60-79

Source data: WHO Mortality Database

Probability of death by Suicide

United Kingdom 4308


Countries with complete vital registration systems Countries with complete vital registration systems demonstrate diverse long-term trends in suicide as demonstrate diverse long-term trends in suicide as well as short-term changes such as in the Russian well as short-term changes such as in the Russian Federation.Federation.

Many explanations are possible but no coherent theory Many explanations are possible but no coherent theory of variation in the level or trends in suicide are of variation in the level or trends in suicide are available. available.

For a number of developed countries, young male For a number of developed countries, young male suicide rates have been rising or are stagnant for suicide rates have been rising or are stagnant for 30-40 years. 30-40 years.

Suicide Trends


1)1) Psychiatric factors -- Psychiatric factors -- major depression; bipolar disorder; schizophrenia; anxiety and disorders of conduct and personality; and impulsivity

2)2) Biological factors – increased risk in familiesBiological factors – increased risk in families

3)3) Precipitating life events – death of loved one, Precipitating life events – death of loved one, physical or sexual abuse, protective effect of stable physical or sexual abuse, protective effect of stable relationships, social isolationrelationships, social isolation

4)4) Social, cultural and environmental factors -- Social, cultural and environmental factors -- availability of the means of suicide; a person’s place of residence, employment or immigration status; affiliation to a religion; and economic conditions

Suicide Risk Factors


1)1) Treatment of psychiatric disorders – increasing Treatment of psychiatric disorders – increasing concern that in young adults suicide risk is not concern that in young adults suicide risk is not affected or may increase.affected or may increase.

2)2) Suicidal behaviour interventionsSuicidal behaviour interventions

3)3) Community interventions such as suicide prevention Community interventions such as suicide prevention centers – little evidence of impact centers – little evidence of impact

4)4) Restricting access to means of suicide – bridge Restricting access to means of suicide – bridge fencing, limit access to toxic compoundsfencing, limit access to toxic compounds

5)5) Responsible media reportingResponsible media reporting

Public Health Approaches to Reducing Suicide




World Health Report 2001 and the World Violence World Health Report 2001 and the World Violence Report in 2002 has brought some increase in policy Report in 2002 has brought some increase in policy attention.attention.

Main problem is that there are few generally effective Main problem is that there are few generally effective public health strategies to reduce suicide. Efforts to public health strategies to reduce suicide. Efforts to restrict means are by nature highly context specific.restrict means are by nature highly context specific.

Public health can contribute little at this point to Public health can contribute little at this point to addressing broad social drivers of suicide such as addressing broad social drivers of suicide such as the status of women in South Asia and rural China. the status of women in South Asia and rural China.

Global Response to Suicide


Burden of Injuries


Suicide

Homicide



Female vs Male Homicide CPD (0-80), 2002

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

0.0% 1.0% 2.0% 3.0% 4.0%

Male CPD

Fem

ale

CP

D

AMR BAMR B

AMR DAMR D

AFR EAFR EEUR CEUR C

AFR DAFR D

AMR AAMR A

WPR AWPR AEUR AEUR A

SEAR DSEAR D

EMR DEMR D


Highest rates are in Africa, Eastern Europe and the Highest rates are in Africa, Eastern Europe and the Former Soviet Union and particularly for males in Former Soviet Union and particularly for males in Latin America.Latin America.

Homicide for males and females is extremely low, less Homicide for males and females is extremely low, less than 0.1% cumulative risk of death in Western than 0.1% cumulative risk of death in Western Europe, Japan, Australia and New Zealand. Europe, Japan, Australia and New Zealand.

AMR A (US and Canada) has male homicide rates 7.8 AMR A (US and Canada) has male homicide rates 7.8 times higher than WPR B and AMR B is nearly 50 times higher than WPR B and AMR B is nearly 50 times higher than WPR B.times higher than WPR B.

Homicide rates demonstrate dramatic fluctuations over Homicide rates demonstrate dramatic fluctuations over relatively short periods of time – some correlate with relatively short periods of time – some correlate with economic trends. economic trends.

Homicide Patterns


0.0

02

.00

4.0

06

.00

8P

roba

bilit

y of

dea

th

1950 1960 1970 1980 1990 2000Year

M 0-14

F 0-14

M 15-39

F 15-39

M 40-59

F 40-59

M 60-79

F 60-79

Source data: WHO Mortality Database

Probability of death by HomicideUnited States of America



Few prevention strategies have been formulated or Few prevention strategies have been formulated or tested. tested.

Much of the policy debate is national and focused on Much of the policy debate is national and focused on law enforcement, prosecution of criminals and the law enforcement, prosecution of criminals and the deterrent effect.deterrent effect.

Cross-country and time-series patterns reveal Cross-country and time-series patterns reveal enormous heterogeneity that must have social, enormous heterogeneity that must have social, cultural and economic causes.cultural and economic causes.

What is the role of access to weapons? What is the role of access to weapons?

Homicide Prevention

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Global Health Challenges Social Analysis 76: Lecture 16