1. Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 16

2. Harvard University Initiative for Global Health Burden of Injuries Road Traffic Accidents Suicide Homicide

3. Harvard University Initiative for Global Health Injuries are a major cause of the burden of disease and have a disproportionate impact on young adults, particularly males. Concept of injuries as a legitimate area of concern for public health and for health authorities in countries is relatively new. Many of the drivers of injury mortality and potential solutions are not in the narrow purview of health systems and require broader solutions and coalitions. Injuries

4. Harvard University Initiative for Global Health Distribution of 5.2 Million Global Injury Deaths, 2002

5. Harvard University Initiative for Global Health Burden of Injuries Road Traffic Accidents Suicide Homicide

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8. Road traffic accidents in different societies vary substantially in the mix of deaths from drivers, passengers and pedestrians. Although the nature of death is often not recorded, a number of studies suggest that a large fraction of deaths in developing countries are in pedestrians and/or passengers. In high-income countries, the majority of deaths are in drivers. Driver, Passenger, Pedestrian Mix

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12. In most but not all higher income countries, there is a characteristic epidemic curve of road traffic accidents. With development the exposure to road traffic accident death, whether as a driver, passenger or pedestrian, increases as total miles travelled increases. At some threshold level of income per capita, societies begin spending resources to reduce the risks per mile travelled resulting in a decline in risk, even though exposure continues to increase. Road Traffic Accidents

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14. 1. Factors influencing exposure to risk 2. Factors influencing crash involvement 3. Factors influencing crash severity 4. Factors influencing post crash injuries Risk Factors

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18. Decreasing exposure – mass transport systems, land-use policies, trip reduction (e.g. work at home), increasing legal age for use. Road design – speed limits, road engineering, road networks, speed bumps, traffic calming, identification and intervention for high-risk crash sites. Vehicle design – seat belts, airbags, daytime lights, vehicle crash worthiness, audible seatbelt reminders, variable speed limitation devices, alcohol interlocks. Compliance with road safety –speed cameras, enforcement of alcohol laws, mandatory child seats and seatbelt laws, bicycle and motorcycle helmet laws and enforcement. Intervention Strategies

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20. Since 1960s, developed countries have developed and tested a range of strategies to reduce the risk of RTAs. Why have these technologies and strategies not diffused to developing countries? Is it a question of cost? Is it a question of problem recognition and policy priority? In regions such as EUR B or EMR B with middle to high levels of income, it is extraordinarily difficult to understand why effective technologies have not been adopted. Key maybe the shift from ethos of personal responsibility to social responsibility for road traffic accidents. RTAs in Developing Countries

21. Harvard University Initiative for Global Health Burden of Injuries Road Traffic Accidents Suicide Homicide

22. Harvard University Initiative for Global Health Suicide death rates are about 3-6 times higher in males except in a belt running from South Asia through China where risks are nearly equal. Suicide rates rise with age except recently in countries where young male suicide has risen dramatically. In many high-income countries, suicide rates in older adults have been dropping over the last 50 years. Highest rates are for males in Eastern Europe and the Former Soviet Union. Suicide Patterns

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24. Countries with complete vital registration systems demonstrate diverse long-term trends in suicide as well as short-term changes such as in the Russian Federation. Many explanations are possible but no coherent theory of variation in the level or trends in suicide are available. For a number of developed countries, young male suicide rates have been rising or are stagnant for 30-40 years. Suicide Trends

25. Harvard University Initiative for Global Health 1)Psychiatric factors -- 1)Psychiatric factors -- major depression; bipolar disorder; schizophrenia; anxiety and disorders of conduct and personality; and impulsivity 2) Biological factors – increased risk in families 3) Precipitating life events – death of loved one, physical or sexual abuse, protective effect of stable relationships, social isolation 4) Social, cultural and environmental factors -- 4) 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

26. Harvard University Initiative for Global Health 1)Treatment of psychiatric disorders – increasing concern that in young adults suicide risk is not affected or may increase. 2)Suicidal behaviour interventions 3)Community interventions such as suicide prevention centers – little evidence of impact 4)Restricting access to means of suicide – bridge fencing, limit access to toxic compounds 5)Responsible media reporting Public Health Approaches to Reducing Suicide

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29. World Health Report 2001 and the World Violence Report in 2002 has brought some increase in policy attention. Main problem is that there are few generally effective public health strategies to reduce suicide. Efforts to restrict means are by nature highly context specific. Public health can contribute little at this point to addressing broad social drivers of suicide such as the status of women in South Asia and rural China. Global Response to Suicide

30. Harvard University Initiative for Global Health Burden of Injuries Road Traffic Accidents Suicide Homicide

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32. AMR B AMR D AFR E EUR C AFR D AMR A WPR A EUR A SEAR D EMR D

33. Harvard University Initiative for Global Health Highest rates are in Africa, Eastern Europe and the Former Soviet Union and particularly for males in Latin America. Homicide for males and females is extremely low, less than 0.1% cumulative risk of death in Western Europe, Japan, Australia and New Zealand. 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. Homicide rates demonstrate dramatic fluctuations over relatively short periods of time – some correlate with economic trends. Homicide Patterns

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36. Few prevention strategies have been formulated or tested. Much of the policy debate is national and focused on law enforcement, prosecution of criminals and the deterrent effect. Cross-country and time-series patterns reveal enormous heterogeneity that must have social, cultural and economic causes. What is the role of access to weapons? Homicide Prevention