Tackling The Toll Of Injuries

In our time we have seen the eradication of smallpox, the unraveling of the human genome, the transplantation of organs and the development of vaccines to eliminate many scourges of childhood. Philanthropic organizations have often played pivotal roles in these developments -- for example, the Carter Center, which is well on its way to eliminating the scourge of river blindness, and the Gates Foundation, which is investing billions in combating infectious diseases.

Now it's time to ignite action on another compelling global problem: deaths from injuries. Five million people around the world die each year from injuries, nearly a million of them children and adolescents. The burden is even more enormous when the large number of people maimed and crippled by injuries is considered.

In the United States and other developed countries, we have made enormous strides in reducing the toll from trauma. Our motor vehicles and roads are far safer now than they were when Ralph Nader's "Unsafe at Any Speed" was published in 1965. Deaths from injuries to children and adolescents have been cut in half in the past 25 years. Mortality from burns has decreased dramatically because of improved treatment.

But in poor and underdeveloped countries, the toll of preventable death and injury remains unacceptably high. Prevention of just 20 percent of the world's deaths from injuries -- a million lives saved each year -- is a bold but realistic goal that can be achieved with the application of current technology and knowledge. How might it be accomplished?

· Reduce motor vehicle injuries and fatalities. Motor vehicle collisions are the leading cause of injuries in nearly all countries, accounting for more than a million deaths and 20 million to 50 million injuries each year. In Europe and North America, these happen primarily to those in automobiles; in Africa and Asia, accidents involving pedestrians and motorcycles account for a much larger proportion. The economic cost to low- and middle-income countries from these crashes is larger than the amount they receive in all development assistance. Few of the lessons we have learned in industrialized countries have been applied to other parts of the world: requiring cars to be built so that they protect the passenger in a crash; requiring and enforcing the use of seat belts and motorcycle helmets; controlling speeding; and vigorously pursuing drunk drivers.

· Prevent childhood drowning. In 2000 more than 400,000 people drowned, including some 116,000 children under the age of 5. Ninety-seven percent of drowning deaths occur in low- and middle-income countries. Prevention of these child drownings will depend on covering water storage cisterns, fencing drainage ditches, giving swimming lessons and improving flood control.

· Work to reduce fire deaths. The World Health Organization estimates that approximately 320,000 people die of fire-related burns each year, most in developing countries (more than half in Southeast Asia alone). Many stem from the use of open fires for cooking, heating and light and could be prevented through the use of simple, safer stoves and safer sources of fuel. Use of such technology could save 50,000 lives annually.

· Change child-labor practices. Around the world, some 250 million children under the age of 15 work, and an estimated 50,000 to 200,000 of them die every year. Unlike most of our working teenagers, children in low-income countries work to help put food on the family table. Work for them is a hard fact of life, a necessity for family survival. Nevertheless, reducing the number of child-labor deaths by restricting the types of high-risk tasks children are asked to do is feasible, humane and necessary.

· Treat depression to prevent suicide. More than 800,000 people die each year from suicide. The most important risk factor for suicide is depression, which affects 100 million people and is the leading cause of disability. Treatment with currently available means could prevent perhaps 5 to 10 percent of suicides.

· Reduce domestic violence. Physical violence to women by their partners is pervasive; 10 to 50 percent of women around the world report being victims of physical violence by intimate partners at some point in their lives. Some 50,000, if not many more, die from such violence each year. Addressing it, and empowering women, could have a substantial impact.

· Improve trauma care. There are enormous disparities in survival rates among injury victims in different countries. Severely injured adults in low-income countries are about six times more likely to die than those in the United States. The World Health Organization has outlined minimum standards for essential trauma care services that are feasible and could be provided to virtually all injured people in the world. Reducing trauma mortality by 10 percent through such available interventions would save 500,000 lives a year.

The millions of deaths from injuries represent an enormous burden to families and societies -- 181 million years of productive life lost annually. The World Health Organization and UNICEF have developed global injury-prevention efforts but have only limited resources available for the task. Few governments have undertaken prevention programs commensurate with the size of the problem, and no large foundation has yet made international injury control a focus of its activities.

Large-scale interventions should be undertaken at the national level to demonstrate that success in preventing injury deaths is possible and to generate lessons that can then be applied globally, especially in low- and middle-income countries. Such interventions would be aided by having international philanthropic organizations devote resources commensurate with the extent of the problem. The means to save a million lives each year are readily available. It only takes the will to do so.

The writers, who are physicians, are with the Harborview Injury Prevention and Research Center at the University of Washington. They were assisted in the preparation of this article by Rajam Krishnan of the University of Malay in Kuala Lumpur, Robert Quansah of Kwame Nkrumah University in Ghana and Alfredo Celis of the University of Guadalajara in Mexico.