By:
Adriana Lein
Brian Meier, MD
“Accidents
happen.” We’re all likely familiar with this adage that suggests unfortunate
happenings are unpredictable and unavoidable. While it may be true to some degree
that tragedy strikes in unexpected ways, a closer look at the global burden of
disease reveals that events such as road traffic injuries, which are
significant contributors to global mortality and morbidity, are anything but
unpredictable and unavoidable. In fact, all of the primary contributors to what
the World Health Organization has termed Global Injury Burden follow patterns
that disproportionately affect certain groups based on demographic differences,
whether gender-based, grounded in socioeconomic inequality, or specific to
regional and political factors. Among these contributors to Global Injury
Burden are road traffic injuries, suicide, homicide and war (a breakdown shown
in the below chart of World Health Organization).
Source: http://www.who.int/violence_injury_prevention/key_facts/en/
Delivering
a guest lecture to the first-year Master’s in Global Health cohort at Duke
University on October 20th, 2015, Dr. Catherine Staton explained why she doesn’t like to
use the word “accident” in her work. An Emergency Medicine physician and an
expert on road traffic injuries, Dr. Staton has worked extensively abroad, in
places including South Africa, Georgia, Armenia, and, recently, Brazil and
Tanzania. According to Dr. Staton, the word “accident” implies a spontaneous and
independent incident. Such levity towards serious phenomena overlooks the
potential for injury and violence prevention by addressing risk factors through
interventions at the community and policy levels. Dr. Staton went on to outline
the clear patterns of predictability that road traffic injuries follow, a theme
central to her work. Dr. Staton and her colleagues have conducted mapping of deemed road traffic “hotspots”
on Brazilian highways and found that crash occurrences could be modeled after
variables related to regional differences and built-environmental analyses and
mainly fell into 5 different patterns. However, traffic accidents are not the
only component of injury burden that could be reduced through understanding
ecological determinants.
Consider
interpersonal violence, a subject that receives considerable attention due to
politicized discussions of mass shootings and gun control. Returning to the
above example of Brazil, homicides were the leading causes of premature
mortality in 2010
(reported in Years of Life Lost). As the Los
Angeles Times highlighted in a recent profile, Brazil’s homicide rate actually
increased between 2000-2012, despite that
"in the same
period…the world overall got about 16% safer from murder, while developed
countries saw a drop of 40%." The profile continued, noting that violence,
not surprisingly, disproportionately affects the economically disadvantaged regions
of the Northeast and its victims are overwhelming young, black males. Emphasizing
the link between violence and social injustices, Christopher Mikton, a
technical officer of the WHO team on Violence Prevention stated, "all else
being equal, we expect that if there is a major drop in inequality, homicide
rates go down."
So is there really such a thing as an “accident”
when it comes to health or can the global injury burden best be understood
through the application of Paul Farmer’s well-known extension of structural violence
theory to health outcomes? The evidence points to the latter.
I really like the point about how calling these incidents "accidents" means that prevention isn't possible. I think that is a really interesting way of looking at it, and I had never thought about it in that way before this lecture. Looking at the graph that you used, everything is preventable through many different types of interventions (except maybe everything in the category for other unintentional injuries because we don't know what those are injuries are or what caused them). I do agree when you say that the evidence points to the fact that health or the global injury burden can be understood through the application of the structural violence theory, although I do think that there are still a few situations that could probably be classified as a true accident. However, I think that this number is far, far fewer than the number that can be attributed to the structural violence theory.
ReplyDeleteThis is a really fascinating topic, and one I hadn't really thought about before Dr. Staton's lecture. The global burden of injury is enormous; yet, people usually focus on other disease burdens in global health. While one burden is not more important or "worthy" than any other, all do deserve attention. What I find most interesting about global injury is this idea that what we conceptualize as an accident is actually a series of factors that are preventable. Even in the US, this is the case - how many "accidents" do we attribute to drunk driving or texting or whatever? Clearly, the word "accident" is a misnomer. Furthermore, I think it is also very important that we remember Dr. Pail Farmer's structural violence theory to health outcomes regarding injury. There exist important correlations with poverty or lower socioeconomic status and homicide, suicide, gender-based violence, and deadly road collisions. Just because something seems like a one-time violent or traumatic event, doesn't mean that there aren't important social determinants and structural components that contribute.
ReplyDeleteGiven that a large percentage of accidents are due to technology (i.e. cars), I think technology can be used to improve our safety. For instance, I am very interested to know what Dr. Staton thinks about driverless cars. Ideally they would reduce the chances of driver-based accidents by avoiding accident prone situations, such as texting while driving, running red lights, driving under the influence, etc. This leads to the question: what is the critical number of driverless cars we need to have on the road before a significant change in road safety is observed? If there are too few driverless cars, then the overall driving experience will be determined by the actions of drivers; however, with enough driverless cars, the overall behavior will change (hopefully for the better). I know that driverless cars will probably not be implemented in low and middle income countries for a while, but traffic injuries are a huge problems globally. If we can show a proof of concept in countries such as the US, Canada, Europe, and China, then we could start to adapt these driverless cars to other environments that have poorer quality roads, less standardized traffic laws, etc.
ReplyDeleteI think that these comments on road traffic incidences are very interesting and it definitely shows the importance of considering risk factors when looking at incidence of injury or death from injury. Something I would like to focus on is how injury affects lives in ways other than death. Something that I have noticed most recently in global research of traffic accidents is that there is very little data on injury caused by traffic incidents in LMICs. Almost all of the data concerns death by injury. I think that this is important information to have as there might be varied risk factors for non-fatal injuries than there are for fatal injuries and these address different changes that must be implemented in hopes of decreasing these RTIs overall.
ReplyDeleteHannah, I think your point on driverless cars is interesting but I'm not sure is one we're close to implementing. One of the greatest issues and reasons for RTIs is the unsafe cars and motorbikes that are on the road and the limited regulation on what is on the road. How can we address these issues? Is it just a matter of legislation and enforcement of that legislation?
When I look at the topic of global burden of injuries. What occurred to me is the horrified images of a young man's badly mutilated hands which were heavily injured by the machine tool in a small factory located in suburban areas. I witnessed this when I was on my internship at a tertiary hospital in China. It is not uncommon, to be honest, it happens a lot. Work injuries in newly-industrialized countries is an undeniable huge problem around the world. Unlike other chronic occupational diseases, work injuries took place in heavy industry sectors such as ship yard, steel production, and construction. It can happen in a second and is always deadly, which caused tragedies to both the worker and the factory owner. We call it as an accident but in fact it is results of underdeveloped occupational protection, which can be prevented. Some countries do not have legislation of occupational protection while in most cases, they do have legislation but no effective enforcement to make sure that all the preventive measures were taken.
ReplyDelete