Child-injury death rates–do international comparisons help?

FEATURE

Child-injury death rates—do international comparisons help?

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dents—which at 41% acount for the greatest single cause of child deaths in rich countries—New Zealand “is not applying, in any comprehensive fashion, well-evaluated prevention strategies such as traffic calming and drastically reduced speed limits in school and residential areas.” The UNICEF report “will be a further tool for promoting efforts to reduce this

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The child-injury iceberg

significant public-health problem”, Chalmers says. Across the Tasman sea, Morris Odell of the Victorian Institute of Forensic Medicine, Australia, agrees that the league table makes “fascinating reading”, but warns that “surveys of this sort can also present the data in such a way as to misinterpret the reasons for differences between countries”. “It would be especially undesirable for countries at the lower end of the ladder to be stigmatised as places where child injury and death is not as important an issue as in countries higher up in the ranking.” This last point must be especially pertinent for South Korea, which takes last place in the league table with 25·6/100 000 child deaths per year. Furthermore, Odell says, it is difficult to draw generalised conclusions about reasons for child-injury deaths in a country such as Australia—geographically huge, with a low-density, diverse population. With a child-injury death rate of 9·5/100 000, Australians “drive a lot and swim a lot”, he says. “In the cities we have a generally well functioning public-health system but in rural areas the infrastructure is not as well developed. There is therefore no such thing as a ‘typical’ Australian person or community.” Finding a nationwide standard also presents problems in Switzerland, says Paul Bouvier of the Institute of Social and Preventive Medicine, University

Photograph: Tony Stone Images/ Figure: UNICEF

s with many public-health trends in rich countries, child-injury death rates have improved significantly since the 1970s. But a Feb 6 report by the UNICEF Innocenti Research Centre in Florence, Italy, warns against complacency, since: “In the world’s rich nations, more than 20 000 children will die from injuries in the next 12 months.” The UNICEF report “presents, for the first time, a standardised league table ranking 26 of the world’s richest nations according to their injury death rates for children aged 1 to 14”. Data in the “death league” of countries within the Organisation for Economic Co-operation and Development (OECD) are presented as the annual number of deaths from unintentional and intentional injuries per 10 000 children during 1991–95. The most common unintentional causes of death are transport accidents, followed by drownings, fires, falls, poisonings, and firearms accidents. While preventable child death is in itself a tragedy, it represents a much greater toll of human misery and public-health-service burden. An analysis of home and leisure accidents in the Netherlands, for example, indicates that every single child death is just the tip of a “child-injury iceberg” of about 160 hospital admissions and 2000 accident and emergency visits. And, although it comes as no surprise that the league table shows a relation between deaths and national wealth, this relation is not clear-cut. For example, South Korea and Mexico are at the bottom of the standardised league table—alongside the USA and New Zealand, which are fourth and fifth from the bottom, respectively. But, apart from being a simple method of presenting data, how enlightening is this “death league”? The low position of New Zealand, with 13·7/100 000 deaths per year, comes as no surprise to David Chalmers, deputy director of the Injury Prevention Research Unit in Dunedin, Otago. “The report is consistent with the results of our own investigations, showing that New Zealand lags well behind other developed countries in a number of areas of injury prevention”, he says. For example, where measures such as child restraints in motor vehicles and fencing around swimming pools have been mandated by law, “we have inadequate compliance and enforcement”, Chalmers says. Furthermore, with regard to preventing transport acci-

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of Geneva. “As a federal state, Switzerland has no national health policy, no proper child health protection policy, and no injury control and prevention policy”, he notes. On March 4, there will be a federal vote on reducing traffic speeds to 30 km/h in towns and villages. But the chances of acceptance of this “Streets for All” initiative are low, says Bouvier, despite death by road accidents being a major public-health issue. Although it is one of the richest OECD countries, Switzerland’s poistion in the league table—17th, with 9·6/100 000 annual deaths—is “appalling”, says Bouvier, but the UNICEF report is a useful reminder that it is possible to do better. “Comparing mortality rates in Switzerland with those in Sweden not only gives us essential targets for our public health policies, it gives us an ethical duty towards our children that we make all needed efforts to prevent accidents, to improve quality of life and to preserve the environment.” So what of Sweden, which occupies top position, with an annual childinjury mortality of 5·2/100 000? Sweden’s success is due to a range of factors, says Leif Svanström, head of public health sciences at the Karolinska Institute, Stockholm, from planning housing away from motorised traffic to almost 100% attendance at mother and child health centres, which offer safety education. Furthermore, “Sweden is one of the few countries that has followed recommendations from WHO to set up policies for safety, to organise a national safety-promotion programme based on intersectoral co-operation, and to have academic institutions that not only do research but also participate in public-health policy making”, Svanström says. In addition, Sweden has been working for the past 50 years towards improving child safety, where evidence from epidemiological studies has been used by state and non-governmental organisations to put successful initiatives in place. It seems that, provided countries occupying low positions are not stigmatised, this international league table does serve a purpose, if only to raise awareness of child injury as a health issue. On that front, however, there is still clearly a long way to go: even Sweden, Svanström says, “needs paediatricians to become concerned about injuries to children again”. Sarah Ramsay

THE LANCET • Vol 357 • February 10, 2001

For personal use only. Reproduce with permission from The Lancet Publishing Group.