8

Injury

Data on injuries in the Sub-Saharan region are limited for both females and males. There are few injury prevention programs operating within any African ministry of health and, with the exception of a handful of researchers in Nigeria and in the Republic of South Africa, there are few professionals conducting research or descriptive studies on injury in the region. Nevertheless, based on the experiences of other developing areas—the Middle East, Southeast Asia, and the Indian subcontinent—injuries are becoming an increasing public health problem that affects development, decreases the quality of life, and increases the costs of health care. There is no reason to believe that Sub-Saharan Africa is exempt in this regard.

In this chapter an attempt is made to synthesize data from other developing regions and to extrapolate these findings to the Sub-Saharan region, a task complicated by the lack of substantial evidence on injury disaggregated by gender. The study of injury viewed through the prism of female health thus presents a challenging task of inference from what is known about social, economic, political, labor, and gender relations in Sub-Saharan Africa and the health hazards typical of this region. What the data presented in this chapter suggest, and Table 8-1 demonstrates, however, is that there are three categories of injury that disproportionately affect females in the region: household burns, domestic abuse, and rape and sexual assault. The evidence for each is reviewed. While other intentional and unintentional injuries— including violence, motor vehicle and other road traffic accidents, and falls—appear to affect Sub-Saharan African males more commonly than they do women, it is expected that rates between males and females will equalize over time for reasons described later in this chapter. Thus, the evidence for these other kinds of injury is described as well.

The approach adopted here first attempts to provide a rationale for recognizing the significance of injury as a general public health problem. The chapter then briefly reviews what is known about injury patterns in the developing world. The life span perspective is employed, where possible, in the systematic evaluation of adverse health outcomes of injury across the female life span. Finally, public health research implications are drawn from a consideration of the information presented. It must be noted at the outset that substantial cross-national differences probably exist for most of what is covered in this chapter. The approach adopted will attempt to be as inclusive of such differences as possible in the hope that it will facilitate application of the variants discovered to future study of individual countries, or subpopulations within them.



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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 8 Injury Data on injuries in the Sub-Saharan region are limited for both females and males. There are few injury prevention programs operating within any African ministry of health and, with the exception of a handful of researchers in Nigeria and in the Republic of South Africa, there are few professionals conducting research or descriptive studies on injury in the region. Nevertheless, based on the experiences of other developing areas—the Middle East, Southeast Asia, and the Indian subcontinent—injuries are becoming an increasing public health problem that affects development, decreases the quality of life, and increases the costs of health care. There is no reason to believe that Sub-Saharan Africa is exempt in this regard. In this chapter an attempt is made to synthesize data from other developing regions and to extrapolate these findings to the Sub-Saharan region, a task complicated by the lack of substantial evidence on injury disaggregated by gender. The study of injury viewed through the prism of female health thus presents a challenging task of inference from what is known about social, economic, political, labor, and gender relations in Sub-Saharan Africa and the health hazards typical of this region. What the data presented in this chapter suggest, and Table 8-1 demonstrates, however, is that there are three categories of injury that disproportionately affect females in the region: household burns, domestic abuse, and rape and sexual assault. The evidence for each is reviewed. While other intentional and unintentional injuries— including violence, motor vehicle and other road traffic accidents, and falls—appear to affect Sub-Saharan African males more commonly than they do women, it is expected that rates between males and females will equalize over time for reasons described later in this chapter. Thus, the evidence for these other kinds of injury is described as well. The approach adopted here first attempts to provide a rationale for recognizing the significance of injury as a general public health problem. The chapter then briefly reviews what is known about injury patterns in the developing world. The life span perspective is employed, where possible, in the systematic evaluation of adverse health outcomes of injury across the female life span. Finally, public health research implications are drawn from a consideration of the information presented. It must be noted at the outset that substantial cross-national differences probably exist for most of what is covered in this chapter. The approach adopted will attempt to be as inclusive of such differences as possible in the hope that it will facilitate application of the variants discovered to future study of individual countries, or subpopulations within them.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 8-1 Injuries in Sub-Saharan Africa: Gender-Related Burden Problem Exclusive to Females Greater for Females than for Males Burden for Females and Males Comparable, but of Particular Significance for Females Domestic abuse   X   Household burns   X   Rape and sexual assault   X   NOTE: Significance is defined here as having an impact on health that, for any reason—biological, reproductive, sociocultural, or economic—is different in its implications for females than for males. DEFINITIONS An injury is physical damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen. Often the term "injury" is used interchangeably with "trauma." Injuries are grouped into three major categories, based on their intent or the context in which they occur. Although the "intent" of an injury is not always clear, classification by intent allows the identification of possible risk factors and the development of prevention strategies. Unintentional injuries are those caused by motor vehicles and other forms of transportation, drowning, poisoning, burns, or falls. Unintentional injuries are sometimes referred to as ''accidents." Intentional injuries (also called "violent injuries") are homicides, suicides, interpersonal assaults, and intergroup violence resulting from war, torture, or genocide. Certain intentional injuries, such as rape, battering, sexual abuse, and domestic violence, affect females almost exclusively. Occupational injuries are the unintentional and intentional injuries that occur at work or traveling to and from a work setting. They do not include injuries that occur in nonwage employment such as homemaking. INJURIES WORLDWIDE Injuries as a Public Health Issue Injuries traditionally have been considered by many health professionals and policymakers as "accidents," uncontrollable events outside the domain of sound public health practice. This belief has been changing, and significant progress is being made in both policy and prevention strategies. For instance, during the past decade, reductions in motor vehicle fatality rates, decreases in unintentional poisonings, and lowering rates of home fire fatalities have been realized in countries with injury prevention programs. In some countries the term "accident" is no longer used to describe an injury-producing event because of its connotation as something uncontrollable or random. "Injury prevention and control" is the term now used to describe the health-directed, scientific approach to reducing the impact of injury—intentional, unintentional, or occupational—on a society. There are a number of reasons why injury programs should be rapidly established in all countries. First, injuries have significant impact on morbidity and mortality. In developed countries, they account for more deaths in persons between the ages 1 and 44 than all infectious diseases combined. They also result in more premature death as measured in years of productive life lost (YPLL) than all other health conditions combined. With the decreasing rates of childhood mortality and increased longevity observed in much of the Sub-Saharan region (see the Appendix), there is reason to expect that injuries will become an ever greater contributor to morbidity and mortality in the region. The second reason to establish injury prevention programs is that injuries impact significantly on health care and societal costs. In the United States, injuries imposed a $180 billion burden on the economy in 1988 (Rice et al., 1989). The final reason for establishing injury prevention and control programs is

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa that injuries are preventable. Although more research into risk factors and prevention and control strategies for injuries is needed, we have available today many strategies to prevent injuries (NRC, 1985). INJURIES IN THE DEVELOPING WORLD Trends in the epidemiology of injury in developing countries raise some troubling questions about the relationship between development and injury (Stansfield et al., 1993) and compel scrutiny. Epidemiologic Transition An epidemiologic transition occurs as countries move from a disease pattern dominated by infectious diseases to one characterized by noncommunicable diseases such as heart disease, cancer, and injury (Omram, 1971). Epidemiologic transition from infectious to noncommunicable diseases increases the relative importance of injuries compared with infectious disease. For instance, in Mexico the proportion of deaths from infectious diseases decreased from 43 percent to 17 percent during the 25-year period from 1955 to 1980. During this same time, the proportion of deaths resulting from unintentional injury increased from 4 percent to 11 percent. In Nigeria, the proportion of deaths from traffic accidents compared with the number of deaths from 16 common infectious diseases increased from 38.9 percent to 60.2 percent in 10 years (Asogawa, 1978). In addition to a shift in the relative importance of injuries, demographic changes, technological changes, and social changes affect the epidemiology of injuries and influence the absolute importance of injury as an epidemiologic category. Changing demographics, produced by improved child survival, elevate the proportion of older persons in a population, so that injuries such as occupational injuries and falls may become more important. Countries such as Thailand, Egypt, and Indonesia are experiencing increased numbers of deaths because of occupational injuries, especially those related to manufacturing. Technological changes, such as greater use of the automobile, local manufacturing, and rural electrification can also produce increases in the absolute numbers and rate of injuries. In Nigeria the number of road traffic fatalities more than doubled in seven years, and the rate of motor vehicle fatalities per 10,000 motor vehicles increased 127 percent in only 10 years (Asogawa, 1978). Similar increases have been seen in other developing countries and are obviously related to the rapid introduction of motor vehicles (see Figure 8-1). Finally, economic and social changes in Sub-Saharan Africa leading to greater urbanization, new family roles, and more alcohol use are likely to expand the absolute numbers of injuries simply by increasing the number of risk factors for injury. In Egypt, for example, the number of suicides among young women living in urban areas is said to be growing because of the conflicting pressures of traditional forced marriages and new kinds of socialization outside of the family (Megid, 1992). INJURY PATTERNS IN DEVELOPING COUNTRIES A few broad statements can be made about injuries in developing countries. First, in countries where national data are available, mortality rates for unintentional and intentional injuries, although they vary considerably among countries, are similar to those observed in developed countries (Smith and Barss, 1991). Injury deaths are usually among the top five causes of death among all age groups; when compared with other causes of death, injuries represent from 3 to 11 percent of all causes (WHO, various years). In Egypt, injuries were the fifth leading cause of death in 1987, accounting for 4.1 percent of all deaths. In Shanghai County, China, injuries are the leading cause of death for people between the ages of 1 and 44 (Gu and Chen, 1982). In most countries of the Americas, unintentional injuries, including motor vehicle injuries, are the leading cause of YPLL. Fatality rates for unintentional injuries vary considerably among countries and age groups. In the United States, peak injury rates are seen in young adult males, largely as a result of motor vehicle crashes; in developing countries, this peak is not always seen because of the relative unavailability of motor vehicles in younger age groups. Table 8-2 shows the rates of unintentional injuries, excluding motor vehicle injuries, per 100,000 population in selected countries for which WHO data were available. These rates show mounting rates of injury deaths in older age groups, with

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa FIGURE 8-1 Motor vehicle fatalities per 10,000 vehicles: 1961 and 1971. SOURCE: Asogawa, 1978. rates generally lower in the group aged 5–14. Rates in older age groups tend to increase for both males and females in all countries. Across all age groups, males generally have higher rates of unintentional injuries than females. National data or systematic reports on intentional injuries are available for no African nation. Based on limited data from Latin American countries and anecdotal reports in Egypt, Nigeria, Zimbabwe, and Zambia, rates for homicides and suicides are probably at least as high as those in the United States, and these injuries occur primarily in young adults, ages 15–24 (PAHO, 1990). Rates of intentional injuries vary among racial groups. In a study of mortality among South African adolescents during a two-year period, assault was found to be the most common cause of death in blacks and coloreds; road traffic deaths were most common for whites (Fisher et al., 1992). In two reports describing a series of injuries treated at a Nigerian hospital, intentional injuries caused by stab or gunshot wounds comprised from 18 to 29 percent of injuries seen in each series (Roux and Fisher, 1992; Udoeyop and Iwatt, 1991). Intergroup violence in Africa is also a significant cause of injury mortality and morbidity. An estimated one million persons died in Uganda during the last two decades, and recent figures from Rwanda indicate that between 200,000 and 500,000 people died in ethnic violence between April and July 1994. In times of war, civilians seem to be most at risk of being killed or injured. In one case series in South Africa, shotgun pellets used by police during civil disturbances accounted for 5 percent of chest injuries seen in 128 children during a five-and-a-half-year period (Roux and Fisher, 1992). Between 80 and 90 percent of all war-related fatalities are among civilians (Werner, 1989). War also directly affects health status by diverting funds needed for health to defense (Ogba, 1989). Injuries significantly affect morbidity and are a leading reason for hospital admission and clinic visit. Outpatient clinic data, although not population-based, strikingly demonstrate the impact of injuries for a country's health care system. In Zimbabwe, injuries were the among the top four reasons for outpatient clinic visits among individuals over the age of 5 years during 1987–1989, and they accounted for over 7.1 percent of all visits in this age group. For children under 5, injuries were at least the seventh leading cause for outpatient visits during this same period (Zimbabwe Ministry of Health, 1989). In one rural health unit in Egypt, injuries constituted 23.1 percent of all patient visits. Wounds, falls, and burns were the primary causes for those visits; males accounted for slightly more visits than females; and intentional injury accounted for 6 percent of the total of all injury visits (Mostafa, 1993).

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 8-2 Unintentional Injury Deaths per 100,000, by Age Group and Yeara     <1 1–4 5–14 15–24 25–34 35–44 45–54 55–64 65–74 75+ All Ages Egypt Males 15 25 11 19 19 13 16 17 24 36 17 1979 Females 11 20 11 27 19 14 12 16 20 37 17 Mauritius Males 42 13 10 20 42 37 61 65 75 170 32 1986 Females 57 16 5 24 24 22 16 13 58 66 20 Thailand Males 9 22 14 36 39 38 46 38 40 59 30 1981 Females 11 16 10 10 9 10 14 11 13 27 11 Mexico Males 48 30 24 92 120 127 135 145 180 348 80 1982 Females 39 21 10 15 16 18 22 31 53 212 20 Costa Rica Males 22 20 9 28 27 39 48 52 80 274 30 1984 Females 8 10 3 5 7 6 2 5 22 276 9 Sweden Males 4 5 3 6 13 23 28 37 44 169 28 1984 Females 7 2 1 1 3 3 5 9 20 157 19 United States Males 20 17 9 22 26 24 27 32 47 145 28 1984 Females 17 11 3 4 5 5 8 11 21 100 13 a Excludes motor vehicle fatalities. SOURCE: Smith and Barss, 1991. Evidence in Females Data collected throughout the developed and developing world would appear to indicate that injuries affect males more often than females. If this is the case, why devote space to injuries in a report that focuses on female health in Sub-Saharan Africa? There are several reasons. First, in working or living situations where risks and exposures are shared equally by both sexes, injury rates are similar. As Africa strives for equal treatment of females, it is possible that injury rates will also equalize. Second, although they presently occur at greater rates overall among males, injuries also befall females. Third, strategies to prevent injuries—the leading cause of premature loss of productive life for the young and for adults throughout the world—are similar, whether applied to females or males. Fourth, although injuries befall persons of all ages and of both genders, the young, the elderly, and the socially and economically disadvantaged are most affected as a group. Because women and their children are so often among the most economically and socially disadvantaged groups in any community, they may be at greatest risk of suffering the consequences of injuries. Last, certain injuries predominantly affect females. These injuries—rape and domestic violence—appear to be the direct result of the position of females in society and society's attitudes toward them. Although there are few descriptive studies of the effect of these injuries on females in Africa, media reports and experience in other developing countries indicate that rape and domestic violence occur at rates high enough to have a significant impact on morbidity and disability. LIFE SPAN APPROACH Injuries occur differentially throughout the female life span, primarily because of the changing exposure to the risk factors that cause injuries. Box 8-1 illustrates the most prevalent of the injuries seen during a female's life span. The section that follows reviews what is known about these injuries in Sub-Saharan African females. Motor Vehicle Injuries Although there are fewer automobiles and miles of roads in developing countries, motor vehicle fatalities are nonetheless the leading cause of injury deaths in most countries, even though motor vehicle fatality rates may vary greatly among countries, and within urban and rural areas in the same country. In Nigeria, Ethiopia, and Kenya.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Box 8-1 Prevalent Types of Injuries Throughout the Female Life Span Prebirth/pregnancy Selective abortion, battering during pregnancy, mass rape Infancy Female infanticide, falls, burns, drowning, poisoning Adolescence Child abuse, sexual abuse, rape, falls, burns, motor vehicle injuries (as pedestrian or occupant) Adulthood Rape, burns, homicide, suicide, battering, assault Old age Suicide, assault, falls, burns for example, rates are higher than those in developed countries (Wintemute,1985). Most reports of motor vehicle injuries in Africa, however, are only gross estimates, and even motor vehicle fatality reports are often based on unreliable data (Asogwa, 1992). There is a consistent and direct relationship between socioeconomic development and motor vehicle mortality (Haight, 1980). The absolute number of fatalities mounts as the pace of socioeconomic development accelerates, probably as a result of the simultaneous impact of the increased number of motor vehicles and increased reliance on them. Lack of improved roads, driver inexperience, and the mix of road-users (four- and two-wheeled vehicles, nonmotorized transport, and pedestrians) further contribute to increases in the numbers of motor vehicle deaths. As the number of motor vehicles increases, the number of deaths per vehicle and the number of deaths per mile or kilometer—both rate measures—gradually decrease. This is most likely the result of improving road conditions and increasing driving experience in the cohort of motor vehicle operators and pedestrians, as well as a greater number of motor vehicles in the mix of road-users. Still, the number of deaths per 10,000 vehicles in Nigeria, Ethiopia, and Kenya exceeds that in the United States and the United Kingdom by at least 6 times (Jacobs and Sayer, 1983; Figure 8-2). The profile of motor vehicle injuries in Sub-Saharan Africa differs from those in developed countries in the ways they involve various groups of road-users. There are very few reports that specifically document the road-user group of an injured person, but in a study from Ile-Ife, Nigeria, in 2,667 cases of road traffic accidents (RTA) described during a four-year period, pedestrian casualties accounted for the largest proportion of traffic injuries—28.3 percent (Udoeyop and Iwatt, 1991). In urban areas in the United States and the United Kingdom, that figure is 50 percent. A study in Delhi, India, reported a similar percentage of pedestrian casualties—33 percent of all road traffic fatalities—to that reported for Ile-Ife. In Delhi, only 3 percent of the fatalities were in cars or taxis; in the United States and United Kingdom, between 21 and 40 percent of the fatalities were among motorists. Over 20 percent of fatalities in Delhi were bicyclists, compared with less than 6 percent in the United States and the United Kingdom. Motorcycle fatalities in the developed countries range between 8 and 19 percent of total RTAs; in Delhi, 16 percent of these fatalities were motorcyclists—not so different. In Delhi, however, 11 percent of road crash fatalities were bus commuters, a figure almost negligible in the United Kingdom and United States. The authors concluded that because of the striking variations in the distribution of fatal injuries between road-users in India and those in developed countries, safety countermeasures in Delhi would have to be significantly different from those in more industrialized countries (Mohan and Bawa, 1985). This recommendation may be pertinent in the African context as well.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa FIGURE 8-2 Motor vehicle fatalities per 100,000 population and per 10,000 vehicles. SOURCE: Trinca et al., 1988. Implications for Females In newly motorizing countries, some groups of road-users are at a higher risk than they would be in developed countries. If it is reasonable to extrapolate from the Delhi data, pedestrians and users of public transport are at particular risk. The extent to which females are pedestrians and use such transport in their daily lives will obviously influence their rates of transport injuries. In addition, there are anecdotal reports that morbidity and mortality among pedestrians may be underestimated in developing countries for several reasons. First, real economic and social class differences between a motor vehicle operator and an injured pedestrian may make the authorities reluctant to report a pedestrian injury unless it is severe, or the motorist is also injured. In addition, the involvement of insurance and other kinds of compensatory payment, as well as legal precedents, may discourage official reporting of the injury (Michael Linnan, USAID, personal communication, 1989). Future efforts to survey pedestrian fatalities among females in Sub-Saharan Africa should thus control for biases that could be expected to result in their underenumeration. Other Unintentional Injuries: Burns, Drowning, Falls, and Unintentional Poisonings Examination of outpatient or hospital admission records in any urban or rural health clinic reveals a wide range of injuries and a great variety of external causal events. During a three-month period in Alexandria, Egypt, among 10,000 patients seen in trauma units throughout the city, almost 27 percent of the patients were seen for the treatment of injuries that occurred during street fights; the number of male patients in this category was more than twice that of females. Falls comprised 26.6 percent of all recorded visits, and motor vehicle injuries accounted for 11.5 percent. Other frequently reported injuries resulted from fire and chemical burns and unintentional firearm injuries. For females, the principal causes for visits to trauma units were for treatment of injuries that occurred as a result of domestic violence (27.9 percent), falls (24 percent), and cuts (14 percent). All of these injuries occurred in the home (Graitcer et al., 1993). In a retrospective cohort of 1,134 preschool children in Alexandria, Egypt, 378 children had 429 "significant"

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa injuries during a one-year period. These injuries resulted in permanent disability in 3.7 percent of the children. The male to female ratio was 1.33:1. Most injuries occurred in the home (81 percent), and common causes of injuries were falls, burns, wounds, and poisoning. Children of illiterate mothers and those who lived in large families and in crowded conditions had a higher probability of being injured (Nossier et al., 1990). Burns Because of their exposure to fires used for cooking and heating, females and their children are at greater risk of burns than males. In one series in Alexandria, Egypt, a greater number of females than males were burned, a difference particularly striking in the 16-to-20-year-old age group, which accounted for over 50 percent of all such injuries. Scald burns were more commonly seen in the younger age groups (Etiaba et al., 1984). Between 40 and 62 percent of all burns reported in three Nigerian studies occurred in children less than five years old and were caused either by flames from cooking or lighting or by scalds from oil or water used in cooking. During cooler weather, there was an increase in burns caused by fires, presumably used for heating (Onuba, 1988). Improper storage of kerosene and other flammables in the home was another risk factor associated with fire burns; over 95 percent of the burns in one series were the result of explosions from the use of contaminated kerosene in cookstoves (Datubo-Brown and Kejek, 1989; Grange et al., 1988; Mabogunje and Lawrie, 1988; Sowemimo, 1983). One Nigerian study describes a series of 11 deliberate burns in children and adults. Eight of these were intentional, inflicted during a robbery or a domestic dispute, and four were caused by what the author terms "ignorance": a common folk treatment for treating convulsions in children by holding their feet in a fire (Datubo-Brown, 1989). In rural Egypt, burns among females accounted for 9 percent of the deaths in the group aged 15 to 45, and they were the third leading cause of death after diseases of the circulatory system and complications of pregnancy and childbirth. Of these deaths 63 percent were associated with burns received from using kerosene or gas cookstoves (Saleh et al., 1986). The percent of burn cases in Zaria, Nigeria, involved persons with epilepsy; since the prevalence of epilepsy in Nigeria is unknown, it is not possible to determine whether epileptics are overrepresented in this series. Drowning Drowning is often underreported as a cause of injury death. Fatal drownings are often underreported to health authorities, and nonfatal events are rarely reported because they may not require medical treatment. Based on a four-year retrospective study in Cape Town, South Africa, the highest rates of drowning were in white children and adult black males. The majority of the adult drownings were associated with elevated levels of alcohol in the blood. Drownings among black males occurred in an occupational setting, and the majority of drownings among white children were in swimming pools (Davis and Smith, 1985). Another study in South Africa of near-drowning in children found different figures: 46 percent of drownings were in swimming pools, 9 percent in the ocean, and 18 percent in household buckets filled with liquid, the last most prevalent in socially disadvantaged communities (Kibel et al., 1990). Falls While there is cause to suspect significant numbers of these events in Sub-Saharan Africa, regional data are virtually nonexistent. In the developed world, outpatient and emergency department case series indicate that falls are one of the leading reasons for visits of both adults and children, but few studies of this topic appear in the developing-world literature. For instance, no data are available that indicate whether falls might be more frequent in young children and in the elderly in developing countries, as they are in the developed world. Anecdotal reports indicate that falls occur both in domestic situations, such as climbing trees or repairing or building roofs, and in occupational settings, such as among climbers of coconut palms in Nigeria (Okonkwo, 1988). There is no quantification of these sorts of events in Sub-Saharan Africa. They are noted here because falls could be a

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa significant cause of morbidity and mortality in the region, although it is not clear that there would be any gender differential in these rates. Unintentional Poisonings Similarly, except for reports describing catastrophic or mass poisonings from contaminated bread flour, agricultural pesticides, or adulterated food, there are no studies of unintentional poisoning in Sub-Saharan African populations. Nonetheless, based on the relatively unrestricted availability of a wide variety of insecticides, agricultural chemicals, and medicines in developing countries and the widespread distribution and use of these products, there are undoubtedly sizable numbers of unintentional poisonings, especially among children, their mothers, and agricultural workers, that merit systematic investigation. VIOLENCE AGAINST FEMALES-A GROWING PUBLIC HEALTH PROBLEM The intentional injuries of violence, which include homicide, suicide, assaults, domestic violence ("battering"), rape, child abuse, and war, are ubiquitous. Violence, particularly violence against females, is universal and respects neither class nor culture (UN, 1991). Although actual levels of violent injuries vary greatly among countries, some developing countries are losing more years of potential life to intentional injuries than to infectious disease (Foege, 1991). Among females subjected to the pressures of economic hardship and racial or social inequities, the prevalence of interpersonal violence is even greater. Violence against females has been recognized by the Pan American Health Organization (PAHO, 1993) as a health policy issue, but action programs have yet to be developed to address the phenomenon as a public health issue. Although violent injury resulting in death is universally condemned, nonfatal violence—especially when inflicted in a domestic living situation or by a husband or partner—is rarely recognized as either a legitimate health issue or, for that matter, a societal concern (Heise, 1993). Societies have developed mechanisms that legitimize and deny violence, leaving the victims stranded in violent relationships that they and their children cannot escape. Accurate worldwide and country-specific estimates of the impact of violence on females are not available, largely because there is a social and cultural stigma attached to reporting such violence, especially when it takes place within the confines of a home and is inflicted by a husband or other partner. There is a growing body of well-documented studies and surveys that quantify violence against females (Heise, 1993). It is from this literature that we are able to extrapolate and generalize to different regions, cultures, and socioeconomic situations. In general, suicide and homicide rates are greater for males than females. Rates of nonfatal intentional injuries, however, prove to be greater for females than for males when violent injuries caused by rape and battering are combined with the other violent injuries that are customarily reported to law enforcement authorities. Along with gender, race is one risk factor closely associated with increased violence. Butchart and Brown (1991) interviewed nearly 1,600 victims of interpersonal violence seen in hospital emergency rooms in Johannesburg-Soweto. For these victims of nonfatal intentional injuries, the rates averaged 1,380/100,000 residents annually, but they varied greatly by race, ranging from 3,821/100,000 for coloreds, to 1,527 for blacks, 467 for whites, and 433 for Asians. In Cape Town, South Africa, white females were far more likely to die a suicidal, as opposed to homicidal, death. For blacks and coloreds, females were more likely to be victims of homicide than suicide (Lerer, 1992). Fatal Violent Injuries in Females Homicide All available reports indicate that males are murdered at rates that are higher than those for females (Rosenberg and Mercy, 1991), but there are no published national data for African countries (WHO, various years). In like manner, the amount of deliberate murder of female children or discriminatory treatment of female children that results in death is unknown for the Sub-Saharan region. Nevertheless, extrapolating from UNICEF mortality data,

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa the rates for girls under age 4 are higher than for boys in 43 of 45 developing countries for which data are available (UNICEF, 1986), which suggests discriminatory patterns in the treatment of female children for the developing world as a whole. Whether this pattern would hold in the Sub-Saharan countries is an open question. Evidence exists in police records that alcohol may play an important role in the precipitation of a homicidal attack because of the intoxicated behavior of victim and assailant (Muscat and Huncharek, 1991). Lerer (1992) noted that 44 percent of female homicide victims were heavily intoxicated at the time of death, but acute alcohol intoxication did not appear to play a major role in suicide in women in Cape Town. Suicide Suicide is the eighth leading cause of death in the United States. Yet even with the sophisticated U.S. health care and data collection systems, it is difficult to accurately determine the number of suicides and suicide attempts in that country. The number of suicides is presumed to be underestimated by 25–50 percent, and the number of suicide attempts that do not lead to death may be still more grossly underestimated. It would be surprising if the underestimation of suicide in the Sub-Saharan region were not at least as severe. In a six-month prospective study of three main general hospitals in Ibadan, 39 cases of self-inflicted injury were reported out of a total of over 23,000 outpatient visits. Of these cases, more than three-quarters were under 30 years of age. The male-to-female ratio was 1.4:1, and more than half of the cases were students. Most suicide attempts were by ingestion of chemicals and psychotropic drugs (Odejide et al., 1986). In Gabon, males and females committed suicide in equal numbers, but three times as many females as males attempted, but did not complete, suicide. The most common method was ingestion of chemicals, mainly antimalarials (Mboussou and Milebou-Aubusson, 1989). In a review of suicide attempts in Benin City, Nigeria, the crude rate over a four-year period was calculated to be 7/100,000. Over 39 percent of those who made the attempt were between ages 15 and 19, and ingestion of drugs (68 percent) or chemicals (20 percent) were the most common methods. Major disposing factors were mental illness and conflicts with parents (Eferakeya, 1984). Unwanted pregnancy may be also a cause for suicide among unwed women in some Islamic countries (Heise, 1993). Nonfatal Violent Injuries in Females Although there is a clear link between domestic violence and subsequent homicide and suicide, injuries from rape and domestic violence are not usually fatal. They do, however, represent a significant cause of nonfatal injuries in females. One study of nonfatal trauma in Johannesburg showed that over 50 percent of injuries were a result of interpersonal violence—in the case of women, often at the hands of spouses and lovers (Butcher et al., 1991). Domestic Abuse (Battering) The most common form of violence against females is domestic abuse, also known as battering, or abuse by intimate male partners. A number of studies from both developed and developing countries indicate that between approximately one-quarter and one-half of all females report having been physically abused by a present or former partner. In a cluster sample survey in Kenya, 20 percent of all women reported that they were battered, and half of the males and females in this survey reported that their mothers were beaten (Raikes, 1990). In an islandwide national probability sample survey in Barbados, 30 percent of women reported being battered as adults (Handwerker, 1991), and in the United States, 28 percent of females surveyed in a statewide sample in Texas reported at least one episode of physical violence (Grant et al., 1989). Domestic abuse and assault have entirely different epidemiologic characteristics. For instance, domestic abuse most frequently occurs among females and happens in the home. In a cohort study in South Africa, Butchart and Brown (1991) found that males were most often attacked in the street, females in their homes. The perpetrators are also different. In the same South African study, almost 38 percent of the females were attacked by spouses or lovers, while two-thirds of the males were attacked by strangers. In the case of assaults, cause seem to relate

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa to economic conflicts, although the causes of assaults on females are less likely to be economic (Grant et al., 1989). In rural Ethiopia, about one-third of the cases concerned disputes over land, cattle, and the like; one-third were the result of interpersonal family conflicts; and one-third involved alcohol intoxication. The role of psychiatric disorders in these assaults was minimal (Jacobsson, 1985). One report from Nairobi indicated that 75 percent of the cases of fracture of the mandible were the result of interpersonal violence, only 13.8 percent were the result of motor vehicle crashes, and over eight times as many males as females were seen in the case series as a whole (Mwaniki and Guthar, 1990). Rape and Sexual Assault Well-designed studies in the United States, Canada, the United Kingdom, New Zealand, and the Republic of Korea indicate that approximately 7 to 18 percent of females have been raped (Heise, 1993). In addition to these formal studies, throughout history there have been reports by observers and victims indicating that females are particularly vulnerable to rape during times of war or civil insurrection. Recent news reports from Liberia, Uganda, Somalia, and Rwanda seem to confirm that this practice continues. Like homicide, rapes are often committed by a person known to the victim and, like other injuries, youth, lower socioeconomic status, and alcohol are all associated variables. Implications of Intentional Injury Directed Specifically Toward Females As we have seen throughout this chapter, most unintentional injuries, homicide, and suicide in Sub-Saharan Africa, as elsewhere in the world, occur more frequently among males than among females. There are several violent injuries that occur almost exclusively in female —domestic assault, rape, and sexual assault. This sort of gender-specific violence is ubiquitous and appears to produce a significant burden of female morbidity and mortality worldwide. That a multitude of cultural, social, and practical constraints have prevented accurate measurement of the actual impact of these injuries on females verges on tragedy. From popular media reports and position papers prepared by various human rights organizations, the concerned researcher and public health worker are left with the impression that while violence is the major injury problem among females, there are few scientific reports to form a basis for valid epidemiologic descriptions of causative risk factors or intervention strategies, not only in Sub-Saharan Africa, but in all regions of the world. CONCLUSIONS This chapter has attempted to outline the extent of the impact of injuries on the health and development of developing country populations, with particular emphasis on the effect of injuries on the health of Sub-Saharan females. Unfortunately, for a number of reasons ranging from a lack of data to public attitudes toward injuries, there are few reports to definitively document this impact. Available evidence suggests that injuries occur in developing countries in numbers and at rates comparable to those in the developed world. Of particular concern are the rising rate of injuries associated with motor vehicles and reports that homicide, suicide, and assaults are increasing, especially in African urban areas. These rising rates of injury have special implications for developing countries because they first affect the young and young adults, those who contribute economically to the growth and development of a country. Table 8-3 indicates the ages at which certain injuries commonly occur in Sub-Saharan African females. What is apparent from the table and from the broader evidence presented in this chapter is that the distribution of injuries in females across their life span is similar to that seen in females in industrialized countries and elsewhere in the developing world. This is, in one sense, good news, because it suggests that injury prevention strategies developed elsewhere in the world may have applicability to the Sub-Saharan African region, and vice-versa. Other conclusions can be summarized as follows:

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 8-3 Ages of Occurrence of Injuries in Sub-Saharan African Females In Utero Infancy/ Early Childhood (birth through age 4) Childhood (ages 5–14) Adolescence (ages 15–19) Adulthood (ages 20–44) Postmenopause (age 45+)   Falls Falls Falls Falls Falls   Burns Burns Burns Burns     Drownings           Unintentional poisonings             Sexual abuse           Rape Rape           Motor vehicle deaths Motor vehicle deaths           Suicide Suicide (early adulthood) Reliable data regarding the target groups, risk factors, and causes of injuries in Sub-Saharan African are largely lacking. Social and cultural taboos prevent the collection of accurate data on violent injury. Evidence from other developing regions suggests that increasing industrialization and development can only drive up rates of injuries in the Sub-Saharan region. Little investment has been made in the prevention and control of injuries, primarily because there are data deficiencies, small numbers of trained personnel, and a dearth of policymakers willing to embrace the concept that injuries are preventable. Nonfatal intentional injuries such as domestic violence and rape are probably as large a public health problem for females in Sub-Saharan Africa as they are for females elsewhere in the world. RESEARCH NEEDS Improved Data Sources The impact of injuries on females, especially those living in developing countries, is underestimated because of the biases in the delivery of health care services and in society in general. Effective systems for the collection, analysis, and interpretation of data on injuries in Sub-Saharan females must be established. These systems should integrate data from sectors such as the police and health systems and should attempt to use population-based mortality and morbidity information to estimate the total impact of injuries in a community. These data should be disaggregated by gender and age. Although falls, burns, and household poisoning cause substantial numbers of injuries, especially in females, there has been little research exploring risk factor for these and other injuries. Instead, injury research has focused on occupational and transport injuries —injuries that primarily affect males. Studies should, therefore, be conducted to identify risk factors for domestic and other injuries in Sub-Saharan females, including burns, falls, nonfatal domestic injuries, intentional and unintentional poisonings, and suicides. A better understanding of risk factors associated with transport injury in females, especially for pedestrian and other nonmotorized road-users, is also needed.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Violence—especially suicide and nonlethal violence—is underreported in females, and rape and domestic violence may be more severely underreported in certain Sub-Saharan populations because of social, cultural, and religious constraints. The extent to which intentional (''violent") injuries are reported as unintentional injuries —falls, burns, bruises, and poisonings—is unknown and should be determined. To achieve understanding of the causes, risk factors, and strategies required to prevent violence, there is a need for a collaborative approach among a variety of disciplines, including anthropology, law, criminal justice, sociology, psychiatry, rehabilitation, epidemiology, and public health. Research exploring the risk and etiologic factors in females should be multidisciplinary, involving in-depth examination of social, economic, and mental health determinants of violence. Prevention Strategies Research on strategies that can prevent and control injuries of importance to females in Sub-Saharan Africa must be undertaken. Research to develop effective and appropriate interventions to prevent injury and to control the resulting disability should be undertaken. This research would include examination, based on epidemiologically based priorities, of specific interventions, systems of trauma care, and rehabilitation techniques. Research and interventions specifically directed toward the prevention and control of household injuries such as burns, falls, and violence are needed. REFERENCES Asogawa, S. E. 1978. Road traffic accidents: a major public health problem. Pub. Hlth. (London) 92:237–245. Asogwa, S. E. 1992. Road traffic accidents in Nigeria: a review and a reappraisal. Accid. Anal. Prev. 24:149–155. Butchart, A., and D. S. Brown. 1991. Non-fatal injuries due to interpersonal violence in Johannesburg—Soweto: incidence, determinants and consequences. Forensic Sci. Intl. 52:35–51. Butchart, A., V. Nell, D. Yach, D. S. O. Brown, A. Anderson, B. Radebe, and K. Johnson. 1991. Epidemiology of non-fatal injuries due to external causes in Johannesburg –Soweto. Part II. Incidence and determinants. S. Afr. Med. J. 79:139–143. Datubo—Brown, D. O. 1989. Deliberate burns in Nigeria. Trop. Doctor 19:137–140. Datubo—Brown, D. D., and B. M. Kejek. 1989. Burn injuries in Port Harcourt, Nigeria. Burns 15:152–154. Davis, L., and L. S. Smith. 1985. The epidemiology of drowning in Cape Town—1980–1983. S. Afr. Med. J. 68:739–742. Eferakeya, A. E. 1984. Drugs and suicide attempts in Benin City, Nigeria. Brit. J. Psychiat. 145:70–73. Etiaba, A. H., S I. Fahmy, F. A. Bassiouni, E. A. Kader, and A. S. El Tantawy. 1984. Burns and scalds among school-aged children. Bull. High Inst. Pub. Hlth. 14:227–240. Fisher, A. J., G. Joubert, and D. Yach. 1992. Mortality from external causes in South African adolescents, 1984 –1986. S. Afr. Med. J. 81:77–80. Foege, W. 1991. Foreword. In Violence in America: A Public Health Approach, M. L. Rosenberg and M. A. Fenley, eds. New York: Oxford University Press. Graitcer, P. L., H. El-Sayed, R. J. Waxweiler, O. A. Mostafa, I. F. Elias, S. G. Boutros, H. Keladah, M. N. Nassery, A. Hamam, S. Fahmy, L. A. M. Abdel Magid, E. Salem, S. Sallam, Z. Youssef, J. Mercy, and T. Chorbaa. 1993. Injury morbidity and mortality. In Injury in Egypt: Injury as a Public Health Problem, A. Y. Mashaly, R. Graitcer, and Z. Youssef, eds. Cairo: New Press. Grange, A. O., A. O. Akinsulie, and G. O. Sowemimo. 1988. Flame burn disasters from kerosene appliance explosions in Lagos, Nigeria Burns 14:147–155. Grant, R., M. Preda, and J. D. Martin. 1989. Domestic violence in Texas: A study of statewide and rural spouse abuse. Wichita Falls, Tex.: Bureau of Business and Government Research, Midwestern State University Gu, X. Y., and M. L. Chen. 1982. Vital statistics of Shanghai County. Am. J. Publ. Hlth. 72 (Suppl.):19–23. Haight, F. 1980. Traffic safety in developing countries. J. Safety Res. 12:50–55. Handwerker, P. 1991. Gender power difference may be an STD risk factor for the next generation Paper presented at the 90th Annual Meeting of the American Anthropological Association, Chicago, Ill. Heise, L. 1993. Violence against women: the missing agenda. In Women's Health: a Global Perspective, M. A. Koblinsky and G. J. Timyan, eds. Boulder, Colo.: Westview. Jacobs, G. D., and I. Sayer. 1983. Road accidents in developing countries. Accid. Anal. Prev. 15:337–353. Jacobsson, L. 1985. Acts of violence in a traditional western Ethiopian society in transition Acta Psychiatr. Scand. 71:601–607. Jamison, D. T., W. H. Mosley, A. R. Measham, and J. L. Bobadilla, eds. 1993. Disease Control Priorities in Developing Countries. New York: Oxford University Press for the World Bank.

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