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Injury Prevention: An International Perspective. Epidemiology, Surveillance and Policy.
  1. Elizabeth Towner
  1. Department of Child Health, University of Newcastle upon Tyne, UK

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    By Peter Barss, Gordon Smith, Susan Baker, and Dinesh Mohan. (£42.50 hardback.) Open University Press, 1998. ISBN 0-19-511982-7.

    Injury Prevention: An International Perspective sets out to provide, “a resource for injury prevention that will be helpful around the world”. Although citing many examples from industrialised and high income countries, the book places much greater emphasis on the special needs of low income countries and remote and indigenous populations. The authors have the credentials and experience to allow them to accomplish such a task. Peter Barss, the first author, has worked in remote communities in eastern Canada and the other three authors have worked in a variety of low and high income countries.

    The adoption of an international perspective to injury prevention and control is to be warmly welcomed. Injury is a highly significant global problem and in recent years, as infectious diseases have become better controlled, the importance of injuries as a cause of death has grown in lower income countries and indigenous communities within “developed” countries. The problem of rapid motorisation can only exacerbate the problem of injuries in the future. The problem of injuries is even more striking in indigenous communities in high income countries than in lower income countries: the stress of loss of traditional life styles, physical hazards such as the introduction of new equipment, and aggressive marketing of alcohol have had a cumulative effect. Indeed for the indigenous population of Canada, injuries are the leading cause of death in all age groups from 1 to 64 years.

    The book divides into three groups of chapters. The first group considers the scale of the problem of injury, the epidemiological basis for prevention, mortality, morbidity, costs, and the determinants of injury. The second documents different injury types. More emphasis has been given to traffic injuries, but it also looks at drownings, falls, burns, poisoning, occupational injuries, and intentional injuries. The final section looks at injury treatment and rehabilitation, the development of prevention programmes and a conclusion, pulling together the different strands. The book spans all age groups and seven specific categories of childhood injuries are included.

    The major strengths of Injury Prevention: An International Perspective are in the wealth of examples covered from a range of contrasting environments that are often neglected in high income countries. We learn, for example, that the most common non-crash bicycling injury in parts of India is the amputation of the right toe by an unguarded cycle chain. In China, public policy has prioritised the use of bicycles and motorcycle use has been restricted by high registration fees. However there is little discussion about the process of changing public policies in different contexts.

    There are a number of useful illustrations of how simple epidemiological data can be used for planning local injury prevention particularly where data collection is rudimentary. Barss' work in Papua New Guinea demonstrated how useful information for prevention could be gleaned about severe fall injuries from trees. To learn more about injury deaths in remote rural areas, staff in health centres were asked to question long term residents about the deaths from injuries that had occurred in recent years. Using such enhanced data collection methods, the types of trees and activities implicated in the most serious falls and the populations at most risk could be identified. This information was then disseminated widely by radio broadcasts and talks by village health educators. Perhaps such use of local data and networks could be explored within local contexts in higher income countries.

    My main criticism is that Injury Prevention: An International Perspective underplays the role of underlying factors that shape the pattern of injury: factors such as poverty and culture are implicit rather than explicit. Poverty gets only three entries in the index, socioeconomic status gets five. Comments such as “poverty is often the underlying factor for many injury hazards” (p95) or “reducing poverty and socioeconomic gradients and improving education requires greater commitment from government and society” or “it must not be forgotten that for injuries, as for many diseases, poverty is often an underlying determinant” (p327) seem somewhat half hearted in view of the scale of the problem.

    In the chapter on the choice and development of injury prevention programmes, social and political considerations are discussed. We are informed that the discussion of the importance of sociopolitical factors has been scarce in the literature on injury in the United States. “This is understandable, since the fundamental changes implicit in such interventions would be politically unacceptable and even unthinkable to many national policy and decision makers” (p287). This seems to run counter to the spirit of William Foege's foreword, which opens with, “designing the `unacceptable' is the challenge and burden of public health”. Perhaps a book such as this should not be so understanding of the views of national policy decision makers, but instead challenge them to do more about problems such as poverty both between and within countries.

    The reference to the World Health Organisation's 1990–91 budget for injury prevention and control for the 34 centres of the Western Pacific of a paltry $5000, is not accompanied by outrage or indignation. It is merely reported. Such indifference to a major world problem by the WHO needs to be questioned and challenged. Foege's foreword says that this is a book about social justice but we are given no guidance on how social justice can be achieved at a local, national, or international level.

    At the time of writing this review the problem of injuries from disasters was particularly topical, with reports of Hurricane Mitch's devastation in Central America. The chapter on “Injuries from Disasters” points out the role that human activities have in contributing to or exacerbating the effect of these injuries. But it does not discuss the role of high income countries in contributing to the land use patterns, deforestation, or soil erosion of low income countries, or the debt burden of low income countries locked into international banking systems. The Nobel Prize for economics, recently awarded to Amartya Sen for his contribution to welfare economics and the complexities that underlie poverty, dramatically illustrates the effects of disasters on poorer economies. In addition to such macro level activity, the book also fails to point out the role of advocacy at a local level, and the power of local voices in affecting policy.

    One of the most striking aspects of this book is the number, range, and breadth of the quotations intended to illustrate different aspects of injury prevention and control. The quotes span time, space, and discipline and include the words of Francis Bacon, Rabindranath Tagore, Aristotle, Anaïs Nin, Henrik Ibsen, and Vaclav Havel. But for me these quotations definitely did not work. I do not think the words of Horatio Nelson at the battle of Copenhagen, “I have only one eye, I have a right to be blind sometimes . . .. I really do not see the signal”, illustrate the importance of eye injuries. Nor do George Orwell's writings from Animal Farm “All animals are equal, but some animals are more equal than others” shed any light on “social and political considerations”.

    On balance however, Injury Prevention: An International Perspective is a useful addition to the literature, providing a wealth of examples for parts of the world all too often forgotten by high income countries. The need to develop acceptable and practical interventions based on local knowledge and tailored to the needs of local communities, is as applicable to communities in high income countries as it is to many of the examples provided in this book. The social and political underpinnings of the patterns of injuries and their solutions are not, however, covered explicitly—the book has no radical subtext. Could this perhaps provide the basis of an accompanying volume?

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