SeriesInjury-related fatalities in China: an under-recognised public-health problem
Introduction
On May 12, 2008, an earthquake occurred in Wenchuan, China. More than 69 000 people were confirmed dead, more than 374 000 were seriously injured, and more than 18 000 were reported missing.1 Intense national and international attention was focused on the rescue and reconstruction efforts, with little appreciation of the fact that these fatalities represent less than a tenth of China's yearly injury-related mortality, an under-recognised public-health problem that results in more than 800 000 deaths per year.
China's rapid economic growth has been accompanied by substantial changes in modes of transport, housing, and other ways of life, all of which affect exposure to risk factors for injury and, thus, the characteristics of injury-related mortality and morbidity in the country. In the past two decades, the main transportation mode has changed from animal carts and bicycles to motor vehicles; more than 8 million new cars are sold in China each year.2 The population is ageing and rapidly urbanising; from 1982 to 2005, the proportion of the population aged 65 years and older increased from about 5% to 8% and the proportion living in urban areas more than doubled from 21% to 43%.3 Before the economic reforms, most of China's population lived in fairly similar levels of poverty, but since the reforms started in 1978 the gap between rich and poor has widened; by 2004, the gross domestic product per person in the richest province was 13 times greater than that in the poorest province.4 And increased access to worldwide media, exposure to western value systems, and participation in national and international web-based networking have contributed to wide-ranging changes in traditional values and cultural practices. All of these changes fundamentally alter the risk, prevalence, and demographic profile of different types of injuries. The focus of China's health system has been on infectious and chronic diseases, but more recently health authorities have begun to recognise the importance of injury to the health and sustainable development of the country.5
In this paper, we describe the scope and nature of the injury problem in China in the context of epidemiological, technological, and cultural transitions. We consider all International Classification of Diseases (ICD) categories of intentional and unintentional injuries,6 except medical misadventure and war (table), and provide a detailed analysis of the China-specific characteristics of the three most important causes of injury-related mortality—road traffic and transport injury, suicide, and drowning.
Section snippets
Epidemiology of injury mortality
China has two mortality registry systems—the Ministry of Health vital registration (MOH-VR) system, covering about 8% of the population (110 million individuals), and the Disease Surveillance Points (DSP) system, covering about 1% of the population (10 million individuals).7 Detailed assessments of the quality of these registration systems8, 9 have identified both strengths and weaknesses. On the positive side, both systems have restricted use of ill-defined categories, expected patterns of
Traffic-related injuries
Motor vehicle production in China has tripled since the early 1990s,20 so the fact that a large and increasing proportion of China's injury-related mortality and morbidity are due to traffic-related injuries is not surprising. But traffic-related mortality is not as tightly linked to economic improvement as might be expected—areas with the highest rates of traffic-related fatalities include the poor western provinces of Tibet, Ningxia, Xinjiang, and Qinghai,5 and most of the increased
Suicide
The demographic pattern of suicide in China—with rural rates two-fold to three-fold greater than the urban rates, and female rates slightly higher than the male rates—is very different from that reported in western countries, where urban and rural rates are roughly equivalent and where male suicide rates are two-fold to four-fold higher than the female rates.27 The main determinant of China's different pattern of suicidal deaths is the frequent use of highly lethal pesticides as a suicide
Drowning
Like most ancient civilisations, China developed around its major waterways (the Yangtze and Yellow rivers). A substantial proportion of the population still lives close to lakes, rivers, canals, ponds, reservoirs, or the ocean. However, only a small proportion of the population can swim and has knowledge of water survival skills47 so the rates of drowning are high. Death by drowning is more common in southern China (where there are more waterways) and during the warmer months of April to
Can China shorten the time frame for injury reduction?
The worldwide burden of injury is expected to increase during the coming decades particularly in low-income and middle-income countries18, 19 but our analysis of injury rates during the past 20 years in China shows that despite rapid increases in traffic-related mortality, overall injury-related mortality has decreased, not increased. The reasons why China is exceptional are unclear but with more than 800 000 injury deaths and 60 million medically treated injury events per year,5 China has no
The way forward for injury prevention in China
China has the financial resources, organisational infrastructure, and public support to rapidly apply lessons from high-income countries to achieve international best-practice standards for injury prevention and control, and to become a model for other low-income and middle-income countries that have similar difficulties. Whether or not this goal is actually realised in China will mainly depend on four factors.
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