Elsevier

The Lancet

Volume 372, Issue 9651, 15–21 November 2008, Pages 1765-1773
The Lancet

Series
Injury-related fatalities in China: an under-recognised public-health problem

https://doi.org/10.1016/S0140-6736(08)61367-7Get rights and content

Summary

The May 2008 earthquake in Wenchuan drew attention to the important but largely unrecognised public-health problem of injury-related mortality and morbidity in China. Injuries account for more than 10% of all deaths and more than 30% of all potentially productive years of life lost due to premature mortality in China. Traffic-related injuries (mainly among cyclists and pedestrians), suicide, drowning, and falls account for 79% of all injury deaths. Rural injury death rates are double those of urban rates and male rates are double those of female rates. Despite an 81% increase in the traffic-related mortality from 1987 to 2006—associated with rapid motorisation—the overall injury mortality decreased by 17%, largely due to a surprising (and unexplained) 57% reduction in the suicide rate. Low-cost prevention measures that are most likely to produce large reductions in injury deaths include enforcement of laws for drinking and driving and for seat belt and helmet use, restriction of access to the most potent pesticides, and teaching children to swim. China needs to improve monitoring of fatal and non-fatal injuries, promote intersectoral collaboration, build institutional capacities, and, most importantly, mobilise community support and political will for investment in prevention.

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.

References (56)

  • International statistical classification of diseases and related health problems 10th revision version for 2007. Geneva: World Health Organization

  • G Yang et al.

    Mortality registration and surveillance in China: history, current situation and challenges

    Popul Health Metr

    (2005)
  • YH Wang et al.

    Evaluation on the reliability of the national health statistical yearbooks, 1987–2003

    Chin J Epidemiol

    (2007)
  • C Rao et al.

    Evaluating national cause-of-death statistics: principles and application to the case of China

    Bull World Health Organ

    (2005)
  • CJL Murray et al.

    The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020

    (1996)
  • WHO mortality database. Geneva: World Health Organization

  • Annual Report of Chinese Health Statistics

    (2003–07)
  • China Statistical Yearbook

    (1988–2007)
  • Bulletin of the 1995 National 1% Sample Survey

    (1996)
  • Bulletin of the 2005 National 1% Sample Survey

    (2007)
  • CD Mathers et al.

    The global burden of disease in 2002: data sources, methods and results. Geneva: World Health Organization

  • J Banister et al.

    Mortality in China 1964–2000

    Popul Stud

    (2004)
  • The injury chartbook: a graphical overview of the global burden of injuries

    (2002)
  • World Health Statistics Report

    (2008)
  • Y Zhou et al.

    Productivity losses from injury in China

    Inj Prev

    (2003)
  • M Peden et al.

    World report on road traffic injury prevention

    (2004)
  • V Routley et al.

    Patterns of seat belt wearing in Nanjing, China

    Inj Prev

    (2007)
  • J Passmore et al.

    Seatbelt use amongst taxi drivers in Beijing, People's Republic of China

    Int J Inj Contr Saf Promot

    (2006)
  • Cited by (228)

    • Future injury mortality burden attributable to compound hot extremes will significantly increase in China

      2022, Science of the Total Environment
      Citation Excerpt :

      According to the Global Burden of Disease Study (GBD), injury is the fifth leading cause of death in China, accounting for almost 734,000 deaths (7.0 % of all deaths) and loss of 12.6 million years of productivity in 2017 (Duan et al., 2019). Many risk factors from human activities, socio-economic status and environmental factors contribute to the high disease burden of injury (Wang et al., 2008). Of those, higher ambient temperature can cause serious adverse effects on injuries (Aboubakri et al., 2018; Lee et al., 2020), including greater mortality risk of unintentional injury (e.g. road traffic injury, falls, drowning) (Aboubakri et al., 2018), as well as intentional injuries such as suicide and assault due to the worsen effects on mental health (Burke et al., 2018; Xu et al., 2020).

    View all citing articles on Scopus
    View full text