Violence and injuries in South Africa: prioritising an agenda for prevention

Summary

Violence and injuries are the second leading cause of death and lost disability-adjusted life years in South Africa. The overall injury death rate of 157·8 per 100 000 population is nearly twice the global average, and the rate of homicide of women by intimate partners is six times the global average. With a focus on homicide, and violence against women and children, we review the magnitude, contexts of occurrence, and patterns of violence, and refer to traffic-related and other unintentional injuries. The social dynamics that support violence are widespread poverty, unemployment, and income inequality; patriarchal notions of masculinity that valourise toughness, risk-taking, and defence of honour; exposure to abuse in childhood and weak parenting; access to firearms; widespread alcohol misuse; and weaknesses in the mechanisms of law enforcement. Although there have been advances in development of services for victims of violence, innovation from non-governmental organisations, and evidence from research, there has been a conspicuous absence of government stewardship and leadership. Successful prevention of violence and injury is contingent on identification by the government of violence as a strategic priority and development of an intersectoral plan based on empirically driven programmes and policies.

Introduction

South Africa, a country not at war, faces an unprecedented burden of morbidity and mortality arising from violence and injury. In 2000, violence and unintentional injuries combined were the second leading cause of all death and disability-adjusted life years (DALYs) lost in the country, after HIV/AIDS, ¹ with interpersonal violence the leading risk factor, after unsafe sex, for loss of DALYs.² Injuries from traffic accidents, fires, and falls are the fourth, 19th, and 20th leading causes of death, respectively.¹ South Africa had 59 935 deaths due to injury in 2000, which is an overall death rate of 157·8 per 100 000 population.3, 4 This rate is higher than the African continental average of 139·5 per 100 000 population, and is nearly twice the global average of 86·9 per 100 000 population.⁴ These high rates are driven by violence. Nearly half South Africa's deaths due to injury are caused by interpersonal violence,³ four and a half times the proportion worldwide.⁵ Data from death certificates and the National Injury Mortality Surveillance System (NIMSS)6, 7 show further that more than a quarter of such deaths are due to road traffic injuries, with the remainder attributable to self-inflicted injuries, fires, drowning, and falls (figure).³

An estimated 3·5 million people every year seek health care for non-fatal injuries,⁸ of which half are caused by violence.⁹ Furthermore, 55 000 rapes of women and girls are reported to the police every year,¹⁰ which is estimated to be nine times lower than the actual number.¹¹ Exposure to rape, intimate partner violence, and abuse and neglect in childhood are risk factors for the country's most prevalent and serious health problems, including HIV and sexually transmitted infections, substance misuse, and common mental disorders, such as post-traumatic stress disorder, depression, and suicidality (RJ, unpublished data).12, 13, 14, 15, 16 Injuries and violence undermine social cohesion and the nation's social and economic development, and are a substantial burden of preventable mortality and physical and emotional disability.¹⁷ Prevention of such violence and injuries is a national public health priority. We describe the size and nature of these issues and the determinants of the high rate of violence, review the responses made since 1994, and point to what is needed to respond effectively.

Key messages

• Violence and injuries are the second leading cause of death and lost disability-adjusted life years in South Africa.

• South Africa's injury death rate is nearly twice the global average.

• The high injury death rate is driven mainly by interpersonal and gender-based violence, followed by traffic injuries, self-inflicted injuries, and other unintentional injuries arising from fires, drowning, and falls.

• Violence is profoundly gendered, with young men (aged 15–29 years) disproportionately engaged in violence both as victims and perpetrators. Half the female victims of homicide are killed by their intimate male partners and the country has an especially high rate of rape of women and girls.

• The social factors driving the problem include poverty and unemployment, patriarchal notions of masculinity, vulnerabilities of families and exposure to violence in childhood, widespread access to firearms, alcohol and drug misuse, and a weak culture of enforcement and failure to uphold safety as a basic right.

• The government should identify reduction in violence and injuries as a key goal and to develop and implement a comprehensive, national intersectoral, evidence-based action plan.