Injury and violence prevention in China - J- '1oo`. .. I T, 1 Q. hhWorld _Hea|th Organization Acknowledgements Contributions from the following individuals are gratefully acknowledged: Jonathon Passmore, WHO China, for drafting this document; Etienne Krug, Margie Peden, Alex Butchart, Tami Toroyan and Laura Sminkey, WHO Headquarters; Henk Bekedam, Cristobal Tunon and Justin Floss, WHO China; Wu Fan and Duan Lei Lei, National Center for Chronic and Noncommunicable Disease Control and Prevention, for useful and constructive review comments on earlier versions of the document; Colin Mathers, and Kenji Shibuya, WHO Headquarters; Gao Jun, Ministry of Health, China, for assistance with provision of data; Pascale Lanvers- Casasola, WHO Headquarters, for administrative support and Elizabeth Loughnan, for editorial assistance. This document can be downloaded from: Turning the tide: Injury and violence prevention in China. 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In event oublloallon do not the exolesslon ol anv oolnlon vvnalsoevel on shall the World Health Organization be liable for damages from the part of the World Health Organization concerning the legal status of 'ts any country, territory, city or area or of its authorities, or concerning the Layout and design by Aleen Squires. delimitation of its frontiers or boundaries. ln Cnlna_ Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. China is the most populous nation on earth with an estimated 1.3 billion people (2002). Although the World Bank estimates that 373 million people in China still live on less than US$2 per day it has one of the fastest growing economies in the world. I I Ia . I.- . esa-. -e .. rr tzIn-dfI._t ily-; . --.- . . ltriis{iiaeImghr-L' JawITL't?j . --1 EF ri"Accidents" versus "injury" Defining vieienee Using ins were "6CCidsnT" perpetuetee the Intent to commit the act itself, irrespective regrettable public view that accidents are inevitable gf ine ie rundemeniei fg ine occurrences lacking any apparent cause. Instead, gf Viejenee; WHO uses the word injury to indicate the ability ..7-ng intentional USG Ofpn}/Sina] force Orpnw?n te Understand Ummetelm prevent threatened or actual, against onesehj another these Occurrencee person, or against a group or community that either results in or has a high likelihood of resulting Defining in injury death, mental harm, mal-development bodily lesion at the organic level, resulting from or deprivation (2). exceed the threehe/el telerenee- indicate an aim to cause damage. tnae deranaudn In (sg- dl'OWn'nQ, gains utility by distinguishing between violence, ins lnlU0' rssuiis n'0n"l en including deliberate harm, and unintended events ef wie! element lil- that leedn in il'ljUl'y. prevention I GS avoided. This document draws on two major data sources to profile injuries: WHO Global Burden of Disease (GBD) mortality database for 2002 (\/ersion 3). Official statistics from the Ministries of Health and Public Security (Police) and from China's National Bureau of Statistics. Both estimates are used when possible. The Ministry of Health in China report mortality rates from rural and urban areas from sample populations, the figures reported in this document have been calculated by comparing these rates to the national population to obtain an estimate of the total number of deaths. Calculations for the years of potential life lost (Y PLL) are based on death estimates from the GBD 2002. 2 Although outbreaks of Severe Acute Respiratory (SARS), Avian Influenza (AI) and other infectious diseases have attracted enormous A interest both domestically and internationally, injuries and violence represent a higher proportion of deaths in China, contributing about 11% of the total mortality each year, compared to the 8.6% attributed to infectious I disease deaths. Overall, injury and violence is a major IN I NA cause of fatality, particularly for those between the ages of 5 and 44 years where it accounts for over 50% of all deaths, the majority from drowning, road traffic injury, and suicide. Cause of death in China, 2002 1005-14 15-29 30-44 45-59 eo+ Ace ercuns - ::an;nunIcabIr maternal, perinatal - Noncommunlcable (chronic) I Injuries anu vlolence Sour?e:WHOGlobel 3 Injuries resulting V. . in death hospitalization ff; . ambulatory treatment emergency treatment primary care treatment paramedic treatment unreported or no treatment at all -N?twr=no -0-a4 -ss-so -s1-ss -69-113 Deaths from Injury' Injury mortality in the WHO Western Pacific the tip of the iceberg Source: WHO Global Burdenofblseue (GBD) Injuries cause an alarmingly high number of deaths in China, but for each death many more um bv mk- 2??2 OCCUT that 1 Cerebrovascular disease hespitelizetien and 2 Chronic obstructive pulmonary disease result in- minor wounds. For example, international experience suggests that for every road traffic death, 15 people require hospitalization and 70 5 suffer minor injuries. Official figures 6 lung from China's Ministry of Health show 1 suicide hospitalized due to injury. Many survivors suffer life-long disabling health consequences. 16 Drowning Injury and poverty Sour?o:WHOGlobal BurdenofDlo?aso(GBD) The burden of injuries also falls disproportionately on the poor - over 90% of injury-related deaths occur in low-income and middle- income countries. Poor people are at higher risk of injury because they often live, work, travel and go to school in unsafe environments. They also benefit less from prevention efforts, and have less access to high-quality treatment and rehabilitation services. 4 INJURY IN CHINA Ministry of Health figures suggest injuries and violence claim more than 750 000 lives each year however WHO estimates or about 11% of all deaths China has one of the for injury in the WHO Western Pacific Region (4). Injuries account for more than anecdotally including the most economically productive age groups (4). 64% of injury deaths are attributable to and Respectively, these are estimated as the 7th, 10th and 16th, leading causes of death in China. Proportion of injury mortality by type, China, 2002 Homicide 4% Suicide 28% Road traffic injuries 25% Other unintentional -- Pgisgnings 7% injuries 14% Falls 10% Drownings 11% Fires 5 The cost of injury and violence Injuries are one of the greatest public health threats to China's continued economic development. In 1999, injuries cost China an estimated 12.5 billion - more than four times the annual public health budget (5). The heaviest burden is among the young. Injury is the leading cause of premature loss of life in China, accounting for approximately 30 million years of potential life lost (YPLL) each year - more than from cardiovascular disease and communicable . . disease combined, I Official statistics calculate that road traffic pu hgalth fgats crashes cost China more than 386 million . . in direct property damage in 2001. The Asian to I na. COHTI ued Development Bank (ADB) estimate for the same year that when medical and other direct costs Econo"] IC development - are included road traffic crashes cost China more than USS 12 billion (6). It is estimated that road traffic collisions cost developing countries about 1.5% of their Gross National Product Applied to China this represents USS 29 billion each year (based on a 2004 GNP of USS 1.9 trillion), more than 17 times the official development assistance (ODA) funds ($1.661 billion) the nation receives as a developing country Further research is needed to accurately and reliably measure the economic burden of injuries in China. Cost benefit studies should be included to show the potential cost saving of investing in injury prevention. By Investing In Injury prevention, China stands to save many lives and enormous financial resources every yean 6 UNDER- STANDING RISK FACTORS Road traffic injury Road traffic injuries are a leading cause of death in China, linked to an increased number of vehicles and lack of awareness, adherence, and enforcement of road safety rules. More than half of the people dying on the roads are aged between 15 and 44 years. This haa devastating acnaaquancaa for tha moat Although various other risk factors aheresse road 896 QFOUP- traffic collisions, China's official statistics place most tt0 000 deaths and a further 550 000 ihiuries drivers. Official statistics indicate that 45% of road (mortality rate 55 per t00 000 peepiei_ This traffic deaths and 52% of all collisions are due to bad represents apprexirhateiy 000 deaths eyery driver behaviour, and that 85% of crashes involve day. er ehe death eyery 5 minum- drivers aged 21 -45 years (2002). There are, however, many other causal factors for road traffic crashes Due to data collection and definitional differences and death and uhtii these ether teetere are takeh ihte ?St'mat?S pr??Iu??d by WHO am much account, road safety will not improve significantly. nlgn?r GStIm8tGd than Road Safety must be in a Systematic people on In China In approach where all factors to the road Mortality rates for males (27 per 100 000 environment, the vehicle and the users are seen as population) are estimated to be more than ?0?TfibUi0fS to Gi'8Sh. iniury Bild d?ath- twI?? f?maI?S pg" 100 000_ Despite the startlingly high figures, road traffic injuries 'mbaI?"F? h'ghI'ghtS th? "Sk receive significantly less public and media attention ?f In mad trafic than more unusual health emergencies. As in many developing countries, it is the vulnerable road users who are at greatest risk of injury and death. In China 60% of all road traffic deaths between 1995-2002 were CURRENT ROAD TRAFFIC SAFETY LAWS among pedestrians bicyclists and In 2003, China's Govemment formed a 17-Ministry National Road Safety Coordination Committee Road traffic death rates vary by province - and R?ad Salim Zhejiang, Tibet, Ningxia and Xinjiang record ;aw? _mItIgaI? w? mortality rates two to three times higher than the I I g' official national average. Protection for pedestrians' rights The Wond Bank estimates that road traffic at fatalities in China increased by 243% between Compulsory use of seat-belts for drivers 1975 and 1998, and predicts that they will rise a and front seat passengers; aa Compulsory helmet use for riders uIg? and passengers; t? md that medical esrshushrhems Shall continues to grow, with more than vehicles registered each day in China in 2003. Immedlately attend to mad mIumS' Mandating that drivers of motor vehicles are responsible for traffic crashes between their Qfe than Qf thQS@ dy| ng vehicle and non-motor vehicles or pedestrians, th in the absence of mitigating circumstances; and On roa are 9 Ween The national road traffic safety law came into 15 and 44 years old. Mavi-200+ Reference: Road Traffic Safety Law of the People': Republic of China. May 1, 2004. 8 Road traffic injuries can be prevented Rvad traffic iniury mvrtaliiv me by China. 2004 There are many intervention opportunities to prevent road traffic injuries in China, including the following examples: Mandate, enforce and advocate the wearing of seat-belts (front and rear) and use of child restraint appropriate to age. Mandate, enforce and advocate the wearing of helmets for and cyclists. Strengthen pedestrian safety by enforcing and communicating the legal right of way of pedestrians at crosswalks. Strengthen police presence for enforcing existing road safety legislation. Control speed through road design (roundabouts, speed breakers etc). Source: Ministry of Public Security, 2005. Improve quality and level of driver training and examination. Segregate motorized from non-motorized R?ad t"af"? MUN chi"a? 2??2 vehicles and prevent vehicular encroachment Mnnalny into bicycle lanes. 00 000 ss Address driver fatigue with mandatory rest periods 70 000 and driving time limits for commercial drivers. 60 000 3? By introducing and enforcing recommendations such 50 000 25 as these, against the current high toll of death and 40 000 20 disability from road traffic injuries, and accompanying 15 them with health promotion messages, China can 3? achieve significant and encouraging declines within 20 000 10 a relatively short period of time. 10 000 5 0 0-4 s-14 1s-2000-uns-an 00-0010-10 00*0 A?o aww COST-EFFECTIVENESS OF . Rudi,-mc mluwdmm STRENGTHENING ROAD SAFETY Madame Injury pu 100000 po?pio Source: WHO Global Burden of Disease (GBD) f0f' 2002 (VHSIOH Introducing and enforcing a mandatory helmet law for bicyclists and in China has been suggested to be a highly cost-effective measure of strengthening road safety. The cost of increasing helmet use from zero to 100% is estimated at 107 per Disability-Adjusted Life Year (DALY) saved for bicyclists and 467 for There are an estimated 400 million bicyclists in I China and an additional 62 million registered Official statistics suggest that bicyclists and accounted for more than 34% of all fatalities in 1995-2002. Note: DALYs estimated at 3% discount rate. Source: Norton et al., eds. Chapter 39, Unintentional Injuries. ln: Jamison DT et al, eds. Disease control priorities ln developing countries, 2nd ed. Oxford Press, 2006:737-754 (vvww.dcp2.org/pubs/DCP/39, accessed 14 July 2008). 9 Suicide Published reports suggest that suicide is the leading cause of death in China for people aged between 15 and 34 years old. Suicide is the most frequent injury death in China. In 2002 an estimated 272 000 people died from self-inflicted injuries (a mortality rate of 22 people per 100 000 people). Someone takes his or her own life approximately every two minutes in China. An estimated 166 000 people commit suicide Someone takes Or each year by intentionally ingesting agricultural pesticides, making this by far the leading method her hire of self-inflicted injury. two fnjnutgs Studies suggest that suicide rates in women are in 8 25% higher than in men. The female suicide rate is particulany high in rural areas. The issue of suicide is cloaked by significant social stigma and sensitivity, hampering prevention efforts. Since 1999, suicide prevention has been listed as summa mom ny ma a mental health priority for the Ministry of Health in II China. However, there is also strong potential for 80 000 collaboration with the injury prevention community, 90 particularly in relation to the prevention of 70 80 pesticide poisoning. 60 000 so 000 Suicide can be prevented 40 Ow Further research towards identifying risk factors so 000 40 and effective prevention strategies specific to 00 the Chinese setting is required. Additionally, 10 000 20 strengthening of social support and community 10 networks, increasing public awareness of mental H, M, SH, an lm nm health issues and improving both quality and M, mul, quantity of mental health senrices, especially . Wu in rural areas are important priorities. 8oIf--InflIctod Injury mortality rata par 100 0M population International experience shows the following intewentions reduce self-inflicted injuries: Promotion of mental health screening and development of treatment sewices. Provision of easy-to-access assistance telephone counseling sewices). Restricted availability of and access to the means of suicide by banning selected highly toxic pesticides and regulating contact, for example by requiring storage at a central village location rather than in homes. 10 Drowning Drowning is the third leading cause of injury Drowning deaths by age group in China, 2002 mortality in China, accounting for 112 000 deaths each year according to WHO estimates. 60+ 12% Half of all drowning deaths occur among children under 15 years of age, and children 45-59 8% under five years of age are almost five times more likely to drown than any other age group. 00.44 10% More Chinese children between the ag of 5 and 14 years die from drowning than any other cause. 15.29 10% No data is available on the burden of near- drowning (or non-fatal drowning) in China. 5-14 31% UNICEF estimates that 80% of children in Chinese east coast cities cannot swim. 0`4 20% Source: WHO Global Burden of Disease (GBD) mortality database for 2002 Location of drowning Neany 44% of all child injury deaths in urban urban Areas areas are from drowning; the percentage is I. . . 58.2% in rural areas. Drowning mortality rates are 4-10 times greater in rural areas compared to urban areas. Drowning is a major cause of childhood mortality in South-East China, where exposure to drowning hazards (rivers, watenivays, lakes etc) is common. Age group Mortality rate* of injury deaths In Guangxi Province drowning is the leading cause of injury death among children aged 5-9 16.8 59.4 1-9 years, and in Jiangsu Province it accounts for 1Q.14 14_0 54_7 70% of injury deaths for the age group 1-4 years old, and 50% for the age group 5-14 years old. Drowning can be prevented . . There are many opportunities to implement effective Ore I nese ch I ren interventions, such as the following methods: between the ag GS Of 5 and Provide safe environments including by limiting . . access to bodies of water. 1 4 years dle from Promote learn to swim campaigns. than 'ffofn any other cauSa_ Promote strengthening and enforcement of water transport safety regulations (such as making mandatory the provision of floatation devices on all water craft). Promote constant and vigilant supewision of children by parents and adults. 1 1 violence Violence mortality in China, 2002 my Deaths rata Homicide (death by violence) is estimated to be 16 000 6 the 4th leading cause of death in the age group estimated 38 000 people died from homicide 10 000 4 related injuries in 2002. 8 000 3 Overall mortality rates for violence have been 6 000 2 estimated at 3 per 100 000 people each year. 4 000 However the rate for males (4.6) is three times 2 1 greater than that among females (1.5). 0 0 For every person who dies as a result of o??oo violence, many more are injured and suffer from a range of physical, sexual, reproductive and - vi?ion umns mental health problems. vi?lon mortality mu pa 100 000 population Domestic violence and familial violence are seems; who Global Burden or Disease (GBD) mcnallty ru 2002 (Version sj. significant problems in China. A survey conducted by the All China Women's Federation's (ACWF) suggests that over 30% of women suffer Wolence can be from domestic violence. Neany half the survey WHO's World report on violence and health respondents considered it acceptable for highlights a number of proven and promising husbands to beat their wives, indicating ingrained strategies for the prevention of violence: home social acceptance of this problem and an visitation by professional nurses and social workers; unwillingness to interfere in what is often seen parent training on child development, non-violent as a family issue. discipline and problem-solving skills; pre-school In provincial surveys, 50% of all children sampled p"?9"amm?S y?u"9 an report experiencing violence directed at them. Start- S??'al slid life skills training to promote non-violent conflict Pla??$ a massive bu'd?" "?tl?"al resolution skills in children and adolescents; economies, costing countries billions of dollars reducing clcohol availability lhrouoh loxcllorh eafih Yea" ln health cam- law costs pricing and the enforcement of liquor licensing laws; ?f and l?$t restricting access to firearms; and multi-media campaigns to promote non-violent social norms. For wolonoo occurs by ago group ln chlna 2oo2 severe physical injuries due to violence measures to improve the efficiency of emergency care will assist in reducing the risk of death, the time for recovery 0`4 1% and the level of long-term impairment. 5-14 3% These interventions have been shown through intemational studies to be effective in preventing 38% violence and have strong potential for effect in China. However; more research is needed to understand the specific causes and risk factors for violence in China and how prevention strategies developed elsewhere can be tailored to local conditions. 30-44 34% 45-59 16% 60+ 8% Source: WHO Global Burden of Disease (GBD) mortality database for 2002 (Version 3). 12 WHO plan of collaboration for injury I prevention in China I In consultation with the IVIinistry of Health and the Chinese Center for Disease Control and Prevention (China CDC), WHO has developed a 2005-2008 cooperative action plan to guide the collaboration between WHO and the Government in injury prevention priorities in key areas. These include: Road traffic injury prevention. Child injury prevention (with particular focus on preventing drowning). Progress towards designation of Safe Communities in China. Prevention of pesticide poisoning (covering both intentional and unintentional poisoning). Investigating the economic burden of injury. Strengthening capacity for injury prevention in the health workforce. Expansion of hospital-based injury surveillance and conducting community surveys. .. .. - Prevention WHO has developed a series of documents calling _o 2 attention to injury and violence prevention. The World A - report on violence and health (2002) and World report on ff, road traffic injury prevention (2004) emphasize I the importance of addressing violence and road traffic E. injury as public health issues, and highlight effective 5 mechanisms. These ground-breaking reports were compiled by leading injury experts from around the world, and are available in Chinese. As a follow on to the WHO, in partnership with the World Bank, the FIA Foundation for the Automobile and Society, and the Global Road Safety Partnership are producing a series of good practice manuals that provide detailed guidelines on how to implement the recommendations of the The manuals in this series include helmet and seat-belt wearing, drinking and driving, speed management, how to develop a lead agency, and mechanisms for strengthening the collection of data. Surveillance In collaboration with the United States Centers for Disease Control and Prevention (US CDC), WHO produced the Injury suryeillance guidelines to assist countries in developing suryeillance systems for injury prevention. In 2004 WHO released the most recent in this series, Guidelines for conducting community sunxeys on injuries and violence. Both guidelines are available in Chinese. The National Center for Chronic and Noncommunicable Disease Control and Prevention of China CDC has used these guidelines to develop a national hospital- based injury suryeillance system, which is currently being implemented in more than 120 hospitals around China. WHO is also supporting an expansion of this system in Shandong Province. 13 Advocacy The material received strong endorsement wono Health Day in zoo4 focused on mac safety by trentjeeipienta in China ae meeting the trajnine highlighting that niqoad Safety is No This for building workforce In major advocacy campaign outlined ina substantial iniurv preventipn. and ie available in Iife-saving potential that implementation of the recommendations from the World report on road Policies rhjUrY preventien eah achieve and addressed Recognizing the need for technical assistance in the enprmeue 9l??al_ tragedy and bunlen er read the development of national policies and strategies traitie 'hidrY- lr] WHO Preddeed a Chlhese for violence and injury prevention, WHO, with the lah9lla9e Versleh the rePert? ladhehed support of leading experts have produced Developing 2004 hY the Health anti Pdhl'e_ seeUr'tY policies to prevent violence and injuries: guidelines for ih ah event that evntbellzegl a 9reWlh9 rhultrseeteral policy makers and planners. In collaboration with the appreaeh te read _saretY the GeVerhmeht lh Ministry of Health and China CDC, WHO is currently China- The next high pretile atlveeaev event will be assisting the development of a national rcpon on the First United Natlehs Glpbal Read Safety Week injury. When completed, attention will turn to the scheduled from 23 te 29 April 2007- development of a national plan of action for injury World rcpon on violence and naaiin, wno will prbvide valuable is also Ieading a global campaign for violence prevention. The objectives ofthe campaign are to Services for pre-hosital and trauma care raise awareness about the problem of violence, prahaspitai and trauma Cara Systems WHO hl9hli9ht the erdelal rele that publie health eah recently released guidelines to support governments plav lh address'h9 'ts eadses and eehseddehees developing minimum sewices for pre-hospital and and enepurase aetipn at everv level et epeietv- trauma cava of those injury. wno recently The Campaign eervee ae the main plattenn ter raounatac a review of cnanac trauma cava systems ??nplentent?ns the et the at tna request ofthe Ministry of noann. rancanga Werld reP0rl Oh Vlelehee arid health- suggested that while the components of the trauma system are well developed, links between the Capacity building components require strengthening. International and other global injury prevention experts together deetere wbuld alee be or Qreat developed the programme: Training, Educating, Advancing Collaboration in Health on Wolence and Injury Prevention, towards meeting the need for greater skills and capacity of injury prevention practitioners (particularly in developing countries). TEACH-VIP is a comprehensive injury prevention and control curriculum, comprising 60 (1 -hour) lessons. Extensively tested and receiving broad acceptance worldwide, TEACH VIP is available to all organizations wishing to teach injury prevention. 14 FROM THE INTERNATIONAL COMMUNITY - Init . -- . 5-I1. ir"? - . ji References 1. Baker SP et al. The injury fact book, 2nd ed. New York, Oxford University Press, 1992. 2. Violence: a public health priority. WHO Global Consultation on Violence and Health. Geneva, World Health Organization, 1996 (document 3. Peop|e's Republic of China, Ministry of Health. China National Health Statistics. Beijing, 1999. 4. World Health Organization Global Burden of Disease (GBD) 2002 estimates 0/ersion 3) whosis/en, accessed 3 August 2006). 5. Zhou et al. Productivity losses from injury in China. Injury prevention, 2003, 9:124-127. 6. Jraiw K. On the road to development: Road safety in the PRC: past present and future. Asian Development Bank, Manila, Philippines, 2002. 7. Peden et al., eds. World report on road trafiic injury prevention. Geneva, World Health Organization, 2004 accessed 31 July 2006). 8. Gross National Income for China. World Bank Database. Washington DC, USA, (http://web. world DK:20394802~menuPK:1 192714~ accessed 31 July 2006). 9. Recipient Aid Charts: China 2002-2004. Development Cooperation Directorate. Organization for Economic Co-operation and Development (OECD), Paris, accessed 31 July 2006). 10. Li G, Baker SP Injuries to bicyclists in Wuhan, Peop|e's Republic of China. American Journal of Public Health, 1997, 11. Passmore J, Ozanne Smith J. Seatbelt use amongst taxi drivers in Beijing, China. International Journal of Injury Control Safety Promotion, 2006, 12. Zhang et al. ownership and injury in China. International Journal of Injury Control Safety Promotion, 2004, 1 1 16 World _Heq|th vvww.wh0.int