The Global Problem of Injuries to Children and Adolescents

Last month the World Health Organization and United Nations Children's Fund released the World Report on Child Injury Prevention.1 The purpose of this report was to draw attention to the magnitude of the problem of injuries to children and adolescents around the world and to spur the development and implementation of strategies to decrease the toll from injuries.In the United States, injuries remain the leading cause of death and acquired disability for children beyond their first birthday and for adolescents. The response to the injury problem in the US has been modest on the part of the states and the federal government, with funding far smaller than the magnitude of the problem. Nevertheless, substantial advances have been made with the unintentional injury mortality rate for children and adolescents 45% lower in 2005 than in 1981.2Less appreciated is that >95% of injury deaths occur in children and adolescents in the developing world, accounting for nearly 1 million deaths annually.3 Examining specific injury problems makes these data even more striking. For example, it is estimated that >98.4% of the world's childhood drowning occurs in low- and middle-income countries (LMIC) versus only 1.5% in high-income countries. In the United States, the rate of drowning for children and adolescents was 1.53 per 100000 in 20022; in LMIC in the Western Pacific region it was 14.9 per 100000,4 and among children 1 to 4 years of age in Bangladesh it was 156.4 per 100000.5Likewise, 95% of road-traffic crash deaths of children and adolescents occur in LMIC despite vehicle ownership being 780 per 1000 population in the United States, 488 per 1000 in the European Union, and <30 per 1000 in Pakistan and Nigeria.6 As the current gas crisis has warned us, the number of road-traffic injuries in the developing world will only increase with the spread of urbanization and motorization. There are an estimated 1 billion people in the world today with no access to roads. As this access improves, the number of vehicles is likely to skyrocket, as will the number of injuries to the most vulnerable class of road users (ie, children). India and China alone are expected to see an increase in the number of road-traffic deaths by 147% and 97%, respectively, by 2020.7The Bellagio Child Survival Study Group has helped to draw the world's attention to the global problem of child death8 and the potential to dramatically decrease the number of deaths through implementation of currently available, effective interventions.9 As these interventions are implemented and deaths from malnutrition, birth asphyxia, and infection decrease, and as industrialization spreads, injuries will account for an increasingly larger portion of the morbidity and mortality occurring in children and adolescents. For example, in Bangladesh, 21% of all deaths of children 1 to 4 years of age are currently a result of drowning.10What can be done to address the problem? The first, and most important, step is to focus wider attention on the magnitude of the burden caused by injuries to children and adolescents in LMIC. As the Bellagio conference did for child survival, the hope is that the World Report on Child Injury Prevention will open eyes and minds to the importance of the injury problem to find that the loss of 1 million child lives annually from injuries is simply unacceptable. This awareness needs to happen both here and abroad, both among organizations and agencies dedicated to improving child survival and in the countries with the greatest injury problem. We as pediatricians need to use our advocacy for children as a way to bring about this shift in thinking.Second, we need to understand that injuries are preventable, and preventable now, not at some future time when there is less poverty or better science or a better educated populace. Seat belts do save lives, helmets do protect brains, and packaging does prevent poisoning. These interventions work in the United States, and they can work, appropriately adapted, in LMIC.Third, the most effective prevention programs are those that are multisectorial and are woven into the fabric of communities as they develop, grow, and change from rural to urban. Sweden did this as they industrialized after World War II, making injury prevention a part of urban planning, road construction, transportation, education, and health systems.11 The result has been that child injury deaths in Sweden are the lowest in the world, a marked change from the 1950s when they were substantially higher than the rate in the United States.This reduction will require investments in research, surveillance, and data collection and in the development of human resources in LMIC to direct these efforts. However, at a time when we increasingly understand the impact of globalization and the interconnectedness of our lives and our children with those in Africa, Asia, and Latin America, it is time to turn our attention to this enormous, but solvable, problem.