Public Health

Reducing inequalities from injuries in Europe Dinesh Sethi, Francesca Racioppi, Inge Baumgarten, Roberto Bertollini

Injuries cause 9% of deaths and 14% of ill health in the WHO European Region. This problem is neglected; injuries are often seen as part of everyday life. However, although western Europe has good safety levels, death and disability from injury are rising in eastern Europe. People in low-to-middle-income countries in the Region are 3·6 times more likely to die from injuries than those in high-income countries. Economic and political change have led to unemployment, income inequalities, increased traffic, reduced restrictions on alcohol, and loss of social support. Risks such as movement of vulnerable populations and transfer of lifestyles and products between countries also need attention. In many countries, the public-health response has been inadequate, yet the cost is devastating to individuals and health-service budgets. More than half a million lives could be saved annually in the Region if recent knowledge could be used to prevent injuries and thus redress social injustice in this area. Injuries, whether unintentional or intentional, are a neglected problem that has devastating effects on individuals and health budgets.1–3 Of the 5 million deaths from injury worldwide in 2002, 790 000 were in the WHO European Region, as estimated by the Global Burden of Disease project.3,4 Despite calls for action, little systematic attention has been given to this largely preventable problem in the European Region.5,6 As elsewhere in the world, the major part of the burden is shouldered by vulnerable populations. In the European Region, most of the burden falls on low-and-middleincome countries (panel 1), which have undergone great changes brought about by transition to marketstyle economies since the 1990s.5–7 These developments have been associated with increases in violence and unintentional injuries.5,6 In all countries of the Region, those most at risk are children, older people, male individuals, the economically deprived, people with less education, and those with fewer social resources.1,2 Without coordinated action, the problem will continue and inequalities will worsen.5,8 In September, 2005, the WHO Regional Committee for Europe adopted a resolution on prevention of injuries in the WHO European Region, which called for action on the basis of the available evidence on risk factors and preventive measures.9 The accompanying WHO report, Injuries and violence in Europe: why they matter and what can be done, summarises the evidence and proposes a way forward.10 In the present paper we highlight the problem of inequalities in injury in the European Region, and emphasise the need for public-health action to stop the relentless daily loss. Panel 2 shows the methods used to obtain data.

Public-health burden from injuries and violence The 52 countries in the WHO European Region are diverse, not only in language and culture but also in the indices of social and economic development that affect the causes and determinants of injuries.15 Injuries rank third among the Region’s leading causes of death, after cardiovascular disease and cancer, and account for 9% of all deaths in the Region. In 2002, the top three causes of deaths from injury were self-inflicted injuries (164 000,

21% of deaths from injury), road traffic injuries (127 000 deaths, 16%) and poisoning (110 000, 14%).4,10 Table 1 ranks the 15 leading causes of death using data from the Global Burden of Disease project.10 It lists the individual causes of injury, both unintentional (road traffic injuries, poisoning, drowning, falls, fires) and intentional (interpersonal violence, self-directed violence, war). These data show clearly that individual injuries are among the top 15 causes of death for people younger than 60 years. For example, the top six causes of death for adolescents and young people aged 15–29 years all fell into the category of injury. Average values from high-income countries (the Netherlands, Sweden, Australia, New Zealand, and the USA) suggest that for every death from injury there are an estimated 30 hospital admissions and 300 emergency department attendances; many more people either seek help from family doctors or self-treat.16 When these ratios are applied to the number of deaths from injuries over 1 year in the WHO European Region, the resulting estimates of 24 million hospital admissions and 240 million hospital attendances are staggering in terms of human suffering and health-service costs.10,17 Many injuries might result in permanent disability. Disabilityadjusted life-years (DALYs) are one way of quantifying the burden of these non-fatal outcomes, where one DALY is 1 year of healthy life lost because of disability or premature

Published Online June 26, 2006 DOI:10.1016/S0140-6736(06) 68895-8 Accidents, Transport and Health, WHO European Centre for Environment and Health, Special Programme on Health and Environment, WHO Regional Office for Europe, Rome 00187, Italy (D Sethi MD, F Racioppi MSc); and Violence Prevention (I Baumgarten PhD), Special Programme on Health and Environment (R Bertollini MD), WHO Regional Office for Europe, Copenhagen, Denmark Correspondence to: Dr Dinesh Sethi [email protected]

Panel 1: Countries in the WHO European Region7 Low-and-middle-income countries Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Poland, Republic of Moldova, Romania, Russian Federation, Serbia and Montenegro, Slovakia, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, Uzbekistan High-income countries Andorra, Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland, UK

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8

1

Public Health

Panel 2: Methods and data sources Three main sources of data were used: the WHO Global Burden of Disease study 2002 version 3 database,4 the WHO health for all database for Europe 2005,11 and the WHO Statistical Information System 2005.12 Standard methods were used to calculate age standardised mortality rates, rate ratios, and potential deaths averted from injuries; a full account of the methods used is given in the WHO report.10 A review of published work was done using the PubMed and Cochrane electronic databases. Relevant studies were also found in the World report on violence and health,13 the World report on road traffic injury prevention,14 and Injuries and violence in Europe: why they matter and what can be done,10 and from bibliographies of specific texts. The articles specifically cited have been selected for their relevance for this paper.

death.4 Injuries accounted for 14% of the burden in the Region in 2002, or 21 million DALYs.4 The top three causes

of DALYs lost from injuries were self-inflicted injuries (18%), road traffic injuries (17%), and interpersonal violence (11%). Three out of four injury deaths (586 000) and 78% of DALYs lost are in male individuals. Whereas 21% of all deaths from injury are in people aged 0–29 years, this group have a disproportionately high share of the burden, accounting for 44% of the DALYs lost. The costs to health services for treating injuries in the Region have not been properly documented, but estimates suggest that they range from €81 billion to €296 billion per year.17 Costs of injury to society are just beginning to be studied, and for road traffic injuries alone are estimated at 2% of national gross domestic product (GDP).14,18 In the UK, the costs of domestic violence were estimated to be about 2·2% of GDP.19 These estimates further emphasise the importance of investment in injury prevention to public health and the economy, since proportionately higher returns can be expected from prevention, especially in young, potentially economically productive populations.

0–4 years

5–14 years

15–29 years

30–44 years

45–59 years

≥60 years

Total

1

Perinatal conditions (65 675)

RTI (4691)*

RTI (37 994)*

Ischaemic heart disease (52 052)

Ischaemic heart disease (253 018)

Ischaemic heart disease (2 064 108)

Ischaemic heart disease (2 373 141)

2

Lower respiratory infections (31 971)

Lower respiratory infections (3793)

Self-inflicted injuries (32 327)*

Self-inflicted injuries (44 830)*

Cerebrovascular disease (106 943)

Cerebrovascular disease (1 309 057)

Cerebrovascular disease (1 447 010)

3

Congenital anomalies (28 660)

Drowning (2863)*

Interpersonal violence (15 679)*

Poisoning (32 292)*

Trachea, bronchus, lung cancer (78 321)

Trachea, bronchus, lung cancer (276 456)

Trachea, bronchus, lung cancer (365 351)

4

Diarrhoeal diseases (11 827)

Leukaemia (1766)

Poisoning (12 051)*

RTI (31 551)*

Cirrhosis of the liver (59 089)

Chronic obstructive pulmonary disease (238 855)

Lower respiratory infections (280 883)

5

Meningitis (9313)

Self-inflicted injuries (1597)*

Drowning (8342)*

Interpersonal violence (24 645)*

Self-inflicted injuries (43 054)*

Lower respiratory infections (203 298)

Chronic obstructive pulmonary disease (260 605)

6

Childhood diseases (4913)

Childhood-cluster diseases (860)

War (7810)*

Cerebrovascular disease (24 023)

Poisoning (41 517)*

Colon and rectum cancer (193 507)

Colon and rectum cancer (229 083)

7

Upper respiratory infections (2517)

Cerebrovascular disease (848)

Tuberculosis (7099)

Cirrhosis of the liver (22 949)

Breast cancer (38 097)

Hypertensive heart disease (157 267)

Hypertensive heart disease (179 849)

8

Drowning (1817)*

Poisoning (810)*

Cerebrovascular disease (5266)

Tuberculosis (22 445)

Colon and rectum cancer (29 247)

Stomach cancer (123 319)

Cirrhosis of the liver (170 600)

9

RTI (1698)*

Interpersonal violence (765)*

Lower respiratory infections (4941)

HIV/AIDS (19 240)

Lower respiratory infections (27 532)

Diabetes mellitus (122 667)

Self-inflicted injuries (163 878)*

10

Endocrine disorders (1309)

Epilepsy (687)

HIV/AIDS (4420)

Breast cancer (11 076)

Stomach cancer (26 786)

Alzheimer’s and other dementias (101 353)

Stomach cancer (157 717)

11

Poisoning (1024)*

Congenital heart anomalies (674)

Falls (3914)*

Drowning (10 127)*

RTI (23 958)*

Breast cancer (100 570)

Breast cancer (150 116)

12

Fire* (976)

Falls (610)*

Ischaemic heart disease (3905)

Trachea, bronchus, lung cancer (10 000)

Tuberculosis (21 095)

Prostate cancer (89 331)

Diabetes mellitus (141 454)

13

Cerebrovascular disease (872)

Lymphomas, multiple myeloma (567)

Leukaemia (3637)

Lower respiratory infections (9347)

Interpersonal violence (20 036)*

Cirrhosis of the liver (85 336)

RTI (126 546)*

14

Leukaemia (861)

Meningitis (554)

Drug-use disorders (3527)

Inflammatory heart diseases (9299)

Inflammatory heart diseases (19 351)

Pancreas cancer (70 212)

Poisoning (109 870)*

15

Inflammatory heart diseases (838)

Fire (551)*

Cirrhosis of the liver (2848)

Drug-use disorders (8417)

Hypertensive heart disease (18 280)

Inflammatory heart diseases (68 891)

Alzheimer’s and other dementias (105 264)

RTI=road traffic injuries. *Injury-related causes of death.

Table 1: Leading 15 causes of death and numbers of deaths by age group for both sexes in WHO European Region, 20024

2

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8

Public Health

Current threats: increasing inequalities and the transborder spread of injury risk

Male

Rate ratios (LMIC/HIC) Female

Male

Female

Both

HIC

LMIC

HIC

LMIC

All injuries

44·92

183·49

18·27

48·44

4·08

2·65

RTI

15·81

24·47

4·83

7·78

1·55

1·61

1·54

1·68

30·18

0·56

8·45

17·93

15·10

16·87

Drowning

1·18

11·63

0·32

2·44

9·83

7·57

9·20

Falls

4·84

8·96

4·45

3·36

1·85

0·75

1·29

Fires

0·65

5·78

0·35

2·14

8·88

6·20

7·80

13·24

37·20

4·20

7·30

2·87

1·74

2·50

1·24

20·11

0·64

6·21

16·18

9·73

13·80

Poisoning

Suicide Interpersonal violence

3·60

RTI=road traffic injuries.

Table 2: Standardised injury mortality rates and rate ratios comparing low-and-middle-income countries (LMIC) with high-income countries (HIC) in the WHO European Region, 20024,10

under the influence of alcohol, and 60% of suicides have tested positive for alcohol in the blood.11,34–36 Patterns of alcohol consumption are affected by geographical, cultural, socioeconomic, and fiscal factors. The liberalisation of access to alcohol, such as 24-h licensing in the UK, is also a cause for general public concern in high-income countries, because of the potential for increased violence and injuries.37 Furthermore, disquiet exists about increased binge drinking in younger people in southern Europe, a problem that was once more common to northern European countries, and about the uptake of male drinking patterns by girls and women.37,38 Rates of homicide and suicide have been linked to alcohol sales, particularly in northern and eastern Europe, where 200 CIS ER EU

180 160 Rates per 100 000 population

140 120 100 80 60 40 20

20 02

20 00

19 98

19 96

19 94

19 92

19 90

19 88

4

19 86

2

19 8

19 8

0

0

19 8

People living in low-and-middle-income countries are 3·6 times more likely to die from injury than those living in high-income countries (table 2).10 This difference exists for all individual causes of injuries. When both sexes are considered, the mortality rates in low-and-middle-income countries are 16·9 times greater for poisoning, 13·8 greater for interpersonal violence, 9·2 times greater for drowning, and 7·8 greater for fires, compared with high-income countries. The exception is falls in female individuals, for which rates are higher in high-income than in low-and-middle-income countries.4,10 Mortality rates are consistently higher in male than in female individuals, although the rate ratios between the sexes vary by cause and setting. By contrast with low-and-middle-income countries, which have some of the highest injury rates in the world, some high-income countries in the Region are amongst the safest places in the world.10 Whereas many of these countries, such as those of the European Union, have falling rates of injury mortality, the trend is upward for the Commonwealth of Independent States (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan; figure).11 This trend has contributed to a marked decline in adult life expectancy, which threatens the economic productivity and development of these countries.20 Such changes have been attributed to the consequences of poorly managed societal transition to market economies.5,21 For example, rapid increases in motorised transport, without the concomitant changes in development of regulation and infrastructure, have been associated with increased rates of road traffic injuries in many countries undergoing transition.18 Alcohol consumption is an obvious risk factor for all causes of unintentional injuries and violence in adolescents and adults, and is thought to be implicated in up to 40–60% of injuries in the whole Region,22,23 particularly in men aged 15–44 years.24 Children may also be victims of alcohol misuse, either from perpetrators of violence or from parents too impaired to provide supervision. Low-and-middle-income countries in the European Region have the highest per-head consumption of alcohol in the world, with the largest share of unrecorded consumption and arguably the most hazardous drinking patterns.25,26 Much of the excess adult mortality in the Commonwealth of Independent States and other eastern countries in the Region has been attributed to alcohol ingestion.21,27–32 In these countries, binge drinking has led to premature adult mortality from injuries, ranging from poisoning due to alcohol intoxication, to road traffic injuries, violence, and cardiovascular mortality.21,33 For example, in some countries, such as the Russian Federation, up to 70% of deaths from acute poisoning are attributed to alcohol, about three-quarters of people arrested for homicide were

Deaths per 100 000

Year

Figure: Standardised mortality rates for all injuries in WHO European Region (ER), Commonwealth of Independent States (CIS), and European Union (EU), 1980–2002 Source: mortality indicators by 67 causes of death, age, and sex, 2005.11

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8

3

Public Health

drinking culture is characterised by episodes of heavy drinking.33,36,39 Whereas the spread of communicable diseases such as HIV and tuberculosis across borders in the Region is well acknowledged, the transfer of injury risk has not been much described.15,40,41 In response to the increasing rates of tuberculosis and HIV in some countries of the Commonwealth of Independent States, public-health measures are being put into place, including international collaboration to tackle these challenges.41 The case for injuries is quite different, and the publichealth community is only just becoming aware of the threats posed by the transfer of injury risk in a globalising and increasingly interdependent world.42,43 These threats include not only the transfer across national boundaries of vulnerable populations at increased risk, such as trafficked children and women, and people travelling for leisure or work to destinations that expose them to unfamiliar risk situations, but also the transfer of lifestyles, working practices, and products (legal and illegal) such as alcohol, drugs, and small arms.42,44–46 For example, intensive marketing by transnational alcohol companies, coupled with poor local controls and relatively low pricing, has contributed to large increases in consumption in young people in low-and-middle-income countries, with a concomitant effect on injury rates.28 The public-health hazard from transborder spread of risk factors for injury needs to be studied further and controls put in place in a more coordinated way.

Inequalities within countries The link between poverty, inequality, and the occurrence of injuries is important for all countries in the European Region and addressing this association is an issue of social justice. Understanding determinants is part of the public-health response to prevention.47 Socioeconomic class and poverty affect the occurrence and outcomes of injuries through physical, social, psychological, educational, and occupational variables, and through other societal factors such as the existence of social capital and social networks.48–50 When injured, poorer people could have less access than richer people to highquality emergency medical and rehabilitative services, and the costs of health care and lost earning capacity have a severe negative effect on their financial situation.50 People in rural as opposed to urban areas can be at increased risk from injuries related to road traffic accidents, drowning, fires, machinery, and small arms. This difference is related to poverty, increased exposure to risks, and poorer access to emergency services.51 Absolute poverty is not restricted to low-and-middleincome countries and continues to exist in the richest countries of Europe.47 High-income countries have inequalities in injuries, with increased rates in socioeconomically deprived people and a widening gap between the rich and poor, and need preventive 4

strategies to address this problem.8,52 In the UK, children from lower social classes were 3·5 times more likely to die from injuries than those from higher classes, and this difference increased to five times in subsequent years, because poorer classes did not benefit from improvements in injury mortality seen in the richer classes.8 The increased mortality risk in deprived people is true for most causes of injury, including drowning, falls, poisoning, road traffic, fires, and homicide.48 Results from the UK show that the increase in risk varies by type of injury; in children from the lowest compared with the highest socioeconomic class, risk is increased by five times in pedestrians in traffic crashes, 16 times for fires, seven times for falls, and six times for homicide.53 Lower educational levels in the Russian Federation are associated with a doubled mortality rate for occupational injury.54 Socioeconomic factors affect risk in the disadvantaged through increased exposure to hazardous environments, unsafe working practices, inadequate knowledge, risk-taking behaviours, inability to pay for safety equipment, and limited access to information and services.55 Low-and-middle-income countries in the Region are undergoing political change and rapid transition to market economies, causing socioeconomic stress. High inflation, unemployment, inequality, social disintegration, the concentration of wealth in fewer hands, and high levels of poverty have led not only to changes in exposure to risk, but also a weakening of the safety and support networks that mitigate the effects of injuries.56,57 Exclusion from society and the inadequacy of social networks, social capital, and community cohesion affect people’s capacity to withstand social conflict without having to resort to violence.13,47 Inequalities in income and social disjunction during the period of transition are associated with increased rates of homicide and suicide.29,33,36 These changes have contributed to two peaks in injury mortality: in the early 1990s, and in the past few years (figure). The subsequent decline in mortality in the mid 1990s has been attributed to the increase in the price of alcohol and the decrease in motor vehicle traffic associated with the economic slowdown in some countries in transition.58,59

Evidence of effectiveness: opportunity to save lives Some countries in the European Region, such as the Netherlands, Sweden, and the UK, are among the safest places in the world. If all countries were to match the lowest national injury mortality rates in the Region, two thirds, or about 508 000, of the lives lost annually from injuries could be saved.10 The WHO report Injuries and violence in Europe: why they matter and what can be done10 draws on growing evidence about preventive interventions against unintentional injuries and violence. It recommends a public-health approach to address the challenges posed.10,13,14 This science-based approach aims

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8

Public Health

to identify the size and cause of the problem, and to find out and implement what works for prevention.2 Such an approach needs to be more widely adopted by policymakers and practitioners throughout Europe. It would counteract the common attitude that violence and unintentional injuries are an unavoidable part of everyday life, and would allow a more efficient use of resources. Countries with low rates of injury have invested in safety as a societal responsibility, rather than delegating this duty to individuals. Legislation and enforcement to ensure safer environments (eg, road and housing design, use of safety equipment) and reduce risk behaviours (eg, driving under the influence of alcohol) are key to changes at the population level. These measures have a synergistic effect when coupled with media and educational campaigns; relying solely on the latter without infrastructural and institutional changes shows little evidence of effectiveness. For example, environmental laws regulating traffic safety and housing design are thought to have halved deaths from injury in Sweden over 25 years, and reduced injury differentials between societal classes.60,61 Reducing inequalities in injuries and other areas of health requires a more equitable and just social policy that provides safety nets for the vulnerable, as in the Nordic countries. Policies have been designed to mitigate against injury and health inequalities in the poor, such as those in the UK.62 Examples include the neighbourhood road safety initiative,63 which targets improvements in safety in deprived areas, linking safer transport to urban regeneration, and the SureStart programme,64 which offers safety equipment loan schemes for children living in deprived areas, but these initiatives need more rigorous evaluation to inform evidence-based policymaking.65 Alcohol is a modifiable risk factor that requires special consideration, in view of the large burden of injuries attributable to it, particularly in low-and-middle-income countries.23–26 Cost-effective strategies at the population level include legislation, taxation, and restricting or banning advertising.25,66,67 Brief advice by doctors is costeffective for individuals at risk.25,66 Controlling alcohol misuse will reduce the burden not only from unintentional injuries and violence but also from other alcohol-related disorders, such as cardiovascular diseases and cirrhosis.25 The anti-alcohol campaign in the Russian Federation, after its introduction in 1985, led to a 63% decrease in alcohol sales at state retail outlets, which although offset by an increase in private production, led to an overall fall in alcohol consumption of 25% over 3 years. This change resulted in a 33% fall in alcohol-associated violent deaths and a 3-year increase in male life expectancy.58,68 There is a growing body of evidence for effective strategies to prevent injury and violence, and many have been shown to be cost effective, although more research is needed.10,69,70 Cost-outcome studies show that investment in safety is a saving for society at large. For example, every €1 invested in child safety seats saves €32; the

corresponding savings from other investments are €29 for bicycle helmets, €69 for smoke alarms, €19 for home visitation schemes with education of parents against child abuse, €10 for prevention counselling by paediatricians, and €7 for poison control services.10,69,70 Much of this evidence comes from the USA, and needs to be adapted to local contexts.

Challenges: barriers to improving injuries In many low-and-middle-income countries, a fundamental problem is that injuries have received too low a policy priority, and consequently little investment in prevention. Public-health systems have been weakened by dwindling economies in many countries, which have seen a decline in the quality of health-care services, including trauma care.71,72 Incomplete surveillance has meant that the public-health threat of injuries has not been fully appreciated. Public-health systems do not have adequate capacity to mount the necessary response.57,73 Partly because of previous isolation, there has been little awareness of the international evidence base on injury prevention and care.73 Local research in prevention and trauma care has lagged, and consequently there is little media interest or participation of civil society in making messages on prevention available.6,24 Non-governmental organisations, such as those that support the rights of victims, and that can engage in community-based responses, are few. Injury control requires cross-sectoral approaches, but traditional hierarchical structures and ways of working make intersectoral work between health, education, housing, welfare, employment, and justice systems difficult to achieve.71–73 More and more countries are formulating national policies for prevention, but are hampered by weak implementation, enforcement, and governance.74 Prevailing norms, beliefs, and cultural attitudes towards alcohol consumption and the uptake of safety measures such as seatbelts and crash helmets are diverse, and interventions and programmes need to be tailored to local settings.18,43 The vested interests of large corporations such as the alcohol industry and car manufacturers need to be taken into account when mounting policy responses.43,75

The way forward: policies and tackling inequalities in injuries Several initiatives have been designed to promote effective policies. The UN General Assembly and the World Health Assembly have passed resolutions on the prevention of violence and on improving global road safety and health, which have raised the policy profile of injuries.76–79 In the area of road safety, the European Union has set a target to halve the number of deaths from road traffic injuries by 2010.80 The European Alcohol Action Plan and the WHO Regional Committee For Europe resolution on the framework for alcohol policy promote legislative, fiscal, and regulatory

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8

5

Public Health

measures to restrict access to and consumption of alcohol.23 Prevention of suicide through the detection and treatment of mental illness and alcohol misuse are key elements of the Mental Health Action Plan for Europe.81 The Regional Committee resolution on the prevention of injuries provides a framework for publichealth action to control unintentional injuries and violence (panel 3).9 Complementary to this framework is the European Commission draft Communication and Council Recommendation on injury prevention for adoption in 2006.82 These initiatives have emphasised injuries as a public-health priority and provide a policy platform from which a more systematic and coordinated approach to injury prevention can be made. The WHO resolution provides an agenda for the national-level action that is needed to change the disproportionate risks of injury in vulnerable subgroups of populations, with more equitable distribution of preventive measures and safe environments, and better access to quality trauma care and rehabilitation (panel 3).9 Addressing this important cause of health inequality provides an opportunity to build commitment to social justice. The health sector is well placed to play a part in coordination to achieve this aim, as it can maximise the potential benefits of tackling unintentional injuries and violence under the same umbrella, by using common elements such as surveillance, prevention of risk factors (eg, alcohol), and providing services for victims.2,10,13,14,17 National injury prevention plans will be central to developing effective policy responses at the population level through system-level changes. Relatively quick gains can be achieved through political commitment and sustained effort, as shown in France, where road safety improvements between 2002 and 2004 led to a fall of 34% in death from road traffic injuries.83,84 In February, 2006, the Russian Federation adopted a national road safety plan, with substantial political backing for systemlevel changes to achieve targets.74,85 Panel 3: Essential elements of the WHO framework for injury prevention in the European Region ●

●

●

●

●

●

●

6

Develop national action plans for prevention of violence and unintentional injury Develop injury surveillance to better define the burden, causes, and consequences of injuries, for advocacy, monitoring, and evaluation Strengthen technical and institutional capacity for primary prevention and care Promote implementation of evidence-based approaches for prevention and care Support activities of the network of national focal points for prevention of unintentional injuries and violence Increase research and development to overcome current gaps in knowledge Allocate adequate resources to implement these actions

Better surveillance to define the size, causes, and consequences of the injury problem is needed in many countries, and should include measurement of the distribution of health states in population groups disaggregated by social, ethnic, and demographic factors as a starting point in tackling inequalities.86 The injury database project funded by the European Community, and WHO’s injury surveillance guidelines are examples of systematic approaches to collection of data on injuries.16,46 The collation and dissemination of such information is important not only for advocacy and evaluation, but also for engaging civil society.6 Health professionals’ organisations and non-governmental organisations have a great potential to advocate injury prevention, as shown by the Royal College of Physicians and the Child Accident Prevention Trust in the UK, whose action led to the introduction of the seat-belt law.87 Both institutional and human-resource capacity need to be developed, especially in low-and-middle-income countries; WHO has developed tools to build violence and injury prevention capacity, such as the TEACH VIP course, but needs investment of resources.88,89 There is also a need to bridge the gap between science and policy in promoting the public-health approach, and the WHO network of national health ministry focal persons for injury and violence prevention could be used as a conduit for disseminating information on best practice.50,90 Adequate resources need to be allocated for research and development, including research on how best to implement the growing international evidence base to address inequalities in the Region.50,91 Conflict of interest statement We declare that we have no conflict of interest. D Sethi, F Racioppi, and I Baumgarten co-authored the WHO report. Acknowledgments All the authors are employed by the WHO Regional Office for Europe. The idea was formulated by R Bertollini and D Sethi, and all authors contributed to the draft of the manuscript. References 1 Sethi D, Zwi AB. Accidents and other injuries. In: Chamie J, Cliquet RL, eds. Health and mortality issues of global concern. Proceedings of Symposium on Health and Mortality, Brussels, 19–22 November 1997, organised by the Population Division United Nations and CBGS. New York: United Nations, 1999: 412–41. 2 Krug E, Sharma G, Lozano R. The global burden of injuries. Am J Public Health 2000, 90: 523–26. 3 Peden M, McGee K, Krug E. Injury: a leading cause of the global burden of disease 2000. Geneva: World Health Organization, 2002. 4 GBD estimates. Geneva: World Health Organization, 2002. http://www3.who.int/whosis/menu.cfm?path=whosis,burden,burd en_estimates,burden_estimates_2002N (accessed Oct 13, 2005). 5 Koupilova I, Leon DA, McKee M, Sethi D, Zwi A. Injuries: a public health threat children and adolescents in the European Region. In: Tamburlini G, Ehrenstein OV, Bertollini R, eds. Children’s health and environment: a review of evidence. Environmental issue report no 29. Copenhagen: European Environment Agency, 2002, 130–40. 6 McKee M, Zwi A, Koupilova I, Sethi D, Leon D. Health policymaking in central and eastern Europe: why has there been so little action on injuries? Health Policy Plan 2000; 15: 263–69. 7 Country classification: classification of economies. Washington DC: World Bank, 2002. http://www.worldbank.org/countryclass/ countryclass.html (accessed Oct 13, 2005).

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8

Public Health

8

9

10

11

12

13 14

15 16 17

18

19 20

21 22

23

24

25 26

27

28

29

30 31

Roberts I, Power C. Does the decline in child injury mortality vary by social class? A comparison of class specific mortality in 1981 and 1991. BMJ 1996, 313: 784–86. WHO Regional Committee for Europe resolution. EUR/RC55/R9 Prevention of injuries in the WHO European Region. Copenhagen: WHO Regional Office for Europe, 2005. http://www.euro.who.int/ eprise/main/WHO/AboutWHO/Governance/resolutions/2005/200 50922_1 (accessed Oct 13, 2005). Sethi D, Racioppi F, Baumgarten I, Vida P. Injuries and violence in Europe. Why they matter and what can be done. Copenhagen: WHO Regional Office for Europe (in press). WHO. Mortality by 67 causes of death, age and sex (off-line version), supplement to the European health for all database (HFA-MDB). Copenhagen: WHO Regional Office for Europe, 2005. http://www.euro.who.int/hfadb (accessed Oct 13, 2005). WHO Statistical Information System (WHOSIS). Geneva: World Health Organization, 2005. http://www3.who.int/whosis/menu. cfm (accessed Oct 13, 2005). Krug E, Dahlberg L, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva, World Health Organization, 2002. Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, Mathers C. World report on road traffic injury prevention. Geneva: World Health Organization, 2004. McKee M, Jacobson B. Public health in Europe. Lancet 2000; 356: 665–70. Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O. Injury surveillance guidelines. Geneva: World Health Organization, 2001. WHO Regional Committee for Europe resolution EUR/RC55/10 on injuries in the European Region: burden, challenges and policy response. Copenhagen: WHO Regional Office for Europe, 2005. http://www.euro.who.int/Document/RC55/edoc10.pdf (accessed Oct 13, 2005) . Racioppi F, Eriksson, Tingvall C, Villaveces A. Preventing road traffic injury: a public health perspective for Europe. Copenhagen: WHO Regional Office for Europe, 2004. Walby S. The cost of domestic violence. London: Women and Equality Unit, 2004. World Bank. Dying too young—addressing premature mortality and ill health due to non-communicable disease and injuries in the Russian Federation, Washington, DC: World Bank, 2005 Shkolnikov V, McKee M, Leon DA. Changes in life expectancy in Russia in the mid-1990s. Lancet 2001; 357: 917–21. Watt K, Purdie D, Roche A, McClure R. Risk of injury from acute consumption and the influence of confounders. Addiction 2004, 99: 1262–73. WHO. European Alcohol Action Plan 2000–2005. Copenhagen: WHO Regional Office for Europe, 2000. http://www.euro.who.int/ document/E67946.pdf (accessed Oct 13, 2005). Powles JW, Zatonski W, Van der Hoorn S, Ezzati M. The contribution of leading diseases and risk factors to excess losses of healthy life in eastern Europe: burden of disease study. BMC Public Health 2005; 5: 116. Room R, Babor T, Rehm J. Alcohol and public health. Lancet 2005; 365: 519–30. Rehm J, Room R, Monteiro M, et al. In: Ezzatti M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks. Global and regional burden of disease attributable to selected risk factors. Vol 1. Geneva: World Health Organization, 2004: 959–1108. Leon DA, Chenet L, Schkolnikov VM, et al. Huge variation in Russian mortality rates 1984–94: artefact, alcohol, or what? Lancet 1997; 350: 383–88. Pomerleau J, McKee M, Rose R, Haerpfer CW, Rotman D, Tumanov S. Drinking in the Commonwealth of Independent States—evidence from eight countries. Addiction 2005; 100: 1647–68. Walberg P, McKee M, Shkolnikov V, Chenet L, Leon D. Economic change, crime, and mortality in Russia: regional analysis. BMJ 1998, 317: 312–18. Bobak M, Marmot M. Alcohol and mortality in Russia: is it different than elsewhere? Ann Epidemiol 1999, 9: 335–38. Chenet L, Britton A, Kaldiene R, Petrauskiene J. Daily variations in deaths in Lithuania: the possible contribution of binge drinking. Int J Epidemiol 2001; 30: 743–48.

32 33

34 35 36 37 38

39

40

41

42

43 44 45 46

47

48

49 50

51

52

53

54

55 56

57 58 59

McKee M, Leon DA. Social transition and substance abuse. Addiction 2005; 100: 1205–09. Men T, Brennan P, Boffetta P, Zaridze D. Russian mortality trends for 1991–2001: analysis by cause and region. BMJ 2003; 327: 964–69. Mortality among the population of the Russian Federation 2002. Moscow: Ministry of Health, 2003. Pridemore WA. Vodka and violence: alcohol consumption and homicide rates in Russia. Am J Public Health 2002; 92: 1921–30. Nemtsov A. Suicides and alcohol consumption in Russia, 1965–1999. Drug Alcohol Depend 2003; 71: 161–68. McAllister JFO. The British disease. Time, Dec 19, 2005. Hibbel B, Andersson B, Ahlstrom S, et al. The 2003 ESPAD Report: alcohol and other drug use among students in 35 European countries. Stolkholm: Swedish Council for Information on Alcohol and Other Drugs, 2004. Rossow I. Alcohol and homicide: a cross cultural comparison of the relationship in 14 European countries. Addiction 2001; 96 (suppl 1): S77–S92. Howson CP, Fineberg HV, Bloom BR. The pursuit of global health: the relevance of engagement for developed countries. Lancet 1998: 351: 586–90. Coker RJ, McKee M. Health-care system frailties and public health control of communicable disease on the European Union’s new eastern border. Lancet 2004; 363: 1389–92. Fustukian S, Sethi D, Zwi A. Workers health and safety in a globalising world. In: Bruce K, Fustukian S, Lee K, eds. Health policy in a globalising world. Cambridge: Cambridge University Press, 2002: 208–28. Roberts I. Injury and globalisation. Inj Prev 2004; 10: 65–66. Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002; 359: 1232–37. McKee M, Nolte E. The implications for health of European Union enlargement. BMJ 2004; 328: 1025–26. Bauer R, Kormer C, Sector M. Scope and patterns of tourist injuries in the European Union. Int J Inj Contr Saf Promot 2005; 12: 57–61. Wilkinson R, Marmot M. Social determinants of health. The solid facts. Copenhagen, WHO Regional Office for Europe, 2003. http://www.euro.who.int/document/e81384.pdf. Cubbin C, Smith G. Socioeconomic inequalities in injuries: critical issues in design and analysis. Annu Rev Public Health 2002, 23: 349–75. Cubbin C, Smith G. Socioeconomic inequalities in injuries. Annu Rev Public Health 2002, 23: 347–75. Zwi A. Injuries, inequalities and health: from policy vacuum to policy action. In: Leon D, Walt G, eds. Poverty, inequality, and health. Oxford: Oxford University Press, 2002, 263–82. Boland M, Staines A, Fitzpatrick P, Scallan E. Urban-rural variation in mortality and hospital admission rates for unintentional injury in Ireland. Inj Prev 2005; 11: 38–42. Mackenbach JP, Bos V, Andersen O, et al. Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol 2003; 32: 830–37. Roberts I. Cause specific social class mortality differentials for child injury and poisoning in England and Wales. J Epidemiol Community Health 1997; 51: 334–35. Schkolnikov V, Leon D, Adamets S, Andreev E, Deev A. Educational level and adult mortality in Russia: an analysis of routine data 1974–1999. Soc Sci Med 1998, 47: 357–69. Towner E. Injury and inequalities: bridging the gap. Intl J Inj Contr Saf Prom 2005; 12: 79–84. World Bank. Transition. The first ten years: analysis and lessons for eastern Europe and the former Soviet Union. Washington, DC: World Bank, 2002. McKee M, Nolte E. Lessons from health during the transition from communism. BMJ 2004; 329: 1428–29. McKee M. Alcohol in Russia. Alcohol Alcohol 1999; 34: 824–29. Dimitrov, P. Overview of the environmental and health effects of urban transport in the Russian Federation and the other countries in eastern Europe, the Caucasus and central Asia. 2004: http://www. cemt.org/topics/urban/Moscow04/Dimitrov.pdf (accessed Oct 13, 2005).

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8

7

Public Health

60 61 62 63

64

65 66

67

68

69

70

71 72

73 74

75

76

8

Laflamme L. Social inequality in injury risks. Stockholm: Sweden’s National Institute of Public Health, 1998. Gustafsson LH. Children in traffic. Some methodological aspects. Paediatrician 1979; 8: 181–87. Department of Health. Reducing health inequalities: an action report. London: Department of Health, 1999. Department for Transport. Background on partnership and demonstration projects. London: Department for Transport, 2004. http://www.dft.gov.uk/stellent/groups/dft_rdsafety_pdf_pdf029227. pdf (accessed April 25, 2006). SureStart. Accidents and injuries. http://www.surestart.gov.uk/ surestartservices/healthrelated/healthandfamilysupport/ accidentsandinjuries (accessed April 25, 2006). Macintyre S. Evidence based policy making. BMJ 2003; 326: 5–6. Chisholm D, Rehm J, Van OM, Monteiro M. Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. J Stud Alcohol 2004; 65: 782–93. Foxcroft DR, Ireland D, Lister-Sharp DJ, Lowe G, Breen R. Primary prevention for alcohol misuse in young people. Cochrane Database Syst Rev 2002; 3: CD003024. Nemtsov AV. Alcohol-related harm and alcohol consumption in Moscow before, during and after a major anti-alcohol campaign. Addiction 1998; 93: 1501–10. Miller TR, Levy DT. Cost-outcome analysis in injury prevention and control: eighty-four recent estimates for the United States. Med Care 2000; 38: 562–82. Working to prevent and control injury in the United States—fact book for the year 2000. Atlanta: National Center for Injury Prevention and Control, 2000. McKee M, Suhrcke M. Health and economic transition. Int J Epidemiol 2005; 1093: 1–4. Andreev EM, Nolte E, Shkolikov VM, Varavikova E, McKee M. The evolving patterns of avoidable mortality in Russia. Int J Epidemiol 2003; 32: 437–46. Jenkins R, Klein R, Parker C. Mental health in post-communist countries. BMJ 2005; 34: 1203–06. European Conference of Ministers of Transport. Road safety performance. National peer review: Russian Federation. Paris: European Conference of Ministers of Transport, 2006. http://www. cemt.org/events/PressReleases/RussiaPeerRevE.pdf (accessed April 25, 2006 ). Room R, Babor TF. World Health Organization’s global action on alcohol: resources required to match the rhetoric. Addiction 2005, 100: 579–80. WHO. World Health Assembly resolution WHA49.25 on prevention of violence: a public health priority. Geneva, World Health Organization, 1996.

77

78 79

80

81

82

83

84

85

86 87 88

89

90 91

WHO. World Health Assembly resolution WHA56.24 on implementing the recommendations of the World report on violence and health. Geneva, World Health Organization, 2003. WHO. World Health Assembly resolution WHA57.10 on road safety and health. Geneva, World Health Organization, 2004. United Nations. United Nations General Assembly resolution 58/289. Improving global road safety. New York: United Nations, 2004. http://www.unece.org/trans/roadsafe/docs/A-RES-58–289e. pdf (accessed Oct 13, 2005). White paper: European transport policies for 2010. Brussels: Commission for the European Communities, 2001. http://europa. eu.int/comm/energy_transport/library/lb_com_2001_0370_en.pdf (accessed Oct 13, 2005). WHO European Ministerial Conference on Mental Health. Mental Health Action Plan for Europe. Facing the challenges, building solutions. http://www.euro.who.int/document/mnh/edoc07.pdf (accessed Oct 13, 2005). European Commission. Consultation of the Member States on elements for a proposal for a Commission Communication and Council recommendation on injury prevention and safety promotion. Luxembourg: European Commission, 2001. http://www. eu.int/comm/health/ph_determinants/environment/IPP/ev_ 20051012_en.htm (accessed April 25, 2006) French National Observatory of Road Safety. France: recent developments in road safety. http://www.securiteroutiere.gouv.fr/ IMG/pdf/FRD1.pdf (accessed April 22, 2005). Mulrhad N. Road safety management in France: political leadership a path to sustainable progress? Gdansk: GAMBIT conference proceedings, 2004. Government of the Russian Federation. Federal targeted programme on enhancing road safety in 2006–2012. http://www. government.gov.ru/data/structdoc.html?he_id=100&do_id=2123 (accessed May 3, 2006). Hyder AA, Peden M. Inequality and road traffic injuries: call for action. Lancet 2003; 362: 2034–35. Breen J. Road safety advocacy. BMJ 2004; 328: 888–90. Mock C, Kobusingye O, Anh LV, Afukaar F, Arreola-Risa C. Human resources for the control of road traffic injury. Bull World Health Organ 2005; 83: 294–300. TEACH_VIP. Users Manuel. Geneva: World Health Organization, 2005. http://whqlibdoc.who.int/publications/2005/9241593547.pdf (accessed Oct 25, 2005). Choi BCK, Pang T, Lin V, et al. Can scientists and policy makers work together? J Epidemiol Community Health 2005; 59: 632–37. Ad hoc committee on health research relating to future intervention options. Investing in health research and development. Geneva: World Health Organization, 1996.

www.thelancet.com Published online June 26, 2006 DOI:10.1016/S0140-6736(06)68895-8