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EPIDEMIOLOGY AND PREVENTION OF
INTENTIONAL INJURIES

by Dr PHUA Kai Lit
School of Medicine and Health Sciences
Monash University Sunway Campus
Bandar Sunway, Malaysia


INJURIES

Injuries are a MAJOR cause of disability, morbidity (sickness) and mortality (death) in middle income developing countries and in rich countries. People aged between 15-35 are more likely to die of injuries than of disease!

Information on injuries

Non-intentional injuries

Intentional injuries: caused on purpose e.g. physical assaults, sexual assaults, self-inflicted injuries, mass & organised violence, legal interventions e.g. executions of convicted murderers

Epidemiology and Prevention of Intentional Injuries

(1) Identify risk factors (ethnicity, class, gender, age, region, education, occupation, marital status)
(2) Identify time and place of occurrence i.e. any "clustering" in time or place?
(3) Design a prevention programme & Emergency Medical Services programme

Interesting article on a "forensic entomologist"

Physical Assault

Actions directly inflicted by one person on another with the intention to cause physical pain, injury or death

Domestic violence i.e. violence that occurs within the home (usually refers to spouse abuse - the victim is usually the wife). Victims may need a safe refuge to avoid further harm.
Child abuse e.g. severe physical punishment of children by parents, relatives or non-relatives. Child abuse can also occur in day care centres, kindergartens or schools. One result may be runaway kids.
Elder abuse (abuse of elderly by family members or unrelated care-takers)
Maid abuse - this is a major problem in countries like Malaysia and Singapore

Other violence
Assault (can be inflicted with or without the use of weapons/physical objects

Alcohol is strongly associated with assault.
Certain physical locations are more dangerous than others in that physical assaults (and other kinds of assaults) occur more frequently e.g. slum areas or high crime areas

Sexual Assault and Sexual Harassment

Molest i.e. inappropriate and unwanted touching of a sexual nature
Rape i.e. forced sex or non-consensual sex. The legal definition may differ in different countries e.g. penetration of a woman's vagina with objects such as bottles or sticks may not be legally defined as rape. Also, forced oral sex may not be defined legally as rape. "Statutory rape" refers to sex (even if consensual) between an adult and a minor. Homosexual rape can also occur e.g. in prisons. Rape victims are likely to suffer from long-lasting Post Traumatic Stress Disorder
Child sexual abuse --> can lead to adult dysfunction i.e. violent adult, adult who abuses children etc
Date rape i.e. non-consensual sex that occurs between two people on a date
Marital rape (not recognised as a problem in many countries). This refers to forced, non-consensual sex between a husband and a wife
"Sexual harassment" refers to unwelcome attention of a sexual nature. Examples include persistent requests for a date, pressure for sexual relations (with direct or implied threats of negative consequences if the victim refuses), verbal harassment of a sexual nature. At the workplace, this can be commited by co-workers or by supervisors. This can result in mental distress for the victim.

Again, alcohol is strongly associated with sexual assault

Cultural attitudes toward women may affect rates of sexual harassment, molest, rape etc.

Johns Hopkins forensic psychiatrist Dr Park Dietz

Suicide and Deliberate Self-Harm (DSH)

Parasuicide: attempted suicide
Suicide: successful suicide (this is related to the
used e.g. the most lethal methods include hanging, firearms and jumping

Risk Factors

Young i.e. teens and young adults
Elderly i.e. especially those living alone
Mental illness i.e. those with serious mental illness
Chronic illness with severe pain
Those who have previously attempted suicide (major risk factor)
Alcoholism
Social isolation
Heavy stress e.g. business failure, loss of job, death of spouse, family problems, relationship problems, examination failure, migration

Effect on the family of the dead person --> feelings of shame, guilt, even resentment and anger

Prevention: identify those at high risk and help them e.g. through mental health counseling
Set up crisis centres where potential suicides can self-refer e.g. phone in or walk in

Other kinds of deliberate self-harm include:
1. Self-mutilation e.g. mentally ill people who mutilate themselves
2. Self-inflicted injuries e.g. to escape military service, to claim compensation,
to simulate assault (to divert attention from one's participation in criminal activity/to arouse sympathy/to falsely implicate another person)
3. Scarification
4. Munchausen syndrome i.e. factitious disorders where symptoms are deliberately
produced to deceive hospital personnel

There may also be copy cat cases of suicide (the so-called "contagion effect")
after mass media reporting of suicides of famous people.

Mass and Organised Violence

Conventional war --> weapons get more and more destructive, more civilians get killed e.g. machine gun, poison gas, aerial bombing, nuclear weapons

Guerrilla war and other "low intensity conflict" --> responsible for many, many deaths in developing countries since World War Two

Terrorism (violence carried out to terrorise the general population and to disrupt the economy) e.g. placing bombs in public places, cars, civilian airliners, sarin gas released in Tokyo subway, attacks on World Trade Center in New York City

Landmines --> serious problem in places like Angola,Cambodia, Afghanistan. Results in many people losing their legs even though fighting may have ended many years ago.

CBW (Chemical and Biological Warfare)--> using poisonous chemicals or using disease-causing biological organisms to attack troops or civilian populations e.g. use of chlorine gas in World War One, the posting of anthrax spores to political leaders (occurred in the USA)

CBW and research carried out on human victims by the Imperial Japanese Army during World War Two

University of Pittsburgh's Center for Biosecurity

Series on Biological Warfare and Bioterrorism

Nuclear Terrorism?

Identifying the victims of massacres

Respiratory problems related to dust from the terrorist attacks on the World Trade Center in USA

"Legal" Interventions

These refer to interventions carried out by the state (government) that cause intentional injuries

Capital punishment (legal intervention that results in death)e.g. hanging, shooting, electric chair, guillotine, lethal injection

Some countries have banned capital punishment while other countries execute a lot of people every year.

Corporal punishment (legal intervention that is intended to cause injury but NOT death)e.g. caning (whipping).

Mentally ill man is executed

Capital punishment in Singapore

Other state-sponsored violence:
Torture and beatings of political prisoners by secret police and military. These are usually not random but organised by the state.
"Disappearances" of political prisoners
Mass rape of women e.g. rape of Muslim women in Bosnian civil war
Mental torture e.g. solitary confinement (sometimes in total darkness in cramped rooms)
Psychotherapy is needed by rape and torture victims as the psychological effects are long-lasting.

Helping torture victims

Health effects of torture

Human Rights Violations in China?

Mass rape as a form of state-sponsored terror

Article on Nazi doctors and their experiments on concentration camp prisoners

Dr Robert Jay Lifton discusses his book "The Nazi Doctors"

Physicians for Human Rights

Amnesty International

Amnesty International Malaysia

Health and Human Rights Violations

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PREVENTION OF INJURIES (SUMMARY)

1. Active versus passive prevention strategies.
An "active prevention strategy" is one where a person needs to actively DO something in order to protect himself or herself e.g. using a motorcycle helmet that needs to be fastened. A "passive prevention strategy" is one which is automatic e.g. an airbag that inflates automatically in a car crash. Passive prevention strategies are preferred to active prevention strategies since changing the behaviour of people is often difficult.
2. Four Es approach i.e. Engineering/Environmental Modification, Economic, Enforcement and Education
3. Haddon Models e.g. Haddon Matrix

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