**2.3. Armed conflicts and wars**

**2.2. Falls**

70 Current Issues in Global Health

to fall down.

outcome of such fall incidents.

fall as compared to those in townships and cities [28].

Although road traffic accidents and falls are known as the leading cause for trauma in many parts of the world, there is still no single cause that dominates every region. Generally, falls are the second leading cause of trauma globally, but in some regions fall incidents surpass RTAs due to the predominating socioeconomic and cultural activities. For example, in a countrywide population-based study in Nepal, it was shown that falls were the leading cause of trauma followed by RTAs [22]. In most cases, falls from height in the rural and semiurban regions of LMICs are a result of socioeconomic and cultural activities that involve climbing trees. Socioeconomically there are several reasons why people in the rural and semi-urban regions of LMICs climb trees. First, climbing trees is necessary when one want to obtain fruits, which are either consumed by the family or sold to generate income. For example, falls from coconut trees and other types of fruit bearing trees have been reported in various rural regions of the LMICs [23, 24]. Falling from palm trees is a common occurrence in the West African countries as they harvest palm heads and fruits for wine making [25]. In other incidents, people climb on prune trees to obtain dry branches or green leaves for firewood and animal feed, respectively [24]. Unlike the adults, children may climb trees in search of edible seeds and fruits or just for fun (e.g., pursuing small animals such as squirrels and demonstrating "climbing skills"). While up in the trees, one might lose a grip, an old branch may be broken, or attack by stinging insects or a snake may occur causing one

Trees are not the only height from which trauma occurs in rural and semi-urban regions of LMICs. Other common heights from which people commonly fall are roof tops during construction or balconies, which are unsafe [26, 27]. These incidents are as a result of violation of occupational and residential safety guidelines either by ignorance or inability to afford safe construction materials. Depending on the height, injuries and fatalities are a common

In these regions, there are significant number of events whereby falls happens as a result of slipping due to uneven road surface and wet or graveled rough road or pathways. These risky road surfaces coupled with absence of road lights and hardly any warning signs add to the risk of falls particularly during the night. For these reasons, falling while walking is a common occurrence especially among the elderly whose sight and protective balance are daunted. Although falls among elderly is globally common, those who live in the rural and semi-urban areas of LMICs have added risk of unfriendly road and pathways. The World Health Organization study on global aging and adult health involving LMICs reported more incidents of falls among elderly women than men and that rural dwellers had higher odds of

The worst case scenario is when individual falls with a heavy load on either the head or back. This may cause head, spine, and/or spinal cord injury especially on the cervical or lumbar region [24]. Various other consequences related to head loading including musculoskeletal pain disorders and minor injuries occurring in the spinal column, which may cause pain in the long run [29, 30]. In these regions, head loading normally happens in the market places by persons Violence of any scale in which force and weapons are involved leads to enormous physical injuries and death. LMICs are disproportionally affected by armed conflicts due to rivalry between particular ethnic groups within or between countries. Although armed conflicts and wars are global, such incidents are predominantly more pronounced in the LMICs. Of recent years, armed conflicts are reported in various LMICs such as; Ethiopia, Libya, Nigeria, the Central African Republic, the Democratic Republic of Congo, Nigeria, Sudan, and South Sudan just to mention some. It is estimated that of all traumatic incidents resulting from armed conflicts, more than 50% are in Africa involving both the armed forces and civilians [32]. Following the Libya unrest of 2011 only, 1761 gunshot injuries were treated in one of the hospitals of whom more than 72% were directly associated with war and more than 27% involving stray bullets and civilian fighting [33]. In one of the military hospitals in Pakistan, 170 combats were identified in the period of 2 years in whom injury to blood vessels due to gunshot were reported. These combats required emergence repair of the injured blood vessels to serve their lives [34].

Although the most frequently reported war injuries are in the extremities, other body regions such as the head and spinal cord, thoracic, peritoneum, and pelvis sustain trauma are life threatening [35]. In order to save life and prevent disabilities, war injuries require timely medical and surgical response. However, in LMICs it is fewer victims of armed conflicts who get such a timely medical and surgical management, hence poorer outcome such as limb amputation and high mortality rate which could otherwise be reduced.

Consequences of war-related trauma are very extensive running from affecting the victims physically and mentally to stunting country's economy. In LMICs, trauma is an added burden to the already constrained economy. An injured victim of war who lives within environment of unrest and poverty faces a broader impact. First such person's ability to attain food, shelter, and clothing like everyone else has been shuttered. Second s/he needs medical, rehabilitative, and psychological services which are scarcely attainable. In most circumstances, the country's response to emergency situation is overwhelmed. In this situation, the injured victims may have to seek medical and surgical care from the nearby countries as refugees. In doing so, the consequences of war and unrest are spread to a wider geographical area. For example, between 2005 and 2007 only Iran received 130 injured victims of war from neighboring countries seeking medical and surgical services [36]. This means that the cost of managing war-related injuries in LMICs is incurred by a wider geographical region, draining even the economy of neighboring countries.

Armed conflicts not only cause physical trauma, but also increases mortality rate. For example, while it is estimated that the crude mortality rate globally and in sub-Sahara region are 1.2 and 1.4, respectively, that of DR Congo during the unrest of 2006/2007 was 2.2 deaths in every thousand people. The mortality increase is not only on adult population for there are reports showing indicating an increase in death rate to post-neonatal in war born regions [37]. Furthermore, armed conflicts create poor living conditions and economic insufficiency. Although many people die as a result of direct trauma during the conflicts, many more are likely to die due to the resulting socioeconomic and environmental constraints such as disease outbreaks and hunger. Armed conflicts are so traumatic that they cannot be forgotten easily. For this reason, even those who survive the war, whether injured or not, still suffer depression.

**3. Common causes of trauma to children in the LMICs**

prepared for such incidents.

Children in rural LMICs incurs trauma frequently from various causes. Although children are also affected by RTAs and falls common causes of trauma in this group for rural and semi-urban regions is burns. Most of the burn injuries to children in these regions happens in the kitchen during cooking but may occur in other activities [45–47]. The use of open fires for cooking in areas is unsafe to children and elderly and ignorance on fire dangers are some of the contributing factors to burn accidents. In Uganda, it was found that burn is the leading cause of injury to children and in one hospital in Iran up to 47% of the burn cases were children less than 16 years of age [48]. Elsewhere in Bangladesh, a population-based study indicated that to every 100,000 children, 528 sustain burn injury of whom two may die while others recover with substantial impairments [45]. However, some studies reported that youth sustain burn injuries even more than children do. For example, in Nepal, it was found that young persons at the age between 24 and 25 had higher incidents of burn injuries than children [46]. A situational analysis of acute burn management in 32 low- and middle income countries indicated that most of the health facilities particularly in the rural and semi-urban regions were not equipped for burn management [49]. This being the case, it is reasonable to expect children who sustain burn injuries in these regions to have higher risk of disability and mortality as compared to those in higher income countries, where healthcare is more

Physical Trauma and Its Consequences in Rural and Semi-Urban Regions of Low and Middle…

http://dx.doi.org/10.5772/intechopen.79545

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Apart from burn injuries, children in the rural and semi-urban regions of LMICs are faced by risks of other forms of physical trauma just like adults. As most of the rural areas of LMICs are characterized by trees and scarce play grounds, children not only tend to climb trees as part of their plays but also in search of edible seeds and fruits. In Bangladesh and India falling from height is one of the leading causes of trauma to children predominantly males dwelling in the rural and semi-urban regions [50, 51]. There are also accounts of children falling from poorly constructed balconies and windows of which the majority dies and the remaining suffering serious injuries with potential for a long-term disability [27]. In India it was reported that fall from height is the second cause of pediatric head injury next to RTAs [51–53]. Incidents of RTAs involving children and teenagers in LMICs are markedly high as compared to the high income countries [54]. This increased risk of being involved in RTAs can be explained by the fact that a majority of children and teenagers walks to school (pedestrians) or plays near roads where they are exposed to accident and other forms of road-related trauma. Crosswalks are few and where available, they are either not used by children due to ignorance or abused by the drivers or motorized vehicle. This problem could be reduced significantly if community members could volunteer in one accord to guide children in safely using the roads especially when going or coming from school. There is a saying in Kiswaili that "Mtoto wa mwenzio ni mtoto wako" meaning that your fellow's child is yours. If such a saying is used in this setting, it means every person will view the child on the road as his or hers, hence ensuring safety to every child.

It is common in these regions for children to join their parents in different socioeconomic and cultural activities such as feeding cattle and farm works in what can be regarded as "learning by doing." While assisting or performing these tasks by themselves, children frequently sustains physical trauma due to mismatch between the forces demanded by the task against

#### **2.4. Other causes of trauma**

Other causes of trauma are less common when compared to road traffic accidents and falls but are of a relatively high incidence in the low and middle than in the high income countries. These other causes include; burns, assaults (either by human or animals), being fallen over by heavy load such as injuries due to a collapse of a wall, tree, or landslide. These causes make a big distinct epidemiological difference between LMICs and high income countries. Burns are among the most common cause of severe injuries, mortality, and disability which affects children than adults.

Assault incidents are frequently reported in these regions and in some studies in South Africa, Uganda, and Latin America are rated as the leading cause of trauma ahead of RTA and falls [4, 38, 39]. Assault incidents in these regions are associated with alcohol consumption, interpersonal, and ethnic conflicts [40, 41]. Poverty as a result of high levels of unemployment among youths in these regions is also associated with violent crimes and attempt to earn a living by illegal means which includes forceful robbery. Incidents of alcohol consumption and violent behavior within lower and middle income countries can further be described. First, availability of local brews in so many alcohol outlets (bars) within the communities offers an opportunity people to access it easily. Local brews are cheap and are socially shared so that even those who cannot afford can still get a drink from a friend. Second, there are social events such as weddings, after burial and thanksgiving in the rural and semi-urban communities in which people can get local brews for free during such occasions. All these features increase accessibility to alcohol for the rural and semi-urban regions of LMICs. As a result, incidences of violence and assaults related to alcohol use increases simultaneously with the increase in traumatic incidents.

Venomous snakes, insects, and other animals that can bite and cause serious injuries are also common especially to rural areas of the LMICs. For example, in Bangladesh, rural areas snake bite had incidence of about 624/100,000 person years, the majority of who works in the farms [42]. In one study from India, most deaths from envenomation were due to scorpion stings and affected mostly the children in rural regions [43]. The incidents of snake bites are so common, and the World Health Organization has issued a guideline for management of such injuries [44]. Despite the issuing of the guideline by the WHO, the challenge that remains is making it accessible to the rural dwellers of the LMICs. Even when the guideline is accessed, read, and understood by the people, they may need to be enabled to attain the tools and equipment to respond to such incidents accordingly.
