**2.2. Falls**

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 to fall down.

who routinely carry heavy loads from the car to the market and vice versa. Also, common are women and children getting farm produce to the house or market, carrying water using containers of different shapes and sizes as well as getting animal feed or firewood to the home among other necessities [29, 31]. The load carried on the head could be firewood for cooking, grasses, and leaves for animal feed or farm produce (cereals, banana, bags of fruit and vegetables) from farm to home or to the market [29, 30]. Of recently, head loading has been referred

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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

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

amputation and high mortality rate which could otherwise be reduced.

to as a significant cause of disability in LMICs [30].

**2.3. Armed conflicts and wars**

economy of neighboring countries.

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 outcome of such fall incidents.

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

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 who routinely carry heavy loads from the car to the market and vice versa. Also, common are women and children getting farm produce to the house or market, carrying water using containers of different shapes and sizes as well as getting animal feed or firewood to the home among other necessities [29, 31]. The load carried on the head could be firewood for cooking, grasses, and leaves for animal feed or farm produce (cereals, banana, bags of fruit and vegetables) from farm to home or to the market [29, 30]. Of recently, head loading has been referred to as a significant cause of disability in LMICs [30].
