Europe’s Injured Children
Jasmine Marshall discusses the important but neglected problem of child injury. This article comes from from a winning project report she wrote for an intercalated BSc in International Health at University College London
Injuries are the leading cause of death for European children under 14 years of age, killing an estimated 28,000 every year (1) and disabling many more. There are striking differences within the European Region. The death rate from injuries, poisoning, and violence in Central and Eastern Europe and the Central Asian Republics is nearly 5 times higher than in Western Europe. (2) A 1998 report by the European Centre on Health in Transition Countries (ECOHOST) showed that injuries accounted for much of the difference in child mortality between east and west. It concluded that this problem had been overlooked by national and international policy makers, and required urgent attention. (3)
Unfortunately, a decade later, “injuries and violence in children [still] present a major, tangible and preventable burden to these societies” (3) and the east-west gap remains. To understand why this is the case we need to consider the eastern European region’s history, its long term health system development and the current economic and political context.
Historical Legacy
Recent Communist rule is a common feature of the countries in Central and Eastern Europe and the Central Asian Republics. The egalitarian-authoritarian political system stifled the mechanisms through which people instigate change, for example campaign groups pressing for higher safety standards. Weak public participation in the policy process, together with a centrally-controlled media (4) probably contributed to a lack of ownership of childhood injuries as a policy issue.
The Soviet Union “Semashko model”, of state-owned centrally-controlled health services was well staffed, but poorly funded and under-resourced. It focused heavily on treating communicable disease but public health organizations were weak (5) and health professionals had little knowledge of preventative medicine and health promotion. This was exacerbated by their isolation from the global epistemic community during the Cold War. The state guarded what statistical and epidemiological data there was available, leaving health professionals unclear about the magnitude of many threats to health. This legacy of inadequate data means that even now, health professionals and academics struggle to define the nature and scale of childhood injuries, making it difficult to draw attention to the issue.
Following the collapse of the former Soviet Union, countries entered a period of economic and political transition. Unemployment, poverty, social stress and increased substance abuse (6) led to higher rates of injuries and violence, particularly amongst low socioeconomic groups. Children living in poverty are at greater risk of sustaining injury, (7) yet they are largely unable to advocate for themselves, especially at the population level. To design effective policy, it is important to facilitate collaboration between families, (particularly socially-excluded parents) health professionals, and public bodies.
Today’s Challenges
Injury prevention is cost-effective; however a lack of awareness of the scale and impact of childhood injuries stifles financial investment in policy. The health sector has multiple responsibilities and is subject to numerous demands. To convince the policymakers who allocate resources that injury prevention is an important priority, the economic burden of childhood injuries must be carefully assessed.
Although the overall burden of childhood injuries within Central and Eastern Europe and the Central Asian Republics is high, there are some notable sub regional variations in 0-14 mortality rates which appear to reflect broader differences in social and political stability following transition. Child mortality is highest in countries such as Kazakhstan, the Russian Federation and Belarus, with a recent history of conflict or restrictive social and political environments and a rising level of alcohol consumption and violent crime.
A survey of the WHO European region (8) concluded that few low- and middle-income countries (predominately those in Central and Eastern Europe and the Central Asian Republics) had “developed an adequate structural response” to reduce the burden of injuries. The most promising commitment comes from the European Union (EU) member states, where the political and financial environment appears to have facilitated a policy response. Poland, Estonia, Hungary, Latvia, Slovakia, Romania and Bulgaria, receive financial and technical support from the European Community which helps to plan, research and implement national child safety interventions. Interestingly, prior to EU accession Poland, Hungary and Bulgaria, were already bridging the east-west mortality gap, and it is possible that countries aspiring to EU accession may have reduced child mortality from injuries by aligning themselves with EU safety standards.
Elsewhere in the region, the environment has not favoured a strong, co-ordinated policy response, and childhood deaths from injuries have had low visibility. Although childhood injury policy should be considered in a wider context of political, economic and social reform, a number of measures that might improve visibility and ownership of the issue and capacity within the health sector could also help to reduce the burden.
Firstly, to increase the visibility of childhood injuries, the WHO and other organisations could help to develop detailed data collection systems. National and international media could use the data to frame the issue to a variety of stakeholders, raising awareness and stimulating public debate.
Secondly, the health sector should take ownership of the problem whilst collaborating with ministries of Education, Transport and Social Policy to integrate injury prevention into existing schemes such as WHO safe communities’, healthy schools programs, and environmental health initiatives. Civil Society Organisations (CSOs) can act as a bridge between the state and communities. The numbers of CSOs in Central and Eastern Europe have risen dramatically during transition. Many receive foreign funding, with the Open Society Institute and its national Soros Foundations playing key roles. However donor priorities strongly influence the type of activities they engage in. Regional and national public health conferences under the aegis of a global health authority such as UNICEF could be used to engage local CSOs.
Thirdly, building public health capacity and encouraging training for health professionals should improve data interpretation and its presentation to stakeholders, policy makers and the media. Hungary has recently developed a new postgraduate training program in public health medicine which may serve as a model for other countries.
The countries in Central and Eastern Europe and the Central Asian Republics have undergone a tumultuous period of political and economic transition. This has, in part, contributed to the high burden of childhood mortality from injuries, particularly when compared with Western European counterparts. Continuing development may lead to a gradual reduction in the number of injury related child deaths. This is not sufficient. With cost effective interventions, already successfully pioneered elsewhere in the world, this crucial and neglected aspect of child health could be actively addressed today. The pivotal first step in these countries is to raise childhood injuries onto the health policy agenda.
Jasmine Armour-Marshall BSc
International Health. Centre for International Health and Development,
Institute of Child Health, University College London
30 Guilford Street, London, WC1N 1EH, UK.
jasmine.marshall@ucl.ac.uk
I would like to thank Ingrid Wolfe, Martin Mckee, Bhanu Williams and the tutors at CIHD, in particular Mike Rowson, for their expertise and support. I would also like to acknowledge the Goldberg Schachmann & Freda Becker Memorial Fund for financially supporting me through this BSc
(1) World Health Organisation (2006) A handbook: planning to protect children from hazards, The Children’s Environment and Health Action Plan for Europe, Geneva
(2) World Health Organisation European Health For All mortality database (WHO-HFA), version 2006
(3) European Centre on Health of Societies in Transition (ECOHOST) (1998). Childhood injuries: A priority area for the transition countries of Central and Eastern Europe and the Newly Independent States, London School of Hygiene and Tropical Medicine, London
(4) Van Hoven B. (2004) Europe Lives in Transition, Pearson Prentice Hall, Essex, England.
(5) McKee M. Bojan F. Normand C. (1993). A new public health training in Hungary. European Journal of Public Health: 3: 58-63
(6) Carlson P. Vagero D. (1998). The social pattern of heavy drinking in Russia during transition. European Journal of Public Health: 8(4): 280-85
(7) Kendrick D. Marsh P. (2001). How useful are sociodemographic characteristics in identifying children at risk of unintentional injury? Public Health: 115 (2): 103-107
(8) Sheilds N. Sethi D. Racciopi F. Aguirre I. Y. Baumgarten I. (2006). National Responses to Preventing Violence and Unintentional Injuries: WHO European Survey, The World Health Organisation, Geneva
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