Risk and burden of injury in Bangladesh

According to Health Bulletins published annually by the Government of Bangladesh's Directorate General of Health Services (DGHS), injury was reported to be the fifth leading cause of death among above five years old Bangladeshi population in 2017 after cardiovascular disease, respiratory disease, cerebrovascular disease, and shock. In the same year, poisoning was ranked as the 6th leading cause of death. In its Annual Health Bulletin, 2018, assault "by unspecified means" was reported as the third top cause of hospital admissions only after diarrhea and gastroenteritis and acute abdomen issues.

This very large number of hospital admissions and fatality cases arising from injuries (including assaults and poisoning) have not yet been taken seriously as a major and growing population health threat in Bangladesh. Little discussion and research occur here on identifying the causes, nature, and severity of injuries, or finding and implementing interventions to reduce the numbers, burden, or affliction of these. Consequently little is done on developing a better clinical management system for these cases or on reducing the socio-economic burden injuries create on the victims and their family members. Similarly, almost no evidence exists on how to deal with the sufferers' rehabilitation issues after sustaining these injuries including community reintegration or reentry to schools or the labor force.

Injuries -- quite strangely -- never get the attention or focus of health professionals, government policymakers, and the national and international NGOs in Bangladesh. Only a very local organisation like the Centre for Injury Prevention and Research, Bangladesh (CIPRB) and Centre for the Rehabilitation of the Paralysed (CRP) where the first tries intervention development and implementation, conducts education and training activities, leads advocacy campaigns on injuries with a particular focus on drowning and burns as well as it has produced good epidemiological research evidence, whereas the latter focuses on clinical management of post-injury complications and rehabilitation of the victims. There are also a few traffic accident-focused organisations like Nirapad Sarak Chai, Road Safety Foundation and  BUET's Accident Research Institute. The first two are more advocacy organisations but the latter despite its huge prospect and availability of resources and professional expertise has not been able to create a large impact. Also, there are occupational injury-focused advocacy organisations like Bangladesh Institute of Labour Studies (BILS), Bangladesh Occupational Safety, Health and Environment (OSHE), and Bangladesh Labour Foundation (BLF) but rarely do they conduct primary research.

In addition to mortality cases, millions of non-fatal injury cases often leave people with lifelong disabilities, functional limitations, and disfigurements. The inability to integrate the victims back into the community and workforce creates an enormous social and economic burden for these victims and their family members. Improvements have been made in high-income countries to reduce morbidity and mortality following major injuries, however, many of these advances in acute care and rehabilitation have not been translated to low- and middle-income countries (LMICs) such as Bangladesh. The emerging evidence of better medical care management in high-income countries is yet to be adopted by many LMICs.  Limited studies in LMICs have been conducted thus far to characterise the epidemiology of injuries with respect to their causes, types, and severity as well as provisions of hospital care or assessment of outcomes. As injuries are still considered mostly an "act of nature" in many LMICs, social awareness on injury prevention, in general, is low, and cost-effective and practical measures available to reduce the risk in the developed countries have not been disseminated to policymakers, practitioners, and health advocates in LMICs.

For a country like Bangladesh with its very large population size, prevention attempts have been meagre on injury-- a major menace to its population's health. One reason mentioned before may be that injuries are still considered by many in this society as "accidental" in nature and the victims are often blamed or held responsible for being careless, irresponsible, and weak.

Bangladesh needs to advance the current understanding level of how certain demographic and socioeconomic population groups fall victim to injuries. Age and gender were both found to be related to the types of injuries sustained in the very few previous studies published. Those studies also suggested that the majority of injury victims were of low education and of low income. Evidence is also needed on how short-term and long-term consequences or outcomes are related to the type and severity of the injury.

 In Bangladesh, one of the most densely populated countries in the world-a substantial proportion of its population, both adult and pediatric, suffer from preventable injuries with a high degree of morbidity and mortality consequences. Although there has been a modest amount of research literature published on injuries in some other LMICs, there is comparably little data published on this in Bangladesh. With improved injury monitoring and surveillance, cost-effective prevention strategies can better target specific risk factors unique to the type of injury sustained. Having ongoing, comprehensive injury surveillance programmes at the national level will help better understand the morbidity and mortality patterns and trends of preventable injuries in Bangladesh.

Dr. Hasnat M Alamgir is a Professor and Chair of Public Health at IUBAT (International University of Business Agriculture and Technology), Dhaka.

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