Pulling on the same oars together - we can make a difference


Published on

Plenary - Pulling on the same oars together—we can make a difference

Author: Michael Linnan

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Pulling on the same oars together - we can make a difference

  1. 1. Dr Michael Linnan Technical Director, The Alliance for Safe Children [email_address] www.tasc-gcipf.org
  2. 2. The Hidden Epidemic <ul><li>The newly visible epidemic of drownings in low and middle income countries in Asia needs your assistance </li></ul><ul><li>It is not just Asia, although that is where it is now visible because we have started looking with tools that can reveal it </li></ul><ul><li>It is likely to be ongoing in other regions predominated by LMICs </li></ul><ul><li>As a global epidemic, it requires a global response </li></ul><ul><li>The vision statement of ILS is “The ILS leads the world-wide effort to reduce injury and death in, on and around the water” </li></ul><ul><li>That’s why TASC is here talking to you about this today </li></ul>
  3. 3. It is different from drownings in wealthy countries <ul><li>Rich countries got rich before they got safe </li></ul><ul><ul><li>They had educated populations </li></ul></ul><ul><ul><li>And well-developed civil governance structures </li></ul></ul><ul><ul><li>With enforced building codes and zoning ordinances </li></ul></ul><ul><ul><li>And large civil services that staffed public safety institutions </li></ul></ul><ul><ul><li>And were already predominantly urban </li></ul></ul><ul><ul><li>And had already limited water exposure mainly to recreational settings </li></ul></ul><ul><ul><li>And then built a culture of water safety on those foundations </li></ul></ul>
  4. 4. Low and middle income countries have none of that <ul><ul><li>Predominantly rural </li></ul></ul><ul><ul><li>Water hazards are ubiquitous in and around the home and throughout the community </li></ul></ul><ul><ul><li>Universal primary education is a goal, not a reality </li></ul></ul><ul><ul><li>Parents, who often have 4 or 5 children must rely on the older children to supervise the younger ones </li></ul></ul><ul><ul><li>There are few, if any, social services </li></ul></ul><ul><ul><li>Including water safety and life saving infrastructure </li></ul></ul><ul><ul><li>That’s why they are called developing countries </li></ul></ul>
  5. 5. It’s not pools, it’s not beaches, and there is no association with alcohol use – it’s just daily life
  6. 6. As an epidemic it will require a public health approach <ul><li>Define the problem: </li></ul><ul><ul><li>Drowning = death from submersion in water irrespective of activity at the time </li></ul></ul><ul><li>Measure the magnitude of the problem </li></ul><ul><ul><li>Community-based surveys with very large sample sizes in order to show drowning rates, risk factors and environmental exposures within each childhood age group </li></ul></ul><ul><li>Develop interventions with partners </li></ul><ul><ul><li>Effective in low resource situations, appropriate for the culture, scalable to national scope and sustainable </li></ul></ul><ul><li>Measure the impact and cost-effectiveness of the interventions </li></ul><ul><ul><li>Improve the intervention effectiveness and increase it in scale </li></ul></ul>
  7. 7. Why cant we use the available data? <ul><li>It works for rich countries, but not poor ones </li></ul><ul><ul><li>Less developed countries don’t register all deaths- for the most part, only the ones that occur in clinics and hospitals </li></ul></ul><ul><ul><li>Most injury deaths (and especially drowning deaths) happen so rapidly that the child is dead, and there is no reason to seek care at a hospital </li></ul></ul><ul><ul><li>The child is simply buried, and the death remains uncounted by the health system </li></ul></ul><ul><ul><li>It never shows up in reports at national level, or at regional or global level data bases </li></ul></ul>
  8. 8. <ul><li>Five regions, 20 provinces </li></ul><ul><li>100,179 households, </li></ul><ul><li>61,464 rural, </li></ul><ul><li>35,706 municipal areas </li></ul><ul><li>3,009 slum areas in Bangkok. </li></ul><ul><li>389,531 population </li></ul><ul><li>98,904 children (0 -17) </li></ul><ul><li>all deaths in the last 3 years and nonfatal injuries in the last year </li></ul><ul><li>Each injury event was classified according to where it happened and whether it was seen or reported to a hospital </li></ul>The Thai National Injury Survey
  9. 9. But drowning is not usually seen in the hospitals or reported there <ul><li>65 fatal child drownings – only 18.5% reported to hospital </li></ul><ul><li>0/51 immediately fatal were reported to a hospital </li></ul><ul><li>15% subsequently fatal were not reported to hospital </li></ul><ul><li>Only 56% of non-fatal were reported to a hospital </li></ul>
  10. 10. The surveys to date 95,000 / 450,000 National, Manila separate Philippines 2004 100,010 / 319,500 Provincial, all counties Jiangxi 2005 29,400 / /104,000 National, 8 provinces Indonesia 2003 72,500 / 348,000 National, all provinces Cambodia 2007 100,100 / 370,000 National, Bangkok separate Thailand 2004 28,000 / 87,000 Beijing capital, all counties Beijing 2003 175,000 / 698,000 National, Dhaka separate Bangladesh 2003 27,000 / 128,000 National with 8 regions Vietnam 2001 (HH/residents) Scope of sample Country and date
  11. 11. What the surveys show
  12. 12. Drowning causes over half of all child deaths after infancy
  13. 13. Drowning kills more children than tuberculosis
  14. 14. more than HIV
  15. 15. more than dengue
  16. 16. more than malaria
  17. 17. more than SARS or Avian Flu combined
  18. 18. more than tetanus, whooping cough and polio put together
  19. 19. Child drowning by season Matlab 1983 - 1995
  20. 20. The current toll of drowning in the region <ul><li>#1 cause of death from age 1 through 17 years </li></ul><ul><li>250,000+/year ─ 670+ per day </li></ul><ul><li>Almost 1 each daylight minute </li></ul><ul><li>Young children not being supervised properly </li></ul><ul><li>Older children not being able to swim </li></ul>
  21. 21. Keys to prevention <ul><li>Over two thirds of drownings in Asia occur in childhood </li></ul><ul><li>Over two thirds of childhood drownings occur before the age of five </li></ul><ul><li>The real impact in reducing the epidemic is in child drownings before the age of five </li></ul><ul><ul><li>but for those, the live-saver will be the mother, father or elder sibling that is supervising the child </li></ul></ul><ul><ul><li>the life-saving act will be keeping the child from being exposed to a water hazard </li></ul></ul>
  22. 22. Only about 2% of drownings result from a stated recreational intent <ul><li>For the one third of child drownings after five, only 5 percent occurred in activities where a child left home with the intention to engage in recreation involving water </li></ul><ul><li>For the other 95% of drownings, (the non-recreational) 90% were alone or with another peer of the same age </li></ul><ul><ul><li>The life-saver will need to be the child or the peer – but that requires knowing how to swim and safely performing a rescue </li></ul></ul><ul><li>For the adults who drowned, less than five percent involved exposure to water in a recreational setting </li></ul><ul><ul><li>The life-saver will need to be the adult or a peer – but only if they know how to swim and to safely perform a rescue </li></ul></ul>
  23. 23. What strategies will be the most effective given this picture? <ul><li>Primary prevention – preventing the exposure itself </li></ul><ul><ul><li>This will work for children under five, since parents and caregivers control the exposure to water hazards </li></ul></ul><ul><ul><li>The life guard here is the parent of the child, because the exposures will be inside, around or near the home </li></ul></ul><ul><ul><li>It wont work for the children over five since they are out and about by themselves and with their peers </li></ul></ul>
  24. 24. What strategies will be the most effective? (cont’d) <ul><li>Secondary prevention – preventing harm from resulting in the exposure after it occurs </li></ul><ul><ul><li>How to prevent the older children from being harmed if they fall or come into contact with water? </li></ul></ul><ul><ul><li>Teach them to swim </li></ul></ul><ul><ul><li>The life guard is the child his/herself– it isn’t possible to have life guards at all the ponds, lakes and rivers </li></ul></ul>
  25. 25. What strategies will be the most effective? (cont’d) <ul><li>Tertiary prevention – preventing death or disability resulting from the failure of secondary prevention </li></ul><ul><ul><li>How to prevent the child drowning if they exceed their swimming abilities and get into trouble? </li></ul></ul><ul><ul><li>Teach the peer that is with them to do a safe rescue </li></ul></ul><ul><ul><li>The life-saver is the peer- and not an adult because no one else is around when the drowning occurs </li></ul></ul>
  26. 26. What about providing life guards in recreational settings? <ul><li>That will work in those settings and will work well if the training, staffing and operational activities are as professional as those provided by ILS members </li></ul><ul><li>But with only 2% of the possible drownings prevented by that strategy, it wont have a measurable impact on the epidemic of drownings in the low and middle income countries of Asia </li></ul>
  27. 27. Does swimming ability prevent drowning? <ul><li>You, as the experts, have debated that </li></ul><ul><ul><li>What is swimming ability? </li></ul></ul><ul><ul><li>What about alcohol in recreational settings? </li></ul></ul><ul><ul><li>Is there a moral hazard factor in swimming? </li></ul></ul>
  28. 28. Does swimming ability prevent drowning? <ul><li>At TASC we have looked at the natural experiment called “childhood” </li></ul><ul><ul><li>In our surveys, we define swimming operationally, and ask “if you were to fall into a pond deeper than your head, and 25 meters across, could you get to the other side and climb out?” </li></ul></ul><ul><ul><li>When we look at risk of dying from drowning (from any cause and in any environment) we find those who can swim by that definition, are between two and three times less likely to drown than those who cant. </li></ul></ul><ul><ul><li>It is independent of age, and of country of survey. </li></ul></ul>
  29. 29. There is also a recent natural experiment we have examined <ul><li>December 26 th , 2004 – the Asian Tsunami Disaster </li></ul><ul><li>Many countries affected, but the worst hit was Indonesia </li></ul><ul><li>The epicenter of the seaquake that created the tsunami was very near Aceh, at the tip of northern Sumatra </li></ul><ul><li>Over 175,000 Acehnese died in one of the largest mass-drowning events in recent history </li></ul>
  30. 30. 3,750 households divided between 4 zones at varying distances from beach 16,240 household members as of morning of 26 December, 2004; 49.9% male. 50.1% female 52% urban, from Banda Aceh and 48% rural from Aceh Besar 2.7% infants, 28.5% 1-17 years, and 68.7% 18+ years Aceh, northern Sumatra Banda Aceh Aceh Besar Direction of waves coming ashore
  31. 31. Mortality rates in tsunami by age and distance to beach
  32. 32. Mortality rates in the tsunami by age and swimming ability
  33. 33. Swimming saves lives <ul><li>At the level of the individual child older than 5 and out-and-about in the community </li></ul><ul><li>It is likely to be the single most effective intervention strategy in this age group </li></ul><ul><li>We need to teach children to swim where there are no pools, no certified instructors, and just ponds, rivers and lakes </li></ul>
  34. 34. If this is their walk to school shouldn’t they know how to swim?
  35. 35. If this is how they go to the store, shouldn’t they know how to swim?
  36. 36. If this is their backyard, shouldn’t they know how to swim?
  37. 37. If they play here, shouldn’t they know how to swim?
  38. 38. If they live on a boat shouldn’t they know how to swim?
  39. 39. Alone or together, shouldn’t they know how to swim?
  40. 40. We need your help <ul><li>You are the world’s experts in water safety and lifesaving </li></ul><ul><li>You are key for intervention in this newly visible epidemic </li></ul><ul><li>It will require new perspectives on who is a lifesaver, and who are life guards </li></ul><ul><li>You’ve developed traditions of excellence and systems that support them </li></ul><ul><li>They will be needed if we are to stop this epidemic </li></ul><ul><li>You will need to work as much in the home, school and community as you have traditionally worked at beaches, pools and other recreational settings </li></ul>
  41. 41. Child drowning
  42. 42. Will you take up the oars? Lifesaving Aye!
  43. 43. Relative risk of child surviving the tsunami according to whether a parent or caretaker could swim