Violence and health = Violence et santé [full issue]

Vol. 46, No. 1, 1993 World Health STATISTICS Quarterly Rapport trimestriel de STATISTIOUES sanitaires mondiales Violence and health Violence et sante World Health Organization Organisation mondiale de la Sante Geneve The World health statistics quarterly replaces (since 1978) the monthly World health statistics report (published since 1967) and its forerunner the Epidemiological and vital statistics report(publ1shed since 1947) It deals with the detailed analysis of selected health topics of current interest. Starting with Vol 41 ( 1988). the Quarterly contains articles 1n either French or English with a summary in both languages. Annual subscription Sw. fr. 100.- Price per copy Sw. fr. 28.- Material from the Quarterly may be reproduced providing due acknowledgement is made. Symbols used in tables Preliminary. approximate or estimated data Data not available Nil or magnitude negligible Category not applicable T Total M Male F Female N Absolute numbers The World Health Organization welcomes requests for permission to reproduce or translate its publications. 1n part or in full. Appl1cat1ons and enquiries should be addressed to the Office of Pubt1cat1ons. World Health Organ12at1on Geneva Switzerland which will be glad to provide the latest information on any changes made to the text, plans for new ed1t1ons, and reprints and translations already available. © World Health Organization 1993 Publications of the World Health Organization en1oy copyright protection 1n accor- aance with the prov1s1ons of Protocol 2 of the Universal Copyright Convention All rights reserved. The des1gnal1ons employed and the presentation of the material 1n this publ1cat1on do nol 1mply the expression of any opinion whatsoever on tre part or the Secretariat of the World Heaith Organ12at,on concerning the legal status of any country, territory, city or area or of its autorit1es or concerning the dehmitat1on of its frontiers or boundaries The mention of spec1f1c companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organ12at1on 1n preferenc:e to others of a similar nature that are not mentioned. Errors and om1ssio'1s excepted, the names of proprietary products are d1st1ngu1shed by initial capital letters Le Rapport trimestriel de stat,stiques sanitaires mondiales remplace (depuis 1978) le Rapport de statistiques sanitaires mond,ales (publie depuis 1967) et son precurseur le Rapportepidemiologique etdemogra- phique (publ1e depuis 1947) II presente des analyses detail lees sur des sujets specifiques d'interet courant. A compter du Vol 41 ( 1988). le Tnmestriel presente des articles originaux en franc;ais ou en anglais, accompagnes d'un resume dans les deux langues. Prix de l'abonnement annuel Fr. s. 100.- Le numero Fr s. 28.- La reproduction d'extraits du Trimestriel est autorisee. sous reserve d'1ndication de la source. Explication des signes Donnee preliminaire. approximative ou estimative Donnee non d1sponible Zero ou quantite negl1geable Categorie non applicable T Total M Masculin F Fem1nin N Nombres absolus L 'Organisation mondiale de la Sante est louiours heureuse de reccvo1r des deman- des d'autorisat1on de reprodu1re ou de traduire ses publications, en part1e ou 1ntegralement Les demandes a cet effet et ies demandes de rense1gnements do1vent Ctre adrcssees au Bureau des Publications, Organisation mondiale de ia Sante, Geneve. Suisse. qu1 se fera un pla1s1r de fourn1r les rcnseignements les plus recents sur les changements apportes au texte. les nouvelles 6d1trons prevues et les r61mpress1ons et traduct1ons deja d1spon1bles. © Organisation mondiale de la Sante 1993 Les publications de l'Organisat1on mond1ale de la Sante benef1c1ent de la protection prevue par les dispos1t1ons du Protocole No 2 de la Convention urnverselle pour la Protection du Droit d'Auteur. Taus dro1ts reserves Les appellations employees dans cette publ1cat1on et la presentation des donnees qu1 y figurent n'1mpliquent de la part du Secretariat de !'Organisation mondiale de la Sante aucune prise de position quant au statut jundique des pays, temto1res v1lles ou 2ones, ou de leurs autontes. ni quant au trace de leurs frontieres ou limites. La mention de f1rmes et de produ1ts commerciaux n'1mpllque pas quc ccs f1rmos et produits commerc1aux sont agrees ou recomrnandes par l'Organisat1on mondiale de la Sante de preference a d'autres. Sauf erreurou omission. unc ma1uscule 1nit1ale indique qu'1I s'ag1t d'un nom depose IX ISSN 0043-8510 Printed 1n Switzerland 92/9383 - Atar S A. Geneva - 5200 ~//,11 /luf_ , ·MQ-~· World Health Statistics Quarterly tl (10 /q?. Rapport trimestriel de statistiques sanitaires mondiales Vol. 46, N°1, 1993 Violence and health Violence et sante Contents Somma ire Introduction [French only] 2 Introduction 2 Comparative analysis of violent deaths in the Analyse comparative de la mortalite violente developed countries and in some developing dans les pays developpes et dans quelques countries, 1985-1989 (summary]. R. Bourbeau. 31 pays en developpement durant la periode 1985-1989. R. Bourbeau. 4 Intentional violence among adolescents Violence intentionnelle chez les adolescents and young adults: an epidemiological et les jeunes adultes: perspective epidemio- perspective. 0. Jeanneret & E. A. Sand. 34 logique [resume]. 0. Jeanneret & EA. Sand. 34 The epidemiology of suicidal behaviour: Epidemiologie des comportements suicidaires: a review of three continents. R.F. W. Diekstra analyse sur trois continents [resume]. & W. Gulbinat. 52 R.F. W. Diekstra & W. Gulbinat. 52 Child abuse: measuring a global problem. La maltraitance des enfants: mesurer un M.A. Belsey. 69 probleme mondial [resume]. M.A. Belsey. 69 Violence against women: the hidden health La violence contre les femmes: un probleme burden. L. Heise. 78 de sante cache [resume]. L. Heise. 78 Wld hlth statist. quart., 46 (1993) Violence et sante Introduction Dans un precedent numero sur les accidents chez les enfants et les jeunes (Rappart trimestriel de statisti- ques sanitaires mondiales, Vol. 39, N° 3, 1986), nous insistions sur le fait que les accidents, en depit de la severite des chiffres connus de mortalite et mor- bidite et done de leurs consequences sur la sante, de leur cout socio-economique et humain consi- derable, ceux-ci ne semblaient toujours pas relever d'une urgence prioritaire de sante. Citant S.P. Baker nous emettions une hypothese quant a ce manque d'interet tendant a mettre celui-ci sur le compte d'une attitude mentale en faisant un pro- bleme de comportement ou de police projetant de facto une ombre sur l'essentiel, c'est-a-dire les bles- sures ou atteintes a l'integrite physique des indivi- dus qu'ils entrainent. Or, en ciblant le debat sur la notion de blessure ou traumatisme (injury en anglais) nous transfe- rons celui-ci sur un registre sante et introduisons un second volet, celui des traumatismes intention- nels. En d'autres termes ii s'agit de l'introduction du phenomene de la violence en sante, que celle-ci soit accidentelle ou non. II est cependant une constante en sante qui veut que les maladies infectieuses et les consequen- ces des situations de violence ont de tout temps fait mourir plus precocement que toutes les autres cau- ses de maladies. Des lors que la mortalite ne consti- tue plus la mesure de reference, mais que des instruments de mesure evaluant la morbidite ou par exemple le nombre d'annees de vie perdues avant 60 ou 65 ans sont utilises, alors les conse- quences de la violence sur la sante mesurees par les traumatismes, qu'ils soient fortuits ou intention- nels, individuels ou collectifs, occupent en general une position malheureusement privilegiee parmi les phenomenes nocifs pour la sante. LaJoumee mondiale de la sante, le 7 avril 1993, dont le slogan etait «Attention! Vie fragile. Refu- sons la violence et la negligence» avait pour but de sensibiliser l'opinion publique intemationale et nationale aux effets desastreux sur la collectivite, les familles et les individus, des consequences de la violence. Le present numero du Rappart trimestriel de statis- tiques sanitaires mondiaks tend a renforcer le mes- sage de la Joumee mondiale de la sante, notam- ment en ce qui conceme la violence intention- nelle. De meme que les accidents ont ete pendant longtemps une affaire de police ou d'assurance 2 tendant a determiner des responsabilites, la violen- ce pour sa part reste encore un phenomene traite par les sociologues et criminologues pour l'analyse des causes ou par la justice et la police pour son controle. Ainsi que nous le mentionnions plus haut, des I ors que le de bat po rte sur I' epidemiologie des traumatismes et blessures, non seulement sur le traitement medical, mais aussi sur les mecanismes et circonstances de survenue, et enfin sur les cau- ses, comme fondements d'une politique de pre- vention, c'est une demarche traditionnelle de san- te publique que nous decrivons. C' est egalement l'objectif du programme de l'OMS sur la preven- tion des traumatismes que d'inclure la violence accidentelle et intentionnelle dans les preoccupa- tions de Sante publique et par la meme de contri- buer a enrichir les contributions d'autres discipli- nes et d'autres secteurs avec le but commun et ultime d'entreprendre une reflexion et batir un cadre conceptuel scientifique que la promotion d'une securite optimale dans la communaute. Ceci amene a definir clairement le role de la sante dans le domaine de la prevention des acci- dents et de la violence. Au moins quatre fonctions apparaissent essentielles: (i) Agir en tant que sensibilisateur ou meme en tant que «conscience» vis-a-vis des autres sec- teurs ou partenaires politiques et sociaux afin de ne pas passer au compte des pertes et profits un sujet considere trop facilement comme le produit du hasard et de la fatalite. (ii) Participer a l'amelioration des donnees sur les traumatismes et la violence, comme prea- lable a la planification de programme de pre- vention. C'est ici l'interet de considerer en- semble traumatismes intentionnels et acci- dentels dont les caracteristiques des systemes de surveillance sont identiques. (iii) Contribuer a la formulation d'un cadre con- ceptuel permettant une analyse scientifique de la securite et de la violence. (iv) Mobiliser enfin la recherche en sante et les professionnels de la sante pour integrer la promotion de la securite et la prevention de la violence aux actions de promotion et pro- tection de la sante. Le present numero du Rappart trimestriel de sta- tistiques sanitaires mondiales reflete en partie les nouvelles tendances du programme OMS de pre- Rapp. trimest. statist. sanit. mond., 46 (1993) vention des traumatismes. Il commence par une mise a jour elargie des donnees OMS sur la mor- talite violente. La brievete du numero ne permet- tait pas une analyse exhaustive des accidents et de la violence. Il a done ete procede a une selection des themes qui paraissent prioritaires ou dont l'interet procede de criteres d'ordre methodo- logique. Un chapitre tente une definition de la vilolen- ce Ueanneret & Sand), mais ce qui sous-tend l'ensemble des chapitres reste d'ordre methodo- logique. Chacun aborde les aspects statistiques, epidemiologiques et methodologiques de l'analy- se de la violence ainsi qu'une reflexion critique sur la fiabilite des donnees et des sources dispo- nibles. La situation actuelle a cet egard reste en- core tres peu satisfaisante et il sera necessaire d'accorder une plus grande attention a l'amelio- ration de l'information sur la violence dans ses aspects de sante si l' on veut des arguments vala- bles pour sensibiliser les decideurs ou les corn- Wld hlth statist. quart., 46 (1993) munautes elles-memes a des actions serieuses de prevention Ce n' est que depuis peu que la dimension sante publique de la securite et de la violence est deve- nue perceptible dans les preoccupations des res- ponsables sanitaires. Un grand effort pour la mise au point d'un cadre conceptuel et l'harmonisation des methodologies d'analyse des phenomenes d'insecurite et de violence sera necessaire. C'est l' etape prealable a une meilleure connaissance et done a une meilleure maitrise. C' est le but des articles presentes dans ce nume- ro que de contribuer a cette reflexion, ce sera aussi un des objectifs prioritaires de l'OMS, car si les pays industrialises ont commence a s'inquieter de ces questions, dont les pays en voie de developpe- ment, preoccupes a juste titre par le controle des maladies transmissibles, un nombre croissant d' en- tre eux perdent deja plus d'annees de vie producti- ve du fait de la violence, en comparaison des mala- dies transmissibles. 3 A~alyse c~mparative de la mortalite violente dans Jes pays developpes et dans quelques pays en developpement durant la periode 1985-1989 Robert Bourbeaua Introduction L_:1 violence est un phenomene de plus en plus repandu dans nos societes; cependant, il est diffici- 1~ de l'~pprehender car il comporte de multiples dimensions. Dans cet article, nous nous limitons a pr~senter la partie la plus visible du phenomene, SOlt la mortalite consecutive a des actes violents. Pour simplifier l'analyse, nous avons inclus sous l'appellation «deces violents» tous les deces clas- ses sous la rubrique «Traumatismes et empoison- nements» de la Classification internationale des maladies ( CIM), en excluant les deces causes par la prise de medicaments au cours de leur administra- tion therapeutique (voir l' encadre 1). Une remarque s'impose d'emblee. Le fait de limiter notre analyse dans cet article a la seule mortalite peut faire en sorte de minimiser l'im- portance de certaines formes de «violence» pour lesquelles la morbidite (blessure non mortelle) est souvent une resultante beaucoup plus fre- quente que la mortalite; par exemple, en ce qui concerne les blessures dues a des bn1lures con- secutives a diverses formes d'incendies, les seuls cas qui donnent lieu a un deces ne don- nent pas une juste image de l'importance des brulures, comme probleme de sante publique, en termes de soins medicaux et hospitaliers et de couts. 11 faudrait faire etat de la morbidite con- secutive a cette forme de blessures pour mieux refleter son importance reelle et pour suggerer des moyens de prevention plus adequats. Cepen- dant, la disponibilite des donnees sur la morbidi- te nous empeche de dresser un portrait d'en- semble du phenomene pour un grand nombre de pays, comme il est possible de le faire pour la mortalite. Cette analyse s'inspire en premier lieu de l'etude de Taket (1) qui portait sur la mortalite par accident chez les enfants, adolescents et jeunes adultes (les 1-24 ans). Cependant, elle ajoute une dimension importante en incluant les deces dont la cause est intentionnelle, soit les suicides, homici- des et autres violences intentionnelles envers autrui. Par ailleurs, notre analyse concerne unique- men t l'ensemble des groupes d'ages et elle s'interesse a la situation de la periode la plus recente, soit la periode 1985-1989. Cet article a Professeur agrege, Universite de Montreal, Canada, et expert de l'OMS en matiere de prevention des traumatismes. 4 prend aussi appui sur les travaux de Lopez (2) pour le choix des pays etudies et pour le regroupement des causes de deces, sur les resultats de Chackiel (3) concernant la critique des donnees provenant des pays en developpement, en particulier les pays d'Amerique latine, sur les travaux de Blum & Monnier (4) pour l'analyse comparative des pays et sur ceux de Brouard & Lopez (5) et de Brouard (6) pour l'etablissement d'une typologie des pays selon leur profit de deces par cause. Cet article a pour but de presenter une analyse comparee de la mortalite par violence dans 68 pays au cours de la periode la plus recente, soit 1985- 1989. Dans un premier temps, les donnees disponi- bles et la methode d'analyse sont presentees. Par la suite, l'analyse des donnees permet: - de situer la mortalite violente parmi l'ensem- ble des causes de deces dans les pays developpes et dans les pays en developpement; - de classer les pays selon le niveau de la mortalite generate et l'importance de la mortalite par violence; - d'etudier les composantes de la mortalite vio- lente, en distinguant les causes non intention- nelles, les causes intentionnelles et les causes pour lesquelles l'intention est indeterminee· - de suggerer une typologie des pays sur la bas; des caracteristiques de leur mortalite violente; - de faire ressortir l'importance de la surmorta- lite masculine surtout pour les deces violents. Les donnees statistiques et les analyses que l'on en tire ne menent pas directement a la solution du probleme etudie, en l'occurrence les diverses formes de violence, mais elles fournissent un nouvel eclairage de la situation. Pendant que s'ameliorent les moyens actifs et passifs de pre- vention contre ces traumatismes, il est important d'assurer un suivi. Les comparaisons internatio- nales, malgre leurs limites liees a la comparabilite des donnees fournies par les divers pays, sont utiles pour faire ressortir les pays dont la performance en matiere de mortalite violente se demarque de celle des autres; on peut alors juger de l'a-propos de certaines mesures de prevention, ou de leur absen- ce, et soulever des questions interessantes. Les donnees et la methode Les donnees Les donnees utilisees concernent 68 pays, soit tous les pays pour lesquels la banque de donnees Rapp. trimest. statist. sanit. mond., 46 (1993) Encadre 1 Causes de deces et categories dans la Classification internationale des maladies, traumatismes et causes de deces (CIM) Categorie de cause de deces Maladies infectieuses et parasitaires Tumeurs malignes Maladies de l'appareil circulatoire Maladies pulmonaires obstructives chroniques Complications de la grossesse et affections perinatales Traumatismes et empoisonnements Accidents de transport Accident de vehicule a moteur sur la voie publique Autres accidents de transport Empoisonnement accidentel Chute accidentelle lncendie Submersion, suffocation accidentelle Accident cause par projectiles d'armes a feu Autres accidents Total des causes accidentelles (causes non intentionnelles) Suicide (cause intentionnelle) Homicide (cause intentionnelle) Lesions causees d'une maniere indeterminee quant a !'intention Autres causes exterieures Total des causes violentes (causes violentes) Medicaments pouvant causer des accidents au cours de leur administration therapeutique Sympt6mes, signes et etats morbides mal definis Autres causes Toutes causes OMS sur la mortalite disposait d'informations suffisantes pour permettre le calcul des indices de mortalite. Bien sur, les donnees ne sont pas les memes pour tous les pays, ni en quantite ni en qualite, et certaines analyses ne porteront en con- sequence que sur des sous-ensembles de ces 68 Wld hlth statist. quart., 46 (1993) CIM-9 CIM-8 (Liste de base pour (Liste A) la mise en tableaux) 01-07, 320-322 A1-44, A99, A90-92 08-17 A45-61 25-30 A80-88 323-326 A93,A96 38-41, 45 A112-118, A131-135 E47-56 AE138-150 E47 AE138-139 E471 AE138 (E47 mains E471) AE139 E48 AE140 E50 AE141 E51 AE142 E521 AE143 E524 AE144 E49, (E52 mains AE145, AE146 E521,E524) E47,48,49,50, AE138-146 51,52 E54AE147 E55 AE148 E560 AE149 (E56 mains E560) AE150 E47,48,49,50,51, AE138-150 52,54,55,56 E53 --- 46 A136,137 Tous autres codes Tous autres codes 01-56 A1-137, AE138-150 pays. Ces pays ont ete repartis en deux grandes categories: les pays developpes (34 pays dont 29 pays d'Europe) et les pays en developpement (34 pays, comprenant surtout des pays d'Ameri- que latine et des Caraibes, soit 23). Meme si cette classification des pays n'est pas ideate, elle 5 s'avere utile pour illustrer la situation mondiale et pour resumer les resultats. Les deux categories utilisees ne sont pas parlai- tement homogenes; ainsi, le groupe des pays deve- loppes contient des pays industriels a economie de marche et des pays industriels a economie plani- fiee qui presentent des ecarts de mortalite assez importants (2). De meme, le groupe des pays en developpement comportent des situations encore plus heterogenes, surtout a cause des differences dans la qualite des donnees; pour cette raison, nous avons subdivise cette categorie en deux grou- pes de pays en distinguant ceux pour lesquels nous disposons de donnees de bonne qualite ( donnees fiables ou relativement fiables, soit 15 pays) et ceux pour lesquels les donnees sont de mauvaise qualite (donnees deficientes, soit 19 pays). De plus, etant donne le contexte particulier de la region de l'Amerique latine et des Caraibes en ce qui con- cerne la mortalite violente (7), nous avons reuni les pays de cette region dans un groupe a part. La qualite des donnees La qualite des donnees varie beaucoup selon les pays; pour l'apprecier, nous avons examine prin- cipalement trois indicateurs: la completude mesu- ree par le pourcentage des deces enregistres, la fiabilite mesuree par le pourcentage de deces enre- gistres qui ont ete certifies par un medecin et la qualite de la classification des deces selon la cause que l'on peut estimer a partir du pourcentage de deces attribues a des causes mal definies. C'est sur la base de ces indicateurs, fournis par l'etude de Chack.iel (3) et par l'OMS (8) que nous avons etabli les regroupements pour les pays en developpe- ment. Ainsi, 10 pays de la region «Amerique latine et Caraibes» et 5 pays d'autres regions ont ete clas- ses parmi les pays a donnees fiables; ces pays peu- vent faire l'objet d'une analyse comparative du meme type que celle des pays developpes. Quant aux 19 pays en developpement a donnees deficien- tes, nous nous limitons a presenter les donnees sans faire de commentaires specifiques sur ces pays. Pour les pays developpes, la qualite des don- nees est en general tres bonne; cependant, le pour- centage de deces attribues a des causes mal defi- nies (symptomes, signes et etats mal definis) varie de fa~on assez importante selon les pays, refletant le fait que certaines causes de deces, en particulier les suicides et les homicides, sont sous-estimees dans certains pays. Une solution a ce probleme aurait ete de repartir ces deces parmi les autres causes de deces bien definies, mais le manque d'informations sur la situation particuliere de chacun des 34 pays developpes nous en a empeche. 11 faudra prendre en compte que la presence de ce phenomene peut biaiser legerement les comparai- sons entre les pays. Un autre probleme a souligner est l'inclusion dans cette etude d'un certain nombre de pays (3 6 pays developpes et 11 pays en developpement) dont l' effectif total de la population est inferieur a 1 million d'habitants; le nombre de deces selon les causes etudiees est souvent petit et les indices calcules a partir de ces deces doivent etre traites avec precaution, meme si les donnees portent sur plu- sieurs annees. Soulignons que les resultats presen- tes concernent, pour la plupart, des indices moyens pour la periode 1985-1989; lorsque les donnees pour cette periode n'etaient pas disponibles, nous avons retenu les donnees les plus recentes. La methode L'indice principal utilise dans cet article pour faciliter les comparaisons internationales est le taUX COmparatif de mortalite OU taUX de mortalite corrige de l'age pour lequel nous avons retenu comme structure par age type, celle de la popula- tion europeenne. Cet indice est largement utilise dans les publications de l'OMS et dans les analy- ses de la situation comparative des causes de deces (2). Etant donne les differences importantes de mortalite entre les sexes, tous les indices ont ete calcules separement pour chacun des sexes. Sur la base de cet indice, nous analyserons d'abord l'importance de la mortalite violente dans les differents pays par rapport aux autres grands grou- pes de causes de deces. Nous etablirons un classe- ment indicatif des pays developpes et des pays en developpement selon le niveau de la mortalite ge- nerate et l'importance relative de la mortalite violente; il sera interessant de rapprocher, pour chacun des pays, le taux comparatif de mortalite generate de la proportion des deces dus aux causes violentes. De fait, on peut penser, en vertu de la theorie classique de la transition epidemiologique proposee par Omran (9), que plus la mortalite generate est faible dans un pays, plus la part des deces dus a des causes exterieures - les causes vio- lentes - sera elevee. Des methodes de regression nous serviront a verifier cette hypothese. Par la suite, nous examinerons les composantes de la mortalite violente pour en voir les variations selon les pays et selon les niveaux de mortalite. La mortalite violente est decomposee en: - causes non intentionnelles (ou accidentelles) comprenant principalement les accidents de vehicule a moteur, les empoisonnements, les chutes, les noyades; - causes intentionnelles comprenant les suicides (violence envers soi-meme), les homicides et les autres actes de violence envers autrui (actes de guerre, intervention legale de la force publique); - causes ou l'intention est indeterminee. Cet examen nous permettra de voir si, pour la mortalite violente, il existe un lien entre le niveau et la structure de la mortalite. De plus, une meilleu- re connaissance de la composition de la mortalite violente dans certains pays peut aider a formuler des moyens de prevention plus adequats. Rapp. trimest. statist. sanit. mond., 46 (1993) De maniere a faciliter l'analyse des ressemblan- ces entre les pays pour les composantes de la mortali- te violente, nous utiliserons une methode statistique permettant d'organiser les nombreuses informa- tions dont nous disposons; il s'agit d'une metho- de de classification hierarchique automatique ( cluster analysis) qui regroupe les pays sur la base de leur proximite mesuree par la methode de Wardb (voir encadres 2 et 3, p. 32). A cause de la qualite des donnees sur la mortalite violente, ce type d'analyse ne sera fait que pour les pays developpes. Un phenomene bien connu est celui de la sur- mortalite masculinec pour l' ensemble des causes de deces. Pour la mortalite violente, on s'attend a ce qu'elle soit plus marquee, etant donne le caractere particulier de cette cause de deces et la plus forte propension des hommes a etre impli- ques dans des incidents violents. Pour etre en me- sure de mieux comparer d'un pays a l'autre la surmortalite masculine par violence, nous avons decompose le rapport de surmortalite masculine totale de chacun des pays, en tenant compte dans chaque pays de la contribution des deces feminins dus a la violence. De cette maniere, nous obtenons un indice qui mesure la contribution reelle de la surmortalite masculine par violence a la surmorta- lite masculine totale et qui permet un classement indicatif des pays selon l'importance de cette contribution (4). L 'importance des deces vialents en tant que cause de deces La part des deces dus a des causes violentes (accidents, suicides, homicides, autres violences) prend de plus en plus d'importance au sein de l' ensemble des deces. Dans les pays developpes, il y a 50 ans, de 2 a 3% des deces etaient de nature violente; actuellement, jusqu'a 10% des deces, b Le principe de cette methode est de calculer le earn~ de la distance euclidienne separant chacun des elements d'une classe donnee de la moyenne de la classe avec laquelle une fusion est envisagee et de faire la somme de ces distances. A chaque etape, les deux classes jointes sont celles pour lesquelles correspond la plus petite valeur de cette somme. Les resultats de la classification sont representes graphiquement par un dendogramme, une figure arborescente illustrant la serie des regroupements de classe successifs. Chaque cas a classifier est represente en ordonnee tan dis que des traits verticaux unissent les elements d'une meme classe. Une standardisation des valeurs empruntees par le carre de la distance euclidienne est indiquee en abscisse sur une echelle de O a 25. L'eloignement a l'ordonnee des traits verticaux est proportionnel au niveau d'agregation correspondant a la fusion de deux classes preexistantes. Nous obtiendrons ainsi des ensembles de pays relativement homogenes presentantdes caracteristiques semblables selon le niveau et la composition de la mortalite violente. Pour plus de details sur cette methode, voir V. Courville, Un essai tk clo.ssification tks pays devewppes su.ivant l,e projil tk la murtalite vioknte tks personnes agees. Me moire de maitrise, Departement de demographie, Universite de Montreal, 1992. c La surmortalite masculine est mesuree en rapportant le taux comparatif de mortalite «toutes causes» des hommes acelui des femmes et en multipliant le resultat par 100. Wld hffh statist. quart., 46 (1993) dans certains pays, sont attribuables a la violence. Cette progression resulte en partie de la baisse de l'importance des autres causes de deces (surtout les deces dus aux maladies infectieuses et parasitai- res) mais elle.tient aussi de l'augmentation reel- le de la mortalite violente. L'augmentation de la mortalite par accident de vehicule a moteur sur la voie publique et par suicide est une bonne illustra- tion de ce second phenomene. Nous presentons aux tabl.eaux la et lb pour les pays developpes et 2a et 2b pour les pays en deve- loppement, la repartition des deces selon les 5 principaux groupes de causes de deces sur la base des taux comparatifs de mortalite: maladies de l'appareil circulatoire; tumeurs malignes; mala- dies infectieuses et parasitaires (y compris la bron- chite aigue, la pneumonie et la grippe); traumatis- mes et empoisonnements (violence); et maladies pulmonaires obstructives chroniques. Pour don- ner une image complete de la mortalite, nous avons egalement ajoute les deces pour causes mal definies et les deces pour les autres causes non comprises dans les 5 groupes retenus. On remarque que les maladies de l'appareil circulatoire constituent la premiere cause de deces dans tous les pays a donnees fiables autant chez les hommes (sauf pour Hong Kong) que chez les fem- mes; les tumeurs malignes sont le deuxieme grou- pe de causes de deces dans la plupart des pays a donnees fiables, sauf dans quelques pays en deve- loppement ou les maladies infectieuses et parasitai- res demeurent plus importantes. Le rang occupe par les 3 autres grands groupes de causes est plus variable selon le type de pays et le sexe. Notons que la sous-representation des pays en developpement dans nos donnees ne permet pas de generaliser cette configuration de la mortalite a l'ensemble des pays. Le tabl.eau 3 resume la repartition des pays selon le rang attribue aux deces par violence. Dans les pays developpes, les deces violents constituent la troisie- me cause de deces (apres les maladies de l'appa- reil circulatoire et les tumeurs malignes) dans la grande majorite des cas, soit respectivement 26 pays sur 33 pour le sexe masculin et 21 sur 33 pour le sexe feminin. Ce resultat correspond au schema classi- que auquel on pouvait s'attendre etant donne le niveau de developpement de ces pays. La situation particuliere de 4 pays est a signaler non seulement parce que les causes violentes vien- nent au cinquieme rang des causes de deces pour l'un ou l'autre, ou bien les deux sexes, mais surtout a cause de l'importance relative plus grande des deces par maladies pulmonaires obs- tructives chroniques; il s'agit de l'Irlande et de l'Angleterre et Pays de Galles pour les deux sexes, de l'Ecosse pour le sexe masculin et de la Roumanie pour le sexe feminin. Dans les pays en developpement, l'apprecia- tion du classement des causes de deces est plus 7 0 ) Ta ble au 1 a- Ta ble 1a Ta ux c om pa ra tifs de m or ta lite (p ou r 1 00 O OO ), to ut es c au se s, e t p ou rce nta ge de s p rin cip ale s c au se s de d ec es p ou r c er ta ins p ay s d ev elo pp es , 1 98 5- 19 89 (o u la p eri od e la plu s r ec en te) Co mp ara tiv e de ath ra tes (p er 10 0 O OO ), a ll c au se s, a nd p erc en tag e of the le ad ing ca us es o f d ea th, fo r s om e de ve lop ed co un trie s, 19 85 -1 98 9 (or the m os t r ec en t p er iod ) Ma lad ies de Tu me urs Ma lad ies Ca use s m at Ma lad ies in fec tie us es Tra um ati sm es et pu lm on air es Pa ys - Co un try Pe rio de /an ne e To ute s c au se s - All c au se s l'ap pa rei l c irc uta toi re m alig ne s et pa ras ita ire s em po iso nn em en ts (vio len ce) ch ron iqu es de fin ies Au tre s c au se s Pe rio d/y ea r Dis ea se s o f th e Ma lign an t Inf ec tio us an d Inju ry a nd po iso nin g ( vio len ce) Ch ron ic pu lm on ary Ill- de fin ed Ot he r c au se s cir cu lat ory sy ste m ne op las ms pa ras itic di se as es dis ea se ca us es Ho mm es - Ma tes Ta ux -R ate Ra ng -R an k % % % % Ra 119 _- Ra nk % % % EU RO PE Al lem ag ne • - Ge nn an ya 19 85 -1 98 9 11 11 .0 15 46 .2 25 .8 2.9 5.9 7 4.8 2.7 11 .8 Au tric he -A us tri a 19 85 -1 98 9 11 30 .8 18 48 .0 23 .9 2.4 9.3 28 3.5 0.8 12 .1 Be lgi qu e - Be lgi um 19 86 11 57 .6 20 37 .4 27 .2 3.7 7.6 17 6.0 6.2 12 .0 Fr an ce 19 85 -1 98 9 1 0 39 .1 10 31 .1 30 .3 3.5 10 .3 32 3.5 5.7 15 .6 lrla nd e - Ire lan d 19 85 -1 98 9 1 2 65 .5 25 49 .0 21 .3 6.5 4.9 4 7.3 0.7 10 .3 Lu xe m bo ur gb 19 85 -1 98 9 1 2 56 .7 23 44 .5 25 .9 2.6 7.6 19 4.2 3.1 11 .8 Pa ys -B as - Ne the rla nd s 19 85 -1 98 9 1 0 34 .6 9 41 .5 30 .2 2.8 4.5 3 6.0 3.6 11 .5 Ro ya um e- Un i- Un ite d Ki ng do m: An gle ter re et Ga lle s - En gla nd & W ale s 19 85 -1 98 9 11 11 .3 17 46 .9 25 .5 4.5 4.0 2 6.8 0.6 11 .7 Ec os se - Sc otl an d 19 85 -1 98 9 1 2 87 .5 26 48 .3 23 .9 6.5 5.4 5 5.4 0.5 9.9 lrla nd e du N or d - No rth er n Ire lan d 19 85 -1 98 9 1 2 65 .5 24 48 .8 21 .5 10 .4 5.4 6 5.3 0.2 8.2 Su iss e - Sw itz erl an d 19 85 -1 98 9 94 8.5 3 41 .4 29 .1 3.6 9.8 29 4.1 1.8 10 .2 Oa ne ma rk - De nm ar k 19 85 -1 98 9 11 11 .2 16 44 .6 25 .5 2.6 7.9 23 5.3 4.2 9.9 Fin lan de - Fin lan d 19 85 -1 98 9 1 2 35 .8 22 50 .1 20 .4 5.4 10 .6 33 3.7 0.5 9.4 lsl an de b - lce lan db 19 85 -1 98 9 86 8.7 2 48 .1 24 .9 7.6 9.1 26 2.8 0.8 7.9 No rve ge - No rw ay 19 85 -1 98 9 1 0 46 .8 11 47 .9 22 .0 5.6 7.7 20 3.0 3.8 10 .1 Su ed e - Sw ed en 19 85 -1 98 9 97 5.9 6 52 .4 20 .9 5.7 7.6 18 2.5 0.9 10 .1 Es pa gn e - Sp ain 19 86 96 6.1 5 39 .0 25 .3 4.0 6.8 10 5.2 2.6 17 .0 Gr ec e - Gr ee ce 19 85 -1 98 9 94 8.7 4 45 .1 22 .9 2.1 6.9 11 1.9 6.5 14 .6 lta lie - Ita ly 19 85 -1 98 9 1 0 48 .3 12 40 .9 28 .0 2.3 6.1 8 5.2 2.4 15 .1 Ma lte b - Ma lta b 19 85 -1 98 9 11 07 .4 14 56 .0 20 .2 3.6 3.6 1 2.7 1.3 12 .5 Po rtu ga l 19 85 -1 98 9 11 85 .0 21 40 .1 17 .7 3.9 9.2 27 3.6 11 .2 14 .3 Yo ug os lav ie - Yu go sla via 19 85 -1 98 9 1 3 11 .8 27 49 .5 16 .9 3.6 7.1 12 2.8 8.8 11 .4 Ex -R ep ub liq ue d em oc ra tiq ue al lem an de - Ex -G erm an D em oc ra tic R ep ub lic 19 85 -1 98 9 1 3 61 .6 28 53 .1 18 .3 2.5 4.9 Bu lga rie - Bu lga ria 19 85 -1 98 9 1 41 2.9 29 58 .2 13 .8 5.0 6.7 9 3.0 4.3 9.1 l Ho ng rie - Hu ng ary 19 85 -1 98 9 1 6 26 .3 34 49 .8 21 .3 1.8 10 .2 31 4.6 0.1 12 .2 15 Po log ne - Po lan d 19 85 -1 98 9 1 5 26 .2 33 50 .5 19 .1 2.8 7.8 21 4.0 6.8 9.0 s Ro um an ie - Ro ma nia 19 80 -1 98 4 1 44 7.4 30 55 .8 12 .5 5.4 7.3 15 8.1 0.0 10 .7 ;:!° Tc he co slo va qu ie - Cz ec ho slo va kia 19 85 -1 98 9 1 5 22 .5 31 51 .7 22 .1 3.5 7.1 13 3.8 0.8 10 .9 m Ex ·U RS S - Fo rm er U SS R 19 87 1 5 24 .9 32 53 .5 9.8 30 0.5 . . . . I AU TR ES R EG IO NS -O TH ER R EG IO NS Au str ali e - Au str ali a 19 85 -1 98 9 1 0 13 .9 8 46 .1 25 .0 2.1 7.1 14 6.7 0.6 12 .3 . . . . Ca na da 19 85 -1 98 9 99 1.8 7 42 .1 26 .3 4.0 7.8 22 5.1 1.6 13 .1 ~ Et ats -U nis d' Am er iqu e - ~ Un ite d St ate s o f A m er ica 19 85 -1 98 9 1 0 75 .6 13 44 .6 23 .2 4.6 8.4 25 4.7 1.5 13 .0 ~ Ja po n - Ja pa n 19 85 -1 98 9 84 0.4 1 35 .8 28 .0 9.5 7.9 24 3.0 3.5 12 .3 No uv ell e- Ze lan de - Ne w Ze ala nd 19 85 -1 98 9 11 47 .8 19 46 .1 23 .0 5.4 7.4 16 7.0 0.7 10 .4 fl- t • Av an t l' un ~ic ati on . - Pr ior to u n~ ica tio n. I • Pa ys do nt ta po pu lat ion es t in fer ieu re a 1 m illio n d 'ha bit an ts. - Co un trie s w ith a po pu lat ion le ss tha n 1 m illio n. ~ § Ta ble au 1 b- Ta ble 1b " ' &r Ta ux c om pa ra tifs de m or ta lite (p ou r 1 00 OO O), to ut es c au se s, e t p ou rce nta ge de s p rin cip ale s c au se s de de ce s po ur ce rta ins p ay s d ev elo pp es , 1 98 5- 19 89 (o u l a p eri od e la plu s re ce nte ) ~ ,.... Co mp ara tiv e d ea th ra tes (p er 10 0 OO O), all ca us es , a nd p erc en tag e of the le ad ing ca us es o f d ea th, fo r s om e de ve lop ed co un trie s, 19 85 -1 98 9 (or the m os t r ec en t p er iod ) . Q Iii ~ Ma lad ies de Tu me urs Ma lad ies Ca use s m al ~ Ma lad ies in fec tie us es Tra um ati sm es et pu lm on air es Pa ys - Co un try Pe rio de /an ne e To ute s c au se s - All c au se s l'ap pa rei l c irc ula toi re m alig ne s et pa ras lta ire s em po iso nn em en ts (vio len ce) ch ron iqu es de fin ies Au tre s c au se s 1 Pe rio d/y ea r Dis ea se s o f th e Ma lign an t Inf ec tio us an d Inju ry a nd po iso nin g ( vio len ce) Ch ron ic pu lm on ary Ill- de fin ed Ot he r c au se s cir cu lat ory sy ste m ne op las ms pa ras itic di se as es dis ea se ca us es Fe mm es -F em ale s Ta ux -R ate Ra ng -R an k 'lo 'lo 'lo 'lo Ra ng -R an k 'lo 'lo 'lo EU RO PE Al lem ag ne • - Ge rm an y• 19 85 -1 98 9 65 5.3 13 48 .2 26 .4 2.8 4.6 14 2.2 2.9 12 .9 Au tric he - Au str ia 19 85 -1 98 9 68 7.9 17 52 .1 24 .3 2.2 6.0 28 1.9 1.2 12 .3 Be lgi qu e - Be lgi um 19 86 67 7.2 16 40 .4 24 .4 3.5 6.3 29 2.3 8.1 15 .1 Fr an ce 19 85 -1 98 9 54 5.4 3 35 .0 25 .4 3.8 8.8 33 2.1 6.9 18 .0 lrla nd e - Ire lan d 19 85 -1 98 9 79 2.8 25 47 .3 23 .5 7.6 3.4 5 5.0 0.9 12 .4 Lu xe m bo ur gb 19 85 -1 98 9 71 7.1 20 48 .5 23 .7 2.3 5.6 25 2.4 3.5 14 .0 Pa ys -B as - Ne the rla nd s 19 85 -1 98 9 57 9.2 6 40 .7 28 .7 3.4 4.3 12 2.5 3.7 16 .7 Ro ya um e-U ni - Un tte d Ki ng do m: An gle ter re et Ga lle s - En gla nd & W ale s 19 85 -1 98 9 69 1.9 18 44 .4 27 .3 5.6 3.1 3 3.5 0.9 15 .2 Ec os se - Sc otl an d 19 85 -1 98 9 80 1.8 26 47 .0 25 .3 7.1 4.1 10 3.4 0.6 12 .5 lrla nd e du N ord - No rth er n Ire lan d 19 85 -1 98 9 77 2.8 23 47 .5 23 .6 12 .0 3.6 7 3.1 0.3 9.8 Su iss e - Sw itz erl an d 19 85 -1 98 9 53 8.0 2 43 .6 28 .6 3.7 7.8 32 1.9 1.9 12 .5 Da ne ma rk - De nm ark 19 85 -1 98 9 69 8.3 19 40 .9 29 .8 2.8 7.3 30 4.0 4.3 11 .0 Fin lan de - Fin lan d 19 85 -1 98 9 66 2.7 14 51 .6 21 .3 5.7 5.9 27 1.3 0.7 13 .6 lsl an de b - lce lan db 19 85 -1 98 9 57 5.9 4 42 .6 29 .6 10 .6 4.8 17 3.0 1.7 8.5 No rve ge - No rw ay 19 85 -1 98 9 59 6.6 9 43 .8 25 .7 7.4 5.6 24 2.1 3.2 12 .2 Su ed e - Sw ed en 19 85 -1 98 9 58 1.9 7 49 .1 25 .6 5.8 5.3 22 1.9 1.1 11 .2 Es pa gn e - Sp ain 19 86 58 7.9 8 47 .4 20 .8 4.0 3.4 6 2.6 3.3 18 .4 Gr ec e - Gr ee ce 19 85 -1 98 9 66 7.9 15 51 .4 17 .4 2.2 4.2 11 1.1 8.0 15 .6 lta lie - Ita ly 19 85 -1 98 9 61 6.9 11 46 .5 24 .3 2.4 4.5 13 2.3 3.3 16 .7 Ma lte b - Ma Jta b 19 85 -1 98 9 79 1.9 24 58 .3 17 .5 3.9 1.9 1 0.9 1.9 15 .4 Po rtu ga l 19 85 -1 98 9 72 4.6 22 46 .5 17 .0 3.3 4.6 15 1.9 13 .5 13 .2 Yo ug os lav ie - Yu go sla via 19 85 -1 98 9 89 1.2 30 57 .0 14 .4 3.6 3.7 8 1.7 9.3 10 .2 Ex -R ep ub liq ue d em oc ra tiq ue al lem an de - Ex -G erm an D em oc ra tic R ep ub lic 19 85 -1 98 9 87 2.5 28 58 .2 17 .6 2.2 1.7 Bu lga rie - Bu lga ria 19 85 -1 98 9 96 0.7 33 64 .6 12 .5 4.7 3.0 2 2.0 5.6 7.6 Ho ng rie - Hu ng ary 19 85 -1 98 9 95 9.9 32 55 .5 20 .0 1.5 7.5 31 2.7 0.1 12 .7 Po log ne - Po lan d 19 85 -1 98 9 86 1.5 27 55 .2 18 .1 2.5 4.0 9 1.6 7.5 11 .0 Ro um an ie - Ro ma nia 19 80 -1 98 4 1 0 68 .5 34 65 .3 11 .0 5.1 3.3 4 6.5 8.7 Tc he co slo va qu ie - Cz ec ho slo va kia 19 85 -1 98 9 89 5.0 31 56 .9 19 .7 3.7 5.6 26 1.9 1.1 11 .2 Ex -U RS S- Fo rm er U SS R 19 87 87 3.7 29 63 .7 4.9 19 0.4 AU TR ES R EG IO NS -O TH ER R EG IO NS Au str ali e - Au str ali a 19 85 -1 98 9 60 6.4 10 48 .7 25 .2 2.3 4.7 16 3.7 0.7 14 .7 Ca na da 19 85 -1 98 9 57 5.9 5 41 .8 28 .8 4.1 5.3 21 2.8 1.6 15 .6 Et ats -U nis d 'Am er iqu e - Un ite d St ate s o f A m er ica 19 85 -1 98 9 64 3.6 12 45 .5 25 .2 4.5 4.9 18 3.4 1.5 15 .0 Ja po n - Ja pa n 19 85 -1 98 9 49 8.4 1 41 .8 24 .2 7.7 5.5 23 1.8 5.5 13 .5 No uv ell e- Ze lan de - Ne w Ze ala nd 19 85 -1 98 9 72 3.5 21 45 .2 25 .2 6.4 5.1 20 4.4 1.0 12 .7 • Av an t !' un ific ati on . - Pr ior to u n~ ica tio n. • Pa ys do nt la po pu lat ion es t in fer ieu re a 1 m illio n d 'ha blt an ts. - Co un trie s w ith a po pu lat ion le ss tha n 1 m illio n. (0 0 Ta ble au 2a - Ta ble 2a Ta ux co m pa rat ifs de m or ta lite (p ou r 1 00 O OO ), to ut es c au se s, e t p ou rce nta ge de s p rin cip ale s c au se s de de ce s p ou r c er ta ins p ay s e n de ve lop pe me nt, 1 98 5- 19 89 (o u l a p eri od e la plu s r ec en te) Sta nd ard ize d de ath ra tes (p er 10 0 OO O), all c au se s, a nd p erc en tag e o f th e lea din g c au se s of de ath , f or so m e de ve lop ing co un trie s, 19 85 -1 98 9 (or the m os t r ec en t p eri od ) Ma lad ies de Tu me urs Ma lad ies in fec tie us es Ma lad ies Ca use s m al T r au m ati sm es et pu lm on air es Pa ys - Co un try Pe rio de /an ne e To ute s c au se s - All c au se s l'ap pa rei l c irc ula toi re m alig ne s et pa ras ita ire s em po iso nn em en ts (vio len ce) ch ron iqu es de fin ies Au tre s c au se s Pe rio d/y ea r Dis ea se s o f th e Ma lign an t Inf ec tio us an d Ill- de fin ed Dt he r c au se s pa ras ijic dis ea se s Inju ry a nd po iso nin g ( vio len ce) Ch ron ic pu lm on ary cir cu lat ory sy ste m ne op las ms dis ea se ca us es Ho mm es - Ma les Ta ux -R ate Ra ng -R an k % % % % Ra ng -R an k % % % AM ER IO UE L AT IN E ET C AR Ai BE S- LA TIN A ME RI CA A ND T HE C AR IBB EA N Do nn ee s f iab les - Re lia ble da ta Ar ge nti ne - Ar ge nti na 19 86 1 2 44 .9 9 48 .4 18 .7 5.0 7.2 6 2.0 Ch ili - Ch ile 19 85 -1 98 9 1 27 0.3 12 29 .7 17 .6 10 .7 11 .1 13 9.0 Co sta R ica 19 58 -1 98 9 11 47 .9 6 35 .7 22 .7 5.9 8.9 10 3.6 Cu ba 19 85 -1 98 9 96 4.9 2 44 .8 20 .7 7.7 0.2 Gu ate ma la 19 84 1 39 5.3 14 15 .0 8.5 9 Me xiq ue - Me xic o 19 86 1 2 00 .0 8 23 .7 10 .1 11 .4 15 .2 14 3.7 Po rto R ico - Pu er to Ri co 19 85 -1 98 9 11 08 .7 5 37 .1 17 .2 7.7 10 .7 11 0.6 Tr ini te ·e t· T ob ag o - Tr ini da d an d To ba go 19 86 1 3 78 .8 13 43 .8 13 .4 4.9 7.8 8 2.1 Ur ug ua y 19 85 -1 98 9 1 2 52 .3 10 38 .0 24 .6 4.2 6.9 4 7.2 Ve ne zu ela 19 85 -1 98 9 11 60 .8 7 31 .8 12 .2 8.5 10 .8 12 18 .5 Do nn ee s d efi cie nte s - De fic ien t d ata Ba ha ma s• 19 87 11 94 .8 30 .1 25 .2 7.4 10 .9 2.1 2.2 Ba rb ad e• -B ar ba do s• 19 88 1 2 11 .8 37 .9 21 .0 5.7 6.7 3.8 Be liz e• 19 86 80 9.4 29 .9 8.3 15 .3 10 .4 13 .0 Do m ini qu e• - Do m ini ca • 19 85 1 0 85 .5 39 .0 17 .4 7.4 6.9 4.0 El Sa lva do r 19 80 -1 98 4 1 3 72 .0 13 .4 3.6 8.7 22 .1 28 .2 Eq ua teu r - Ec ua do r 19 85 -1 98 9 1 2 34 .5 22 .8 11 .1 12 .5 11 .9 17 .0 M ar tin iqu e• 19 85 1 47 2.1 35 .1 20 .0 4.4 8.5 11 .3 Pa na ma 19 85 -1 98 9 88 0.6 34 .5 15 .3 7.8 11 .5 8.3 Pe ro u- Pe ru 19 80 -1 98 4 97 9.9 22 .2 10 .3 28 .3 8.8 Re p. do m ini ca ine - Do m ini ca n Re p. 19 85 11 51 .9 31 .1 8.3 9.8 7.9 19 .0 Sa int e· Lu cie •-S ain t L uc ia• 19 85 -1 98 9 1 6 50 .2 40 .3 13 .1 8.4 7.4 12 .4 Sa int -V inc en t-e t· G ren ad ine s• Sa int V inc en t a nd G ren ad ine s• 19 86 1 5 40 .1 42 .0 12 .7 3.5 5.9 9.1 Su rin am e• 19 85 1 5 57 .2 32 .3 8.4 8.9 12 .6 15 .7 AU TR ES R EG IO NS -O TH ER R EG IO NS ~ Do nn ee s f iab les - Re lia ble da ta ~ Ho ng K on g 19 85 -1 98 9 84 4.8 1 28 .3 30 .8 10 .9 5.0 2 10 .0 2.0 13 .1 s Isr ae l - Isr ae l 19 85 -1 98 9 98 3.1 3 43 .7 19 .0 4.6 7.2 5 4.1 6.1 15 .3 3· Ko we n - Ku wa it 19 85 -1 98 9 11 08 .1 4 43 .6 13 .8 8.2 7.5 7 2.0 8.9 16 .0 Bl Ma ur ice - M au riti us 19 85 -1 98 9 1 6 94 .1 15 50 .3 7.2 6.0 4.8 1 6.1 5.4 20 .0 ,. .. . Sin ga po ur - Sin ga po re 19 85 -1 98 9 1 2 56 .6 11 34 .5 22 .2 14 .5 5.3 3 10 .4 2.0 11 .2 [& Do nn ee s d efi cie nte s - De fic ien t d ata ~ - Ba hr ein •-B ah ra in• 19 87 1 2 20 .1 40 .0 11 .5 4.4 4.6 3.6 21 .0 14 .8 ,. .. . !(l Re p. de C ore e - Re p. of Ko rea 19 85 -1 98 9 1 42 6.2 32 .0 15 .1 4.5 7.3 2.8 25 .2 13 .2 ~ Sa o T om e et Pr in cip e" - 3 Sa o T om e an d Pr inc ipe • 19 87 1 6 44 .8 19 .9 4.2 15 .8 2.3 3.3 31 .3 23 .2 g Se yc he lle s• 19 85 -1 98 9 1 7 86 .1 32 .6 16 .0 13 .4 8.9 3.4 13 .6 10 .5 ?- Sr i L an ka 19 80 -1 98 4 1 2 74 .4 18 .6 4.3 8.4 10 .1 2.1 37 .3 19 .4 ~ Th a'i lan de - Th ail an d 19 80 1 3 31 .1 9.7 4.6 8.3 9.6 0.5 57 .2 10 .2 . . . . . . . . • Pa ys do nt la po pu lat ion es t in fer ieu re ii 1 m illio n d 'ha bit an ts. - Co un trie s w ith a po pu lat ion le ss tha n 1 m illio n. is ~ La so m m e de s p ou rce nta ge s p eu t d iffe rer de 10 0% a ca us e de s p eti ts no m bre s e t d es ar ro nd is. - Th e p erc en tag es m ay no t a dd up to 10 0% , b ec au se of sm all nu m be rs an d r ou nd ing . ~ Ta ble au 2b - Ta ble 2b § Ta ux c om pa ra tifs de m or ta lite (p ou r 1 OD O OO ), to ut es c au se s, e t p ou rce nta ge de s p rin cip ale s ca us es d e d ec es p ou r c er ta ins p ay s e n de ve lop pe me nt, 1 98 5- 19 89 (o u l a pe rio de la p lus re ce nte ) 13- St an da rdi ze d de ath ra tes (p er 10 0 OO O), all c au se s, a nd p erc en tag e of the le ad ing ca us es o f d ea th, fo r s om e de ve lop ing c ou nt rie s, 19 85 -1 98 9 (or the m os t r ec en t p er iod ) ~ Ma lad ies de Tu me ur s Ma lad ies in fec tie us es Ma lad ies Ca us es m al Au tre s ca us es . Q T r au m ati sm es et pu lm on air es Ot he r c au se s !ii Pa ys - Co un try Pe rio de /an ne e T o ute s ca us es - All c au se s l'a pp are il c irc ula toi re m ali gn es et pa ras ita ire s em po iso nn em en ts (vio len ce) ch ro niq ue s de fin ies ~ Pe rio d/y ea r Di se as es o f th e Ma lig na nt Inf ec tio us an d Inju ry an d po iso nin g (vio len ce) Ch ron ic pu lm on ary Ill- de fin ed - cir cu lat or y sy ste m ne op las ms pa ras itic d ise as es ca us es t dis ea se j Fe mm e - Fe ma les Ta ux - Ra te Ra ng - Ra nk % % % % Ra ng -R an k % % % AM ER IO UE LA TIN E ET C AR AI BE S- LA TIN A ME RI CA A ND T HE C AR IBB EA N Do nn ee s f iab les - Re lia ble da ta Ar ge nti ne - Ar ge nti na 19 86 81 1.2 7 51 .4 18 .2 5.3 3.9 7 1.9 Ch ili - Ch ile 19 85 -1 98 9 82 2.5 9 33 .9 21 .3 10 .7 4.5 11 9.5 Co sta R ica 19 58 -1 98 9 76 6.8 4 37 .0 23 .3 5.9 4.2 10 3.8 Cu ba 19 85 -1 98 9 77 2.7 5 47 .9 18 .7 7. 6 - 0.2 Gu ate ma la 19 84 11 62 .0 15 15 .6 2.2 1 Me xiq ue - Me xic o 19 86 87 2.0 11 28 .7 13 .6 12 .2 4.7 12 4.3 Po rto R ico - Pu ert o Ri co 19 85 -1 98 9 68 9.1 2 44 .1 16 .5 7.5 3.7 6 0.9 Tr ini te- et- To ba go - Tr ini da d an d T ob ag o 19 86 1 0 74 .8 14 44 .7 14 .5 5.0 3.3 4 3.1 Ur ug ua y 19 85 -1 98 9 78 9.4 6 43 .7 22 .2 5.0 3.9 8 6.5 Ve ne zu ela 19 85 -1 98 9 85 8.9 10 34 .9 14 .6 8.6 4.0 9 18 .5 Do nn ee s d efi cie nte s - De fic ien t d ata Ba ha ma s• 19 87 77 5.0 37 .0 18 .2 6.9 5.0 3.9 3.8 Ba rba de • - Ba rba do s• 19 88 75 6.8 39 .8 21 .5 4.0 2.9 3.2 Be lize • 19 86 63 1.6 35 .0 6.7 13 .6 3.7 13 .3 Do m ini qu e• - Do mi nic a a 19 85 74 6.9 50 .4 12 .4 5.6 0.5 6.3 El Sa lva do r 19 80 -1 98 4 87 9.7 15 .6 7.0 9.6 5.8 38 .2 Eq ua teu r - Ec ua do r 19 85 -1 98 9 95 9.2 24 .9 14 .2 12 .9 4.2 20 .2 M ar tin iqu e• 19 85 71 7.3 39 .6 21 .1 3.8 3.9 12 .2 Pa na ma 19 85 -1 98 9 67 5.8 38 .7 16 .7 7.7 4.1 8.8 Pe ro u- Pe ru 19 80 -1 98 4 86 1.1 24 .1 11 .7 28 .7 10 .2 Re p. do mi nic ain e - Do mi nic an R ep . 19 85 93 2.2 33 .8 8.6 9.6 2.7 21 .9 Sa int e- Lu cie •- Sa int Lu cia • 19 85 -1 98 9 1 0 86 .4 46 .7 11 .4 6.9 1.9 13 .7 Sa int -V inc en t-e t-G re na din es •- Sa int V inc en t a nd G ren ad ine s• 19 86 11 07 .2 46 .8 15 .3 3.5 2.5 8.9 Su rin am e• 19 85 96 5.5 31 .5 13 .2 6.8 6.3 20 .6 AU TR ES R EG IO NS -O TH ER R EG IO NS Do nn ee s f iab les - Re lia ble da ta Ho ng K on g 19 85 -1 98 9 52 0.2 1 3.2 3 27 .4 9.3 4.7 13 6.6 3.7 16 .0 Isr ae l - Isr ae l 19 85 -1 98 9 75 9.2 3 44 .5 20 .0 5.0 5.3 14 2.9 5.1 17 .2 Ko we it - Ku wa it 19 85 -1 98 9 89 5.1 12 42 .2 13 .0 7. 6 3.0 2 1.1 15 .9 16 .8 Ma uri ce - Ma ur itiu s 19 85 -1 98 9 1 0 31 .9 13 51 .4 9.0 5.9 3.5 5 4.3 5.6 20 .3 Sin ga po ur - Sin ga po re 19 85 -1 98 9 81 2.8 8 39 .6 20 .0 14 .1 3.3 3 4.9 2.8 15 .3 Do nn ee s d efi cie nte s - De fic ien t d ata Ba hre in• - Ba hra in• 19 87 1 0 78 .2 32 .1 7.7 3.3 1. 7 1.8 32 .9 20 .4 Re p. de C ore e - Re p. of Ko rea 19 85 -1 98 9 71 0.2 35 .1 12 .8 3.7 5.1 2.6 30 .2 10 .5 Sa o T om e et Pr inc ipe • - Sa o T om e an d Pr inc ipe " 19 87 1 0 89 .6 28 .B 3.4 17 .0 1.3 2.3 30 .6 16 .6 Se yc he lle s• 19 85 -1 98 9 11 00 .2 32 .7 15 .2 12 .3 2.7 3.1 23 .3 8.8 Sr i L an ka 19 80 -1 98 4 1 0 11 .7 13 .6 5.5 8.0 4.7 2.5 47 .8 18 .5 Th aT ian de - Th ail an d 19 80 88 6.1 8.3 4.7 7.0 3.9 0.2 66 .5 9.3 • Pa ys do nt la po pu lat ion es t in fer ieu re ii 1 m illio n d'h ab ita nts . - Co un trie s w rth a po pu lat ion le ss th an 1 m illio n. La so m m e de s p ou rce nta ge s p eu t d iffe re r d e 1 00 % a ca us e de s p eti ts no m bre s e t d es ar ro nd is. - Th e pe rce nta ge s m ay n ot ad d up to 1 00 % b ec au se of sm all n um be rs an d ro un din g. Tableau 3 Repartition des pays selon le rang attribue aux deces violents (traumatismes et empoisonnements) parmi les cinq principaux groupes de causes de deces pour 33 pays developpes et 31 pays en developpement durant la periode 1985-1989 (ou la periode la plus recente pour laquelle les donnees sont disponibles) Table 3 Ranking of countries according to violent deaths (injury and poisoning) in relation to the five main groups of causes of death, for 33 developed and 31 developing countries during the period 1985-1989 (or the most recent period for which data were available) Developed countries Developing countries Pays developpes Pays en developpement Reliable data Data not reliable Rank - Rang Donnees fiables Donnees deficientes M• F• M F M F 1 0 0 0 0 1 0 2 0 0 1 0 3 0 3 26 21 8 1 9 2 4 4 9 1 9 4 13 5 3 3 3 3 1 3 Number of countriesb Nombre de paysb 33 33 13 13 18 18 a M: masculin -males; F: feminin - females. b Le nombre total de pays correspond au nombre de pays pour lesquels !'information sur les causes de deces etait disponible. -The total number of countries corresponds to the number of countries for which data were available. difficile. Le rang des deces par violence peut etre trompeur dans la mesure ou l'on n'a pas d'information sur les maladies pulmonaires obs- tructives chroniques pour tousles pays d'Ameri- que latine et des Caraibes. Dans les pays a donnees fiables, les causes violentes sont le plus souvent la troisieme cause de deces chez les hommes et la quatrieme chez les femmes, pour lesquelles les maladies infectieuses et parasitaires devancent en- core les causes violentes. La distribution pour les pays a donnees deficientes est donnee uniquement a titre indicatif. C/assement des pays selon le niveau de la mortalite generale et selon /'importance des deces dus a Ja violence La mortalite genera le. Les tabl.eaux 1 a et 1 b font appa- raitre, pour la mortalite toutes causes, le rang des 34 pays developpes, par ordre croissant de mortali- te. Les tabl.eaux 2a et 2b donnent un classement du meme type pour les 15 pays en developpement a donnees fiables. Pour illustrer ce classement, nous avons porte sur les figures 1 a 4 les taux comparatifs de mortalite generate de chacun des pays en rela- tion avec le pourcentage de deces violents pour chaque sexe. Pour les pays developpes (figures 1 et 2), on retrouve les indices de mortalite generate les plus faibles aujapon, en Suisse, et en Islande, pour les deux sexes et on peut aussi mentionner la Grece et l'Espagne pour les hommes et la France et le Canada pour les femmes. Par ailleurs, on note une situation nettement defavorable (taux comparatifs de mortalite les plus eleves) dans les pays d'Euro- pe de l'Est (pays industriels anciennement a eco- 12 nomie planifiee), autant chez les hommes, en par- ticulier en Hongrie, Pologne, Union Sovietique, Tchecoslovaquie, Roumanie, et Bulgarie, que chez les femmes, en particulier en Roumanie, Bulgarie, Hongrie, Tchecoslovaquie, Yougoslavie, et en Union Sovietique. La mortalite generate est globa- lement environ deux fois plus elevee dans les pays les moins favorises que dans les pays les plus favori- ses; des disparites importantes subsistent done en- core entre les 34 pays dits developpes. Elles pro- viennen ten bonne partie de l'existence d'une mortalite differentielle importante en Europe en- tre pays de l'Ouest et pays de l'Est. Dans les pays en developpement (figures 3 et 4), la situation est egalement loin d'etre homogene puisqu'on y retrouve des ecarts de mortalite qui vont du simple au double, chez les deux sexes. On doit toutefois noter que les donnees sont moins directement comparables pour ce groupe de pays, car les periodes de disponibilite des donnees va- rient davantage que dans les pays developpes. Les pays en developpement a donnees fiables les plus favorises sont Hong Kong, Porto Rico, Israel, et Costa Rica, pour les deux sexes, auxquels on peut ajouter le Koweit et le Venezuela pour les hommes et l'Uruguay pour les femmes. A l'autre extre- me du classement, on retrouve le Guatemala, Mau- rice, et Trinite-et-Tobago. Les pays en developpe- ment dont Jes donnees sont deficientes apparais- sent aussi sur Jes figures 3 et 4 a titre indicatif seule- ment (ils sont identifies par un asterisque). On constate que pour plusieurs pays en deve- loppement, le niveau de la mortalite est compara- ble a celui de plusieurs pays developpes; ainsi, la situation est beaucoup moins contrastee que ce a quoi on pouvait s'attendre entre pays develop- Rapp. trimest statist. sanit. mond., 46 (1993) Fig. 1 Relation entre la mortalite generale et le pourcentage de deces violents chez les hommes, pays developpes, 1985-1989 Relationship between crude death rate and percentage of violent deaths, males, developed countries, 1985-1989 U) t CL> -,:, E CL> ~ ~ E ~ ·s: U) ,Cl.) 0 ·CL> -,:, CL> -,:, ~ Fig. 2 25 20 15 F~A FIN URS ,-, SUi • rr - • ·-- - USA ~ i - JA~ :~ NNOAII DA BEL LUX YOU ROU POL • SUE ~gtA lkrll • • •• • GREmj 11 • ESP ·-· . IRN~~O UUL TCH • ,.. ...... IHL• I 10 5 MAL 0 800 1000 1200 1400 Taux comparatif tous ages (pour 100 OOO) Standardized death rate (per 100 OOO) - all ages HON - 1600 1800 Relation entre la mortalite generale et le pourcentage de deces violents chez les femmes, pays developpes, 1985-1989 Relationship between crude death rate and percentage of violent deaths, females, developed countries, 1985-1989 10 9 8 U) 7 .<:: m CL> -,:, E 6 :§ -u, > ~ 5 II ~ c: .!!! 4 0 ·s: U) ·CL> 0 ·CL> 3 -,:, CL> -,:, ~ 2 0 400 500 Wld hlth statist. quart., 46 (1993) FAA • SUi • DiN ·-· II • BEL ' ·~ FINIIC LIT T,. , ,,v su.91 I • - URs' • CAN.A 111~ USA •NZE ISL • .. .. RFA • POR El • HOL. ~o P~Lyr, I ITA .GI E ·-· II ESI AN3 .IH -. • • BUL • - - MA,- • 600 700 800 900 Taux comparatif tous ages (pour 100 OOO) Standardized death rate (per 100 OOO) - all ages ROU • 1000 1100 1200 13 Fig. 3 Relation entre la mortalite generale et le pourcentage de deces violents chez les hommes, pays en developpement, 1985-1989 Relationship between crude death rate and percentage of violent deaths, males, developing countries, 1985-1989 Fig. 4 23 22 21 20 19 .,, 18 'i 17 ~ 16 J 15 * 14 13 ! 12 j 11 ti 10 ~ 9 8 7 6 5 4 3 2 BI L' • - ·- - - 800 - - ·"tlf •• SUR' I:~ • • ~AN VENu:_ - u, -PUE• ••• -::. c cTHA u~u - • GlA MAR' ""' -KbW ':, ·-· TAii • -"'" • -· - EAR'ili'_U -• •su · --··- I• c!l'M .... COR' ,;, .:'....."' BAH'• - MPIU • • C:AI"\' • 900 1 OOO 1100 1200 1300 1400 1500 1600 1700 1800 Taux comparatif tous ages (pour 100 OOO) Standardized death rate (per 100 OOO) - all ages Relation entre la mortalite generale et le pourcentage de deces violents chez les femmes, pays en developpement, 1985-1989 Relationship between crude death rate and percentage of violent deaths, females, developing countries, 1985-1989 Cl) ..c:. "la "' "C E 1 .ft I j!l c ~ ·;; -21 . .,, "C "' "C * 14 9 8 7 6 5 4 3 2 9 400.0 . .. - .- 500.0 SUR• SAL* • ISR • coR· •f!.A~ • I• . ·-· '"'' . - I.JMI • cos • • Eau· PAN" MAR· ·- ARG V5..N _ • ......... • • • URL 1• -lW MAU TRI PUI s~· • • • c,,~, • i:inrv "'' Iv• • KO N. !~G· - "' ' . BAE·.- • c,11,r.• DOM• • 600.0 700.0 800.0 900.0 1000.0 1100.0 Taux comparatif tous ages (pour 100 OOO) Standardized death rate (per 100 OOO) - all ages GUA • 1200.0 Rapp. trimest. statist. sanit. mond., 46 (1993) pes et pays en developpement. 11 faut cependant mentionner que }'absence, dans la banque de donnees utilisee, des pays en developpement les moins favorises biaise la comparaison entre ces deux types de pays. La mortalite violente. La comparaison des pays selon l'importance de la mortalite violente est interes- sante d'une part, pour identifier les problemes particuliers a certains pays et d'autre part, pour voir s'il existe un lien entre des indicateurs de la mortalite generale et de la mortalite violente. En Europe, quelques pays ressortent pour l'importance relative de la mortalite violente; la Finlande, la France, la Hongrie, l'ex-URSS, la Suisse, I' Autriche, le Portugal et l 'Islande sont des pays oil, relativement aux autres pays, ii y a une plus forte proportion de deces violents chez les hommes (figure 1). Pour le sexe feminin, on note une mortalite violente plus elevee en France, en Suisse, en Hongrie et au Danemark (figure 2). Par ailleurs, certains pays se denotent plutot par leur bon classement; on retrouve une proportion relativement moindre de deces violents chez les hommes dans les pays suivants: Malte, Angleterre et pays de Galles, Pays-Bas et Irlande. En ce qui a trait aux femmes, les situations les plus favorables se retrouvent a Malte, en Bulgarie, en Angleterre et au pays de Galles, en Roumanie, en Irlande et en Espagne. On aura remarque que, pour le pourcentage de deces violents, le clivage entre les pays d'Europe de l'Ouest et d'Europe de l'Est est beaucoup moins evident qu'il ne l'est sur la base des taux comparatifs de mortali- te generale. Pour les pays en developpement (figures 3 et 4), la mauvaise qualite generate des donnees nous empeche de dresser un classement sembla- ble a celui utilise pour les pays developpes. L'importance relative des deces violents est souvent biaisee par la presence des deces pour causes mal definies dont la proportion varie beaucoup d'un pays a l'autre et est parfois tres importante. Pour les quinze pays a donnees relativement fiables, on remarque une plus forte proportion de deces violents en Amerique latine; ce phenomene a deja ete mis en evidence (7). En effet, la violence est elevee dans cette region, sur- tout pour le sexe masculin et plus particuliere- ment au Mexique, au Chili, au Venezuela et a Porto Rico. Bien sur, le cas du Salvador se demar- que des autres avec 22% de deces violents chez les hommes et pres de 6% chez les femmes et doit etre souligne malgre la mauvaise qualite des donnees; ii semble bien exister un probleme par- ticulier dans ce pays ou I' on retrouve une forte mortalite par suicide et par homicide. D'ailleurs, le probleme est de taille en Ameri- que latine car la proportion relative des deces violents surpasse meme celle de la majorite des pays developpes. Wld hlth statist. quart., 46 (1993) Relation entre mortalite generale et mortalite violente. En reponse a la question evoquee plus haut con- cemant }'existence d'un lien entre le niveau de la mortalite generate et l'importance relative de la mortalite violente, ii apparait clairement (surtout chez les hommes) qu'il n'existe pas de rela- tion statistique significative entre les deux indica- teurs; ainsi, ce n'est pas forcement dans les pays a faible mortalite generate que l'on retrouve une plus forte proportion relative de deces vio- lents. De fait, selon la theorie de la transition epi- demiologique, a mesure que le niveau de la morta- lite generale diminue, le profil de la mortalite par cause se modifie: ainsi, une forte mortalite genera- te est souvent associee a une predominance des deces par maladies dites de civilisation, soit les maladies cardio-vasculaires, les tumeurs malignes et les causes violentes. Bien que les resultats obte- nus n'aillent pas dans le sens attendu, cela ne remet pas necessairement en cause la theorie de la transition epidemiologique puisque I' on utilise dans cet exemple des pays qui presentent des dif- ferences importantes sur le plan social, politique et economique et que les donnees utilisees ont un caractere transversal. Cependant, les resultats ne vont pas dans le sens attendu. Les figures 1 et 2 laissent toutefois apparaitre certains regroupe- ments de pays; nous tenterons plus loin de retrou- ver ces regroupements et de les caracteriser a l'aide d'une methode de classification auto- matique. Les composantes de la mortalite violente Pour analyser la mortalite violente et mieux com- prendre les differences de niveau que nous avons mises a jour precedemment, nous allons decom- poser cette mortalite en trois sous-ensembles de causes definies par rapport a }'intention: causes non intentionnelles, causes intentionnelles, causes a intention indeterminee. Les taux comparatifs detailles sont presentes aux tab/,eaux 4a et 4b (pays developpes) et 5a et 5b (pays en developpement); les repartitions en pourcentage calculees a partir de ces taux apparaissent aux tab/,eaux 6a et 6b, pour les pays developpes et aux tab/,eaux 7a et 7b, pour les pays en developpement. Rappelons que la qualite des donnees, meme dans les pays developpes, peut etre variable en particulier en ce qui conceme les deces par suici- de. 11 est connu que certains pays ( entre autres, les pays oil la religion catholique est predominan- te) ont tendance a classer ces deces soit parmi les causes non intentionnelles, soit parmi les causes a intention indeterminee. Ainsi, les ecarts de morta- lite observes peuvent tenir a des facteurs autres que des differences de comportement. De fait, la proportion de deces pour des causes oil }'inten- tion est indeterminee est tres variable: de moins de 1 % a environ 6%, avec quelques situations ex- ceptionnelles oil la proportion atteint plus de 15 0 , Ta ble au 4a - Ta ble 4a Ta ux c om pa ra tifs de m or ta lite (p ou r 1 00 OO O) po ur les p rin cip ale s c au se s de d ec es p ar vio len ce p ou r c er ta ins p ay s d ev elo pp es , 1 98 5- 19 89 (o u l a pe rio de la p lus re ce nte ) St an da rdi ze d de ath ra tes (p er 10 0 O OO ), fo r t he le ad ing ca us es o f d ea th by vi ole nc e in so m e de ve lop ed c ou nt rie s, 19 85 -1 98 9 ( or th e m os t r ec en t p eri od ) Ca use s n on in ten lio nn ell es - Un int en tio na l c au se s Ca use s in ten tio nn ell es - Int en tio na l c au se s Ve hic ule s a No ya de s, Pe rio de /an ne e To tal Ta ux m ote ur Em po iso nn em en ts Ch ute s su bm ers ion Au tre s c au se s Ta ux Int en tio n i nd ete rm ine e Pa ys - Co un try Mo tor Su icid e Ho mi cid e Un de ter mi ne d w he the r Pe rio d/y ea r vio len ce Ra te ve hic le Po iso nin g Fa lls Dr ow nin g, Ot he r c au se s Ra te int en tiO na l o r n ot Ho mm es - Ma les ac cid en ts su bm ers ion EU RO PE Al lem ag ne •-G en na ny • 19 85 -1 98 9 65 .1 36 .9 17 .5 0.3 10 .0 1.3 7.9 26 .0 24 .7 1.2 2.3 Au tric he - Au str ia 19 85 -1 98 9 10 5.0 64 .0 27 .9 1.1 18 .3 2.4 14 .1 39 .9 38 .5 1.4 0.9 Be lgi qu e - Be lgi um 19 86 87 .5 53 .0 29 .7 1.7 10 .3 2.7 8.5 32 .4 30 .1 2.3 2.1 Fr an ce 19 85 -1 98 9 10 5.6 66 .9 25 .7 1.0 14 .8 2.4 23 .2 33 .6 32 .1 1.4 5.1 lrl an de -I re lan d 19 85 -1 98 9 62 .4 45 .3 19 .7 1.6 9.3 3.5 11 .9 14 .3 13 .1 1.2 3.2 Lu xe m bo ur gb 19 85 -1 98 9 95 .5 65 .9 31 .2 0.0 17 .4 1.7 9.4 25 .5 23 .9 1.6 3.5 Pa ys -B as - Ne the rla nd s 19 85 -1 98 9 46 .1 29 .8 13 .3 0.6 9.3 1.3 5.4 15 .3 14 .1 1.2 1.0 Ro ya um e-U ni - Un ite d Ki ng do m: An gle ter re et Ga lle s - En gla nd an d W ale s 19 85 -1 98 9 44 .8 27 .3 12 .7 1.5 5.7 0.8 6.8 12 .6 11 .8 0.8 4.9 Ec os se - Sc otl an d 19 85 -1 98 9 68 .8 44 .3 15 .9 1.5 12 .0 1.9 13 .0 19 .3 15 .9 3.4 5.2 lrla nd e du N or d - No rth er n Ire lan d 19 85 -1 98 9 68 .3 43 .4 18 .4 3.3 11 .3 1.8 8.0 21 .9 12 .2 9.3 3.0 Su iss e - Sw itz erl an d 19 85 -1 98 9 92 .6 56 .4 21 .2 2.1 18 .9 1.8 12 .2 33 .4 32 .3 1.1 2.8 Da ne m ar k- De nm ark 19 85 -1 98 9 88 .2 48 .9 18 .8 4.2 16 .3 1.2 8.9 35 .7 34 .3 1.4 3.9 Fin lan de - Fin lan d 19 85 -1 98 9 13 0.6 78 .2 16 .6 17 .4 18 .7 5.4 20 .5 48 .6 42 .9 4.1 4.3 lsl an de b- ice lan db 19 85 -1 98 9 79 .4 51 .0 17 .7 5.3 4.5 3.4 24 .5 26 .7 26 .1 0.6 1.8 No ive ge - No rw ay 19 85 -1 98 9 80 .2 56 .5 13 .9 3.8 17 .7 4.0 17 .0 23 .1 21 .5 1.6 0.7 Su ed e - Sw ed en 19 85 -1 98 9 74 .0 38 .7 13 .0 2.9 10 6 1.7 10 .3 26 .6 24 .9 1. 7 8.6 Es pa gn e - Sp ain 19 86 65 .3 50 .8 24 .7 1.3 3.4 3.5 17 .9 13 .1 11 .4 1.7 1.5 Gr ec e - Gr ee ce 19 85 -1 98 9 65 .6 57 .8 29 .3 0.4 7.2 4.0 16 .8 6.9 5.7 1.2 0.8 lta lie -I tal y 19 85 -1 98 9 63 .8 48 .5 23 .6 1.0 13 .3 1.9 8.8 14 .1 11 .6 2.5 1.2 M all e b -M an a b 19 85 -1 98 9 40 .1 32 .9 6.5 0.0 5.9 0.6 11 .0 2.1 2.1 0.0 1.9 Po rtu ga l 19 85 -1 98 9 10 8.6 74 .3 42 .8 0.6 13 .4 2.8 14 .9 17 .2 14 .9 2.3 17 .5 Yo ug os lav ie - Yu go sla via 19 85 -1 98 9 92 .5 62 .5 27 .1 1.7 8.3 3.7 21 .8 28 .6 26 .2 2.3 1.4 Ex -R ep ub liq ue d em oc ra tiq ue al lem an de - Ex -G erm an D em oc ra tic R ep ub lic 19 85 -1 98 9 15 .7 5.1 14 .6 3.1 Bu lga rie - Bu lga ria 19 85 -1 98 9 94 .7 66 .3 18 .1 5.6 9.9 6.8 26 .3 27 .5 23 .5 4.0 1.0 l Ho ng rie - Hu ng aiy 19 85 -1 98 9 16 5.8 95 .4 25 .6 4.4 35 .3 5.4 25 .0 70 .0 66 .4 3.5 0.7 Po log ne - Po lan d 19 85 -1 98 9 11 8.4 82 .9 26 .0 13 .0 14 .6 6.5 22 .8 25 .6 23 .1 2.5 9.9 , :, Ro um an ie - Ro ma nia 19 80 -1 98 4 10 6.3 s Tc he co slo va qu ie - Cz ec ho slo va kia 19 85 -1 98 9 10 8.5 72 .8 16 .7 5.4 25 .6 5.3 19 .9 31 .6 30 .3 1.3 4.1 ~ - Ex -U RS S - Fo rm er U SS R 19 87 15 0.1 22 .0 22 .2 5.4 11 .3 44 .2 35 .2 9.0 !il. AU TR ES R EG IO NS -O TH ER R EG IO NS ~ Au str ali e - Au str ali a 19 85 -1 98 9 72 .2 48 .1 25 .1 1.5 7.4 3.0 11 .5 23 .2 20 .6 2.5 1.0 ~ Ca na da 19 85 -1 98 9 77 .6 50 .6 21 .5 2.2 9.6 2.6 15 .0 24 .5 21 .7 2.7 2.6 ,. .. . ~ Et ats -U nis d 'Am er iqu e - 1.8 Un ite d St ate s o f A m er ica 19 85 -1 98 9 90 .3 55 .1 26 .4 3.1 6.1 2.9 16 .5 33 .4 20 .8 12 .4 ;::.. .- Ja po n - Ja pa n 19 85 -1 98 9 66 .7 37 .5 16 .2 0.8 4.9 3.8 11 .8 26 .3 25 .4 0.9 2.9 3 No uv ell e- Ze lan de - Ne w Ze ala nd 19 85 -1 98 9 84 .6 60 .7 30 .5 0.9 10 .8 3.8 14 .5 22 .3 19 .7 2.6 1.5 g ?- • Av an t l' un ific ati on . - Pr ior to u nif ica tio n. t b Pa ys do nt la po pu lat ion es t in fer ieu re a 1 m illio n d'h ab tta nts . - Co un trie s w ith a po pu lat ion le ss tha n 1 m illio n. I La so m m e de s p ou rce nta ge s p eu t d iffe rer de 10 0% a ca us e de s p ett ts no m bre s e t d es ar ro nd is. - Th e p erc en tag es m ay no t a dd up to 10 0% be ca us e o f s m all nu m be rs an d r ou nd ing . ~ Ta ble au 4b - Ta ble 4b :: ,- § Ta ux c om pa ra tifs de m or ta lite (p ou r 1 00 OO O) po ur le s p rin cip ale s c au se s de d ec es p ar vio len ce p ou r c er ta ins p ay s d ev elo pp es , 1 98 5- 19 89 (o u la p eri od e la plu s re ce nte ) ~ St an da rdi ze d de ath ra tes (p er 10 0 OO O), fo r t he le ad ing ca us es o f d ea th by vi ole nc e in so m e de ve lop ed co un trie s, 19 85 -1 98 9 (or the m os t r ec en t p eri od ) 5i- ,.... . Q Ca use s n on in ten tio nn ell es - Un int en tio na l c au se s Ca use s in ten tio nn ell es - Int en tio na l c au se s 1.1 .~ Ve hlc ule s a No ya de s, Pe rio de /an ne e To tal Ta ux m ote ur Em po iso nn em en ts Ch ute s su bm ers ion Au tre s c au se s Ta ux Int en tio n i nd ete rm ine e ~ Pa ys - Co un t,y Pe rio d/y ea r vio len ce Ra te Mo tor Po iso nin g Fa lls Dr ow nin g, Ot he r c au se s Ra te Su icid e Ho mi cid e Un de ter mi ne d w he ter j ve hic le su bm ers ion int en tio na l o r n ot Fe mm es - Fe ma les ac cid en ts EU RO PE Al lem ag ne • - Ge rm an y• 19 85 -1 98 9 29 .8 18 .2 6.2 0.1 8.5 0.4 2.9 10 .5 9.5 1.0 1.0 Au tric he - Au str ia 19 85 -1 98 9 41 .2 26 .4 8.1 0.5 13 .4 0.7 3.6 14 .3 13 .1 1.2 0.5 Be lgi qu e - Be lgi um 19 86 42 .1 25 .8 9.9 1.6 9.8 0.9 3.6 15 .3 13 .3 2.0 1.1 Fr an ce 19 85 -1 98 9 47 .3 32 .8 9.0 0.5 13 .7 0.6 9.0 12 .6 11 .7 0.9 2.0 lrta nd e - Ire lan d 19 85 -1 98 9 26 .7 20 .5 6.3 0.7 8.5 0.5 5.3 5. 2 4.4 0.8 1.3 Lu xe m bo ur gb 19 85 -1 98 9 40 .0 26 .5 7.6 0.0 11 .2 0.0 3.7 8.6 8.6 0.0 2.2 Pa ys -B as - Ne the rla nd s 19 85 -1 98 9 25 .1 16 .1 5.2 0.2 8.2 0.4 2.3 8.5 7.9 0.6 0.5 Ro ya um e-U ni - Un ite d Ki ng do m: An gle ter re et Ga lle s - En gla nd an d W ale s 19 85 -1 98 9 21 .3 13 .6 4.7 0.8 4.8 0.3 3.0 5.1 4.5 0.6 2.7 Ec os se - Sc otl an d 19 85 -1 98 9 32 .2 22 .4 5.7 0.6 10 .6 0.2 5.2 7.5 5.8 1.7 2.1 lrla nd e du N or d - No rth er n Ire lan d 19 85 -1 98 9 27 .8 20 .7 6.5 1.7 8.6 0.0 3.0 5. 4 4.5 0.9 1.0 Su iss e - Sw itz erl an d 19 85 -1 98 9 42 .2 27 .3 6.4 0.7 15 .2 0.7 4.4 13 .6 12 .4 1.2 1.2 Da ne ma rk - De nm ark 19 85 -1 98 9 50 .7 27 .9 7.7 2.1 14 .9 0.3 3.3 20 .1 18 .9 1.2 3.0 Fin lan de - Fin lan d 19 85 -1 98 9 39 .1 24 .7 6.9 2.9 9.9 0.9 4.7 13 .3 11 .0 1.8 1.5 lsl an de b - lce lan db 19 85 -1 98 9 26 .9 16 .8 8.4 0.0 3.9 0.0 1.3 11 .5 10 .8 0.7 0.0 No rve ge - No rw ay 19 85 -1 98 9 33 .2 24 .0 5.4 1.0 13 .8 0.7 3.4 9.0 7.8 1.2 0.4 Su ed e - Sw ed en 19 85 -1 98 9 30 .9 16 .0 5.2 0.5 7.0 0.3 2.9 11 .1 10 .2 0.9 3.6 Es pa gn e - Sp ain 19 86 20 .0 15 .7 7.4 0.5 1.6 0.7 5.5 4. 0 3.5 0.5 0.4 Gr ec e - Gr ee ce 19 85 -1 98 9 28 .2 25 .1 8.9 0.2 5.5 1.1 9.3 2. 8 2.1 0.7 0.3 lta lie - Ita ly 19 85 -1 98 9 27 .5 22 .5 6.7 0.5 12 .3 0.4 2.7 4. 5 4.0 0.5 0.4 Ma lte b - Ma lta b 19 85 -1 98 9 14 .9 14 .4 1.1 0.0 7.1 0.0 1.8 0.5 0.5 0.0 0.0 Po rtu ga l 19 85 -1 98 9 33 .5 22 .6 10 .3 0.2 7.0 0.6 4.7 5. 3 4.6 0.7 5.7 Yo ug os lav ie - Yu go sla via 19 85 -1 98 9 33 .4 21 .4 7.3 0.7 6.2 1.0 6.3 11 .3 10 .1 1.2 0.6 Ex -R ep ub liq ue d em oc ra tiq ue al lem an de - Ex -G erm an D em oc ra tic R ep ub lic 19 85 -1 98 9 5.4 3.1 11 .3 1.1 Bu lga rie - Bu lga ria 19 85 -1 98 9 28 .6 18 .2 5.9 1.2 2.9 1.2 7.1 10 .2 8.6 1.6 0.4 Ho ng rie - Hu ng ary 19 85 -1 98 9 71 .7 46 .8 7.8 1.6 29 .5 0.9 7.3 24 .8 22 .7 2.1 0.3 Po log ne - Po lan d 19 85 -1 98 9 34 .6 26 .5 6.2 3.0 9.7 1.2 6.4 5. 7 4.5 1.2 2.2 Ro um an ie - Ro ma nia 19 80 -1 98 4 34 .9 Tc he co slo va qu ie - Cz ec ho slo va kia 19 85 -1 98 9 50 .4 39 .1 5.0 2.3 25 .5 1.3 5.1 9.9 8.8 1.1 1.3 Ex -U RS S - Fo rm er US SR 19 87 43 .0 6.2 6.4 2.4 2.7 13 .0 9.3 3.7 AU TR ES R EG IO NS -O TH ER R EG IO NS Au str ali e - Au str ali a 19 85 -1 98 9 28 .0 20 .3 10 .2 0.9 5.5 0.8 3.1 7. 3 5.7 1.6 0.4 Ca na da 19 85 -1 98 9 30 .2 21 .7 8.9 1.0 6.5 0.6 4.8 7. 5 6.1 1.4 1.1 Et ats -U nis d 'Am er iqu e - Un tte d St ate s o f A m er ica 19 85 -1 98 9 31 .2 21 .3 10 .5 1.2 3.2 0.7 5.8 9.2 5.3 3.9 0.6 Ja po n - Ja pa n 19 85 -1 98 9 27 .5 12 .8 5.2 0.4 2.0 1.5 3.9 13 .4 12 .8 0.6 1.2 No uv ell e- Ze lan de - Ne w Ze ala nd 19 85 -1 98 9 37 .0 28 .3 13 .5 0.2 9.4 0.9 4.2 7. 7 6.3 1.4 1.1 • Av an t l' un ~ic ati on . - Pr ior to u nif ica tio n. • Pa ys do nt la po pu lat ion es t in fer ieu re a 1 m illio n d 'ha bit an ts. - Co un trie s w ith a po pu lat ion le ss tha n 1 m illio n. La so m m e de s p ou rce nta ge s p eu t d iffe rer de 10 0% a ca us e de s p et~ s n om bre s e t d es ar ro nd is. - Th e p erc en tag es m ay n ot ad d u p t o 10 0% be ca us e o f s m all nu m be rs an d r ou nd ing . ~ 00 Ta ble au 5a - Ta ble 5a Ta ux co m pa rat ifs de m or ta lite (p ou r 1 00 OO O) po ur les p rin cip ale s c au se s de d ec es p ar vio len ce p ou r c er tai ns p ay s e n de ve lop pe me nt, 1 98 5- 19 89 (o u l a p eri od e la plu s r ec en te) St an da rdi ze d de ath ra tes (p er 10 0 OO O), fo r t he le ad ing ca us es o f d ea th by vi ole nc e in so m e de ve lop ing co un trie s, 19 85 -1 98 9 (or the m os t r ec en t p er iod ) Ca us es no n int en tio nn ell es - Un int en tio na l c au se s Ca us es in te nt ion ne lle s- Int en tio na l c au se s Int en tio n Ve hic ule s a No ya de s, ind ete rm ine e Pa ys /zo ne - Co un try /ar ea Pe rio de /an ne e To tal vi ole nc e Ta ux m ote ur Em po iso nn em en ts Ch ute s su bm ers ion Au tre s ca us es Ta ux Su icid e Un de ter mi ne d Pe rio d/y ea r Ra te M oto r v eh icl e Po iso nin g Fa lls Dr ow nin g, Ot he r c au se s Ra te Ho mi cid e w he the r Ho mm es - Ma les ac cid en ts su bm ers ion int en tio na l o r no t AM ER IO UE L AT IN E ET C AR AiB ES -L AT IN A ME RI CA A ND T HE C AR IBB EA N Do nn ee s t iab les - Re lia ble da ta Ar ge nti ne - Ar ge nti na 19 86 89 .9 57 .8 17 .1 1.0 5.5 6.2 28 .0 25 .3 14 .0 10 .0 6.8 Ch ili - Ch ile 19 85 -1 98 9 14 1.3 49 .3 13 .3 0.2 7.4 1.5 27 .0 17 .9 11 .7 6.2 73 .9 Co sta R ica 19 85 -1 98 9 10 2.7 79 .9 30 .0 1.9 22 .6 10 .0 15 .9 20 .8 12 .1 8.7 3.6 Cu ba 19 85 -1 98 9 10 9.5 Gu ate ma la 19 84 11 8.9 2.1 1.8 Me xiq ue - Me xic o 19 86 18 1.7 12 3.2 34 .4 1.9 12 .7 9.5 64 .7 53 .9 5.3 48 .6 4. 6 Po rto R ico - Pu ert o Ri co 19 85 -1 98 9 11 8.6 58 .2 33 .2 2.7 7.0 5.1 10 .1 51 .9 18 .5 33 .4 8. 7 Tr ini te- et- To ba go - Tr ini da d an d T ob ag o 19 86 10 8.1 63 .4 28 .1 1.6 7.5 11 .2 15 .0 28 .7 14 .2 12 .8 16 .0 Ur ug ua y 19 85 -1 98 9 86 .0 64 .8 14 .6 1.5 5.4 7.9 35 .2 21 .0 16 .0 4.9 0.0 Ve ne zu ela 19 85 -1 98 9 12 5.1 93 .9 49 .3 2.0 13 .0 7.0 22 .6 28 .0 10 .9 16 .9 3.1 Do nn ee s d eti cie nte s - De fic ien t d ata Ba ha ma s• 19 87 13 0.7 70 .3 26 .6 4.4 1.7 18 .6 19 .0 18 .8 2.6 16 .2 41 .7 Ba rba de • - Ba rba do s• 19 88 81 .4 54 .6 22 .2 0.7 10 .3 15 .0 6.4 19 .1 9.1 10 .0 7. 7 Be liz e• 19 86 83 .9 81 .8 15 .4 0.5 23 .8 42 .0 2.1 2.1 0.0 0.0 Do mi niq ue • - Do mi nic a• 19 85 74 .4 72 .3 13 .9 9.1 12 .8 5.4 31 .0 2.1 0.0 2.1 0.0 El Sa lva do r 19 80 -1 98 4 30 3.4 10 5.1 33 .1 9.6 13 .2 9.8 39 .2 12 7.5 22 .5 10 5.0 Eq ua teu r - Ec ua do r 19 85 -1 98 9 14 6.7 11 4.2 42 .2 3.0 17 .4 10 .7 41 .8 32 .1 7.8 24 .3 0.5 M ar tin iqu e• 19 85 12 4.2 43 .7 27 .9 0.9 6.4 4.2 4.2 16 .1 5.9 10 .2 64 .5 Pa na ma 19 85 -1 98 9 10 0.4 70 .6 36 .5 0.7 7.7 11 .3 14 .1 19 .2 7.1 11 .5 10 .2 Pe ro u- Pe ru 19 80 -1 98 4 44 .4 0.1 0.4 1.2 Re p. do mi nic ain e - Do mi nic an R ep . 19 85 90 .1 60 .8 23 .8 1.3 2.4 4.2 29 .0 21 .4 4.9 14 .2 7. 9 Sa int e-L uc ie• - Sa int Lu cia • 19 85 -1 98 9 12 1.3 80 .7 45 .8 0.0 3.9 1.9 3.5 27 .5 18 .5 9.0 0.0 Sa int -V inc en t-e t-G ren ad ine s•- Sa int V inc en t a nd G ren ad ine s• 19 86 90 .5 34 .4 8.4 0.0 12 .0 7.0 6.9 19 .5 0.0 19 .5 36 .6 Su rin am e• 19 85 19 6.4 11 5.2 57 .4 0.0 10 .2 22 .2 25 .5 67 .1 53 .6 12 .9 14 .1 ~ AU TR ES R EG IO NS - OT HE R RE GIO NS ~ Do nn ee s f iab les - Re lia ble da ta Ho ng K on g 19 85 -1 98 9 42 .0 21 .3 7.6 0.8 4.4 1.9 6.6 18 .0 16 .3 1.6 2. 8 §" Isr ae l - Isr ae l 19 85 -1 98 9 70 .7 52 .0 15 .9 0.1 5.6 2.1 28 .1 14 .6 10 .7 2.9 4. 3 !ll Ko we it - Ku wa it 19 85 -1 98 9 82 .7 79 .1 54 .7 1.1 4.1 2.3 15 .2 2. 6 1.0 1.3 1.0 ,. .. . Ma uri ce - Ma ur itiu s 19 85 -1 98 9 81 .0 50 .7 8.0 0.2 17 .3 7.2 14 .7 13 .4 12 .0 1.4 17 .7 fa. Sin ga po ur - Sin ga po re 19 85 -1 98 9 66 .4 33 .9 18 .9 0.6 6.3 0.0 7.9 22 .5 19 .5 2.8 9.8 ~ Do nn ee s d eli cie nte s - De fic ien t d ata ,. .. . Ba hr e" in• -B ah rai n• 19 87 56 .5 30 .5 23 .1 0.7 0.0 4.1 2.7 26 .0 3.5 2.5 0.0 I • Pa ys do nt la po pu lat ion e st inf er ieu re a 1 m illio n d" ha bit an ts. - Co un trie s w ~h a po pu lat ion le ss th an 1 m illio n. :3 g p. La so m m e de s p ou rce nta ge s p eu t d iffe re r d e 1 00 % a ca us e de s p eti ts no m bre s e t d es a rro nd is. - Th e pe rce nta ge s m ay n ot ad d up to 1 00 % be ca us e of sm all n um be rs an d ro un din g. ~ j ~ ~ ::::;- Ta ble au 5b - Ta ble 5b fa. ~ Ta ux co m pa ra tifs de m or ta lite (p ou r 1 00 OO O) po ur les p rin cip ale s c au se s de d ec es p ar vio len ce p ou r c er ta ins p ay s e n de ve lop pe me nt, 1 98 5- 19 89 (o u l a pe rio de la p lus re ce nte ) ,. .. . St an da rdi ze d de ath ra tes (p er 10 0 O OO ), fo r t he le ad ing ca us es o f d ea th by vi ole nc e in so m e de ve lop ing co un trie s, 19 85 -1 98 9 (or the m os t r ec en t p eri od ) . Q Iii ~ Ca us es no n int en tio nn ell es - Un int en tio na l c au se s Ca us es in ten tio nn ell es - Int en tio na l c au se s - Int en tio n ~ Ve hic ule s a No ya de s, ind ete rm ine e I Pa ys /w ne - Co un try /ar ea Pe rio de /an ne e To tal vi ole nc e Ta ux m ot eu r Em po iso nn em en ts Ch ute s su bm ers ion Au tre s ca us es Ta ux Su icid e Ho mi cid e Un de ter mi ne d Pe rio d/y ea r Ra te M oto r v eh icl e Po iso nin g Fa lls Dr ow nin g, Ot he r c au se s Ra te w he the r Fe mm es - Fe ma les ac cid en ts su bm ers ion int en tio na l o r no t AM ER IO UE L AT IN E ET C AR AiB ES -L AT IN A ME RI CA AN D TH E CA RIB BE AN Do nn ee s f iab les - Re lia ble da ta Ar ge nti ne - Ar ge nti na 19 86 31 .4 22 .4 5.1 1.4 4.7 1.1 10 .9 7.1 4.7 2.2 1.9 Ch ili - Ch ile 19 85 -1 98 9 37 .0 18 .5 2.5 0.5 4.3 0.3 11 .4 2. 9 2.2 0.7 15 .6 Co sta R ica 19 85 -1 98 9 31 .7 28 .4 7.1 0.1 16 .0 1.4 4.2 3.1 1.3 1.8 0.8 Cu ba 19 85 -1 98 9 55 .6 Gu ate ma la 19 84 25 .7 0.9 0.4 Me xiq ue - Me xic o 19 86 40 .2 34 .3 8.6 0.5 6.5 1.4 16 .6 5.1 0.7 4.4 0.9 Po rto R ico - Pu ert o Ri co 19 85 -1 98 9 24 .8 16 .1 7.4 0.1 3.7 0.5 3.7 7. 0 2.4 4.6 1.9 Tr ini te- et- To ba go -T rin ida d a nd T ob ag o 19 86 35 .8 23 .3 7.8 0.3 4.7 0.7 8.8 9. 7 6.1 3.6 2. 7 Ur ug ua y 19 85 -1 98 9 30 .8 25 .6 4.5 0.5 5.5 1.9 12 .4 5. 2 3.8 1.4 0.0 Ve ne zu ela 19 85 -1 98 9 33 .6 29 .3 11 .6 0.2 7.7 1.2 8.1 3. 7 2.1 1.6 0.6 Do nn ee s d eti cie nte s - De fic ien t d ata Ba ha ma s• 19 87 38 .8 25 .8 12 .0 0.0 3.5 6.3 4.0 2. 9 0.0 2.9 10 .2 Ba rba de • - Ba rba do s• 19 88 22 .1 13 .8 3.7 0.0 7.9 0.0 2.1 6. 7 0.8 5.9 1.6 Be liz e• 19 86 23 .5 22 .7 4.8 0.0 1.3 2.7 10 .7 0.8 0.8 0.0 0.0 Do mi niq ue • - Do mi nic a• 19 85 3.7 3. 7 3.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 El Sa lva do r 19 80 -1 98 4 51 .0 30 .1 8.9 0.0 6.4 1.8 10 .0 14 .7 5.6 9.1 Eq ua teu r - Ec ua do r 19 85 -1 98 9 40 .0 34 .2 12 .3 0.2 6.7 2.3 12 .2 5. 9 2.9 3.0 0.1 M ar tin iqu e• 19 85 27 .1 10 .5 6.8 0.0 0.7 0.0 2.1 4. 2 4.2 0.0 12 .4 Pa na ma 19 85 -1 98 9 27 .2 22 .6 8.6 0.0 4.7 1.7 6.8 3.4 1.6 1.8 2. 0 Pe ro u- Pe ru 19 80 -1 98 4 14 .0 0.0 0.1 0.3 Re p. do mi nic ain e - Do mi nic an R ep . 19 85 25 .5 18 .0 6.2 0.0 2.3 1.3 7.8 4. 7 2.0 1.3 2. 9 Sa int e-L uc ie• - Sa int Lu cia • 19 85 -1 98 9 20 .9 15 .1 3.1 0.0 0.0 1.8 0.8 0.0 0.0 0.0 0.0 Sa int -V inc en t-e t-G ren ad ine s•- Sa int V inc en t a nd G ren ad ine s• 19 86 27 .9 20 .8 9.7 0.0 8.7 2.4 0.0 0.0 0.0 0.0 7.1 Su rin am e• 19 85 58 .3 31 .7 13 .7 1.4 6.3 0.9 10 .8 22 .5 18 .4 4.1 4.1 AU TR ES R EG IO NS - OT HE R RE GI ON S Do nn ee s f iab les - Re lia ble da ta Ho ng .Ko ng 19 85 -1 98 9 24 .5 10 .2 4.9 0.1 1.8 0.8 2.3 12 .5 11 .6 0.9 1.8 Isr ae l- Isr ae l 19 85 -1 98 9 40 .0 32 .2 6.6 0.0 6.7 0.6 17 .7 5. 5 4.5 1.0 2.1 Ko we 'it - Ku wa it 19 85 -1 98 9 27 .0 24 .9 12 .1 0.0 1.6 0.4 8.7 1.0 0.5 0.5 0.3 Ma uri ce - Ma uri tiu s 19 85 -1 98 9 35 .8 23 .1 2.0 0.0 5.1 2.0 14 .8 6.1 5.8 0.3 4. 6 Sin ga po ur - Sin ga po re 19 85 -1 98 9 26 .9 9. 7 5.1 0.0 2.3 0.0 2.1 14 .4 13 .2 1.2 3. 3 Do nn ee s d efi cie nte s - De fic ien t d ata Ba hr ein • - Ba hra in• 19 87 18 .6 11 .3 10 .9 0.0 0.0 0.0 0.0 7. 3 1.0 0.0 0.0 Re p. de C ore e - Re p. of Ko rea Sa o T om e et Pr inc ipe •- Sa o T om e a nd P rin cip e• 19 87 Se yc he lle s• Sr i L an ka Th a'il an de - Th ail an d • Pa ys d on t la p op ula tio n es t in fer ieu re a 1 m illio n d'h ab ita nts . - Co un trie s w rth a po pu lat ion le ss th an 1 m illio n. La so m m e de s p ou rce nta ge s p eu t d iffe re r d e 1 00 % a ca us e de s p etr ts no m bre s e t d es ar ro nd is. - Th e pe rce nta ge s m ay n ot ad d up to 1 00 % b ec au se of sm all n um be rs an d ro un din g. ~ < D Tableau &a - Table &a Repartition des deces violents selon !'intention (pour 100), pour certains pays developpes, 1985-1989 (ou la periode la plus recente) Distribution of violent deaths by intention (per 100) for some developed countries, 1985-1989 ( or most recent period) Pays - Country Periode/annee Violence (total) Causes non Causes Intention Period/year intentionnelles intentionnelles indeterminee Unintentional Intentional Undetermined whether causes causes intentional or not Hammes - Males Taux-Rate % % % EUROPE Allemagne• -Germany• 1985-1989 65.1 56.7 39.9 3.5 Autriche - Austria 1985-1989 105.0 61.0 38.0 0.9 Belgique - Belgium 1986 87.5 60.6 37.0 2.4 France 1985-1989 105.6 63.4 31.8 4.8 lrlande - lrlande 1985-1989 62.4 72.6 22.9 5.1 Luxembourg b 1985-1989 95.5 69.0 26.7 3.7 Pays-Bas - Netherlands 1985-1989 46.1 64.6 33.2 2.2 Royaume-Uni - United Kingdom: Angleterre et Galles - England and Wales 1985-1989 44.8 60.9 28.1 10.9 Ecosse - Scotland 1985-1989 68.8 64.4 28.1 7.6 lrlande du Nord - Northern Ireland 1985-1989 68.3 63.5 32.1 4.4 Suisse - Switzerland 1985-1989 92.6 60.9 36.1 3.0 Oanemark - Denmark 1985-1989 88.2 55.4 40.5 4.4 Finlande - Finland 1985-1989 130.6 59.9 37.2 3.3 lslandeb - lcelandb 1985-1989 79.4 64.2 33.6 2.3 Norvege - Norway 1985-1989 80.2 70.4 28.8 0.9 Suede - Sweden 1985-1989 74.0 52.3 35.9 11.6 Espagne - Spain 1986 65.3 77.8 20.1 2.3 Grece - Greece 1985-1989 65.6 88.1 10.5 1.2 ltalie - Italy 1985-1989 63.8 76.0 22.1 1.9 Malteb - Maltab 1985-1989 40.1 82.0 5.2 4.7 Portugal 1985-1989 108.6 68.4 15.8 16.1 Yougoslavie - Yugoslavia Ex-Republique democratique allemande - 1985-1989 92.5 67.6 30.9 1.5 Ex-German democratic republic 1985-1989 Bulgarie - Bulgaria 1985-1989 94.7 70.0 29.0 1.1 Hongrie - Hungary 1985-1989 165.8 57.5 42.2 0.4 Pologne - Poland 1985-1989 118.4 70.0 21.6 8.4 Roumanie - Romania 1980-1984 106.3 Tchecoslovaquie - Czechoslovakia 1985-1989 108.5 67.1 29.1 3.8 Ex-URSS - Former USSR 1987 150.1 29.4 AUTRES REGIONS - OTHER REGIONS Australie - Australia 1985-1989 72.2 66.6 32.1 1.4 Canada 1985-1989 77.6 65.2 31.6 3.4 Etats-Unis d'Amerique - United States of America 1985-1989 90.3 61.0 37.0 2.0 Japan - Japan 1985-1989 66.7 56.2 39.4 4.3 Nouvelle-Zelande - New Zealand 1985-1989 84.6 71.7 26.4 1.8 • Avant l"unrtication. - Prior to unification. b Pays dont la population est inferieure a 1 million d'habitants. - Countries with a population less than 1 million. 10% (Angleterre et pays de Galles, Suede et Por- tugal). Structure de la mortalite violente dans les pays developpes. L'examen des tab/,eaux 6a et 6b permet de faire ressortir des differences assez importantes dans la structure de la mortalite violente parmi les pays developpes. Les causes non intentionnelles regrou- pent dans tousles cas la majorite des deces violents (saufaujapon ou les causes intentionnelles, essen- tiellement les suicides, depassent les causes non intentionnelles pour les femmes) avec des pour- centages variant de 52 a 88% chez les hommes et de 46 a 89% chez les femmes. La structure detaillee de la mortalite violente. De manie- re a mieux connaitre les composantes de la morta- lite violente, nous avons soumis les donnees des tabkaux 4a et 4b a la procedure de classification automatique. Ainsi, pour chaque classe de pays retenue, nous pouvons identifier les causes plus precises de deces violents qui rendent compte des similitudes entre les pays. On sait d'emblee que l'importance de la composante non intention- 20 nelle de la mortalite violente est surtout tributaire du niveau de la mortalite par accident de vehicule a moteur, en particulier chez les hommes, et de la mortalite par chutes, surtout chez les femmes, alors que !'importance de la composante intention- nelle depend essentiellement du niveau de la mor- talite par suicide. Sur la base du niveau de la morta- lite violente et de la structure detaillee de la morta- lite violente, nous avons retenu 5 classes de pays pour chaque sexe (figures 5 et 6); les figures 5 et 6 presentent les resultats de la classification automa- tique. Les tabkaux Ba et Bb ainsi que les figures 7 et B font ressortir les caracteristiques de chacune des classes de pays. Pour les hommes ( tab/,eau Ba et figure 7), la classe 1 regroupe 3 pays a tres faible mortalite violente ( taux comparatif moyen de 44 pour 100 OOO) ou les causes non intentionnelles prennent le plus d'importance relative, soit pres de 70%. De plus, chacune des composantes de cette mortalite est en moyenne la plus faible parmi les pays developpes; la mortalite par accident de vehicule a moteur et par suicide se demarque particulierement de celle des autres classes. Les classes 2 et 3 sont formees respectivement de 13 et de 8 pays qui peuvent etre Rapp. trimest. statist. sanit. mond., 46 (1993) Tableau 6b - Table 6b Repartition des deces violents selon !'intention (pour 100), pour certains pays developpes, 1985-1989 (ou la periode la plus recente) Distribution of violent deaths by intention (per 100). for some developed countries, 1985-1989 (or most recent period) Pays - Country Periode/annee Violence (total) Causes non Causes Intention Period/year intentionnelles intentionnelles indeterminee Unintentional Intentional Undetermined whether causes causes intentional or not Femmes - Females Taux-Rate % % % EUROPE Allemagne• -Germany• 1985-1989 29.8 61.1 35.2 3.4 Autriche - Austria 1985-1989 41.2 64.1 34.7 1.2 Belgique - Belgium 1986 42.1 61.3 36.3 2.6 France 1985-1989 47.3 69.3 26.6 4.2 I rlande - I rlande 1985-1989 26.7 76.8 19.5 4.9 Luxembourgh 1985-1989 40.0 66.3 21.5 5.5 Pays-Bas - Netherlands 1985-1989 25.1 64.1 33.9 2.0 Royaume·Uni - United Kingdom: 21.3 63.8 23.9 12.7 Angleterre et Galles - England and Wales 1985-1989 Ecosse - Scotland 1985-1989 32.2 69.6 23.3 6.5 lrlande du Nord - Northern Ireland 1985-1989 27.8 74.5 19.4 3.6 Suisse - Switzerland 1985-1989 42.2 64.7 32.2 2.8 Danemark - Denmark 1985-1989 50.7 55.0 39.6 5.9 Finlande - Finland 1985-1989 39.1 63.2 34.0 3.8 lslandeb - lcelandh 1985-1989 26.9 62.5 42.8 0.0 Norvege - Norway 1985-1989 33.2 72.3 27.1 1.2 Suede - Sweden 1985-1989 30.9 51.8 35.9 11.7 Espagne - Spain 1986 20.0 78.5 20.0 2.0 Grece - Greece 1985-1989 28.2 89.0 9.9 1.1 ltalie - Italy 1985-1989 27.5 81.8 16.4 1.5 Malteb - Maltab 1985-1989 14.9 96.6 3.4 0.0 Portugal 1985-1989 33.5 67.5 15.8 17.0 Yougoslavie - Yugoslavia 1985-1989 33.4 64.1 33.8 1.8 Ex·Republique democratique allemande - Ex-German democratic republic 1985-1989 Bulgarie - Bulgaria 1985-1989 28.6 63.6 35.7 1.4 Hongrie - Hungary 1985-1989 71.l 65.3 34.6 0.4 Pologne - Poland 1985-1989 34.6 76.6 16.5 6.4 Roumanie - Romania 1980-1984 34.9 Tchecoslovaquie - Czechoslovakia 1985-1989 50.4 77.6 19.6 2.6 Ex·URSS - Former USSR 1987 43.0 30.2 AUTRES REGIONS - OTHER REGIONS Australie - Australia 1985-1989 28.0 72.5 26.1 1.4 Canada 1985-1989 30.2 71.9 24.8 3.6 Etats·Unis d'Amerique - United States of America 1985-1989 31.2 68.3 29.5 1.9 Japan - Japan 1985-1989 27.5 46.5 48.7 4.4 Nouvelle·Zelande - New Zealand 1985-1989 37.0 76.5 20.8 3.0 a Avant !'unification. - Prior to unification. • Pays dont la population est inferieure a 1 million d'habitants. - Countries with a population less than 1 million. La somme des pourcentages peut differer de 100% a cause des petits nombres et des arrondis. -The percentages may not add up to 100% because of small numbers and rounding. qualifies de pays a mortalite violente intermediaire (taux comparatifmoyen de 70 et 91 pour 100 OOO) et qui presentent une repartition semblable des deces violents entre Jes causes non intentionnelles, environ Jes deux tiers, et Jes causes intentionnelles, environ le tiers. Cependant, elles se distinguent l'une de l'autre par la plus faible frequence des suicides et des accidents de vehicules a moteur dans Jes pays de la classe 2. Les classes 4 et 5 regroupent 7 pays a forte mortalite violente (taux comparatif moyen de 113 et 166 pour 100 OOO); dans ces pays, quoique toutes Jes composantes soient plus elevees que dans Jes autres pays, ce sont Jes chutes, les empoisonnements et Jes suicides qui ressortent davantage. Le cas de la Hongrie est ex- ceptionnel et ii ne peut etre reuni a une autre classe; sa mauvaise situation est redevable principa- lement aux suicides, aux chutes et aux autres cau- ses non intentionnelles. Par contre, le niveau de la mortalite par accident de vehicule a moteur se compare a celui des pays des autres classes sauf la premiere. La classification pour Jes femmes ( tab/,eau 8b et figure 8) presente des similitudes avec celle des hommes, mais certains pays changent de classes, Wld hlth statist. quart., 46 (1993) refletant ainsi une situation differentielle de la mortalite violente selon le sexe. La classe 1 comp- te 3 pays qui presentent la plus faible mortalite violente, au total (taux comparatif moyen de 19 pour 100 OOO) et pour chacune des composantes de celle-ci. De plus, la mortalite violente est sur- tout de nature non intentionnelle (pres de 80%). La classe 2 est formee de 7 pays dont la mortalite violente est plutot faible (29 pour 100 OOO) mais qui se demarque de la premiere et de la troisieme classes par l'ampleur de la composante inten- tionnelle: la mortalite par suicide y est respective- ment trois fois et deux fois plus frequente que dans Jes pays de la classe 1 et de la classe 3. Cette demiere classe 3 reunit 13 pays dont le niveau de la mortalite violente est assez proche de celui de la classe 2 (32 pour 100 OOO) mais dont la composi- tion est tres differente: la composante non inten- tionnelle constitue 72% de la mortalite violente. On retrouve 7 pays dans la classe 4 qui se distingue a la fois par une plus forte mortalite violente (taux moyen de 45 pour 100 OOO) et par une composi- tion particuliere: 2 deces violents sur 3 sont non intentionnels. De nouveau, la Hongrie se retrouve dans une classe a part, a cause du niveau excep- 21 Tableau 7a - Table 7a Repartition des deces violents selon !'intention {pour 100), pour certains pays en developpement, 1985-1989 {ou la periode la plus recente) Distribution of violent deaths by intention {per 100), for some developing countries, 1985-1989 {or most recent period) Pays - Country Periode/annee Violence (total) Causes non Causes Intention Period/year intentionnelles intentionnelles indeterminee Unintentional Intentional Undetermined whether causes causes intentional or not Hammes - Males Taux-Rate % % % AMERIQUE LATINE ET CARAIBES - LATIN AMERICA AND THE CARIBBEAN Donnees fiables - Reliable data Argentine - Argentina 1986 89.9 64.3 28.1 7.6 Chili-Chile 1985-1989 141.3 34.9 12.7 52.3 Costa Rica 1985-1989 102.7 77.8 20.3 3.5 Cuba 1985-1989 Guatemala 1984 118.9 Mexique - Mexico 1986 181.7 67.8 29.7 2.5 Puerto Rico 1985-1989 118.6 49.1 43.8 7.3 Trinite-et-Tobago- Trinidad and Tobago 1986 108.1 58.6 26.5 14.8 Uruguay 1985-1989 86.0 75.3 24.4 0.0 Venezuela 1985-1989 125.1 75.1 22.4 2.5 Donnees deficientes - Deficient data Bahamas• 1987 130.7 53.8 14.4 31.9 Barbade• - Barbados• 1988 81.4 67.1 23.5 9.5 Belize• 1986 83.9 97.5 2.5 0.0 Dominique• - Dominica• 1985 74.4 97.2 2.8 0.0 El Salvador 1980-1984 303.4 34.6 42.0 Equateur- Ecuador 1985-1989 146.7 77.8 21.9 0.3 Martinique 1985 124.2 35.2 13.0 51.9 Panama 1985-1989 100.4 70.3 19.1 10.2 Perou -Peru 1980-1984 Rep. dominicaine - Dominican Rep. 1985 90.1 67.5 23.8 8.8 Sainte-Lucie• - Saint Lucia• 1985-1989 121.3 66.5 22.7 Saint-Vincent-et-Grenadines• - Saint Vincent and Grenadines• 1986 90.5 38.0 21.5 40.4 Suriname• 1985 196.4 58.7 34.2 7.2 AUTRES REGIONS-OTHER REGIONS Donnees fiab/es - Deficient data Hong Kong 1985-1989 42.0 50.7 42.9 6.7 Israel - Israel 1985-1989 70.7 73.6 20.7 6.1 Kowe"it - Kuwait 1985-1989 82.7 95.6 3.1 1.2 Maurice - Mauritius 1985-1989 81.0 62.6 16.5 21.9 Singapour- Singapore 1985-1989 66.4 51.1 33.9 14.8 Donnees deficientes - Deficient data Bahre"in•-Bahrain• 1987 56.5 54.0 46.0 0.0 Rep. de Coree - Rep. of Korea 1985-1989 103.4 83.2 16.3 0.5 Sao Tome et Principe•-Sao Tome and Principe• 1987 37.4 89.0 11.0 0.0 Seychelles 1985-1989 159.3 52.5 14.4 22.8 Sri Lanka 1980-1984 129.0 47.1 44.3 9.2 Thailande - Thailand 1980 128.0 48.7 51.2 0.1 Nouvelle-Zelande - New Zealand • Pays dont la population est inferieure il 1 million d'habitants. - Countries with a population less than 1 million. La somme des pourcentages peut differer de 100% il cause des petits nombres et des arrondis. - The percentages may not add up to 100% because of small numbers and rounding. tionnel de la mortalite violente (72 pour 100 OOO); la composition de la mortalite violente est sembla- ble aux pays de la classe 4, mais les niveaux de la mortalite par chutes et par suicide sont deux fois plus eleves. Les resultats de la classification montrent qu 'ii n' existe pas de lien evident entre le ni- veau de la mortalite violente et sa composition. Ainsi, on peut retrouver des differences tres impor- tantes de composition dans des pays oii le niveau de la mortalite violente est semblable. Par exem- ple, le Japon et la Grece ont un niveau de mortalite violente relativement semblable chez les femmes, mais ils ne se retrouvent pas dans la meme classe car la structure de leur mortalite est tres differente: aujapon, la repartition entre causes non intention- nelles ( 46%) et intentionnelles ( 49%) est a peu pres egale alors qu'en Grece, 89% des deces violents sont de nature non intentionnelle. Les regroupements obtenus ne sont pas simples a interpreter puisque deux caracteristiques ont ete prises en compte simultanement: le niveau et la composition de la mortalite violente. Ainsi, on ne 22 retrouve pas necessairement des regroupements qui seraient associes a la localisation geographique des pays. Tout au plus, on peut relever que les pays hors Europe se retrouvent dans la meme classe chez les femmes; les deces violents feminins dans ces pays se concentrent davantage dans les causes non intentionnelles, mis a part le cas tres particu- lier dujapon, oii les femmes ont une mortalite par suicide beaucoup plus elevee que dans les autres pays hors Europe. Cette situation peut s'expli- quer en bonne partie par une mortalite feminine plus elevee pour les accidents de vehicules a mo- teur sur la voie publique (voir le tabkau 4b); le haut niveau de motorisation atteint dans ces pays (Etats- U nis, Canada, Australie et Nouvelle-Zelande) n'est surement pas etranger a ce phenomene. Les pays hors Europe se caracterisent aussi par le fait que les femmes presentent une structure de mortalite violente assez differente de celle des hommes, ce qui est moins apparent dans les pays europeens. Pour les pays europeens, leur appartenance aux diverses classes depend beaucoup des differences Rapp. trimest. statist. sanit. mond., 46 (1993) Tableau 7b - Table 7b Repartition des deces violents selon !'intention (pour 100), pour certains pays en developpement, 1985-1989 (ou la periode la plus recente) Distribution of violent deaths by intention (per 100), for some developing countries, 1985-1989 (or most recent period) Pays - Country Periode/annee Violence (total) Causes non Causes Intention Period/year intentionnelles intentionnelles indeterminee Unintentional Intentional Undetermined whether causes causes intentional or not Femmes - Females Taux-Rate % % % AMERIOUE LATINE ET CARAIBES- LATIN AMERICA AND THE CARIBBEAN Donnees fiables - Reliable data Argentine -Argentina 1986 31.4 71.3 22.6 6.1 Chili - Chile 1985-1989 37.0 50.0 7.8 42.2 Costa Rica 1985-1989 31.7 89.6 9.8 2.5 Cuba 1985-1989 Guatemala 1984 25.7 Mexique - Mexico 1986 40.2 85.3 12.7 2.2 Puerto Rico 1985-1989 24.8 64.9 28.2 7.7 Trinite-et-Tobago- Trinidad and Tobago 1986 35.8 65.1 27.1 7.5 Uruguay 1985-1989 30.8 83.1 16.9 0.0 Venezuela 1985-1989 33.6 87.2 11.0 1.8 Donnt!es dt!ficientes - Deficient data Bahamas• 1987 38.8 66.5 7.5 26.3 Barbade• - Barbados• 1988 22.1 62.4 30.3 7.2 Belize> 1986 23.5 96.6 3.4 0.0 Dominique• - Dominica• 1985 3.7 100.0 0.0 0.0 El Salvador 1980-1984 51.0 59.0 28.8 Equateur - Ecuador 1985-1989 40.0 85.5 14.8 0.3 Martinique 1985 27.1 38.7 15.5 45.8 Panama 1985-1989 27.2 83.1 12.5 7.4 Perou - Peru 1980-1984 R~p. dominicaine - Dominican Rep. 1985 25.5 70.6 18.4 11.4 Sainte-Lucie• -Saint Lucia• 1985-1989 20.9 72.2 0.0 0.0 Saint-Vincent-et-Grenadines• - Saint Vincent and Grenadines• 1986 27.9 74.6 0.0 25.4 Suriname• 1985 58.3 54.4 38.6 7.0 AUTRES REGIONS - OTHER REGIONS Donnt!es fiab/es - Deficient data Hong Kong 1985-1989 24.5 41.6 51.0 7.3 Israel - Israel 1985-1989 40.0 80.5 13.8 5.3 Koweil - Kuwatt 1985-1989 27.0 92.2 3.7 1.1 Maurice - Mauritius 1985-1989 35.8 64.5 17.0 12.8 Singapour - Singapore 1985-1989 26.9 36.1 53.5 12.3 Donnt!es dt!ficientes - Deficient data Bahrein•- Bahrain• 1987 18.6 60.8 39.2 0.0 Rep. de Goree - Rep. of Korea 1985-1989 36.0 83.6 15.8 0.6 Sao Tome et Principe• -Sao Tome and Principe• 1987 14.0 40.7 59.3 0.0 Seychelles 1985-1989 29.8 47.7 21.5 0.0 Sri Lanka 1980-1984 47.3 46.5 46.3 8.2 ThaHande - Thailand 1980 34.8 60.9 39.1 0.0 • Pays dont la population est inferieure a 1 million d'habitants. - Countries wtth a population less than 1 million. La somme des pourcentages peut differer de 100% a cause des petits nombres et des arrondis. - The percentages may not add up to 100% because of small numbers and rounding. de mortalit.e par chutes, par suicide et pour les autres causes non intentionnelles. De fait, la morta- lite par accident de vehicule a moteur varie assez peu entre les classes, mis a part les pays de la classe 1 (Angleterre et pays de Galles, Malte, Pays-Bas et Espagne). Par contre, les ecarts de mortalite par suicide entre les pays europeens sont impression- nants et vont du simple ( taux comparatif de 5, 7 en Grece) au decuple (taux comparatif de 66,4 en Hongrie). Cependant, ces ecarts doivent etre inter- pretes avec prudence car on sait que cette cause de deces est enregistree d'un fa~on variable selon les pays. En Europe, on retrouve un niveau plus faible dans les pays d'Europe du Sud (Espagne, Grece, Italie, Malte, Portugal) et dans les pays anglo- saxons (Royaume-Uni). Certains pays d'Europe de l'Est, surtout la Hongrie, l'ex-URSS et la Tchecoslovaquie, sont particulierement touches par cette cause de deces mais aussi certains pays d'Europe de l'Ouest, tels l'Autriche, la France, la Belgique, la Suisse, et d'Europe du Nord, tels le Danemark et la Finlande. Wld hlth statist. quart., 46 (1993) La situation plutot desavantageuse des pays d'Europe de l'Est en matiere de mortalite vio- lente ne tient pas specifiquement a une mortalite intentionnelle elevee; meme pour la Hongrie ou la mortalite par suicide est la plus elevee, la compo- sante non intentionnelle est egalement importan- te. Les pays d'Europe de l'Est se classent mal a la fois pour les accidents de vehicules a moteur, les empoisonnements, les chutes, les noyades et pour les autres causes non intentionnelles. On retrouve id un trait caracteristique d'une mortalite qui releve d'un schema plus traditionnel ou la mor- talite par accident de vehicule a moteur prend moins de place (27 a 45%) et ou les autres causes non intentionnelles en prennent davantage. En resume, ce qui semble caracteriser les pays developpes est une concentration de la mortalite violente parmi les causes suivantes: accidents de vehicules a moteur, chutes et suicide. De plus, la mortalite par suicide depasse largement la mortali- te par homicide qui est une composante marginale de la mortalite violente, sauf aux Etats-Unis et en Irlande du Nord. Enfin, la mortalite par empoison- 23 Fig. 5 Classification (selon la methode de Ward) des pays developpes suivant !'importance des principales causes de mortalite violente chez les hommes, tous ages, 1985-1989 Classification (using Ward's method) of developed countries by importance of the leading causes of violent death, males, all ages, 1985-1989 Echelle standardisee des distances - Standardized distance scale Pays-Bas - Netherlands Angleterre et Galles - England & Wales Malte - Malta Espagne - Spain Grece - Greece lrlande - Ireland ltalie - Italy Ecosse - Scotland lrlande du Nord - Nothem Ireland Allemagne - Germany Japan - Japan Suede - Sweden Australie - Australia Canada lslande - Iceland Norvege - Norway Suisse - Switzerland Danemark - Denmark Belgique - Belgium Luxembourg Nouvelle·Zelande- New Zealand Yougoslavie - Yugoslavia Bulgarie - Bulgaria Etats-Unis d'Amerique - United States of America Portugal Pologne - Poland Autriche - Austria France T checoslovaquie - Czechoslovakia Finlande - Finland Hongrie - Hungary 0 5 WHO 93301 10 15 20 25 2 3 4 5 Source: Banque de donnees de !'Organisation mondiale de la Sante. - Data bank of the World Health Organization. nement non intentionnel n'est pas negligeable dans plusieurs pays developpes. Structure de la mortalite violente dans Jes pays en developpement Les tabl.eaux 7a et 7b mettent en evidence la struc- ture de la mortalite violente pour quelques pays en developpement. Bien sur, plus on detaille les cau- ses de deces, plus la qualite de l'enregistrement risque d'avoir un effet sur les resultats, meme dans les pays a donnees relativement fiables. De ce fait, on retrouve des situations tres variees dans les pays en developpement. De fa~on generale, on remarque que, compara- tivement aux pays developpes, les deces violents se retrouvent davantage concentres parmi les causes non intentionnelles, surtout pour les pays d' Amerique latine et surtout chez les femmes. La 24 situation des 5 pays en developpement des «autres regions» se rapproche un peu plus de celle des pays developpes, quoique le niveau de la mortalite vio- lente y soit plus faible. Ce resultat correspond a un schema plus tradi- tionnel de la mortalite ou, un peu comme dans les pays d'Europe de l'Est, les causes de deces non intentionnelles prennent plus d'importance que les causes intentionnelles. Les tabl.eaux 5a et 5b four- nissent des resultats plus detailles qui montrent encore mieux la specificite de la mortalite violente en Amerique latine. Tout d'abord, elle est moins concentree dans les deces par accident de vehicule a moteur, par chutes et par suicide. Ensuite, les noyades et, surtout, les autres causes non inten- tionnelles prennent une plus grande importance; de plus, les homicides ont une importance relative plus marquee et sans egal avec la situation des pays developpes. La forte mortalite par homicide est un Rapp. trimest. statist. sanit. mond., 46 (1993) Fig. 6 Classification (selon la methode de Ward) des pays developpes suivant !'importance des principales causes de mortalite violente chez les femmes, tous ages, 1985-1989 Classification (using Ward's method) of developed countries by importance of the leading causes of violent death, females, all ages, 1985-1989 Echelle standardisee des distances - Standardized distance scale lrlande - Ireland lrtande du Nord - Northern Ireland ltalie - Italy Grece - Greece Australie - Australia Canada Etats-Unis d'Amerique - United States of America Portugal Ecosse - Scotland Norvege - Norway Pologne - Poland Luxembourg Nouvelle-Zelande - New Zealand Yougoslavie - Yugoslavia Bulgarie - Bulgaria lslande - Iceland Japon - Japan Allemagne - Germany Suede - Sweden Pays-Bas - Netherlands Angleterre et Galles - England & Wales Espagne - Spain Malte - Malta Autriche - Austria Suisse - Switzertand Belgique - Belgium Finlande - Finland 0 France ----1 Danemark- Denmark --~ 5 10 15 20 25 3 2 3 4 Tchecoslovaquie - Czechoslovakia ____ ___. 5 Hongrie-Hungary ---------------' WHO 93300 Source: Banque de donnees de !'Organisation mondiale de la Sante. - Data bank of the World Health Organization. autre trait marquant des pays d'Amerique latine. Dans plusieurs pays tels le Mexique, Porto Rico et le Venezuela, la mortalite masculine par homicide est plus elevee que celle due au suicide. Les pays en developpement des autres regions ne presentent pas cette surmortalite par homicide; le suicide y est beaucoup plus important que l'homicide, com- me dans les pays developpes. Les pays a mortalite violente elevee sont le Mexique, le Chili et le Venezuela. Le Mexique doit son mauvais classement a sa forte mortalite par homicide, par accident de vehicule a moteur et pour les autres causes non intentionnelles. Au Ve- nezuela, la mortalite par accident de vehicule a moteur est une des pires a la fois des pays en developpement et des pays developpes. Au Chili, la mauvaise qualite de la classification des deces selon la cause ne nous permet pas de porter un juge- ment. Ces resultats sont preoccupants dans la mesure ou plusieurs pays en developpement sont confron- tes avec une forte mortalite violente, au moment meme ou les autres composantes de leur mortalite generate demeurent elevees (maladies infectieuses Wld hlth statist. quart, 46 (1993) et parasitaires) ou sont en augmentation (maladies de l'appareil circulatoire et tumeurs malignes). Ainsi, dans certains pays, la mortalite par accident de vehicule a moteur est plus forte que dans les pays developpes; peut-on penser que ces pays dis- posent des ressources humaines et physiques pour mettre en place des programmes de prevention de ces accidents alors que les niveaux demeurent pre- occupants pour d'autres grandes causes de deces ou la prevention est mains avancee que dans les pays developpes? Analyse de la surmortalite masculine due a la violence Le phenomene de la surmortalite masculine est bien connu; elle est particulierement elevee pour les causes violentes comme en temoignent les ta- b"leaux 9a et 9b. Dans les pays developpes, le rapport de surmor- talite masculine pour l'ensemble des causes de deces varie de 135 en Roumanie a 191, en France; pour les causes violentes, ce rapport est plus eleve variant de 174 au Danemark a 349 dans l'ex- 25 "" a , I 15 s- 3· ~ ,-.. "' fir 5i' ,-.. kl ::, ""' ~ ?- ~ --.. j Ta ble au B a - Ta ble B a Ta ux c om pa ra tits d e m or ta lite (p ou r 1 00 OO O ) p ou r le s p rin cip ale s c au se s de d ec es vi ole nts e t s elo n la cla ss e de p ay s d ev elo pp es , 1 98 5- 19 89 St an da rdi ze d m or ta lity ra tes (p er 10 0 OO O) fo r l ea din g ca us es o f v iol en t d ea ths , b y c at eg ory o f c ou nt ry, to r s ele cte d de ve lop ed co un trie s, 19 85 -1 98 9 Ho mm es - Ma les Ca us es no n int en tio nn ell es - Un int en tio na l v iol en ce Ca us es in ten tio nn ell es - Int en tio na l v iol en ce Vio len ce Ta ux - Ra re % Ve hic ule II m ote ur Em po iso nn em en ts Ch ute No ya de Au tre -O the r Ta ux - Ra re % M oto r v eh icl e Po iso nin g Fa lls Dr ow nin g Cla sse - Ca teg ory Cla ss e 1 - Ca teg ory 1 44 30 69 11 0.7 7 0.9 8 10 23 Cla ss e 2 - Ca teg ory 2 70 47 67 20 2.0 9 2.8 13 20 29 Cla ss e 3 - Ca teg ory 3 91 59 65 25 2.4 12 3.1 15 30 33 Cla ss e 4 - Ca teg ory 4 11 3 73 65 26 6.4 18 4.1 19 33 29 Cla ss e 5 - Ca teg ory 5 16 6 95 58 26 4.4 35 5.4 25 70 42 So urc e: OM S- W HO . Ta ble au B b - Ta ble B b Ta ux c om pa ra tifs d e m or ta lite (p ou r 1 00 OO O ) p ou r le s pr inc ipa les ca us es d e d ec es vi ole nts , p ar cla ss e de p ay s, po ur ce rta ins p ay s d ev elo pp es , 1 98 5- 19 89 St an da rdi ze d m or ta lity ra tes (p er 10 0 OO O) to r l ea din g ca us es o f v iol en t d ea ths , b y c at eg ory o f c ou nt ry, to r s ele cte d de ve lop ed co un trie s, 19 85 -1 98 9 Su icid e 9 18 26 30 66 Ho mi cid e 0.7 2.3 3.5 2.2 3.5 Fe mm es - Fe ma les Ca us es no n int en tio nn ell es - No nin ten tio na l v iol en ce Ca us es in ten tio nn ell es - Un int en tio na l v iol en ce Vio len ce Ta ux - Ra te % Ve hic ule II m ot eu r Em po iso nn em en ts Ch ute No ya de Au tre -O the r Ta ux - Ra te % Su icid e Ho mi cid e M oto r v eh icl e Po iso nin g Fa lls Dr ow nin g Cla sse - Ca teg ory Cla ss e 1 - Ca teg ory 1 19 15 79 Cla ss e 2 - Ca teg ory 2 29 17 59 Cla ss e 3 - Ca teg ory 3 32 23 72 4 0.4 5 0.3 3 3 16 3 0.4 6 0.4 6 0.7 4 11 38 10 0.9 8 0.9 9 0.6 5 7 22 5 1.2 Cla sse 4 - Ca teg ory 4 45 29 64 Cla sse 5 - Ca teg ory 5 72 47 65 8 1.5 15 0.8 5 14 31 13 1.3 8 1. 6 30 0.9 7 25 35 23 2.1 So urc e: OM S- W HO . Int en tio n ind ete rm ine e Un de ter mi ne d w he the r i nte nti on al or n ot 2.6 2.7 2.3 7.0 0.7 Int en tio n ind ete rm ine e Un de ter mi ne d w he the r i nte nti on al or n ot 1. 0 1.0 1.4 1.5 0.3 Fig. 7 Taux de mortalite selon le traumatisme et la classe de pays developpes, tous ages, sexe masculin, 1985-1989 Death rate by injury and category of developed countries, males, all ages, 1985-1989 Vehicule a moteur Empoisonnement Motor vehicle Poisoning Chute Fall Noyade Drowning Autre Other Suicide Homicide Cause de deces - Cause of death Fig. 8 Taux de mortalite selon le traumatisme et la classe de pays developpes, tous ages, sexe feminin , 1985-1989 Death rate by injury and category of developed countries, females, all ages, 1985-1989 Vehicule a moteur Empoisonnemeni Motor vehicle Poisoning Chute Fall Noyade Drowning Autre Other Suicide Homicide Cause de deces - Cause of death • Groupe 1 Group 1 Groupe 2 Group 2 D Groupe3 Group 3 F:'l l:.;J Groupe 4 Group 4 Groupe 5 Group 5 Union Sovietique. Si on rectifie ces indices en te- nant compte de la proportion des deces feminins dus a la violence dans chacun de pays, on peut obtenir un classement des pays selon la contribu- tion reelle de la surmortalite masculine par violen- ce a la surmortalite masculine to tale. On y voit que la Finlande et la France, avec des contributions egales a 20, ont les situations les plus differenciees; un probleme de surmortalite masculine par violen- ce se pose egalement dans l'ex-Union Sovieti- que, en Hongrie et en Suisse ou les contributions atteignent 17. Par contre , c 'est au Royaume-Uni (Angleterre et pays de Galles) que l'on retrouve la plus petite contribution, soit 6. Ces resultats Wld hlth statist. quart., 46 (1993) avaient deja ete mis en evidence par l'etude de Blum & Monnier (3), a partir des donnees de l'annee 1985. Dans les pays en developpement, la surmortali- te masculine «toutes causes» est mains marquee que dans les pays developpes; le rapport de sur- mortalite masculine generale varie de 120 au Gua- temala a 162 a Hong Kong. Par contre, la surmorta- lite masculine par violence est plus elevee que dans les pays developpes, particulierement en Amerique Latine; on retrouve des indices qui vont de 278 en Uruguay a 469 a Porto Rico. Dans les pays des «autres regions», la surmortalite masculine due a la violence est semblable a celle des pays developpes. 27 "" CD i?i' ~ ;::, §' D: ,.... "' ii!' ~- ,.... kl ~ 3 g f>- ~ i Ta ble au 9 a - Ta ble 9a An aly se de la su rm or ta lite m as cu lin e du e a la vio len ce p ou r c er ta ins p ay s d ev elo pp es , 1 98 5- 19 89 ( o u la pe rio de la p lus re ce nte ) An aly sis o f e xc es s m ale m or ta lity du e t o vio len ce in so m e de ve lop ed co un trie s, 19 85 -1 98 9 ( or th e m os t r ec en t p eri od ) Pa ys - Co un try Pe rio de /an ne e Ta ux de m or ta lite to ut es ca us es Ra pp ort de su rm or ta ltte Su rm or tal ite m as cu lin e po ur : Pe rio d/y ea r De ath ra te, a ll c au se s Ex ce ss m or ta lity ra tio Ex ce ss m ale m or ta lity fo r: Ho m m es Fe mm es Ma les Fe ma les Ma lad ies - Dis ea se Vio len ce EU RO PE Al lem ag ne • - Ge rm an y• 19 85 -1 98 9 11 11 .0 65 5.3 17 0 16 7 21 8 Au tric he - Au str ia 19 85 -1 98 9 11 30 .8 68 7.9 16 4 15 9 25 4 · Be lgiq ue - Be lgiu m 19 86 11 57 .6 67 7.2 17 1 16 9 20 7 Fra nc e 19 85 -1 98 9 10 39 .1 54 5.4 19 1 18 7 22 2 lrla nd e - Ire lan d 19 85 -1 98 9 12 65 .5 79 2.8 16 0 15 7 23 2 Lu xe mb ou rg b 19 85 -1 98 9 12 56 .7 71 7.1 17 5 17 1 23 9 Pa ys -B as - Ne the rla nd s 19 85 -1 98 9 1 0 34 .6 57 9.2 17 9 17 8 18 4 Ro ya um e-U ni - Un ite d Kin gd om An gle ter re et Ga lles - En gla nd an d W ale s 19 85 -1 98 9 11 11 .3 69 1.9 16 1 15 9 21 0 Ec os se - Sc otl an d 19 85 -1 98 9 12 87 .5 80 1.8 16 1 15 8 21 2 lrla nd e du N ord - No rlh ern Ir ela nd 19 85 -1 98 9 12 65 .5 77 2.8 16 4 16 1 24 2 Su iss e - Sw itz erl an d 19 85 -1 98 9 94 8.5 53 8.0 17 6 17 3 21 9 Oa ne ma rk - De nm ark 19 85 -1 98 9 11 11 .2 69 8.3 15 9 15 8 17 4 Fin lan de - Fin lan d 19 85 -1 98 9 12 35 .8 66 2.7 18 6 17 7 33 4 lsl an de b- lce lan db 19 85 -1 98 9 86 8.7 57 5. 9 15 1 14 4 28 8 No ive ge - No rw ay 19 85 -1 98 9 10 46 .8 59 6.6 17 5 17 2 24 2 Su ed e - Sw ed en 19 85 -1 98 9 97 5.9 58 1.9 16 8 16 4 23 9 Es pa gn e - Sp ain 19 86 96 6.1 58 7.9 16 4 15 9 32 4 Gr ec e - Gr ee ce 19 85 -1 98 9 94 8.7 66 7.9 14 2 13 8 23 3 lta lie - Ita ly 19 85 -1 98 9 10 48 .3 61 6.9 17 0 16 7 23 2 Ma lte b - M alt ab 19 85 -1 98 9 11 07 .4 79 1.9 14 0 13 7 26 9 Po rlu ga l 19 85 -1 98 9 11 85 .0 72 4. 6 16 4 15 6 32 4 Yo ug os lav ie - Yu go sla via 19 85 -1 98 9 13 11 .8 89 1.2 14 7 14 2 27 7 Ex ·R ep ub liq ue d em oc rat iqu e a lle ma nd e - Ex -G erm an d em oc rat ic re pu bli c 19 85 -1 98 9 13 61 .6 87 2.5 15 6 Bu lga rie - Bu lga ria 19 85 -1 98 9 14 12 .9 96 0.7 14 7 14 1 33 1 Ho ng rie - Hu ng aiy 19 85 -1 98 9 16 26 .3 95 9.9 16 9 16 4 23 1 Po log ne - Po lan d 19 85 -1 98 9 15 26 .2 86 1.5 17 7 17 0 34 2 Ro um an ie - Ro ma nia 19 80 -1 98 4 14 47 .4 1 0 68 .5 13 5 13 0 30 5 Tc he co slo va qu ie - Cz ec ho slo va kia 19 85 -1 98 9 15 22 .5 89 5.0 17 0 16 7 21 5 Ex ·U RS S - Fo rm er US SR 19 87 15 24 .9 87 3.7 17 5 16 5 34 9 AU TR ES R EG IO NS - OT HE R RE GI ON S Au str ali e - Au str ali a 19 85 -1 98 9 1 0 13 .9 60 6.4 16 7 16 3 25 7 Ca na da 19 85 -1 98 9 99 1.8 57 5.9 17 2 16 8 25 6 Et ats -U nis d 'A m er iqu e- Un ite d S tat es of A me ric a 19 85 -1 98 9 1 0 75 .6 64 3.6 16 7 16 1 28 9 Ja po n - Ja pa n 19 85 -1 98 9 84 0.4 49 8.4 16 9 16 4 24 3 No uv ell e-Z ela nd e - Ne w Ze ala nd 19 85 -1 98 9 11 47 .8 72 3.5 15 9 15 5 22 8 Pr op or tio n de d ec es fe m ini ns p ar: Co ntr ibu tio n ii l a s ur m or ta lite m as cu lin e Pr op or tio n of fem ale d ea ths fr om : Co ntr ibu tio n t o m ale e xc es s m or ta lity Ma lad ies - Dis ea se Vio len ce Ma lad ies - Dis ea se Vio len ce 95 .4 4.6 16 0 10 94 .0 6.0 14 9 15 93 .7 6.3 15 8 13 91 .2 8.8 17 1 20 96 .6 3.4 15 2 8 94 .4 5.6 16 2 13 95 .7 4.3 17 1 8 96 .9 3.1 15 4 6 95 .9 4.1 15 2 9 96 .4 3.6 15 5 9 92 .2 7.8 15 9 17 92 .7 7.3 14 6 13 94 .1 5.9 16 7 20 95 .2 4.8 13 7 14 94 .4 5.6 16 2 13 94 .7 5.3 15 5 13 96 .6 3.4 15 3 11 95 .8 4.2 13 2 10 95 .5 4.5 16 0 10 98 .1 1.9 13 5 5 95 .4 4.6 14 9 15 96 .3 3.7 13 7 10 97 .0 3.0 13 7 10 92 .5 7.5 15 2 17 96 .0 4.0 16 3 14 96 .7 3.3 12 6 10 94 .4 5.6 15 8 12 95 .1 4.9 15 7 17 95 .3 4.7 15 5 12 94 .7 5.3 15 9 13 95 .1 4.9 15 3 14 94 .5 5.5 15 5 13 94 .9 5.1 14 7 12 ~ :::,- § ~ ?! Ta ble au 9b - Ta ble 9b . c: , !i:i An aly se d e l a su rm or ta lite m as cu lin e du e a la vio len ce p ou r c er ta ins p ay s e n de ve lop pe me nt, 1 98 5- 19 89 (o u l a p eri od e la plu s re ce nte ) . ?- An aly sis o f e xc es s m ale m or ta lity du e t o vio len ce in s om e de ve lop ing c ou nt rie s, 19 85 -1 98 9 ( or th e m os t r ec en t p eri od ) ~ I Pa ys/ zon e - Co un try /ar ea Pe rio de /an ne e Ta ux de m or tal ite to ute s c au se s Ra pp ort de su rm or tal ite Su rm ort alit e m as cu line po ur: Pr op ort ion de de ce s f em inin s p ar: Co ntr ibu tio n a la su rm or tal ite m as cu line Pe rio d/y ea r De ath ra te, a ll c au se s Ex ce ss m or tal ity ra tio Ex ce ss m ale m or tal ity fo r: Pr op ort ion of fe ma le de ath s f rom : Co ntr ibu tio n t o m ale ex ce ss m or tal ity Ho m m es Fe mm es Ma les Fe ma les Ma lad ies - Dis ea se Vio len ce Ma lad ies - Dis ea se Vio len ce Ma lad ies - Dis ea se Vio len ce AM ER IQ UE L AT IN E ET C AR AiB ES - LA TIN A ME RI CA A ND T HE C AR IBB EA N Ar ge nti ne - Ar ge nti na 19 86 12 44 .9 81 1.2 15 3 14 8 28 6 96 .1 3.9 14 2 11 Ch ili- Ch ile 19 85 -1 98 9 12 70 .3 82 2.5 15 4 14 4 38 0 95 .5 4.5 13 7 17 Co sta R ica 19 85 -1 98 9 11 47 .9 76 6.8 15 0 14 2 32 2 95 .8 4.2 13 6 13 Cu ba 19 85 -1 98 9 96 4.9 77 2. 7 12 5 - - - - Gu ate ma la 19 84 13 95 .3 11 62 .0 12 0 11 2 46 3 97 .8 2.2 11 0 10 Me xiq ue - Me xic o 19 86 12 00 .0 87 2.0 13 8 12 2 44 8 95 .3 4.7 11 7 21 Pu er to Ri co 19 85 -1 98 9 11 08 .7 68 9.1 16 1 14 9 46 9 96 .3 3.7 14 4 17 Tr ini te -e t-T ob ag o- Tr ini da d an d To ba go 19 86 13 78 .8 1 0 74 .8 12 8 12 2 30 2 96 .7 3.3 11 8 10 Ur ug ua y 19 85 -1 98 9 12 52 .3 78 9.4 15 9 15 4 27 8 96 .1 3.9 14 8 11 Ve ne zu ela 19 85 -1 98 9 11 60 .8 85 8.9 13 5 12 6 36 9 96 .0 4.0 12 1 15 Do nn ee s d efi cie nc es - De fic ien t d ata Ba ha ma s• 19 87 11 94 .8 77 5.0 15 4 14 5 33 7 95 .0 5.0 13 7 17 Ba rba de • - Ba rba do s• 19 88 12 11 .8 75 6.8 16 0 15 4 36 8 97 .1 2.9 14 9 11 Be liz e• 19 86 80 9.4 63 1.6 12 8 11 9 35 7 96 .3 3.7 11 5 13 Do m ini qu e• - Do mi nic a• 19 85 1 0 85 .5 74 6.9 14 5 13 6 2 01 1 99 .5 0.5 13 5 10 El Sa lva do r 19 80 -1 98 4 13 72 .0 87 9.7 15 6 12 9 59 3 94 .2 5.8 12 1 35 Eq ua teu r - Ec ua do r 19 85 -1 98 9 12 34 .5 95 9.2 12 9 11 8 36 4 95 .8 4.2 11 3 15 M ar tin iqu e• 19 85 14 72 .1 71 7.3 20 5 19 5 44 8 96 .1 3.9 18 8 17 Pa na ma 19 85 -1 98 9 88 0.6 67 5.8 13 0 12 0 36 6 95 .9 4.1 11 5 15 Pe ro u- Pe ru 19 80 -1 98 4 97 9.9 86 1.1 11 4 - - - - Re p. do mi nic ain e - Do m ini ca n Re p. 19 85 11 51 .9 93 2.2 12 4 11 7 35 4 97 .3 2.7 11 4 10 Sa int e- Lu cie • - Sa int L uc ia• 19 85 -1 98 9 16 50 .2 10 86 .4 15 2 14 3 58 0 98 .1 1.9 14 1 11 Sa int -V inc en t-e t-G re na din es "- Sa int V inc en t a nd G ren ad ine s• 19 86 15 40 .1 1 10 7.2 13 9 13 4 32 4 97 .5 2.5 13 1 8 Su rin am e• 19 85 15 57 .2 96 5.5 16 1 15 0 32 5 93 .7 6.3 14 1 20 AU TR ES R EG IO NS -O TH ER R EG IO NS Do nn ee s l iab les - Re lia ble da ta Ho ng K on g 19 85 -1 98 9 84 4.8 52 0.2 16 2 16 2 17 2 95 .3 4.7 15 4 8 Isr ae l - Isr ae l 19 85 -1 98 9 98 3.1 75 9.2 12 9 12 7 17 6 94 .7 5.3 12 0 9 Ko we ·~ - Ku wa ~ 19 85 -1 98 9 11 08 .1 89 5.1 12 4 11 8 30 7 97 .0 3.0 11 5 9 Ma ur ice - M au riti us 19 85 -1 98 9 16 94 .1 10 31 .9 16 4 16 2 22 5 96 .5 3.5 15 6 8 Sin ga po ur - Sin ga po re 19 85 -1 98 9 12 56 .6 81 2.8 15 5 15 1 24 6 96 .7 3.3 14 6 8 Do nn ee s d eli cie nc es - De fic ien t d ata Ba hr ein • - Ba hra in• 19 87 12 20 .1 10 78 .2 11 3 11 0 30 4 98 .3 1.7 10 8 5 Re p. de C ore e - Re p. of Ko rea 19 85 -1 98 9 14 26 .2 71 0.2 20 1 19 6 28 7 94 .9 5.1 18 6 15 Sa o T om e et Pr in cip e• -S ao T om e a nd P rin cip e• 19 87 16 44 .8 10 89 .6 15 1 14 9 26 7 98 .7 1.3 14 8 3 Se yc he lle s• 19 85 -1 98 9 17 86 .1 11 00 .2 16 2 15 2 53 5 97 .3 2.7 14 8 14 • Pa ys do nt la po pu lat ion es t in fer ieu re a 1 m illio n d 'ha bija nts . - Co un trie s w ith a po pu lat ion le ss tha n 1 m illio n . . . . , CD L'indice corrige nous indique que c'est au Mexique, a Porto Rico et au Chili que la surmorta- lite masculine par violence contribue davantage a la surmortalite masculine totale. De nouveau, le profit de l'Amerique latine se detache des autres pays en developpement. Vue d'ensemble et conclusion Une analyse comparee de la mortalite generate et, en particulier, de la mortalite violente a ete menee pour un ensemble de pays developpes et en deve- loppement qui foumissent des donnees sur les cau- ses de deces a la banque de donnees de l'Organi- sation mondiale de la Sante. Pour cet ensemble de pays, l'analyse a d'abord permis de rappeler que les deces violents se dassent au troisieme rang des grandes causes de deces, apres les maladies de l'appareil circulatoire et les tumeurs malignes, dans la plupart des pays developpes et dans cer- tains pays en developpement a donnees fiables. L'analyse comparative a aussi permis de mettre a jour l'existence de disparites importantes dans le niveau et dans la structure de la mortalite, a la fois entre les pays developpes et entre les pays en deve- loppement. Ainsi, le niveau de la mortalite genera- te varie du simple au double, chez les deux sexes, autant dans les pays developpes que dans les pays en developpement. Pour la mortalite violente, les ecarts sont plus importants; la mortalite la plus basse est trois a quatre fois plus faible que la morta- lite la plus forte, sauf pour les femmes dans les pays en developpement ou les ecarts vont du simple au double. Notre methode a fait ressortir les pays ou, en comparaison avec d'autres, la situation en matiere de mortalite violente est plutot favorable et ceux ou au contraire la situation est nettement defavorable. A l'aide de la methode de la classification automatique et de l'analyse detaillee des tab'leaux 4 et 5, nous avons constate qu'un certain nombre de pays presentaient un profil de mortalite selon la cause assez caracteristique; ce sont surtout les pays developpes (pays de l'Europe de l'Ouest et pays des autres regions) et certains pays en developpe- ment (Hong Kong et Israel) a basse mortalite gene- rate. Ainsi, pour ces pays, le niveau de developpe- ment atteint fait en sorte que certaines causes de deces violents predominent: ce sont les accidents de vehicule a moteur, les chutes et les suicides. Par ailleurs, dans les autres pays developpes (pays de l'Europe de l'Est) et dans les pays en develop- pement (saufHong Kong et Israel), on retrouve un profil de mortalite selon la cause plus «tradition- nel»; il caracterise des pays moins developpes OU l'on observe en general moins de deces par suici- de et par accident de vehicule a moteur et ou les composantes non intentionnelles prennent plus de place que les composantes intentionnelles. Notre analyse a aussi fait ressortir la situation fort particuliere des pays d'Amerique latine 30 quanta la mortalite violente et surtout !'impor- tance de la mortalite par homicide dans plusieurs de ces pays. 11 s'agit sans nul doute d'une region a haut risque pour laquelle d'autres etu- des doivent etre entreprises et ou des moyens de prevention doivent etre mis en oeuvre pour en- rayer une hausse de la violence et de ses conse- quences nefastes pour ces societes ( 10). Enfin, l'analyse de la surmortalite masculine par violence a non seulement montre l'ampleur de la difference entre les sexes mais a aussi mis en exergue certains pays ou la surmortalite masculine par violence etait plus forte: la Finlande, la France, le Mexique, Porto Rico et le Chili. Notre etude s'est bornee a l'etude de la mortalite violente pour !'ensemble des groupes d'ages. Or, on sait que la mortalite violente n'est pas uniforme selon l'age; elle est particu- lierement elevee chez lesjeunes (15-24 ans) pour certaines causes, telles les accidents de vehicules a moteur et le suicide, et chez les personnes agees, surtout a cause des chutes non intentionnelles. 11 serait done utile de s'interesser a certains grou- pes d'age et de detailler davantage les causes de deces violents de maniere a mieux identifier les groupes cibles et les moyens de prevention ade- quats. De plus, une analyse des donnees de mortali- te pour plusieurs periodes permettrait de faire res- sortir des tendances selon les causes et de faire certaines projections pour les annees a venir. En- fin, pour connaitre le veritable impact de la violen- ce comme probleme de sante publique, il faudrait inclure un examen de la morbidite violente; en ce domaine, les donnees sont limitees mais pourtant essentielles a la fois pour assurer un meilleur suivi epidemiologique du phenomene et pour amelio- rer la prevention et le traitement medical (soins d'urgence et rehabilitation) des blessures liees a la violence. Malgre ses limites, notre etude presente tout de meme l'avantage de donner une vue d'ensem- ble d'une mortalite qui resulte d'un meme phenomene, soit la violence: violence non inten- tionnelle ou intentionnelle, violence envers soi- meme ou envers les autres. Bien que des strategies particulieres puissent convenir davantage a chaque categorie de causes de deces violents (accidents de vehicules a moteur, empoisonnements, chutes, noyades, suicides, homicides), il n 'en demeure pas moins qu'une approche globale de preven- tion basee sur la recherche d'une plus grande «securite» dans tous les domaines de la vie couran- te est plus appropriee: securite dans les transports, dans le milieu de travail, a la maison, dans les sports et autres activites de loisirs. L'etablissement de veritables politiques de securite est un objectif sou- haitable, non seulement dans les pays developpes ou les diverses formes de violence sont deja impor- tantes, mais aussi dans les pays en developpement ou, du fait de la diffusion croissante des produits et Rapp. trimest statist. sanit. mond., 46 (1993) des techniques modernes, le probleme de la vio- lence devient de plus en plus prioritaire. Remerciements Cette recherche a ete realisee grace au soutien financier du Fonds pour la formation de cher- cheurs et l'aide a la recherche (FCAR) - Pro- gramme d'action concertee de soutien a la re- cherche en securite routiere - ( Quebec, Canada) et grace a la collaboration du Programme de preven- tion des traumatismes de l'Organisation mon- diale de la Sante (Geneve). L'auteur tient a remercier Valerie Courville pour son assistance technique dans la realisation de cet article. Resume Une analyse comparee de la mortalite generale et, en particulier, de la mortalite violente a ete menee pour un ensemble de pays developpes et en developpement qui fournissent des donnees sur les causes de deces a la banque de donnees de !'Organisation mondiale de la Sante. Pour cet ensemble de pays, !'analyse permet d'abord de montrer que les deces violents se classent au troisieme rang des grandes causes de deces, apres les maladies de l'appareil circulatoire et les tumeurs malignes, dans la plupart des pays developpes et dans certains pays en developpement a donnees fiables. L'analyse comparative permet aussi de mettre a jour !'existence de disparites importantes dans le niveau et dans la structure de la mortalite, a la fois entre les pays developpes et entre les pays en developpement. Ainsi, le niveau de la mortalite generale varie du simple au double chez les deux sexes, autant dans les pays developpes que dans les pays en developpement. Pour la mortalite violente, les ecarts sont plus importants; la mortalite la plus basse est trois a quatre fois plus faible que la mortalite la plus forte, sauf pour les femmes dans les pays en developpement, ou les ecarts vont du simple au double. La methode fait ressortir les pays ou, en comparaison avec les autres pays, la situation en matiere de mortalite violente est plutot favorable et ceux ou au contraire la situation est nettement defavorable. Bien qu'il soil difficile d'etablir une typologie claire permettant de regrouper les pays selon leur profil de deces par cause, nous constatons qu'un certain nom- bre de pays presentent un profil de mortalite selon la cause assez caracteristique; ce sont surtout les pays developpes (pays de l'Europe de l'Ouest et pays des autres regions) et certains pays en developpement (Hong Kong et Israel) a basse mortalite generale. Ainsi, pour ces pays, le niveau de developpement atteint fail en sorte que certaines causes de deces violents predo- minent: ce sont les accidents de vehicules a moteur, les chutes et les suicides. Par ailleurs, dans les autres pays developpes (pays de !'Europe de l'Est) et dans les pays en developpement (sauf Hong Kong et Israel), on retrou- ve un profil de mortalite selon la cause plus «tradition- nel»; ii caracterise des pays mains developpes ou l'on observe en general mains de deces par suicide et par accident de vehicule a moteur et ou les composantes Wld hlth statist. quart., 46 (1993) non intentionnelles prennent plus de place que les composantes intentionnelles. L'analyse fail aussi ressortir la situation fort particuliere des pays d'Amerique latine quanta la mortalite violente et surtout !'importance de la mortalite par homicide dans plusieurs de ces pays. II s'agit sans nul doute d'une region a haul risque pour laquelle d'autres etudes doi- vent etre entreprises et ou des moyens de prevention doivent etre mis en oeuvre pour enrayer une hausse de la violence et de ses consequences nefastes pour ces societes. Entin, !'analyse de la surmortalite masculine par violen- ce montre non seulement l'ampleur de la difference entre les sexes, mais elle met aussi en exergue certains pays ou la surmortalite masculine par violence est plus forte: la Finlande, la France, le Mexique, Porto Rico et le Chi Ii. Summary Comparative analysis of violent deaths in the developed countries and some developing countries, 1985-1989 A comparative analysis of crude death rates and specif- ically of deaths from violence was conducted for a large number of developed and developing countries which provide data to the World Health Organization's data bank. For these countries, the analysis shows. first of all, that violent deaths rank third among the major causes of death, after diseases of the circulatory system and malig- nant tumours, in most developed countries and in some developing countries with reliable data. The comparative analysis also reveals substantial variations in the level and structure of death rates, both among the developed and the developing countries. Thus the crude death rate varies by a factor of 2 in both sexes, both in the devel- oped and the developing countries. For violent deaths, the ranges are even wide: the highest death rate is 3 to 4 times greater than the lowest, except for women in developing countries where it is only twice as high. The method reveals in which countries the situation regard- ing violent deaths is relatively tolerable and in which countries the situation is decidedly bad. Although it is difficult to draw up a clear classification whereby countries can be grouped according to their profile of deaths by cause, it can be seen that a number of countries have a fairly characteristic profile of mortal- ity by cause; these are mainly the developed countries (Western Europe and other regions) and some develop- ing countries (Hong Kong and Israel) with low crude death rates. In these countries certain causes of violent death predominate as a result of the level of develop- ment achieved: motor vehicle accidents, falls and sui- cides. Moreover, in the other developed countries (in Eastern Europe) and in the developing countries (ex- cept Hong Kong and Israel) there is a more "traditional" profile of mortality by cause; this profile is characteristic of the less-developed countries where there are gener- ally fewer deaths from suicide and from motor-vehicle accidents and where unintentional factors predominate over intentional factors. 31 This analysis also brings out the very distinctive situation of the countries of Latin America with regard to violent deaths, particularly the large number of deaths from homicide in a number of countries. This is unquestion- ably a high-risk region for which further studies need to be undertaken, and where preventive measures need to be applied in order to curb the rising tide of violence and its harmful consequences for these societies. Lastly, the analysis of excess male mortality from vio- lence shows not only the extent of the difference be- tween the sexes, but also highlights certain countries where excess male mortality form violence is highest: Finland, France, Mexico, Puerto Rico and Chile. References I References 1. Taket, A. Mortalite par accident chez les enfants, les adolescents et les jeunes adultes. R.appurt trimestriel de statistiques sanitaires mondiales, 39 (3): 232-256 (1986). Taket, A. Accident mortality in children, adolescents and young adults. World health statistics quarterly, 39 (3): 232-256 (1986). 2. Lope2, A.D. Causes of death: An assessment of global patterns of mortality around 1985. World health statistics quarterly, 43 (2): 91-104 (1990). Encadre 2 Les resultats de la classification automatique: Hammes. 3. Chackiel, J. L'etude des causes de deces en Amerique la tine: situation actuelle et perspectives d' avenir. In: Vallin,J. etal. (ed.) Mesureetanalysedelamortalite. Nouvelles approches. Paris, INED, UIESP, PUF, (Collection Travaux et Documents, Cahier No.119), chapitre 18, 1988. 4. Blum, A. & Monnier, A. La mortalite selon la cause en Union Sovietique. Papulation, 44 (6):1053-1100 (1989). 5. Brouard, N. & Lopez, A. Causes of death patterns in low mortality countries: a classification analysis. Actes du Congres international de la papulation de Florena, Liege, UIESP, 1985, p. 385-406. 6. Brouard, N. Robustesse d'une typologie des pays developpes suivant leur profil de deces par cause: 1968-1984. In: Vallin, J. et al. (ed.). Mesure et analyse de la mortalite. Nouvelles approches. Paris, INED, UIESP, PUF, (Collection Travaux et Documents, Cahier No. 119), chapitre 14, 1988. 7. PAHO (Pan American Health Organization). Violence: A growing public health problem in the region. Epidemiowgical Bulletin, 11 (2): 1-7 (1990). 8. OMS (Organisation mondiale de la Sante). Annuaire de statistiques sanitaires mondiales. Geneve, OMS, 1991. WHO (World Health Organi2ation). World health statistics annual Geneva, WHO, 1991. 9. Omran, A. The epidemiological transition: a theory of population change. Milhank Memorial Fund Qµarterly, 49 (1971). 10. PAHO (Pan American Health Organization). A collaborative study of accidents in children and adoksants, Brazi~ Chil.e, Cuba and Venezuela. Washington, D.C., 1987. Classe 1: Pays-Bas, Angleterre et pays de Galles, Malle 32 Classe 2: Espagne, Grece, lrlande, ltalie, Ecosse, lrlande du Nord, RFA, Japan, Suede, Australie, Canada, lslande, Norvege Classe 3: Suisse, Danemark, Belgique, Luxembourg, Nouvelle-Zelande, Yougoslavie, Bulgarie, Etats-Unis Classe 4: Portugal, Pologne, Autriche, France, Tchecoslovaquie, Finlande Classe 5: Hongrie Encadre 3 Les resultats de la classification automatique: Femmes. Classe 1: Angleterre et pays de Galles, Espagne, Malte Classe 2: Yougoslavie, Bulgarie, lslande, Japan, RFA, Suede, Pays-Bas Classe 3: lrlande, lrlande du Nord, ltalie, Grece, Australie, Canada, Etats-Unis, Portugal, Ecosse, Norvege, Pologne, Luxembourg, Nouvelle-Zelande Classe 4: Autriche, Suisse, Belgique, Finlande, France, Danemark, Tchecoslovaquie Classe 5: Hongrie Rapp. trimest statist. sanit. mond., 46 (1993) Liste des abreviations - List of abbreviations Surles figures 1 a 4, la position de chaque pays est indiquee a l'aide d'un code de trois lettres. Un asterisque (*) est parfois place a la fin de ce code pour indiquer que les donnees de ce pays sont deficientes et doivent etre interpretees avec precaution. La liste de ces abreviations est fournie ci-desscus. - In Figs. 1 to 4, the position of each country is indicated by a 3-letter code. Some codes are followed by an asterisk (*) which indicates that the data for this country are inadequate and should be treated with caution. The list of abbreviations follows. Pays developpes ANG: Angleterre et pays de Galles - England & Wales AUS: Australie -Australia AUT: Autriche -Austria BEL: Belgique -Belgium BUL: Bulgarie -Bulgaria CAN: Canada DAN: Danemark -Denmark ECO: Ecosse -Scotland ESP:Espagne -Spain FIN: Finlande -Finland FRA: France GRE: Grece -Greece HOL: Pays-Bas - Netherlands HON: Hongrie - Hungary IRL: lrlande - Ireland IRN: lrlande du Nord - Northern Ireland ISL: lslande -Iceland ITA: ltalie -Italy JAP: Japan -Japan LUX: Luxembourg MAL: Malte -Malta NOR: Norvege -Norway NZE: Nouvelle-Zelande - New Zealand POL: Pologne -Poland POR: Portugal RFA: Allemagnea -Germany ROU: Roumanie -Romania SUE: Suede -Sweden SUi: Suisse - Switzerland TCH: Tchecoslovaquie - Czechoslovakia URS: Ex-URSS - Former USSR USA: Etats-Unis d'Amerique - United States of America YOU: Yougoslavie - Yugoslavia Pays en developpement ARG: Argentine -Argentina BAE: Bahrein -Bahrain BAH: Bahamas BAR: Barbade - Barbados BEL: Belize CHI: Chili -Chile COR: Republique de Coree - Republic of Korea COS: Costa Rica DOM: Dominique -Dominica EOU: Equateur - Ecuador GUA: Guatemala HKO: Hong Kong ISR: Israel - Israel KOW: Kowen -Kuwait MAR: Martinique MAU: Maurice -Mauritius MEX: Mexique -Mexico PAN: Panama -Panama PUE: Porto Rico - Puerto Rico RDO: Republique dominicaine - Dominican Republic SAL: El Salvador SAO: Sao-Tome-et-Principe - Sao Tome and Principe SEY: Seychelles SIN: Singapour -Singapore SLU: Sainte-Lucie - Saint Lucia SRI: Sri Lanka SUR: Suriname SVG: Saint-Vincent-et-Grenadines - Saint Vincent and the Grenadines THA: Tha'ilande -Thailand TRI: Trinite-et-Tobago - Trinidad and Tobago URU: Uruguay VEN: Venezuela • Republique federale d'Allemagne avant l'unificalion - Federal Republic of Germany before unification. Wld hlth statist. quart, 46 (1993) 33 Intentional violence among adolescents and young adults: an epidemiological perspective Olivier Jeannereta & E.A. Sandb Introduction The purpose of this article is to draw attention to intentional violence, which has been studied much less than accidental violence. The subject is seen from a public health perspective and supported with factual data, for the 15-19 and 20-24 age groups. The article looks at the secular trend in deaths by murder and suicide in a number of coun- tries, and to data gleaned from recent literature on morbidity (injuries), risk factors and/ or protective factors, etc. ( see Tab/,e 1). The data on mortality were obtained from HST/GSP at WHO headquarters. The other data come from a selective search in computerized banks of bibliographical references; this explains the scarcity of works from developing countries. Finally, only recent bibliographical references have been taken into account, on the assumption that readers will be familiar with the older ones. Definitions and demarcation The definition of ''violence" used here is that of Rosenberg & Mercy, "the use of physical force with the intent of causing harm, injury or death" ( 1). According to Chesnais, it is character- ized by brutality, external origin and painful ef- fect (2) (see also Tab/,e 2). Violent deaths consist in the main of accidents, murders and suicides, with 3 accessory categories. The legitimacy of this grouping, which appears in successive editions of the International Classifica- tion of Diseases (3), is not disputed, even by clini- cians (4). The classic definition of "murder" is a death due to injuries inflicted by another person with intent to injure or kill, by any means. There are more difficulties surrounding the definition of be- haviour described in the English-language litera- ture as "assaultive violence", cause of the mortality and morbidity discussed here. This term, used in several publications by Rosenberg & Mercy in- cludes both fatal and non fatal interpersonal vio- lence where physical force by one person is used with the intent of causing harm, injury or death to another ( 1, 5). a Professeur, Faculr.e de Medecine, Universite de Geneve, Geneve, Suisse. b Professeur, Facult.e de Medecine, Universit.e libre de Bruxelles. 34 Table 1 Classification of trends in violence Tableau 1 Classification des tendances de la violence Fig. Men/ Hommes Women I Femmes 15·19 20-24 15·19 20·24 years/ans years/ans years/ans years/ans Canada 1 / / (/) (/) Chile I Chili 7 --+ --+ (--+) ('-..) Mexico I Mexique 6 ""' ""' (',.,.) ('-..) Guatemala 5 / / ('-..) (/) Poland I Pologne (/) (--+) (--+) (--+) Australia I Australie 2 / / (/) (/) United States of America I 8 / / (/) (/) Etats-Unis d'Amerique Norway I Norvege 3 / / (/) (/) Hungary I Hongrie 3 ""' ""' ('-..) ('-..) Portugal (--+) (/) (--+) (--+) Italy/ ltalie (--+) (/) (/) (/) Spain I Espagne (/) (/) (--+) (--+) Greece I G rece (--+) (--+) (/) (/) Japan I Japan 4 / / (/) (/) Singapore I Singapour 4 / --+ (--+) (--+) Hong Kong 4 --+ / (/) (/) Ireland/ lrlande (/) (/) (/) (/) Scotland I Ecosse (/) (/) (/) (/) Northern Ireland I 9 / / (--+) (/) lrlande du Nord England & Wales I (/) (/) (--+) (--+) Angleterre et Galles ( ) not shown in the graphics I pas represente dans les figures. / increasing trend I tendance a la hausse. '-.. decreasing trend I tendance a la baisse. --+ stable trend I tendance stable. Physical force is often associated with abuse of people of all ages, but it does not necessarily come into play when children and young adolescents- or old people - do not receive due care; when they are neglected by their parents, family or guardians. Rapp. trimest. statist. sanit. mond., 46 (1993) Table 2 Classification of modes of violence Tableau 2 Classification des modalites de la violence PRIVATE VIOLENCE -VIOLENCE PRIVEE Criminal - Criminelle Fatal - Martelle ! Murder- Meurtre Assassination - Assassinat Deliberate poisoning - Empoisonnement volontaire Capital punishment - Executions capitales Corporal - Corporelle Deliberate blows and injuries - Coups et blessures volontaires Sexual - Sexuelle Rape-Viols Non-criminal - Non-criminelle { Suicidal: suicides and attempted suicides - Suicidaire : suicides et tentatives Accidental - Accidentelle COLLECTIVE VIOLENCE - VIOLENCE COLLECTIVE Of citizens against the authorities - Des citoyens contre le pouvoir { Terrorism - Terrorisme Revolution - Revolutions Strikes - Greves Of the authorities against the citizens - ( Du pouvoir contre les citoyens State terrorism - Terrorisme d'etat Industrial violence - Violence industrielle Paroxysmal violence - Violence paroxystique Source: Chesnais (2) Hence a second definition of violence which does not necessarily include physical force: "re- current behaviours intended to cause pain, dam- age, or destruction to another person" (6). "Domestic violence" is "a set of destructive behaviours within a family or household, or among intimates" (1). Whereas this is probably of second- ary importance for young adults who have left the parental household and have not yet founded an- other, it obviously affects adolescents living with their parents; it adds to the violence suffered ( or done) in school, in the street and in leisure time. The following definition seems to be of rele- vance, in spite of its legal ring: "behaviour toward a family member that would evoke legal action if directed toward a stranger" (7). Many authors also use the term "family vio- lence" or "intrafamily violence". In this context, the three adjectives "domestic", "family" and "intrafamily" are regarded for simplicity, as syn- onyms. In some recent review articles, all injuries due to violence in a given age group, such as 0-19 years, are taken into account: from maltreatment to mur- der, via assault; this confirms the usefulness of an overall view, with recourse to many additional indi- cators (8). Suicide, violence against the self, does Wld hlth statist. quart., 46 (1993) not count as interpersonal violence. Here again, violence cannot be regarded as physical unless it involves firearms, hanging, defenestration, etc.; drugs and medications are not counted. Intentional violence could also be seen to in- clude: (a) violence perpetrated by gangs or by sev- eral people who do not constitute a group, on one or more persons, such as gang rape, which is still interpersonal violence; and (b) violence regarded as social and/or political in nature, which goes beyond the bounds of interpersonal violence to become public violence, as defined by Chesnais (2). In the interests of brevity, category (a) has not been included in this study. As regards (b), such phenomena will be discussed under "other vio- lence", in the presentation of national statistical data. The choice of two adjacent age groups ( 15-19 and 20-24 years of age) is justified by the appear- ance in the former and increase in the latter of intentional violent behaviour which is likely to have a serious - or terminal - effect on the health of the people concerned; these consequences them- selves have obvious repercussions not only at the individual level but also in society, particularly in economic terms. 35 Changes in mortality rates between 1960-1964 and 1985-1989 in selected countries The choice of countries was made in order to bring out contrasts or similarities in secular trends in the relative levels of murder, suicide and, in some cas- es, other forms of violence. The two conditions for selection were existence of reliable national data, and a total population of more than one million. Because space is short, we have not made separate comments on each of the graphs, which tend to be self-explanatory in any case. Composition of mortality due to intentional violence • Among young men in Canada (Fig. 1), Australia (Fig. 2), Hungary and Norway (Fig. 3) and in 3 countries of the Far East (Fig. 4), murder ac- counts for a minimal to small proportion of death by intentional violence. • In contrast, it is suicide that plays a minor role for 2 of the 3 Latin American countries consid- ered - Guatemala (Fig. 5) and Mexico (Fig. 6) - at least as far as the younger age group, 15- 19 years, is concerned. • In Chile (Fig. 7) and the United States of Amer- ica (Fig. l!), however, murder and suicide ac- count for mortality due to intentional violence in more or less equal measure. Fig. 1 Other forms of violent death Regularly recorded since the first 5-year period considered (1960-1964) in most of the countries providing reliable statistics, the "other violence" category is prominent in Guatemala (Fig. 5), Mexi- co (Fig. 6), Chile (Fig. 7) and Northern Ireland (Fig. 9). Strangely, it hardly seems to influence the trend in intentional violence in Chile (Fig. 7) or Mexico (Fig. 6), whereas it does in Guatemala (Fig. 5) and Northern Ireland (Fig. 9). This con- trast, which suggests the presence of extraneous factors, would seem to call for a special study. Divergent or convergent secular trends in intentional mortality? • There is a marked decline in Hungary - where the suicide rate for all ages has long been one of the highest in Europe - except between 1975- 1979 and 1980-1984 (Fig. 3), and also in Hong Kong, but to a lesser extent (Fig. 4). • A clear increase in Canada until 1980-1984 (Fig. 1), in Australia (Fig. 2), in Norway (Fig. 3), in the United States of America (Fig. l!), and in Northern Ireland (Fig. l!), although only until 1975-1979. • Absence of any clear trend in Singapore and Japan, except between the first and second peri- ods, where the rate had fallen (Fig. 4). Comparison of trends in mortality (per 100 OOO) due to accidental and intentional violence among men aged 15-19 and 20-24, Canada, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par accident et par violence intentionnelle au Canada, chez les hommes de 15-19 ans et de 20-24 ans entre 1960 et 1990, par periodes quinquennales 0 -o Oo 8g g~ ~s ~o Q) Cl. o.-i& "'"" ~~ .c "' m~ ,:, := ""' :;:t:: ·u ~ ~"' d,,, Cl" <i ... 36 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 ! l..__j~~~l====;::::=:!:=:::::;::::=~::::::::;===9::===::;==:::::!.__J; 1960-64 1965-69 1970-74 Intentional injury Suicide -&- Traumatismes intentionnels -+- 15-19 years/ans 15-19 years/ans Intentional injury +--- Traumatismes intentionnels 20-24 years/ans Suicide ._. 20-24 years/ans 1975-79 1980-84 1985-89 Homicide All accidents -e- t 5-19 years/ans --+- Ensemble des accidents 15-19 years/ans Homicide --- 20-24 years/ans All accidents -+- E1semble des accidents 20-24 years/ans Rapp. trimest. statist. sanit. mond., 46 (1993) Fig. 2 Comparison of trends in mortality (per 100 OOO) due to intentional violence among men aged 20-24, Australia, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle en Australie chez les hommes de 20-24 ans entre 1960 et 1990, par periodes quinquennales 60 Males - Hammes 15-19 years/ans Intentional injury Traumastismes intentionnels 10 Suicide Homicide o_j__Jt::=:=;:===-===:::;==:::!~=::;:==~==:::;:::::::::::~::::;:==~___j 60 10 1960-64 Males - Hammes 20-24 years/ans 1960-64 1965-69 1965-69 1970-74 1975-79 Years - Annees Intentional injury T raumastismes intentionnels • 1970-74 Homicide • 1975-79 Years - Annees These comparisons, based on a restricted num- ber of countries, concern only males. It is a well- known fact that intentional violence among fe- males is much less frequently fatal, so that all the trends are less marked, if they are distinguishable at all (such that the highlighting of differences and trends would have called for a lengthening of the y axis). Even this expedient is unlikely to show up secular trends, and only very few murders, even in the 20-24 age group. For males, there is always a clear increase be- tween the former age group (15-19) and the latter (20-24): in this study it is shown only for Canada, so as to avoid statistical overload. For the same reason, Fig. 1 is also the only one which shows the rate for Wld hlth statist. quart., 46 (1993) 1980-84 1985-89 • • 1980-84 1985-89 all accidents, where the recent, dramatic drop in mortality is in contrast with the rise in intentional violence already mentioned. Murder The spectacular and worrying significance of this "tip of the iceberg" of interpersonal violence is seen in statistics from the United States of America, which show the reality in a less conventional and abstract way. • The life-time chance of becoming a homicide victim is approximately 1 in 240 for whites and one in 45 for blacks and other ethnic minori- ties (1). 37 Fig. 3 Comparison of trends in mortality (per 100 OOO) due to intentional violence (murder and suicide) among men aged 20-24, Hungary and Norway, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle (homicide et suicide) en Hongrie et en Norvege chez les hommes de 20-24 ans entre 1960 et 1990, par periodes quinquennales 60 Males - Hammes Hungary - Hongrie Norway - Norvege 15-19 years/ans -a- Intentional injury -+- Intentional injury Traumatismes intentionnels Traumatismes intentionnels 50 s -+- Suicide -+- Suicide -o go oo 00 -a- Homicide ....... Homicide 40 o- - ::i -o " 0. o.- ; (I) mg 30 -- .c "' .; 0. .,.., 'C:: _g ~ ·o ~ 20 ~ .. .,,, Cl>< <::, {!. 10 0 1960-64 1965-69 1970-74 1975-79 Years -Annees 60 'Males - Hammes Hungary - Hongrie 20-24 years/ans -a- Intentional injury Traumatismes intentionnels 50 i5 -+- Suicide -o Oo 8g g- - ::i 40 -& :L ;a, ~·i ~[ 30 (l)•Q) 'C :!: ""' ;;:.t:: -~ ~ ~~ 20 ~ .. <::, "' ..... 10 0 1960-64 1965-69 1970-74 1975-79 Years-Annees • "Assaultive violence causes 19 OOO to 23 OOO deaths each year ... [and] is taking its greatest toll among minorities, men and the young" (5). • Homicide is among the leading causes of death in the general population, but the first cause among African American males between the ages of 15 and 34 (5). • In 1980, almost 24 OOO people were murdered, which constituted almost 700 OOO potential years of life lost (PYLL) (1). • Between 1968 and 1985, the death rate due to murder for all ages increased by 44%, and the PYLL indicator by 93% (9). 38 1980-84 1985-89 Norway - Norvege -+- Intentional injury T raumatismes intentionnels -+- Suicide ~ 0 I 1980-84 1985-89 • In the decade from 1980 to 1989, it is estimated that 11 OOO people were killed by high-school- aged youths, two-thirds of them by fire- arms (10). • Between 1979 and 1989, among young African Americans between 15 and 19 years of age, the rate of death by murder with firearms was al- ways the leading of death. As of 1984, it in- creased faster than the corresponding rate for motor vehicle accidents, but in tandem with the rate for suicide by firearm ( 11). As previously mentioned, for other industrial or non-industrial countries, the number and annual rates of death by murder are known, but the recent Rapp. trimest. statist. sanit. mond., 46 (1993) Fig. 4 Comparison of trends in mortality (per 100 OOO) due to intentional violence among men aged 20-24, in Hong Kong, Japan and Singapore, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle a Hong Kong, au Japan et a Singapour, chez les hommes de 20-24 ans entre 1960 et 1990, par periodes quinquennales Males - Hammes Intentional injury (Hong Kong) -s- Homicide (Hong Kong) 15-19 years/ans ...__ Traumatismes intentionnels (Hong Kong) -e- Intentional injury (Japan) ....... Homicide (Japan - Japan) Traumatismes intentionnels (Japan) -+- Intentional injury (Singapore) -+- Homicide (Singapore - Singapour) Traumatismes intentionnels (Singapour) 1960-64 1965-69 1970-74 1975-79 1980-84 1985-89 Years - Annees Males - Hammes 20-24 years/ans ...__ Intentional injury (Hong Kong) -e- Homicide (Hong Kong) Traumatismes intentionnels (Hong Kong) -e- Intentional injury (Japan) ....... Homicide (Japan - Japan) Traumatismes intentionnels (Japan) -+- Intentional injury (Singapore) -+- Homicide (Singapore - Singapour) Traumatismes intentionnels (Singapour) 1960-64 1965-69 1970-74 1975-79 Years - Annees literature reviewed through the databases consult- ed contains no data comparable to that published about the United States of America. We do not have enough space to discuss the reli- ability of the various sources (5). It should, however, be recalled that the completeness of mortality statis- tics is always superior to that for morbidity, even though, as already mentioned (see Introduction), an unknown proportion of murders are disguised as accidents or even suicides for a variety of reasons. A relatively recent method, dating from 1978, of elucidating the causes and processes of child death (under 15 years) is that adopted by the Child Wld hlth statist. quart., 46 (1993) 1980-84 1985-89 Death Review Teams ( 12) which pool information and resources from such diverse institutions as the police, the courts and child health and welfare services. It has been established gradually in the United States, and by 1992 it covered 40% of the population of that country. This is an important innovation not only for preventive action, but also for epidemiological research in so far as the quality of information gathered makes for fruitful compar- isons between the various teams on the ground. In fact, should the practice not be extended to the ''violent deaths" of adolescents (15-19 years of age) and young adults? 39 Fig. 5 Comparison of trends in mortality (per 100 OOO) due to intentional and other violence among men aged 15-19, Guatemala, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle et par autre violence au Guatemala chez les hommes de 15-19 ans entre 1960 et 1990, par periodes quinquennales 60 Males - Hammes 15-19 years/ans 50 s -o Oo 8g g- 40 -s ~ &. 8.-;Q) ~~ 30 .c:la m: -a== ~~ iii~ 20 g.., 8,~ <::, ~ 10 0 1960-64 1965-69 1970-74 1975-79 Years - Annees 300 Males - Hammes 20-24 years/ans 250 s sg 8g g- 200 -s ~o CD Q. ~- ii ~~ 150 I! 'C == _g ~ ·u ~ ~CD 100 Intentional injury . ,, &x Traumatismes intentionnels <::, "' I- Homcide 50 0 1960-64 1965-69 1970-74 Years - Annees Non-fatal assault This is "a common endpoint of many quite differ- ent behavioral pathways, such as arguments be- tween acquaintances, escalating domestic violence between spouses or robberies perpetuated by strangers". Furthermore "each pathway or type of assaultive violence may be associated with a unique set of causes or risk factors" (5). In the United States, the proportion of cases of such assault to the number of murders varies from 69:1 - according to police reports- to 100:1 - ac- cording to the National Crime Survey (5). This shows how important it is to study such assaults, not 40 Other violence Autre violence Intentional injury T raumatismes intentionnels Homcide Suicide 1980-84 1985-89 1975-79 Other violence Autre violence ! Suicide i 1980-84 only from the epidemiological point of view, but also in terms of their cost to the community ( 13). We now tum to some recent studies based on morbidity data from various sources, selected to show how difficult it is to get to the crux of a problem whose complexity is evident from the above quotation. Cases from hospitals and emergency clinics In Johannesburg-Soweto (South Africa), Butchart studied a sample of 3 535 cases from 1989 and 1990, which can be extrapolated to an annual aver- age incidence of 2 886 cases per 100 OOO popula- Rapp. trimest statist. sanit. mond., 46 (1993) Fig. 6 Comparison of trends in mortality (per 100 OOO) due to intentional and other violence among men aged 15-19, Mexico, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle et par autre violence au Mexique chez les hommes de 15-19 ans entre 1960 et 1990, par periodes quinquennales 60 Males - Hommes 15-19 years/ans 50 0 -o Oo 8g Other violence g~ 40 Autre violence ~s ~o " Q. a.- -; (I) 1ij .g> Intentional injury ~~ ,:: "' .; Q. 30 Traumatismes intentionnels ., . ., "C := 0"' i.:c -~ ~ 20 Homcide ~~ ~~ <( "' I- 10 Suicide 0 1960-64 1965-69 1970-74 Years -Annees 100 90 0 80 -o Oo 8g g~ 70 ~s ~o (I) Q. a.- 60 -;a, «i·i ~~ ,:: "' .; Q. (l)•Q) 50 1:) :!:: 0"' 40 = 'C I~ "'" &~ 30 <( ::, Other violence "' I- Autre violence 20 10 Suicide 0 1960-64 1965-69 1970-74 Years-Annees tion, half of which are due to interpersonal vio- lence ( 14). This incidence is three times higher for blacks between the ages of 20 and 24, and seven times higher for "coloured" people of the same age group. The authors rightly point out that the strictness of their criteria for inclusion in the sam- ple led to a definite underestimation of the reality, especially for blacks. On the other hand, the calcu- lation of the sex ratio of the injured people is probably not affected by this bias (since it was made within the sample): from an average of2.9 it rises in the 15-19 age group to 7.1 for blacks and 6.1 for coloureds. This is the first confirmation of male predominance, in terms of morbidity, as well. Wld hffh statist. quart., 46 (1993) 1975-79 1980-84 Males - Hommes 20-24 years/ans ~ 0 !l j 1975-79 1980-84 In Norway, a retrospective study of facial inju- ries between 1960 and 1989 showed that violent behaviour gradually overtook road accidents as a causative factor ( 15). Most victims now are young, unemployed, ill-educated city dwellers, half of whom had taken alcohol at the time of the "acci- dent". That is a first sketch of a high-risk group for a physically very localized set of injuries. In Denmark, a group of researchers has ex- plored the causes and consequences of "street violence" in the town of Arhus, using data from the emergency services of the hospitals, and the local legal-medical institute. This violence, which is re- sponsible for one-quarter of injuries, is concentrat- 41 Fig. 7 Comparison of trends in mortality (per 100 OOO) due to intentional and other violence among men aged 15-19, Chile, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle et par autre violence au Chili chez les hommes de 15-19 ans entre 1960 et 1990, par periodes quinquennales 70 Males - Hammes 15-19 years/ans 60 0 sg 8g 50 g- -s ~ &. o.- 40 i& !!!~ .r:m .; Q. .,.., "t:I:!: 30 _g ~ ·o ~ ~., 20 . .,, &~ <., I- • ·----- 10 .... ::===-==-• : : 0 1960-64 1965-69 1970-74 1975-?9 Vears-Annees 100 Males - Hammes 90 20-24 years/ans 80 0 -o Oo 8g 70 g- -s ~ 8. "-- 60 -;a, ni .gi 50 ~ ~ .r:m .; Q. .,.., "t:I:!: 40 ~~ l~ 30 .,., . .,, &~ <., 20 I- • • 10 0 1960-64 1965-69 1970-74 1975-79 Years - Annees ed in the centre of town, in the neighbourhood of the pubs. It happens in the evening, at night and on weekends, and usually involves young men; in both the people involved and the spatial-temporal context, this is a very typical study. In the United States, Dannenberg et al. used a national registry (national eye trauma system regis- try) to study 648 cases of eye injury caused by violence between 1985 and 1991 (17). More than 4 out of 5 patients were male; 77% were under the age of 40; and 17% were less than 20 (median age was 28). Alcohol played an obvious role in at least half of the cases. The authors prudently refrained from extrapolating their observations to the whole 42 Other violence Autre violence Intentional injury Traumatismes intentionnels • ..... : Suicide Homcide ::; 1980-84 1985-89 Other violence Autre violence Intentional injury Traumatismes intentionnels Suicide • 1980-84 1985-89 country in calculations of national incidence, since the registry in question is not population-based, but depends on reports submitted by a volunteer network of ophthalmologists. Field studies Halfway between hospital studies and those deal- ing with the whole population or subgroups, are the research studies conducted in medical prac- tices. In a non-representative sample of adolescents at school in Massachusetts who were systematically questioned during a medical examination, "50% Rapp. trimest. statist sanit. mond., 46 (1993) Fig. 8 Comparison of trends in mortality (per 100 OOO) due to intentional violence among men aged 20-24, United States of America, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle aux Etats-Unis d'Amerique, chez les hommes de 20 a 24 ans entre 1960 et 1990, par periode quinquennales 70 Males - Hammes 15· 19 years/ans 60 0 -o Oo 8g 50 g- - '5 Iii 8. a.- 40 -; " ea ,gi --,:: ., Intentional injury "iii a. T raumatismes intentionnels Q)•G) 30 't) :E ""' ;;:C -~ ~ ~" 20 8,~ <::, ., Homcide I- 10 Suicide 0 1960-64 1965-69 1970-74 1975-79 1980-84 1985-89 Years - Annees 70 Males - Hammes 60 20-24 years/ans Intentional injury Traumatismes intentionnels 0 -o Oo 50 8g g- - '5 - 8. L 40 ;" 1ii ,gi --,:: ., "iii a. 30 .,.., -c :E Homcide ""' .:: c ·u ~ 8. (I) 20 'l'-o &~ <., Suicide I- 10 0 1960-64 1965-69 1970-74 1975-79 Years -Annees of the males experienced at least one pushing or shoving fight per year and by 16 years of age, 25% had already been threatened with a knife or a gun" (8). These two studies provide information that is useful, although obviously not generalizable, in view of the very selective nature of the samples. In an epidemiological study that set out to show the relationship between mental illness and vio- lence, Swanson et al. questioned approximately 10 OOO inhabitants of 3 of the 5 regions constitut- ing the "Epidemiologic Catchment Area": Balti- more, Raleigh-Durham and Los Angeles ( 19). The Diagnostic Interview Schedule (DIS) contains 5 questions on violence: a positive reply to at least I Wld hlth statist. quart., 46 (1993) 1980-84 1985-89 of the 5, indicating violent behaviour over the pre- vious 12 months, qualified the person answering as "positive for violent behaviour". Since one-third of the people (both sexes) interviewed were be- tween the ages of 18 and 24, the study is taken into account here. It is especially interesting since, in addition to the careful sampling that reflects a well- established population base, there is a multivariate analysis of the results (logistic regression): "the main effects of sex (male), being younger (age), lower socioeconomic status, substance abuse and major mental illness were all significant predictors of violent behaviour". Nevertheless, the indepen- dent effects of each of these characteristics on vio- 43 Fig. 9 Comparison of trends in mortality (per 100 OOO) due to intentional violence and other violence, among men aged 20-24, Northern Ireland, 1960-1990, 5-year periods Evolution comparee des taux de mortalite (pour 100 OOO) par violence intentionnelle, et par autre violence en lrlande du Nord chez les hommes de 20-24 ans entre 1960 et 1990, par periodes quinquennales 20 Males - Hammes 20-24 years/ans 0 -o Oo 8g g~ ~s a;&. a.- 10 -; "' ~·g> ,:: i;; 1;j a. (l)•Q) 'C:: ~~ iii~ g.., • 't:I 8-~ <( C1I I- 0 1960-64 1965-69 1970-74 1975-79 Years - Annees 70 Males - Hammes 20-24 years/ans 60 0 -o Oo 8g 50 Other violence g~ Autre violence ~s a; &. a.- 40 -;"' ~·g> ,:: i;; 1;j a. (l)•Q) 30 'C := O C1I - 'C 'iii~ g."' 20 • 't:I ~~ <( C1I I- 10 0 1960-64 1965-69 1970-74 1975-79 Years - Annees lence enabled the authors to specify that "being male, young, and of lower socioeconomic status increased the risk (of violent behaviour) substan- tially, apart from psychiatric illness" ( 19). Space is lacking to quote other field studies, in spite of their epidemiological interest; they are able to take account of a larger number of variables than the national or international studies, and they often provide rates that are more realistic than those based on extrapolation from hospital studies. All things considered, while it seems clear that the data on mortality and morbidity are largely in agreement, it is worth stressing a remark that often crops up in the literature: the under-estimation of 44 Other violence Autre violence Homicide 1980-84 1985-89 ~ 0 ~ ~ 1980-84 1985-89 data gathered by official bodies (judicial or other) when compared with spontaneously reported data (20). It remains to be seen whether the latter cate- gory should be suspected of over-estimation due to boasting, or under-estimation through fear of the investigators' bad opinion. Next, we shall look at risk factors to see whether they could be regarded entirely or partly as risk predictors. Risk factors and predictors Rosenberg & Mercy (5) speak of four aspects of the epidemiology of violence: public health surveil- Rapp. trimest. statist sanit. mond., 46 (1993) lance; risk group identification; risk factor identifi- cation; and programme development, implemen- tation and evaluation. This section concentrates on the third, with a few allusions to the second. Once again, rather than try to cover everything, we shall summarize a few recent studies to show both their approaches and their results. As several of the authors cited have emphasized, this identifi- cation should make prevention its target (20). In a study whose methodology was very original - following a cohort of 15 117 Swedish newborns chosen at random over a period of 30 years - Hod- gins studies the links between criminality, intellec- tual deficiency, and mental disorder (21); here we shall consider only the summary of the author's findings on members of the cohort who were free of intellectual deficiency or mental disorder. He showed a statistically significant inverse correlation between criminality and the socioeconomic status of the subject's family, as indicated by the occu- pation of the head of the household; he also found a higher proportion of delinquents from families receiving social welfare payments. As we shall see when we come to discuss the use of firearms in United States schools, there is a small number of other, clearly identified socio-cultural risk factors. Given the crucial role of the family environment in occurrence of abuse, not only of children but also and above all of adolescents, we must mention the intrafamily factors that have been well identified and described by Schellenback & Guernez (22): - modes of communication characterized by ei- ther authoritarianism or excess laxity, but rein- forced by an over-readiness to punish; - a recent, major conflict within the family; - adolescents who have suffered stress them- selves, and are thereby moved to challenge their parent(s); - parents who are more ready to punish than to support (and comfort?) their adolescents. Furthermore, in the review of United States literature by the same authors at the beginning of their study, we find the following factors in parents that could be used to predict abuse of their chil- dren, even adolescent children: "low self-esteem, fears of threat and control, highly unrealistic ex- pectations of child". At the level of family and society, the same authors point out that high-risk families tend to be large, with children born at short intervals, with less in the way of economic resources and social support, and living in an environment where vio- lence to children is an acceptable cultural model. As regards family violence, the previous person- al experience of 1 025 university students of both sexes was recently studied on three campuses in Southern California: M.D. Pagelow (quoted in 23) obtained (apparently by questionnaire) particular- ly alarming information: Wld hlth statist. quart., 46 (1993) - 42% of the subjects said they had been physical- ly attacked by their father and 49% by their mother, during adolescence; the forms of pa- ternal aggression were more violent than mater- nal forms; - of those who, at the age of 12, had brothers and sisters at home, almost half had carried out or undergone ''violent acts of kicking and punch- ing", 10% declaring that they had been beaten up and 4% threatened or even attacked with a knife or firearm; and - 1 father in 3 abused the mother (7% by beating her, 3% by threatening her with a weapon) and 1 mother in 4 abused the father. According to the same author, violence against children is so common that it is regarded as normal behaviour; individual interviews with students showed the parents tended to ignore or even hotly defend an aggressive child, refusing to believe in the reality of the behaviour, even when weapons were involved. In order to highlight risk factors of a cultural nature, we should also mention two publications on phenomena typical of violence in two contrast- ing contexts, though both involve the school sys- tem: the carrying of firearms by schoolchildren in the United States and bullying in Scandinavian schools. Firearms The role of firearms in mortality due to murder in the Americas has long been known. In the United States for example, Christoffel (8) showed that in 2 agegroups-10.14and 15-19-2outof3homicide cases involving of black, male adolescents and half of these cases of white, female adolescents also involved firearms, although the latter category is the one least exposed to murder in those two age groups; the contrasts between these two categories are even more apparent when the "mortality" in- dicator is replaced by "potential years of life lost" (PYLL). In 1990, the Youth Risk Behaviour Survey (con- cerning a national sample of 11 631 pupils in the ninth to twelfth grades) showed that the preva- lence of carrying weapons (firearm, knife or razor) at least once in the 30 days preceding the study ranged from an average of 5.3% for white girls to 41.1 % for Hispanic boys and 39.4% for young black boys. Furthermore, more than a third of all the people who carried these weapons said they carried a weapon 6 times a month or more. Finally, whereas only 1 case in 5 involved the carrying of a firearm, the proportion rose to 1 in 2 among young black boys ( 10). In another study, concerning the significance of carrying weapons in threatened attacks on pu- pils, Sheley et al. anonymously interviewed a sam- ple of 1 653 pupils in 6 urban schools in 4 states (24). No less than 23% of pupils were regarded as 45 victims. It was extremely interesting to note that the aggression could be attributed to chance in only 1 out of 10 cases; in the other nine, the follow- ing principal predictors came into play: sex, num- ber of brothers and sisters, exposure to violence outside of school, and certain personal characteris- tics related to violence, especially carrying a weapon in or out of school and drug trafficking. The authors conclude that, even in schools that are known sites of habitual violence, the violence relat- ed to carrying of weapons originates outside of school. Thus the victims in school and on the way to school are "youths from families in which males carried guns routinely, youths who carried guns themselves (either in or out of school) and youths who used or sold drugs". From this it follows that prevention at the individual level makes no sense; it must be done at the family and community level. Bullying In the Scandinavian study on bullying at school (25), the descriptive data have to be distinguished from those that evaluate the effectiveness of a pre- vention programme: we are concerned here with the former. Olweus begins with the following indis- pensable operational definitions: • "A person is being bullied when he or she is exposed, repeatedly and over time, to negative actions on the part of one or more person. • It is a negative action when someone intention- ally inflicts, or attempts to inflict, injury or dis- comfort upon another - basically what is im- plied in the definition of aggressive behaviour. • Negative actions can be carried out by physical contact, by words, or in other ways, such as by making faces or dirty gestures or by refusing to comply with another person's wishes. • The term bullying is not ( ... ) used when two persons of approximately the same strength (physical or psychological) are fighting or quar- relling." With a definition as broad as this, one can ex- pect relatively high incidence and prevalence, whatever the level of "intensity" taken into ac- count. Tabk 3 shows the number of cases of victims and perpetrators of bullying as defined above, ac- cording to two levels ofintensity, and their approx- imate proportion of all classes in all Norwegian schools. As one might expect, the older the pupils are, the lower the proportion of victims, as we go from second to ninth grades at primary school the pro- portions drop from 16% to 3% among girls and from 18% to 7% among boys. On the other hand, the perpetrators of bullying increase in proportion among boys - but only slightly- while among girls the proportion falls a little, from 5% to 2%, be- tween the second and ninth grades. Finally, draw- ing on information from various sources, the au- 46 thor estimates that the prevalence and gravity of bullying are higher than 10 to 15 years ago (25). These two illustrations of violence in schools - each with one major risk factor, either carrying weapons or bullying- are based on the same investi- gatory tool, the anonymous questionnaire. Despite the many precautions taken by these authors to avoid the well-known biases in surveys relying on self-reported behaviour or habits, epidemiologists inevitably prefer to consider observed and de- scribed behaviour (26). In this respect, the experi- ence of some Dutch researchers deserves attention (27). They have observed the drinking habits of young people in their favourite meeting places, and tried to quantify them. Would it be too much to hope for similar observations of violent behav- iour, especially in schools? A specific bibliographi- cal search might provide an answer to that ques- tion. The only attempt we have encountered at using data observed by parents on children's experiences with violence is that of Schellenbach & Guernez (22). Since it deals with twins in a single family, one may doubt its relevance to large groups of families. Protection factors Less well known and probably less well studied than risk factors, are protection factors, which should surely be considered, especially since at least as much significance is attached to health promotion - especially psychological and social - as to specific prevention of violent behaviour. To cite but one example, Garmezy, quoted by Schellen- bach & Guernez (22), proposed that there is a triad of "buffers" which individuals develop against stressful experiences in childhood, including: (a) personality, intelligence and temperament; (b) the immediate family environment; and ( c) accessibility of support services. By their very nature, these are the same factors which, depending on their quality- (a) or (b)-or their degree - ( c) - can have good or bad effects. Attitudes In the recent literature concerning adolescents and young adults, few references take this type of parameter into account - hence the importance of a study by two American sociologists ( cited in 23): Carson & Daane questioned 3 357 middle and senior high school pupils in the town of Anderson, Indiana, most of them white and from working- and middle-class families, on their attitude to vio- lence among pupils, and within couples. The re- sults are worth reporting fully, given the originality of this study. • Between brothers and sisters: 3 out of 4 pupils would think it right to strike their brother or sister in retaliation; almost half would regard this violence as justified if the sibling had bro- Rapp. trimest statist. sanit. mond., 46 (1993) Table 3 Cases of bullying (both victims and perpetrators) among schoolchildren in Norway Tableau 3 Cas de brimades (victimes et auteurs) chez les ecoliers en Norvege Frequency lntensite Now and then or more frequently - De temps a autre au plus souvent Category Categorie Victims - Victimes Perpetrators -Auteurs Victims and perpetrators at the same time - No. of cases Proportion N° de cas % 53 OOO 9 42 OOO 7 A la fois victimes et auteurs 9 OOO 1.5 At least once a week - Au mains une fois par semaine Total Victims - Victimes Perpetrators - Auteurs Victims and perpetrators 83 OOO 15 18 OOO 3 10 OOO 2 at the same time - A la fois 1 OOO 0.2 victimes et auteurs Total Source: Ref. - Ref. (25). ken his or her stereo; almost 1 in 3 would think it right to strike the brother or sister if he or she had made fun of the respondent in the pres- ence of friends; and almost 1 in 4 if he or she did not agree with them in an argument. • Between classmates: almost 1 in 3 approved of hitting a classmate ifhe made fun of the respon- dent in front of his friends, or if he had dam- aged his car; or to defend his group or gang. More than half would approve of a classmate setting upon anyone who had insulted his par- ents. Worse still is the fact that 34% approved of carrying a knife and 14% of carrying a firearm to school, at least from time to time. • Between spouses: approximately 10% of pupils thought it right for a husband to strike his wife if she would not agree with him; 7.2% if she ridiculed him in front of his friends; 6.5% if she damaged the car; but considerably more (22.6%) to defend himself if she had hit him first. In the other direction, the proportions are slightly higher: more than 12% approved of a wife striking her husband if he would not agree with her; 11.8% ifhe mocked her in front of her friends; 8.4% ifhe damaged the car; and almost 60% if he had hit her first. • With a boyfriend or girlfriend: to the surprise of the study's authors, tolerance of violence here is even higher, except in the instance of one disagreeing with the other. The authors of the study conclude that these young people must learn this violence from some- where and that there is a good chance that they themselves were either witnesses or even victims of Wld hlth statist. quart., 46 (1993) 27 OOO 5 violence in the home; the authors wonder to what extent approval of violence leads to its practice. They propose appropriate prevention pro- grammes - including mediation - and recommend that the home be considered a "no-hitting zone". It would be useful or could even be essential to have such data for other cultural contexts, so that surveys of attitudes could be used as a basis for more detailed interviews. Finally, as regards predictors, the distinction must be made between "prediction of violence" at the individual level, as demanded by the legal sys- tem (for example, 28) and the prediction of trends by epidemiologists (29) or certain crimino- logists (30), which are valid only for groups of indi- viduals at elevated risks of violent behaviour. This section has shown a series of correlations between risk factors or predictors (variables which can be independent or interdependent) and events (such as murders), behaviours, or attitudes regarded as dependent variables. Most of these authors correctly warn against a causal interpreta- tion. Yet such an interpretation becomes defensi- ble in longitudinal studies, as has long been recog- nized in this "etiological" approach (31, 32), and as Farrington has shown in the Cambridge Study in Delinquent Development (30). lnterventional studies and their results Experimental, "interventional" studies, provide even more incisive demonstrations of cause-and- effect relationships, if, of course, they are correctly evaluated. While many of the studies referred to 47 emphasize the need for evaluation (e.g. 29 and 33), few of them so far have produced results of such evaluations. Consider firstly Kellam et al. (34) in Baltimore, and the series of brief reports on recent projects or programmes discussed in Public health reporls (35). We should mention especially the Norwegian Ministry of Education's national programme to reduce bullying in schools (25). Since, in the absence of control schools or classes, a strictly experimental evaluation could not be made, Olweus used a quasi-experimental design consisting of 4 parallel cohorts of 600 to 700 pupils each: "analyses indicate that the frequency of bul- ly /victim problems decreased by 50% or more dur- ing the two years following the campaign"; "simi- lar results were obtained for boys and girls and across all grades"; and "in addition student satis- faction with school life increased". Having eliminat- ed other possible explanations, the author con- cluded that these changes were caused mainly by planned intervention. As regards optimal evaluation of these interven- tions, it must be recalled that they should take account of both potential costs and benefits (13). Conclusions and proposals Highlights of our findings • The traditional type of research papers, classi- fied according to mode (accident, murder, sui- cide, rape, abuse, etc.) or age (early childhood, school age, adolescence, etc.) or according to a specific point of view (legal, biological, psychos- ocial, sociocultural, socioeconomic, etc.) are in- creasingly accompanied by those which adopt a holistic approach in closer harmony with mod- em concepts of public health in general and prevention in particular (4, 5, 7, 8, 13, 22, 23, 29, 33, 35, 36, 37). • National data on mortality due to intentional violence, in spite of certain vagaries in their recording, produce findings with temporal and geographic significance. As long as recording methods within a given country are not changed, chronological trends within that country are more reliable than comparisons between countries. This is why we have attached less importance to the levels of mortality due to intentional killing, in presentation and discus- sion of national data, than to their trends over the last 30 years and the relationship between the two major components: murder and sui- cide. • The paucity of epidemiological studies devoted to behaviour (reactions) caused by intentional, non-fatal violence and to the related attitudes, can be accounted for by the difficulty of collect- ing reliable data and distinguishing such behav- iour from what is regarded as socially normal. 48 • On the whole, the traditional indicators of in- tentional violence -whether mortality, morbidi- ty or behaviour and attitudes - are on the in- crease in many countries, which is worrisome. • The identification of risk and/ or protection factors, and the objective estimation of their importance, has made such progress in recent years that they should be taken into account when establishing objectives and strategies for prevention. Some proposals tor research Promoting multidisciplinarity. "Violence is a multidis- ciplinary field in which collaboration among disci- plines has not yet been developed. We must support exchanges of knowledge among fields and the de- velopment of a common language and body of knowledge." (38) This does not, of course, mean that we should give up on specialized research pro- grammes or projects such as those which are now concerned with identifying the micro- and macro- social and economic psychological predictors of sui- cidal behaviour in adolescence. We should promote programmes with the following objectives: to sur- mount interdisciplinary barriers; to harmonize re- search instruments; and to increase the relevance of results, and hence their impact and repercussions on action, especially preventive action. The methodology of such programmes should couple traditional quantitative approaches of an epidemiological nature ( descriptive, analytical and/or interventional) with qualitative approach- es of equal rigour, dealing, for example, with sub- samples of previous target populations. These should be sufficiently contrasted to show not only the range of attitudes and behaviours previously investigated (usually self-reported) but also the un- derlying motives, their origins and variability with- in and between individuals. Intervene in preven- tive action programmes in time to conduct evalua- tions by: calling on experts from outside the pro- gramme; using duly validated instruments; and tak- ing account of constraints inherent in or imping- ing upon the programme, especially legal, eco- nomic, cultural and psychological constraints but also those of an ethical nature. Further improvement of the quality of mortality data. In response to the remarks in Bourbeau's article in this issue, concerning the reliability of mortality data, here are a few proposals for research: • Design instruments for better evaluation (at the national level if possible) of the relative impor- tance and exact nature of the superimposition zones seen in Fig. 2. Example 1: How many deaths reported as acci- dents are actually suicide or murder? Example 2: How many de;iths recorded as sui- cide are actually murder? Example 3: Why do some countries put the same number of deaths under the ICD rubrics Rapp. trimest. statist. sanit. mond., 46 (1993) "other violence" (E56-E560) and "intention not determined" (E560)? • On the basis of findings for 5-year periods in certain countries where collective intentional violence appears to modify the data on individ- ual intentional violence, conduct more detailed temporal (annual) and spatial (administrative subdivisions of countries) investigations, where possible with the help of those in possession of information other than health statistics. Fostering and promoting further studies of morbidity. Since the figures for morbidity are larger than those for mortality, several authors advocate giving them priority when designing preventive strate- gies. Here, for example, are the four lines of re- search proposed in 1988 by Mercy & O'Carroll (29): (i) developing surveillance systems for morbidity associated with interpersonal vio- lence; (ii) precisely identifying risk groups for non- fatal violence events; (iii) applying case-control methods to the exploration of potentially modifi- able risk factors for injuries and violent behaviours; and (iv) rigorously evaluating existing program- mes that are intended to prevent interpersonal violence or modify a suspected factor for violence. These proposals call for a number of brief com- ments: • Monitoring systems, in the epidemiological sense, call for facilities for the continuous gath- ering, analysis and interpretation of reliable data obtained from trustworthy sources. In some countries, such systems are already in operation; in others, they will require a certain effort; in many others still they are out of the question due to shortage of staffing and funding. • The identification of risk groups, while it con- fers the advantages mentioned above, has ethi- cal drawbacks which, due to lack of space, can- not be discussed here; furthermore, there is an important distinction to be made between the risk of doing and the risk of suffering violence. • The exploration of modifiable risk factors calls for a different approach from that of the case- control studies, as Mercy & O'Carroll agree; it calls in particular for cohort studies, promis- ing examples of which are discussed above. • We have already touched on the rigorous evalua- tion of programmes in progress or at the plan- ning stage; but not everyone agrees they need be rigorous: the Carnegie Council on Adolescent Development is now advocating "non-tradition- al evaluation designs" in order to "reduce the difficulties and the ethical dilemmas that can be imposed by strict experimental designs" (38). Finally, a number of authors (not all of them cited) have come up against two classic problems in measurement of morbidity: instruments of mea- surement, and delimitation from normality. To quantify violent events, we need forms on which we can record their duration and intensity as Wld hlth smtist. quart., 46 (1993) well as their frequency and when they started (26). For proper evaluation of their nature we need ap- propriate scales: the one used by Gidycz & Koss to "calibrate" sexual violence is a good example (39), although it depends on a subjective account by the interviewee, and especially on that person's memory. Where should the limit between normal vio- lence (that which is permitted by cultural or legal norms) and pathological violence be set? The clos- er the behaviour studied is to normal behaviour, the more important it is to have criteria for decid- ing what is understood and accepted; the case of bullying in schools as studied by Olweus is a prime example of this (25). Summary Intentional violence consists mainly of non-accidental interpersonal violence and suicidal behaviour; the re- sults are other violence and/or violence whose intention is undetermined. In almost all the countries considered in this study, intentional violence is taking on worrying proportions in adolescence (10-19-year-olds) and is on the increase among young adults (15-24-year-olds). The scale of the problem is relatively well known thanks to national mor- tality rates. The relative proportions of murders and suicides vary considerably from one country to another, though they remain fairly constant over time, whether the diachronic progression of mortality due to intentional violence increases, remains stable or falls in the country concerned; this is true for both sexes and for both the age groups considered (15-19 and 20-24). Nevertheless, in view of the much higher incidence of intentionally violent behaviour that does not result in death, more resources should be allocated to epidemi- ological studies in that area, especially in terms of quantitative and qualitative methods, where possible in association with interdisciplinary projects. Only with a better knowledge of the risk factors and if possible identification of the predictive factors (in the probabilistic sense of the term) could we devise, conduct and evaluate preventive measures that are better target- ed than those used so far. whether the factors are socio- cultural, socioeconomic or psychosocial. This is the justi- fication, especially the ethical justification, of further epi- demiological studies of an analytical or even intervention- al nature, going beyond the descriptive studies that have been made by most researchers to date. Resume Violence intentionnel/e chez les adolescents et les jeunes adultes : perspective epidemiologique La violence intentionnelle se compose principalement des manifestations de violence interpersonnelle non 49 accidentelle et des comportements suicidaires et ac- cessoirement d'autres violences et/ou de violence dont !'intention reste indeterminee. Dans presque tous les pays pris en compte dans ce travail, la violence intentionnelle prend des dimensions preoccupantes a !'adolescence (10-19 ans) et s'accen- tue chez les jeunes adultes (15-24 ans). Ses dimensions sont relativement bien connues grace aux taux nationaux de mortalite. Les proportions respectives des homicides et des suicides varient beaucoup d'un pays a l'autre, mais restent assez constantes dans le temps, que !'evolution diachronique du taux de mortalite intentionnelle augmen- te, reste stable ou diminue dans le pays considere, et cela pour les deux sexes et pour les deux tranches d'age considerees (15-19 ans et 20-24 ans). Neanmoins, en raison de !'incidence beaucoup plus elevee des comportements, relevant toujours de la violence intentionnelle, qui n'aboutissent pas au deces, c'est aux eludes epidemiologiques de ces comporte- ments qu'il importe a l'avenir de donner plus de moyens, en termes notamment de methodes quantitatives et qualitatives, si possible associees dans des projets interdisciplinaires. Seule une meilleure connaissance, en effet, des fac- teurs de risque et si possible !'identification de facteurs predicteurs (au sens probabiliste du terme) devraient permettre de concevoir, de mettre en oeuvre et d'eva- luer des mesures preventives mieux ciblees que jus- qu'ici, que ces facteurs soient de nature socio-culturel- le, socio-economique, ou psycho-sociale. C'est ainsi que se justifient, du point de vue ethique, notamment, la poursuite d'etudes epidemiologiques de nature analyti- que, voire d'intervention, allant au-dela des eludes descriptives auxquelles se sont livres une majeure par- tie des chercheurs jusqu'ici. References I References 1. Rosenberg, M.L. & Mercy, J.A. Homicide: Epidemiologic analysis at the national level. Bulletin of the New Y orli Academy of Medicine, 62 (5): 376-399 (1986). 2. Chesnais, J • .ct. Histoire de fa Violence, Ed. Robert Laffont, Paris, 1981. 3. World Health Organization. Manual of the international statistical classification of diseases, injuries and causes of death. Ninth Revision. Geneva, WHO, 1977. Organisation mondiale de la Sante. Manuel de fa classification statistique intemationale des maladies, traumatismes et causes de deas. Neuvieme revision. Geneve, OMS, 1978. 4. Rivara, F.P. Epidemiology of violent deaths in children and adolescents in the United States. Pediatrician, 12: 6 (1983- 85). 5. Rosenberg, M.L. & Mercy, J.A. Assaultive violence in Rosenberg M.L. & Fenley M.A. (ed.) Violence in America: a public health approach, New York, Oxford, Oxford University Press, 1991. 6. Lewis, D.O. From abuse to violence: Psycho-physiological consequences of maltreatment Journal of the American Academy of Chil,d and Adolescent Psychiatry, 31 (3): 383-391 (1991). 7. Goodwin,J. Family violence: principles of intervention and prevention. Hospit.al & community psychiatry, 36 (10): 1074- 1079 (1985). 8. Christofell,K.K. Violentdeathandinjuryin US children and adolescents. American journal of diseases of chiMren, 144 (6): 697-706 (1990). 50 9. Martinez-Schnell, B. & Waxweiler, R.J. Increases in premature mortality due to homicide: United States 1968- 1985. Violence& victims, 4 (4): 287-293 (1989). 10. Weapon-carrying among high school students. Morbi.dity and mortality wedt.ly report, 40 ( 40) : 681-684 ( 1991) . 11. Fingerhut, L.A. et al. Firearm homicide among black teenage males in metropolitan counties. Journal of the American medical association, 267 (22): 3054-3057 (1992). 12. Durfee, M.J. et al. Origins and clinical relevance of child death review teams. Journal of the American medical association, 267 (23): 3172-3175 (1992). 13. Rosenberg, M.L. & Mercy, J.A. Introduction in: Rosenberg M.L. & Fenley MA. (ed.) Violence in America: a public health approach, New York, Oxford, Oxford University Press, 1991. 14. Trumpy, I.G. The faces of violence: Norway, a violent society? Tidsskriftfii.rdenNorskeLaegeforening, 112(3): 321-324 (1992). 15. Butchart, A. et al. Epidemiololgy of non-fatal injuries due to external causes in Johannesburg-Soweto. South African medical journal, 79(8): 472-479 (1991). 16. Petersen, K.K. et al. Street violence in Arhus. Ugeskrift fii.r Laeger, 153(4): 272-274 (1991). 17. Dannenberg, A.L. et al. Penetrating eye injuries related to assault. Archives of ophthalmol.ogy, 110(6): 849-852 (1992). 18. Stringham, M.D. & Weitzman, M. Violence counseling in the routine health care of adolescents. Journal of adolescent health care, 9: 389-393 (1988). 19. Swanson,J.W. et al. Violence and psychiatric disorder in the community: evidence from the epidemiologic catchment area surveys. Hospit.al and community psychiatry, 41 ( 7) ( 1990) . 20. Palermo, G.D. etal. On the predictability of violent behavior: considerations and guidelines. Journal of forensic sciences, 36(5): 1435-1444 (1991). 21. Hodgins, S. Mental disorder, intellectual deficiency and crime. Evidence from a birth cohort. Archives of general psychiatry, 49(6): 476-483 (1992). 22. Schellenbach, CJ. & Guemez, L.F. Identification of adolescent abuse and future intervention prospects.Journal of adolescence, 10(1): 1-12 (1987). 23. Randall, T. Adolescents may experience home, school abuse; their future draws researchers' concern. Journal of the American medical association, 267(23): 3218-3131 (1992). 24. Sheley,J.F. et al. Gun-related violence in and around inner- city schools. American journal of diseases of chil,dren, 146(6): 677-682 (1992). 25. Olweus, D. Bully /victims problems among school children: basic facts and effects of a school based intervention program. In D.J. Pepler & K. Rubin (eds). The devel.opment and treatment of chil,dhood aggression, Hillsdale, N.J.: Erlbaum, 1991. 26. Jeanneret 0. L 'Alcoolisation a l'adolescence: les perplexites d 'un epidemiologiste. [in press - en preparation]. 27. Van De Goor L.A.M. et al. Adolescent drinking behaviour. An observational study of the influence of situational factors in adolescent drinking rates. Studies on alcoholism, 51, 548-555 (1990) 28. Gottfredson & Gottfredson Violence prediction methods: statistical and clinical strategies. Violence & victims, 3 ( 4): 303- 323 (1988). 29. Mercy, J.A. & O'Carroll, P.W. New directions in violence prediction: the public health arena. Violence& victims, 3(4): 285-301 (1988). 30. Farrington, D.P. Early predictors of adolescent aggression and adult violence. Violence& victims, 4(2): 79-100 (1989). 31. Kandel, D.B. Convergences in prospective longitudinal surveys of drug use in normal populations. In Kandel, D.B. (ed.) Longitudinal research on drug use: empirical findings and methodol.ogical issues, Washington, DC, Hemisphere Pub. Corp. 1978 [out of print]. 32. Jeanneret, O. Drinking problems in adolescence: three issues in future field research. In:Jeanneret, O.(ed.) Alcohol and youth, Basel, Karger, 1983. Rapp. trimest statist. sanit. mond., 46 (1993) 33. US National Committee for Injury Prevention and Control. Injury prevention: Meeting the Challenge. Oxford, Oxford University Press, 1989 34. Kellam, S.G. Development epidemiologically based preventive trials: baseline modeling of early target behaviors and depressive symptoms. American jwmal of community psychology, 19 ( 4) : 563-584 ( 1991) . 35. Forum on youth violence in minority communities. Public health report 106 ( 3) , 1991. Wld hlth statist. quart., 46 (1993) 36. Violent deaths in childhood and adolescence. Pediatrician, 12 (1): 83-85 (1985) 37. Adolescence et violence au quotidien. Cahiers midico-sociawc, 33 (4): 197-249 (1989) 38. Viol.enr.epmientionforearlyt.uns:areviewofthestateoftheart. New York, Carnegie Foundation,1990. 39. Gidycz, C.A. &: Koss M. Prediction oflong-term sexual assault trauma among a national sample of victimized college women. Viof.enr.e& victims, 6 (3): 175-190 (1991). 51 The epidemiology of suicidal behaviour: a review of three continents R.F. W. Diekstraa & W. Gulbinafb Definition of suicidal behaviour In everyday life, the words "suicide" and "suicid- al" are used to refer to self-chosen behaviour that is intended to bring about one's own death in the short( est) term. However, of all the behaviours and experiences to which these words are attached, many are or might not be motivated by a wish to die or to do away with oneself for good. Often they are not even meant to harm oneself, but only to express or communicate feelings such as despair, hopelessness and anger. Contemporary literature, therefore, usually divides suicidal behaviour into three categories. Suicidal ideation refers to cognitions that can vary from fleeting thoughts that life is not worth living, through very concrete, well-thought-out plans for killing oneself, to an intense delusional preoccupation with self-destruction (1). The term parasuicidec covers behaviours that can vary from what are sometimes called suicidal gestures and manipulative attempts to serious but unsuccessful attempts to kill oneself. It refers to any deliberate act with non-fatal outcome that at- tempts to cause or actually causes self-harm or with- out intervention from others would have done so, or that consists of ingesting a substance in excess of its generally recognized or prescribed therapeutic dose (2). There is another important aspect of the definition of parasuicide: the act should be non- habitual. A habitual user of excessive quantities of alcohol or a habitual user of dangerous quantities of (hard) drugs is not to be considered a case of parasuicide if found unconscious as a result of an overdose (assuming that other information indi- cating suicidal intent such as a suicide note is not present). Also, habitual self-mutilation ( cutting, piercing, head-banging) is not implied under the term parasuicide. a Professor of Psychology, University of Leiden, Netherlands. b Senior Scientist, Division of Mental Health, World Health Organization, Geneva, Switzerland. c More and more authors on the subject prefer the term parasuicide to attempted suicide or suicide attempt since it makes no reference to intention. As Kreitman has pointed out, intention cannot be used as a criterion since the person's motive may be too uncertain or too complex to ascertain readily. When asked, "Why did you do it?" most will deny (afterwards) that they wanted to kill themselves. Many will reply, "I just don't know". (Kreitman, N. Some research aspects of suicide and attempted suicide (parasuicide), with special reference to young people WHO/EURO (ICP/MNH 015 III) 1976). 52 The term suicide refers to any death that is the direct or indirect result of a positive or negative act accomplished by the victim him- or herself which he or she knows or believes will produce this result (3). This definition implies, first, that the term suicide should only be applied in case of a death. Second, risk-taking that leads to death, if the indi- rect causal sequence can be specified and was in- tentional, is suicide. Indirect suicide is a common but neglected form of suicide. Some authors (4) believe that it is particularly common in adoles- cence and young adulthood and that a consider- able number of road traffic fatalities in young males are in actual fact suicides. Third, self-neglect- ing behaviour, sometimes referred to as suicidal "erosion", such as a hunger strike or refusal to take life-preserving medication, if death is the end result, is also to be considered suicide. It is apparent from these definitions - and re- search has confirmed - that considerable overlap exists among the three classes of suicidal behav- iour. There is also some evidence of developmen- tal pathways that sequentially link suicidal ideation to parasuicide to suicide. Yet, little is known of the causes and patterns of recruitment from suicidal ideation to parasuicide and from parasuicide to suicide and on the factors which precipitate or protect against these transformations. Assessing suicidal behaviour: suicidal ideation and parasuicide There are three major ways to measure suicidal behaviours: self report, interview and administra- tive procedures. For the assessment of suicidal ide- ation a number of psychometrically sound ques- tionnaires do exist (5), but they do not appear to have been widely used. The same is the case with so called "suicide attitudes" towards one's own sui- cide (6). Most studies have tended to use their own individual questions or questions that are included in commonly used instruments for assessing (men- tal) health status such as the General Health Ques- tionnaire (5). Consequently, it is difficult to com- pare results between studies, particularly because the period of inquiry regarding such feelings varies substantially between studies, including "over the past weeks", "over the last year", and "ever". With regard to parasuicide, most studies have been using hospital admission data, which are es- sentially administrative data, for case identifica- tion. Since criteria for reporting a case as a parasui- Rapp. trimest. statist. sanft. mond., 46 (1993) cide/suicide attempt are often obscure and even where they are clear, may vary considerably both in and between countries, comparison between stud- ies of prevalence/incidence and characteristics of parasuicide are obviously limited. Furthermore, there is evidence of a relationship between method (not just medical seriousness) and probability of hospital referral of parasuicide cases. In addition, there are substantial differences between countries and regions allowing for a much more valid esti- mate of the parasuicide incidence in one place than in another. But either way, hospital-based rates significantly underestimate "true" rates as community surveys have shownd . In order to avoid these problems, some surveysd have used a so- called Self Destructive Behaviour Questionnaire in which the terms "attempted suicide" and "sui- cide attempt" are deliberately avoided. In addition, only those episodes reported for which also a cer- tain number of information criteria are met, are then reported as parasuicide. A slightly adapted version of this method is also being used in the Parasuicide Monitoring Project of the World Health Organization's European Regional Office. This study is currently in progress in 16 centres in 11 European countries. Most of these centres collect cases of parasuicide from a variety of sources: hospitals, general practitioners, out-patient clinics, mental health centres, social work agencies, etc. So far only a preliminary report of this study has been published ( 6) and although it is to be expected that it will soon provide the first internationally comparable data on period preva- lence (12 months) and lifetime prevalence (retro- spectively) of parasuicide, such data are not avail- able yet. Suicidal behaviours: suicide The preliminary conclusion from the discussion on measurements so far is that, however strange as it may sound, our only "hope" for studying ques- tions about suicidal behaviour and its change over time lies in completed suicide. In many European countries, in the Americas, and in Asia suicide rates have been recorded for extended periods of time. This seems to offer an opportunity to answer such questions as: ''What is the pattern of suicide behaviour world-wide?" and ''What has been the trend in suicide over the last 35 years?"e More spe- cifically, suicide among the young (age group 15- 24 years) and the old (age group 75+ years) will be studied in this article. d Diekstra, R. F. W.& Kienhorst, C. & et al. Suicide and parasuicide. Paper prepared for the Academia europaea Study Group on Youth Problems. 1992. e A 35-year period was chosen because WHO's mortality data base, into which many countries report suicide data, was established in the mid-1950s. Wld hlth statist. quart., 46 (1993) The validity of the results of such an analysis is, of course, a direct function of the validity of the data used, in this case national suicide statistics. Therefore, any discussion of secular trends in sui- cide first has to address the issue of how valid and reliable the available data for trend description and analysis - national suicide statistics - are. The salient question here is whether methods and crite- ria in identifying suicides vary so much among different populations that they may account for the differences in rates. Several authors have argued that cultural attitudes towards suicide so affect re- porting that official suicide statistics are valueless (7). In 1982 a World Health Organization Working Group expressed "confidence in the use of offi- cial suicide statistics from European countries for trend analysis" (8). This conclusion was based on a careful examination of all the empirical evidence available on the matter. The review clearly indicat- ed that differences in ascertainment procedures do not explain differences in suicide rates between populations. In a now classic study, Sainsbury and Barraclough (9) compared the rank order of sui- cide rates among immigrants to the United States from 11 countries with those reported in their countries of origin. Cases of suicide in the various immigrant groups were all identified by United States procedures, whereas suicides in the home countries were all identified by the particular method(s) of each country. The rank order of the two sets appeared to be nearly identical (r=0.90). It was possible to confirm this finding in a study of suicide mortality statistics of immigrants to Austra- lia ( 10, 11) and at the same time to show that it holds for both sexes. The correlation between the suicide rates of male immigrants from 16 countries and rates in their countries of birth was 0.79; for females it was 0.76. considering the small number of suicides in some immigrant groups and hence the large standard error in their rates, the correla- tions are surprisingly high. There is yet another aspect of the problem that needs to be mentioned. Suicide is certainly under- reported to some extent everywhere (12,13). If the agent responsible for certifying deaths in a country is reluctant to report a death as suicide the most likely categories for reporting the case are "unde- termined cause of death" or "accidental death". The report of the 1968 WHO Working Group found that there is indeed wide variation in the extent to which agents resort to these alternatives (14). It is therefore of considerable interest to ex- amine how the varying tendencies of nations to use these two categories rather than suicide, alters their suicide rates relative to other nations. Barra- clough (15) was the first to look into this matter and found that the rank order of officially reported suicide rates of 22 countries and their rank order of a rate derived by combing their suicide and 53 undetermined mortality rates were highly correlat- ed (r=0.89). Sainsbury et al.f report on a study showing that variations in the use of the categories "accidental" and "undetermined" causes of death contribute little towards explaining differ- ences in suicide rates among European countries. If, as all the studies mentioned show, differen- ces in the rank order of suicide rates in countries or cultural groups are barely alteredwhen the ef- fects of varying methods of reporting are con- trolled, national suicide mortality statistics can be assumed to be a valuable source of data on which to base comparative epidemiological studies. This conclusion is supported by the fact that consistent differences in rates between national, demographic and social groups have been record- ed over very long periods, in several instances far more than a century, and these differences persist despite political changes that have altered report- ing procedures in many countries. To ignore the implications of such conspicuous similarities as higher suicide rates among males, among those who live alone or are divorced, among the mentally ill, and the strong increase in youth suicide over the last three decades, is surely a failure of vision. In summary, then, suicide is underreported for a number of reasons and the rates are subject to many errors of the kind encountered in reporting mortality figures in general. Nevertheless, the evi- dence from studies designed to settle this point clearly indicate that these errors are random, at least to an extent that permits epidemiological comparison of rates within countries, between countries, and over time. The epidemiology of suicidal behaviour Suicidal ideation There is no satisfactory answer to the question of what percentage of people have episodes of suicid- al ideation. A review of community-survey studies of adolescent populations ( defined as high-school student populations) published after 1985 report- ed various estimates of the prevalence of suicidal thoughts: Kienhorst et al. - 3.5% ( 16), Canton et al. - 14% ( 17), Pronovost et al. - 15.4% ( 18), Diekstra et al.,- 18.9% (19), Nagy et al.- 23.3%, (20), Watanabe - 38% (21), Smith et al.- 52.1 % (22), and Harkavy et al. - 52.9% (23). To a large extent, the differences in rates reported can be explained by differences in the definition of suicidal ideation and differ- ences in period of reference. In some studies the subjects have been asked about "recent" suicidal thinking (16), in others about suicidal thoughts f Sainsbury, P.&Jenkins,J. & et al. Suicide trends in Europe: a study of the decline in suicide in England and Wales and the increase elsewhere. Copenhagen, WHO/EURO (ICP/MNH 036), 1981 54 during the past year ( 19, 20, 22), and again in others for suicidal ideation "ever" or "at least once" (18,22,23). Not surprisingly, the longer the period of assessment (retrospectively) the higher the rate tends to be. If the reasonable assumption is made that measuring suicidal ideation "ever" or "at least once" can be equated with measuring lifetime prevalence rate, we find a range of about 15% to 53%, which proves it to be a phenomenon quite common indeed in adolescence. Most of the stud- ies reviewed showed a clear preponderance of sui- cidal girls. There is also some evidence of a positive correlation of prevalence of suicidal ideation and age, at least from ages 12 through 17, and more prominently in girls than in boys (19). No data are available on pre-and postpuberty differences with regard to the prevalence of suicidal ideation, but it seems safe to assume that such differences, similar to the ones found for depressed mood and depres- sive disorders, do exist. Parasuicide A review of 10 community-survey studies on sam- ples of adolescents (high school students), pub- lished after 1986, showed estimates of yearly preva- lence of parasuicidal acts to vary between 2.4% and 20% (18,20,24,25). These differences in rates have to be interpreted in the light of differences in case definition and of comments on measurements, above. All studies report a clear preponderance of girls: the female/male ratio for attempted suicide in Europe has been estimated to range between 1.4 and 4.0 (26), and similar rations have been report- ed in may other countries as well (2.0 in Sri Lanka, for example) (27). However, the question of whether there is an age effect (in the adolescent period) remains obscure. Studies of clinical sam- ples also provide controversial data with regard to the relationship between parasuicide rates and age, although a number of clinical studies support the existence of both a puberty as well as an age effectd (18,28). Both community-survey studies and studies of clinical samples show that a considerable percent- age ofparasuicidal adolescents repeated their para- suicidal acts: between 14% (28) and 51 % (30,31), depending partially on length of follow-up period. WHO is coordinating the first study on parasui- cide that is expected to produce comparable data (6,32). First preliminary results reveal considerable variation, not only in the incidence of parasuicide among the participating centres, but also in male/ female ratios and age distributions. Suicide: the epidemiology of suicide on three continents For the purpose of this paper, 31 countries in the Americas, Asia and Europe have been selected. Rapp. trimest. statist. sanit. mond., 46 (1993) The selection criterion was their uninterrupted re- porting of death from suicide into WHO's mor- tality data bank (33). Data will be presented cross- sectionally, i.e., referring to the most recent sui- cide data reported by these countries to WHO, and longitudinally, i.e., comparing suicide rates be- tween the 1950s and today. The analysis in this report is based on the most recent data reported by countries to the WHO mortality data base. For most countries this refers to the period 1990-1992. For some countries, how- ever, the most recent reporting period goes back several years. The most recent data available in the Americas are: Canada: 1990, Chile: 1989, Colom- bia: 1990, Mexico: 1990, Puerto Rico: 1990, United States of America: 1989, Venezuela: 1989. From Asia: Japan: 1991, Singapore: 1990, Sri Lanka: 1986, Thailand: 1987. From Europe: Austria: 1991, Belgium: 1987, Czechoslovakia: 1990, Denmark: 1991 , Finland: 1991, France: 1990, Germany: 1990, Greece: 1990, Hungary: 1991, Ireland: 1990, Italy: 1989, Netherlands: 1991 , Norway: 1990, Poiand: 1991, Portugal: 1991, Spain: 1989, Sweden: 1989, Switzerland: 1991, United Kingdom: 1991. Figs. 1-3 show that reported suicide rates vary considerably among countries and that countries with low and high rates are to be found in the Americas, in Asia and in Europe. If rates below 5 Fig. 1 per 100,000 population are considered low, be- tween 5 and 15 as medium, between 15 and 30 as high, and above 30 very high, countries in the first three groups are to be found in all of these conti- nents, but only countries in Asia and in Europe are found in the fourth category. The rates in Latin America are lower than in North America, and generally lower in southern Europe than in other areas of the continent. Rates around 30 or higher are reported in Finland (29.8 in 1991), Hungary (38.6 in 1991), and Sri Lanka (33.2 in 1986) . Figs. 1-3 also demonstrate that men are at con- siderably higher risk of suicide than women. For most countries the male/ female ratio is well above 3. This phenomenon is well-known and not re- stricted to any continent or other geographically described area. In the following analysis, particular emphasis will be given to suicide in adolescents and young adults (15-24 years) and those over 75. Adolescent and young adult suicide is a rare event; however, given the low general mortality in this age group the relative importance of suicide is remarkable: adolescent and young adult suicide figures among the five leading causes of death in many countries. Countries with high adolescent and young adult suicide are Canada ( 15 per 100 OOO in 1990), Sri Lanka (62.3 in 1986), Austria (16.2 in 1991), Fin- Suicide rate per 100 OOO population , by sex, for all age groups, selected countries/areas in the Americas, latest available year Taux de suicide pour 100 OOO habitants, par sexe et pour tousles groupes d'age dans certains pays/zones des Ameriques, derniere annee disponible 30 25 5 .. ~ .. .. · . , · .-·:· ..... ... ... .. .. ................... ..... .... ............. .... ... .......... .... .. ... 25 20 15 10 _.:·· 5 0 Both sexes - Les deux sexes 0 WH093278 Wld hlth statist. quart., 46 (1993) 55 Fig. 2 Suicide rate per 100 OOO population, by sex, for all age groups, selected countries in Asia, latest available year Taux de suicide pour 100 OOO habitants par sexe et pour tousles groupes d'age dans certains pays d'Asie, derniere annee disponible 70 ................. .... ... .. .... .. ........................................... ..... ... ..... 60 60 50 c: U) Cc 50 . .,_ ctS ro-~~ o..c:: .. 40 0-o 40 oo oo Oo ··-··· ---- --- ---- ------. - · ··· · -·-··· · ·-····--- - ----- 30 oo o~ ~:::, Q) 0 c. c. 30 20 Q) x - :::, ctS ctS cc I- 20 10 0 10 Both sexes - Les deux sexes 0 i -..J 0 WH093279 Fig. 3 Suicide rate per 100 OOO population, by sex, for all age groups, selected countries in Europe, latest available year Taux de suicide pour 100 OOO habitants par sexe et pour tousles groupes d'age dans certains pays d'Europe, derniere annee disponible 70 ... ~ .... ----:--- 60 60 50 c: U) _;.-·· Cc ·..;:. C'CI 50 ro-g_~ ... ~ -o..c:: 40 c.o -~ .. oo oo 40 Oo oo .• o~ 30 ~ :i ~g_ 30 Q) x ,. <ii :::, ctS cc I- ; - 20 10 20 0 10 Both sexes - Les deux sexes 0 WH093280 56 Rapp. trimest. statist. sanit. mond., 46 (1993) land (25.1 in 1991), Switzerland (16.2 in 1991). Suicide in old age is of considerable public health importance because of its frequency, as Figs. 4-6 show clearly. There are countries with suicide rates of the elderly well above 30 in the Americas (Uru- guay), in Asia (Japan, Singapore, Sri Lanka), and Europe (Austria, Belgium, the former Czechoslo- vakia, Denmark, France, Germany, Hungary, Swit- zerland). The highest rate is 108 in Hungary. It is interesting to observe that the overall sui- cide rate in a country is not necessarily indicative of the suicide patterns in adolescence or in old age: Hungary reports the highest overall suicide in Eu- rope, the highest rate in old age, but average sui- cide rates in adolescence. On the contrary, Finland with the highest adolescent suicide rate in Europe reports only average suicide in old age. An out- standing and alarming rate of 62.3 (in 1986) of adolescent suicide is reported in Sri Lanka where old age suicide, with a rate of 73.7, ranks equally high. In view of the fact that suicide rates vary consid- erably between men and women and in different age groups, it is of interest to look at young and old-age suicide rates for men and women separate- Fig. 4 ly (Figs. 7-12). Suicide rates for men are consistently about three times as high as for women. Fig. 13 shows the rates for the countries with the most severe suicide problems in old age. It is remarkable that once again, the Americas, Asia and Europe are all represented. Similarly, Fig. 14 shows countries with the highest rates of adolescent suicide. For methodological reasons it is difficult to as- sess trends in suicide over long periods of time. Definitions and recording procedures for causes of death change as do awareness and readiness to label a death as a suicide. Nevertheless, Figs. 15-20 show reported changes in suicide rates for those countries in the Americas, Asia and Europe which have reported suicide mortality to WHO since about 1955. Consequently, the changes cover roughly a 35-year interval. For each of the three regions, separate figures are presented for male and female suicide. Within each figure changes in young and old age suicide are shown. The coun- tries of the Americas and Asia are ranked alphabet- ically but European countries, because of their great number, and in order to facilitate readability, are ranked by increasing order of adolescent sui- cide rates. Suicide rate per 100 OOO population, by age group, selected countries/areas in the Americas, latest available year Taux de suicide pour 100 OOO habitants par sexe et selon l'age, dans certains pays d'Amerique, derniere annee disponible c: u, Oc ~-~ ::, .0 a."' 0 .c a.a 30 gg 20 Oo ao a~ ~ ::, Q) 0 a. a. $~ "'"' a: I- 10 0 .. . ~ ..... Wld hlth statist. quart., 46 (1993) ..... ...... ....................... 30 20 0 All ages - Tous ages confondus 15-24 years - ans WH093281 57 Fig. 5 Suicide rate per 100 OOO population, by age group, selected countries in Asia, latest available year Taux de suicide pour 100 OOO habitants par sexe et selon l'age dans certains pays d'Asie , derniere an nee disponible ---- -- -· -- ------ ----- --- ---------- --- -·--- --··· --- --- --------------- ----- --- --- - 100 .... -· 100 80 .. -·: 80 -- 60 .-:-·· 60 -- 40 40 --- 20 20 0 75 + years - ans et plus All ages - Tous ages confondus 0 15-24 years - ans WH093282 Fig. 6 Suicide rate per 100 OOO population, by age group, selected countries in Europe, latest available year Taux de suicide pour 100 OOO habitants par sexe et selon l'age, dans certains pays d'Europe, derniere annee disponible c U) Oc ·..::::; ro rn- "g_~ 0 _c a_o oO oo Do oo o~ 58 120 100 80 60 40 20 0 .. . ---:--· .. -- -:- --· .... . -· ·--· - · ·-···· - - · ·· ·· · · · · -· ·· · - ·· ·· ·· -- · ·· · · · ··· · ·- ···· --· · · · ·· ··· · · · . · ··-···· -· ·· ·- · ··· ··· · · · · · · · · ·· · · ·· · · ·· · · 80 0 75 + years - ans et plus All ages - Tous ages confondus 15-24 years - ans WH093283 Rapp. trimest statist_ sanit. mond., 46 (1993) Fig. 7 Suicide rate per 100 OOO population, by sex, for the age group 15-24 years, selected countries/areas in the Americas, latest available year Taux de suicide pour 100 OOO habitants par sexe pour le groupe d'age des 15-24 ans dans certains pays/zones des Ameriques, derniere annee disponible . ·-- - - - ---- · -··· · ·········· ··· · ·- ---- ------- --- c (/) De ~~ ::, .0 o_ CU Q..C:: o_o oo oo Oo oo a~ 20 0 In the Americas over the last 35 years, there has been a general increase in suicide rates among elderly men and a sharp increase in adolescent suicide in Canada (317% and 257% for men and women respectively), in Colombia (233% for men), and in the United States of America (226% for men and 110% for women) . A general increase in adolescent and young adult suicide can also be observed among young men in Europe, while there is no clear trend in suicide rates among young European women. However, Ireland, Nor- way and the Netherlands have had dramatic in- creases in reported adolescent suicide over the 35- year period under consideration. In Ireland, sui- cide at young ages increased by 84 7% for males and 720% for females; the increases in Norway were 439% and 530% respectively. The increase in the Netherlands was particularly pronounced for young women with 260%. There are no clear gen- eral trends for old age suicide in Europe. It seems that there is a slight increase among old men, but this is definitely less pronounced than in the young age group. Ireland is the only country reporting a threefold increase for both old men and women. The United Kingdom is the only European country Wld hlth statist. quart., 46 (1993) 0 Both sexes - Les deux sexes Women - Femmes WH093284 with a clear decrease in old age suicide, among both men and women (60% and 56% respect- ively). One of the remarkable observations in Asia is the striking decrease in suicide rates in Japan for both age groups under consideration and among both men and women. Japan is one of the few countries in which a clear decrease in suicide can be established (almost 83% for male and 87% for female adolescents). The other important phe- nomenon in Asia is the steep increase in reported suicides in Sri Lanka; here the change is particular- ly pronounced in adolescence and early adulthood with a 511 % increase among young men and a 424% increase among young women. Discussion General patterns of suicidal behaviour are not dis- tinctively different in the Americas, Asia or Eu- rope. As a rule, men are several times more likely to commit suicide than women, and this observa- tion holds true across age groups. Nevertheless, there are exceptions to this general pattern, and the ranges of the male/female ratio extend from 59 Fig. 8 Suicide rate per 100 OOO population, by sex, for the age group 15-24 years, selected countries in Asia, latest available year Taux de suicide pour 100 OOO habitants par sexe pour le groupe d'age des 15-24 ans dans certains pays d'Asie, derniere annee disponible 90 80 70 c:"' 60 Oc .,, ro ro-g_~ 50 Q..C: a.a oo oo Do oo 40 o~ ~::, Q) 0 a. a. 30 Q) >< -::, ro ro a: f- 20 10 0 Fig. 9 ~--~---;--r~~~~~~~~~~~~~~~so ---:·· ; .. --· .- -·· : ·---· .... . ~ .. ~ -. ___ , .. - I •• •• . -.. -~ .. __ .;.--·· .. i····· -· -~ -·. -· -· ·t.. .... .. · .- --·: .-:-· .-· : - ····- .. --- ---- ----- ·-···· ···--·--· -· ··------ - - --· -- ·········· · ·- --- -- ----------- --- --------- ···-------- . ····· - ·-······ ---·--------- ------ ---- 80 --- 70 60 50 40 30 20 10 0 Both sexes - Les deux sexes Women - Femmes WH093285 Suicide rate per 100 OOO population, by sex, for the age group 15-24 years, selected countries in Europe, latest available year Taux de suicide pour 100 OOO habitants par sexe pour le groupe d'age des 15-24 ans, dans certains pays d'Europe, derniere annee disponible 50 c:"' .g~ 40 ro- "g_~ Q..C: a.a oO g~ 30 oo o~ ~::, Q) 0 a. a. ~ ~ 20 a: f- 10 0 60 ---- -:-·· . ~ .. . ~-. .-:-- -- · ------------ --------------------- ------ ---- -- --------------------------------- 50 ···············-· · · ·· · ··· - -·-···· ·· · ·· · · ···· ···· · · -· ·· · · · ··· ··········--· .. ---- ··- ------ ---- --- ------- -- --- - -------- ------ -- -------·-··· . -------- ----- ·-- ------ ------------ ----------- 0 Both sexes - Les deux sexes Women - Femmes WHO 93286 Rapp. trimest. statist. sanit. mond., 46 (1993) Fig. 10 Suicide rate per 100 OOO population by sex. for the age group 75 years and over, selected countries/areas in the Americas, latest available year Taux de suicide pour 100 OOO habitants par sexe pour le groupe d'age des 75 ans et plus, dans certains pays/zones des Ameriques, derniere annee disponible ... ~. 60 c (/) Oc ., "' <tl-g_ :g 0 .c . ~- .. a.a oo oo 40 Oo oo .. :-·· o~ ~ :::, Q) 0 Q. Q. Q) x - :::, "'"' a: 1-- 20 0 Both sexes - Les deux sexes 0 Women - Femmes WH093287 Fig. 11 Suicide rate per 100 OOO population , by sex, for the age group 75 years and over, selected countries in Asia, latest available year Taux de suicide pour 100 OOO habitants par sexe pour le groupe d'age des 75 ans et plus, dans certains pays d'Asie, derniere annee disponible c (/) Oc ~ -~ :::, .0 Q."' 0 .c a.a oo oO Oo oo o~ ~ :::, Q) 0 Q. Q. ·Q) x - :::, "'"' a: 1-- 200 160 100 50 200 160 100 50 0 Men- Hammes Both sexes - Les deux sexes 0 Women - Femmes WH093288 Wld hlth statist. quart., 46 (1993) 61 Fig. 12 Suicide rate per 100 OOO population, by sex, for the age group 75 years and over, selected countries in Europe, latest available year Taux de suicide pour 100 OOO habitants par sexe pour le groupe d'age des 75 ans et plus, dans certains pays d'Europe, derniere annee disponible 200 150 . . . ~. -.. .. :- · · 100 50 0 Fig. 13 .. - ~ . . ~- .. . ------- -·- ··-···· ···· ·· · --- ---··· ·· · -· · · · · - 150 0 Both sexes - Les deux sexes Women - Femmes WH093289 Countries with the highest suicide rate a per 100 OOO population, for men aged 15-24 years, latest available data Pays ou le taux de suicide pour 100 OOO habitants est le plus elevea chez les hommes de 15 a 24 ans, dernieres donnees disponibles 90 80 c"' 70 Oc ~~ 60 5- ro o.c: a.o 50 oo oo Oo oo 40 o~ ~::, Q) 0 a. a. 30 Q) x - ::, ro ro a: I- 20 10 0 Sri Lanka Finland Switzerland Finlande Suisse ~ 15-24 years - ans Austria Autriche Canada United States of America Etats-Unis d'Amerique Norway Norvege Japan Japon a Among countries for which data were available. - Parmi les pays pour lesquels l'OMS dispose de donnees. 62 Rapp. trimest. statist. sanit. mond., 4o (1993) Fig. 14 Countries with the highest suicide rate a per 100 OOO population, for men aged 75 years and over, latest available data Pays ou le taux de suicide pour 100 OOO habitants est le plus elevea chez les hommes ages de 75 ans et plus, dernieres donnees disponibles 200 c: (/) Oc 150 :.;::::. CCI "'-"S i:i c."' o..c: c.a oo oo Oo 100 oo a~ ~::, Q) 0 c. c. 50 Q) x - ::, "'"' a: I- 0 Hungary Hongrie 75 + years - ans et plus ~ Sri Lanka Austria Autriche a Among countries for which data we re available. - Parmi les pays pour lesquels l'OMS dispose de donnees. Fig. 15 Uruguay Percentage change in suicide rates per 100 OOO population, for men , by age group, selected countries/areas in the Americas, 35-year period, around 1957-1992 Evolution (en%) des taux de suicide pour 100 OOO habitants chez les hommes, par groupe d'age, dans certains pays/zones des Ameriques, periode de 35 ans, vers 1957-1992 ~ 0 c: 0 300 i 200 LJ.J I l 100 Q) 0, c: "' ..c: () Fig. 16 0 • 15-24 years - ans ~ 75 + years - ans et plus Percentage change in suicide rate per 100 OOO population, for men, by age group, selected countries in Asia, 35-year period, around 1957-1992 Evolution (en%) des taux de suicide pour 100 OOO habitants chez les hommes, par groupe d'age, dans certains pays d'Asie , periode de 35 ans , vers 1957-1992 • 15-24 years - ans 500 ·····-········· ··· ··-··············· ····· ····· ···- ···· ······ ···· ······· · l ~ 75 + years - ans et plus § 400 5 ] 300 I l 200 Q) 0, c: "' ..c: (.) 100 0 -100 Wld hlth statist. quart., 46 (1993) • All ages - Tous ages confondus 63 Fig. 17 Percentage change in suicide rate per 100 OOO population , for men. by age group, selected countries in Europe, 35-year period, around 1957-1992 Evolution (en%) des taux de suicide pour 100 OOO habitants chez les hommes, par groupe d'age, dans certains pays d'Europe, periode de 35 ans. vers 1957-1992 900 800 700 • 15-24 years - ans l 600 c 0 ·5 ~ 75 + years - ans et plus 0 500 ·····-········-·------------------------ -- -----------------------------------------------------------------------···-······- > w I 400 l 300 Q) • All ages - Tous ages confondus Q) c 200 "' .c (.) 100 0 -100 Fig. 18 Percentage change in suicide rate per 100 OOO population , for women, by age group, selected countries/areas in the Americas, 35-year period, around 1957-1992 Evolution (en%) des taux de suicide pour 100 OOO habitants chez les femmes. par groupe d'age, dans certains pays/zones des Ameriques, periode de 35 ans. vers 1957-1992 Q) Q) c "' .c (.) 200 100 -100 • 15-24 years - ans ~ 75 + years - ans et plus • All ages - Tous ages confondus 3.4 to 9.2 with a median of 4.1 in the Americas; from 1.0 to 2.2 with a median of 1.3 in Asia; and from 1. 7 to 5.4 with a median of 3.0 in Europe. Adolescent suicide and suicide in old age pose particular public health problems; suicide ranks among the leading causes of death among adoles- cents, while suicide in old age is remarkable because of its increased frequency. There seems to be a definite, general upward trend in reported male adolescent suicide on all three continents over the last 35 years. There are very few count- ries with clearly pronounced decreases in suicide rates. There are quite a number of individual coun- tries with extraordinary patterns of suicide behav- iour: Sri Lanka (dramatic increase, high rates), 64 MEX USA CDN COL Japan and the United Kingdom (falling rates over time), Ireland (steep increase in rates over time), Hungary (very high rates in old age), Finland (high adolescent male suicide rates) and Canada ( a high increase in adolescent suicide over time)- It is not clear, however, what these countries have in common or in which specific socio-cultural or oth- er relevant aspects they differ which could explain such similar or discrepant behaviour. An analysis of the epidemiology of suicide world-wide can point to such situations with "unusual" suicide behaviour. But it seems that the factors causing such behaviour are very situation-specific. The identification of causative or preventive factors, on the other hand, is a prerequisite for the develop- ment of preventive programmes. Rapp. trimest. statist. sanit. mond., 46 (1993) Fig. 19 Percentage change in suicide rates per 100 OOO population, for women, by age group, selected countries in Asia, 35-year period , around 1957-1990 Evolution (en%) des taux de suicide pour 100 OOO habitants chez les femmes, par groupe d'age, dans certains pays d'Asie , periode de 35 ans , vers 1957-1992 Fig. 20 400 l 300 c 0 ., ::, 0 > w 200 <l) • 15-24 years - ans ~ 75 + years - ans et plus All ages - Tous ages confondus ~ 100 ------ ····· ·· ··········· ····-·· ····· · .c () 0 -100 THA SRL Percentage change in suicide rate per 100 OOO population, for women, by age group, selected countries in Europe, 35-year period, around 1957-1992 Evolution (en%) des taux de suicide pour 100 OOO habitants chez les femmes, par groupe d'age , dans certains pays d'Europe, periode de 35 ans, vers 1957-1992 • 15-24 years - ans " ~ 700 .. ,,,. -·- ----·-···········-- ----- ---·····-·· ·········--- -- ------ ---············· ······ ····----- --------------- --------- --- --········· i ~ 75 + years - ans et plus 600 ~ 500 ~ c 0 ·g ~ 400 w l 300 <l) Cl c CU 6 200 100 Wld hlth statist. qualt., 46 (1993) • All ages - Tous ages confondus 65 There has been much speculation about risk factors for suicidal behaviour and, in particular, for suicide. They may be classified, broadly, as either societal or psychological. Potential risk factors in the first group include predominant religious affil- iation. (Suicide rates in Islamic countries are con- siderably lower than in Buddhist countries. Suicide rates in Protestant northern Europe and in North America are higher than in Roman Catholic south- ern Europe or in Latin America.) There are clear correlations between suicide and unemployment rates (34), divorce and crime rates (35), and wars (8). Less dramatic events of high public attention such as a soccer championship in Scotland (36) or public holidays (37)- have been related to decreas- es in suicidal acts. While of considerable scientific interest, such factors are of limited public health relevance as they do not point to preventive action. In contrast, certain psychological risk factors, to varying degrees, may be amenable to preventive intervention. Major precipitating factors for sui- cide seem to be mental illness (it is estimated that between 60% and 80% of suicides are related to depression) (38,39), physical illness, alcoholism, financial problems, and interpersonal disputes (factors which, of course, are not mutually exclu- sive). Two additional factors, apparently, are strongly and directly related to the frequency of suicidal acts: easy access to a killing agent or method, and publicity about suicidal acts. A striking example of the former is reported by Bowles (40) who demon- strated that a rapid and steep increase in the sui- cide rates in Western Samoa in the early 1980s was caused by the easy availability of the highly toxic herbicide Paraquat and could be reversed by re- stricting access to this poison. It is likely that easy access to organophosphorous insecticides and ace- tic acids, which account for 75% of all suicides, are also one of the main reasons for the high suicide rates in Sri Lanka (26, 41). Evidence that a decrease in suicide rates can be obtained by restricting ac- cess to poisonous substances has been reported by others (35). Publicity about suicidal acts in the media may trigger a "copycat" effect and lead to an increase in the overall suicide rate in a country or geographical area. This phenomenon was de- scribed in the 18th century by the German poet and writer J. W. von Goethe in his novel Die Leiden des jungen Werther. More recently, Schmidtke re- ported the increase of suicide in Germany on two occasions after TV series had been broadcast in which the fictitious suicide of the main actor was shown in great detail (42). The "Werther effect" in suicidal behaviour has also been show by Sonneck who demonstrated that the number of subway-sui- cides in Vienna over a 10-year period increased and subsequently decreased with the level of press coverage of such events (43). 66 Summary Suicidal behaviour includes suicidal ideation, parasui- cide or attempted suicide, and completed suicide. As- sessment and recording of suicidal ideation and para- suicide is most difficult, and the first internationally comparable data on parasuicide are expected from an ongoing WHO-coordinated study in 15 European cen- tres. On the other hand, about 50% of WHO's 186 Member States report suicide as part of their mortality statistics. Although there is no uniformity in definitions of suicidal acts nor in recording procedures, certain pat- terns of suicidal behaviour emerge across countries. The incidence of parasuicide is 10 to 20 times higher than that of completed suicide; the male/female ratios for suicide and attempted suicide are reciprocal: 3 times more women then men commit parasuicide, while in most countries about 3 times more men than women commit suicide. From a public health point of view, suicide in adolescents and young adults is particularly important: suicide in adolescence and young adulthood ranks among the 5 leading causes of death in many countries. There have been clear and dramatic in- creases in suicide rates in most WHO Member States which report mortality statistics to the Organization, especially among young men. Suicide in old age, partic- ularly among men, is about 2 to 3 times more frequent than in younger age groups. Although it is not surprising that mortality increases with age, death by suicide is considered in most cultures and by most people as particularly deplorable and unnecessary. The epidemi- ological analysis of suicidal behaviour globally does not identify clear-cut risk factors amenable to preventive programmes. It does, however, pinpoint countries with "unusual" suicide patterns which, it is hoped, will initiate country-specific research into causes of such behav- iour. Particularly promising, from the perspective of suicide prevention, seems to be research into the meth- ods of suicide, and the impact of publicity of suicidal acts, as it has been shown repeatedly that restricting access to the prevailing method of suicide in a country will decrease suicide rates, while wide publicity about suicidal acts will increase them. Resume Epidemiologie des comportements suicidaires: analyse sur trois continents Les comportements suicidaires comprennent les idees de suicide, les tentatives de suicide et le suicide propre- ment dit. L'evaluation et l'enregistrement des idees de suicide et des tentatives de suicides est une tache particulierement difficile, et une etude coordonnee par l'OMS dans 15 centres europeens devrait en principe livrer les premieres donnees internationalement compa- rables sur les tentatives de suicide. D'un autre cote, 50% environ des 186 Etats Membres de l'OMS font figurer le suicide dans leurs statistiques de mortalite. Bien que les definitions des actes suicidaires ne soient pas unifor- mes et que les methodes d'enregistrement varient selon les pays, on peut degager certains schemas de com- portement suicidaire. Rapp. trimest. statist. sanit. mond., 46 (1993) Les tentatives de suicide sont 1 O a 20 fois plus frequen- tes que les suicides proprement dits; le rapport de masculinite pour le suicide et la tentative de suicide est inverse: trois fois plus de femmes que d'hommes font une tentative de suicide tandis que, dans la plupart des pays, environ trois fois plus d'hommes que de femmes se suicident. Du point de vue de la sante publique, le suicide chez les jeunes et les adultes est particuliere- ment important: le suicide parmi les adolescents et les jeunes adultes se situe au cinquieme rang des causes de deces dans de nombreux pays et ii y a eu manifes- tement une augmentation considerable du nombre des suicides, notamment parmi les hommes jeunes, dans la plupart des Etats Membres de l'OMS qui communique a !'Organisation des donnees statistiques de mortalite. Le suicide chez les personnes a.gees, en particulier les hommes, est de deux a trois fois plus frequent que dans les groupes mains ages. Si l'accroissement de la morta- lite avec l'age n'a rien de surprenant, la mart par suicide est consideree dans la plupart des cultures et par la plupart des gens comme particulierement regrettable et inutile. Dans !'ensemble, !'analyse epidemiologique des comportements suicidaires ne permet pas de degager de facteurs de risque clairs qui puissent faire l'objet de programmes de prevention. Elle fait toutefois ressortir des schemas specifiques suicidaires «inhabituels» dans certains pays qui, ii faut l'esperer, entreprendront des recherches specifiques sur les causes de ces comportements. Un element particulierement promet- teur - semble-t-il - est la recherche sur les moyens employes pour se suicider et sur l'impact du caractere plus ou mains public des actes suicidaires; on a en effet constate a maintes reprises que le fait de limiter l'acces au principal moyen de suicide dans un pays contribuait a faire reculer la frequence des suicides, alors que le fait de parler largement des actes suicidaires produisant l'effet inverse. References I References 1. Goldney, R.D. et al. Suicidal ideation in a young adult population. Acta psychiatrica scandinavica, 79: 481-489 (1989). 2. Kreitman, N. Parasuicide. London, Wiley, 1977. 3. Maris, R.W. Suicide. In: Encyclopedia of human biology. New York, Academic Press, 1991, 372-335. 4. Farberow, N.L. Themanyfacesofsuicide. New York, McGraw- Hill, 1980. 5. Diekstra, R.F.W. &: Kienhorst, A.J. Attitudes towards suicide: the development of a suicide-attitude questionnaire (SUIAIT). In: Diekstra, R.F.W. & Maris, R. & et al. (eds). Suicide and its prevention: the rol.e of attitude and imitation. Leiden, New York, (WHO co-publication), Brill, 1989, 91- 107. 6. Bille-Brahe et al. Parasuicide in Europe: the WHO/EURO Multicentre Study on Parasuicide. I. Introduction and Preliminary Analysis of 1989. Acta psychiatrica scandinavica, 85: 97-104 (1992). 7. Douglas, J.D. The social meanings of suicide. Princeton, University Press, 1967. 8. World Health Organization. Changing patterns in suicide behaviour. Rep<nt of a WHO working group (Athens, 29 September - 2 October 1981) EURO Rep<nts and Studies No. 74 (E,F,G,R) (1982). Copenhagen, Regional Office for Europe, WHO, 1982. 9. Sainsbury, P. &:Barraclough, B. Differences between suicide rates. Nature, 2202: 1252 (1968). Wld hlth statist. quart., 46 (1993) 10. Whitlock, F.A. Migration and suicide. Medical journal of Australia, 2: 840-848 ( 1971) . ll. Lester, D. Why peofle kill themselves: a summary of research findings on suicidal behaviour. Springfield, Thomas, 1972. 12. McCarthy, P.D. &: Walsh, D. Suicide in Dublin: I The underreporting of suicide and the consequences for national suicide statistics. British journal of psychiatry, 126: 301- 308 (1975). 13. Jobes, D.A. et al. The impact of psychosocial autopsies on medical examiners' determination of manner of death. Journal of forensic sciences, 31 (1): 177-189 (1986). 14. World Health Organization. Suicide statistics: the problem of comparability. WHO Chronicle, 29: 188-193 (1975). 15. Barraclough, B. Differences between national suicide rates. British journal of psychiatry, 122: 95-96 (1973). 16. Kienhorst, C.W.M. et al. Characteristics of suicide attempters in a population-based sample of Dutch adolescents. British journal of psychiatry, 156: 243-248 (1990). 17. Canton, G. et al. L'ideazione di suicidio nell'adolescenza: prevalenza in un campione di studenti e relazione con i sintomi psichiatrici. Rivista di psichiatria, 24(3): 101-107 (1989). 18. Pronovost, J. et al. Epidemiological study of suicidal behaviour among secondary-school students. Canada's mental health, 38: 9-14 (1990). 19. Diekstra, R.F.W. et al. High school student research 1990: behaviour and health of high school students. Leiden, State University of Leiden, 1991. 20. Nagy, S. &: Adcock, A. The Alabama adokscent health suruey: health knowledge and behaviours. Summary rep<nt Il Alabama, The University of Alabama and Troy State University, 1990. 21. Watanabe, N. et al. Structural analysis ofbehavioral patterns of junior high school students. Japanese journal of chil,d and adokscent psychiatry, 29: 160-172 (1988). 22. Smith, K. &: Crawford, S. Suicide behaviour among "normal" high school students. Suicide and life-threatening behaviour, 16: 313-325 (1986). 23. Harkavy-Friedman,J.M et al. Prevalence of specific suicidal behaviours in a high school sample. American journal of psychiatry, 144: 1203-1206 (1987). 24. Dubow, E.F. et al. Correlates of suicidal ideation and attempts in a community sample of junior high and high school students: Journal of clinical chil,d psychology, 18: 158-166 ( 1989). 25. Rubinstein, J.L. et al. Suicidal behaviour in "normal" adolescents: risk and protective factors. American journal of <nthopsychiatry, 59: 59-71 (1989). 26. Diekstra, R.F.W. Suicide and suicide attempts in the European Economic Community: an analysis of trends with special emphasis on trends among the youth. Suicide and life- threatening behaviour, 15: 402-421 (1885). 27. Dissanayake, S.A.W. &:De Silva, P. Suicide in Sri Lanka. In: Headley, L.A. (ed). SuicideinAsiaandtheNearEast. Berkeley, Los Angeles, London, University of California Press, 1983. 28. Andrus, J .K. et al. Surveillance of attempted suicide among adolescents in Oregon. American journal of public Health, 8 l: 1067-1069 (1991). 29. Hawton, K. et al. Adolescents who take overdoses: their characteristics, problems and contacts with helping agencies. Britishjournalofpsychiatry, 140: ll8-123 (1982). 30. Mehr, M. et al. Continued self-destructive behaviours in adolescent suicide attempters: part I. journal of adolescent health care, l: 269-274 (1981). 31. Mehr, M. et al. Continued self-destructive behaviours in adolescent suicide attempters: part II. Journal of adokscent health care, 2: 182-187 (1982). 32. Platt, S. et al. Parasuicide in Europe: the WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta psychiatrica scandinavica, 85: 97-104 (1992). 33. World Health Organization. WorU health statistics annual. Geneva, World Health Organization, 1991. 34. Platt, S. Suicidal behaviour and unemployment: a literature review. In: Westcott, G. & Svensson, P.G. & etal. (eds). Health 67 policy implications of unempwymmt. Copenhagen, WHO, 1985, 87-132. 35. Diekstra, R.F.W. Suicide and parasuicide: a global perspective. In: Diekstra, R.F.W.Gulbinat, W.H. (eds). Preventive strategies on suicide. Leiden, New York, Kobenhaven, Kain, E.J. Brill, 1993, 36. Masterton, G. & Strachan,J.A. Parasuicide, Scotland and the World Cup. British medicaljourna~ 295: 368 (1987). 37. Schreiber, G. et al. A unique monthly distribution of suicide and parasuicide through firearms among Israeli soldiers. Acta psychiatrica scandinavica, 87: 110-113 (1993). 38. Zung, W.W.K. et al. Seasonal variation of suicide and depression. Archives for general psychiatry, 30: 89-91 ( 1973). 39. Monk, M. Epidemiology of suicide. Epidemiowgical review, 9: 51-69 (1987). 68 40. Bowles, J.R. Suicide in Western Samoa: an example of a suicide prevention program in a developing country. In: Diekstra, R.F.W.Gulbinat, W.H. (eds). Preventive strategies on suicide. Leiden, New York, Kopenhaven, Kain, E. J. Brill, 1993, 126-156. 41. Lawrence, R. & Berger, M.D. Suicides and pesticides in Sri Lanka. American journal of public health, 7: 826-828 ( 1988). 42. Schmidtke, A. & Hafner, H. The Werther effect after television films: new evidence for an old hypothesis. Psychowgical medicine, 18: 665-676 (1988). 43. Sonneck, G. Subway suicide in Vienna (1980 - 1990): a contribution to the imitation effect in suicidal behaviour. In: Diekstra, R.F.W.Gulbinat, W.H. (eds). Preventive strategies of suicide. Leiden, New York, Kopenhaven, Kain, E. J. Brill, 1993, 215-223. Rapp. trimest. st1Jtist. sanit. mond., 46 (1993) Child abuse: measuring a global problem Mark A. Belseya Introduction Child abuse has been noted as a societal phenome- non for centuries (1). Nevertheless, since the origi- nal clinical reports by Henry Kempe and others 30 years ago (2), the magnitude of the problem has not been well defined, and the lack of epidemi- ological data limits the extent to which sound pub- lic health and social welfare policies and interven- tion programmes could be developed, implement- ed and evaluated. Child abuse and neglect (sometimes known as "CAN") includes four distinct conditions: physical abuse, neglect, emotional abuse and sexual abuse (3) (See Box 1 j<YT definitions). The epidemiology of each differs widely within countries, although it appears that even between countries some underly- ing factors may be common among different cul- tural settings. Child abuse and neglect occur within and outside of family settings. Extra-familial child abuse and neglect may occur in an institutional or non-institutional setting. In recent years two approaches have been de- veloped to document the magnitude and nature of child abuse and neglect: regional or national case registers, and a screening instrument for suspected cases of child abuse and neglect (SCAN) for use in health service facilities. We are proposing an addi- tional approach for monitoring presumed child abuse and neglect-related mortality. The combina- tion of the three approaches will provide a better profile of the epidemiology of child abuse and neglect, a crude means by which reliability of the information could be estimated, and tools for the evaluation of various community-based interven- tion programmes. Community-based registers The reporting systems for child abuse and neglect from 30 countries have been recently described in a survey conducted by the International Society for Prevention of Child Abuse and Neglect (4). These included 16 from developed and 14 from develop- ing countries, 10 of the former and 5 of the latter having been described as mandatory. In many of the countries, reporting is limited to specific re- gions and is the mandatory or voluntary responsi- bility of different individuals or sectors. The report- a Programme Manager, Maternal and Child Health and Family Health, World Health Organization, Geneva, Switzerland Wld hlth statist. quart., 46 (1993) Box 1 Definitions of the different forms of child abuse in the registers of the National Society tor the Prevention of Cruelty to Children (England and Wales) Physical abuse: Physical injury to a child, includ- ing deliberate poisoning, where there is a definite knowledge, or a reasonable suspicion, that the injury was inflicted or knowingly not prevented. Neglect: The persistent or severe neglect of a child (for example, by exposure to any kind of danger, including cold and starvation) which results in serious impairment of the child's health or development, including non-organic failure to thrive. Emotional abuse: The severe adverse effect on the behaviour and emotional development of a child caused by persistent or severe emotional ill-treatment or rejection. All abuse involves some form of emotional ill-treatment or rejection; this category should be used where it is the main or sole form of abuse. Sexual abuse: The involvement of dependent, developmentally immature children and adoles- cents in sexual activities they do not truly com- prehend, to which they are unable to give in- formed consent, or that violate the social taboos of family roles. The NSPCC studies in England and Wales in- cluded a fifth category, "Grave concern" in which social and medical assessment suggested that children were at significant risk of abuse. This category has been dropped in subsequent data collection. Source: Ref. (3) ing system or registers are most often maintained by ministries or departments of child or social wel- fare, or law enforcement authorities. The effective- ness of such reporting systems in measuring the magnitude of the problem and in serving as the basis for interventions is dependent on three fac- tors: awareness of the reporting systems and the obligations of potential contributors of informa- tion; the ease with which information passes from one sector to another; and the ability of the local community to respond with either public or volun- tary services to ameliorate the problem. 69 One of the early community-based registers was developed by the National Society for the Preven- tion of Cruelty to Children (England and Wales) (NSPCC) (3) in 1973. It initially covered about 13% of the child population under 18 years. In the last several years, the Department of Health has pub- lished national statistics on child abuse, based on local authority registrations. A comparison is shown (Tab/,e 1) of the rate ofregistrations by age in England according to the NSPCC and Department of Health registers in 1990. The physical injury rate among children 0-4 from the NSPCC ranged from 1.0 to 1.5 per 1 OOO population from 1980 through 1990. Approximately 0.5% of such injuries were recorded as being fatal, i.e., 0.5-0.75 per 100 OOO children 0-4 years of age. Table 1 Rate of registrations in the child protection registers by the Department of Health and the NSPCC in 1990 (per 1 OOO population) Tableau 1 Taux d'inscription sur les registres de la protection de l'enfance par le Ministere de la Sante et le NSPCC en 1990 (pour 1 OOO habitants) Age-Ages Under 1 year - Mains d'1 an 1-4 years - 1-4 ans 5-9 years - 5-9 ans 10-15 years- 10-15 ans 16 and over- 16 ans et plus Total (under 18 years)- Total (mains de 18 ans) Source: Ref. (3). Table 2 Department of Health - Ministere de la Sante 6.15 3.29 2.65 2.07 0.67 2.60 The Montreal Children's Hospital Accident-SCAN Has the patient: NSPCC 7.91 3.76 2.92 2.58 0.44 3.02 Reported that she/he has been physically ill-treated? Shown evidence of neglect? Shown evidence of repeated injury? Has the parent/caretaker: Reported that the child has been abused or neglected? Delayed unduly in seeking medical attention for treatment? Shown detachment or hostility? Presented contradictory history and/or unsatisfactory explanation of the injury? Been reluctant to give information or refused consent for further studies? Is there any other reason to suspect that this incident was non-accidental? Was a skeletal survey required? Source: Ref. (6) 70 Facility-based data from standardized assessment: suspected child abuse and neglect (SCAN) Within a country, facility-based data can provide reasonable information on the trends and patterns of child abuse, if standardized definitions and methods of data collection are used, and the data are obtained from institutions covering defined populations. Such a scheme has been developed and evaluated in a number of settings (Tab/,e 2), and more recently has been adapted by WHOb as a standardized protocol. Comparison of such data between countries should be interpreted with cau- tion since facility-based data is dependent on the level of awareness, concern and action by the child care provider or other responsible person in bring- ing the abused child to the attention of the medical care system. Reports from individual facilities, usually hospi- tal emergency rooms, have been used to make estimates of the incidence of child abuse in differ- ent communities. One such study from a defined urban population in the United States of America reported an annual incidence rate of9.19 per 1000 population for violence-related injuries in children under 5 years, with an overall rate of 3.28 per 1000 for those under age 19 (5). A comparable report from three populations of Danish children under age 15 years is shown in Tab/,e 3. Presumed child abuse and neglect mortality While child abuse and neglect have been classified into four categories, in order to derive estimates of b Protorol JM the study of interpersonal physical abuse of children, Maternal and Child Health and Family Planning, Global Programme for Injury Control and Division of Mental Health, World Health Organization, Geneva, MCH/92.1, 1992 Tableau 2 Enquete sur les accidents a l'hopital des enfants de Montreal Est-ce que le patient/la patiente: a signale qu'il/elle avait ete victime de sevices? presentait des signes d'une absence de soins? presentait des signes de traumatismes repetes? Est-ce que le parent/l'accompagnateur: a signale que l'enfant etait victime de mauvais traitements ou d'une absence de soins? a trap attendu avant de demander des soins medicaux? s'est montre indifferent ou hostile? a presente une anamnese contradictoire et/ou des explications peu satisfaisantes pour le traumatisme? a ete reticent au cours de l'interrogatoire ou a refuse de donner son accord pour des examens plus approfondis? A-t-on d'autres raisons de soupr;onner que cet incident ail pu ne pas etre accidentel? A+il fallu proceder a une radiographie du squelette ? Rapp. trimest. statist. sanit. mond., 46 (1993) Table 3 Violence against children under 15 years of age as registered at 3 Danish emergency wards: annual incidence rate per 1 OOO population Tableau 3 Violences contre des enfants de mains de 15 ans enregistrees dans trois services d'urgence danois: taux d'incidence annuel pour 1 OOO habitants Population Boys - Gar~ons Girls-Filles Provincial/rural district - Provinciale/rurale 0.6 0.7 Urban - middle income area - Urbaine a revenu moyen 2.8 0.6 Urban - low income area- Urbaine a faible revenu 4.0 0.9 Source: Ref. (7). mortality from all reported deaths it is necessary to assess whether specific categories of injury and in- jury-related deaths are likely to have resulted from intentional, unintentional or neglectful behaviour. Based on clinical experience, a "likelihood of intent" model is proposed in Tabl.e 4 for the classifi- cation of the external causes of deaths of children under 5. In a long-term review of homicide deaths of children of all ages in a metropolitan area of the United States of America, nearly one-fourth of childhood homicide deaths was associated directly with the "battered" child syndrome (8). The cate- gories of injury-related mortality in infants and young children provide a useful indicator of such mortality for purposes of trend analysis in a specific country, and between countries, assuming reason- ably complete and reliable registration of causes of death. In the Ninth International Classification of Table 4 Diseases (ICD) these include categories of homi- cide (B55), accidental poisoning (B48), accidental falls (B50), accidents caused by fire and flames (B51), and injury undetermined whether acciden- tally or purposely inflicted (B56). Limiting an analysis of such deaths in reference to children under the age of 5 may provide a reasonable esti- mate of SCAN deaths based on the assumption that such deaths are more often the result of actions or the environment established by those responsible for, or in regular contact with those providing for the child's care. Limiting such analysis further to infant deaths probably increases the specificity of the estimates, but would underestimate the magni- tude of the problem, particularly as registry-based data suggest that a higher incidence occurs be- tween 2 and 4 years than during infancy. Physical abuse The use of the homicide category (B55) as an indicator of death by physical abuse appears to work in some countries but not others. A few coun- tries, such as Colombia, Cuba, Greece and Ireland, consistently fail to report either homicide or deaths from injury of undetermined origin in in- fants. Other countries classify all infant and young child deaths into known categories of cause, in- cluding homicide, while others have varying, some- times large proportions of deaths from external causes grouped in the category of undetermined cause (B56). While it is accepted that not all deaths either from homicide or undetermined external causes are as a result of physical abuse, the report- ing patterns appear consistent over time, and the grouping of homicides and deaths due to undeter- mined causes appears to give a more consistent Classification of external causes of death of children under 5 years of age as a measure of suspected child abuse and neglect mortality Tableau 4 Classification des causes exterieures de deces d'enfants de mains de 5 ans comme mesure de la mortalite par maltraitance presumee Cause of Death - Causes de deces Poisoning (848) - Empoisonnement (E48) Falls (850)- Chute (E50) Fires (851) - lncendie (E55) Homicide (855) - Infanticide (E55) Other, unknown (856) - Autre, inconnue (E56) Wld hffh smtist. quart., 46 (1993) Intentional - Volontaire possible but less likely - possible mais assez peu probable possible but less likely - possible mais assez peu probable possible but less likely- possible mais assez peu probable most likely - tout a fait probable very likely - tres probable Neglect - Manque de soins Unintentional - lnvolontaire possible probable possible probable possible probable unlikely- peu probable possible but unlikely- possible mais peu probable possible possible but less likely - possible mais assez peu probable 71 pattern, with one exception (Chile), for compari- son among countries. There are several advantages in using the cate- gories of homicide and death by external violence from undetermined causes as indicators of child abuse mortality in the under-5 age groups. By com- bining the two categories one "captures" the cases that might be less likely to be classified as homi- cide, either because of failure to satisfy full judicial definitions of homicide, or because of the caution or discretion of the medical authorities. The case definition is reasonably dear and unlikely to be confused with other causes of death except per- haps the sudden infant death syndrome (SIDS), which usually has a different clinical pattern and age distribution. Limitation to the under-5 age group covers the period of greatest vulnerability to fatal injury, and minimizes the contribution of oth- er forms of external violence to mortality. Further- more, the use of these categories as indicators elim- inates the requirement of a detailed case-by-case investigation which may be beyond the means or technical capacity of the authorities in many places. The latter, however, should be the goal for all programmes. Some of the disadvantages of using the homi- cide and death due to undetermined causes cate- gories as surrogate indicators of child abuse mor- tality are obvious: in most settings, child abuse deaths constitute an unknown proportion of homi- cide deaths in children; the case-fatality ratio may vary widely in different countries and communities so that the use of such an indicator for comparative purposes for characterizing the epidemiology of child abuse and neglect should be undertaken only with caution. Finally, in most settings, the age group of greatest vulnerability to fatal injury, i.e., those in the first year of life, does not correspond to the period of highest incidence, in the second to fourth years. The most recent reports available for infant deaths in the categories of homicide and death due to undetermined causes for 64 countries are presented by WHO region in Tabk 5. A more complete indicator of presumed child abuse mortality would be the cumulative incidence in a cohort of children born in a specific year (Tabk 6). For analytical and comparative purposes such a cohort analysis should be limited to those under the age of 5 since the patterns of interper- sonal violence and of homicide among older chil- dren resemble the patterns of the adult population (5, 7). Although the data are limited to only three developed countries, they suggest that the cumula- tive risk of death from presumed child abuse by exact age 5 is two to three times the risk in the first year of life. Applying this figure to the presumed child abuse mortality rate for infants in regions or groups of countries for which there are sufficient data, e.g., the industrialized countries, Latin Amer- ica, and the Caribbean, at 6.8 (Tabk 6), the expect- 72 ed cumulative risk of presumed child abuse mortal- ity by age 5 would be between 11 and 20 per 100 OOO live births. These estimates are at least 10 times higher than those made either from com- munity-based registers (3) or forensic reporting sys- tems (9). In view of the discrepancy between these two levels of estimates, further efforts are required to validate the use of the "presumed rate of child abuse mortality" indicator. Neglect mortality Mortality figures do not measure the incidence or prevalence of child neglect, but only deaths from the problem. Death from physical abuse represents a wilful act or series of actions. Death from neglect may arise from wilful behaviour but may also arise from ignorance and irresponsible behaviour. These include failure to recognize hazardous cir- cumstances or children's nutritional, health and developmental needs, and leaving infants and chil- dren unattended or inadequately supervised. Thus, in some circumstances, one could interpret deaths from falls, burns and poisoning in children under 5 as neglect-related. Nevertheless, the same behaviour in a hazardous environment may result in death, while in a less hazardous environment the same neglectful behaviour could easily go undetec- ted and without obvious physical consequences. Consequently, the application of the model pro- posed in Tabk 4 would require more research and evaluation before one could apply such an ap- proach to the analysis of the problem of child neglect. Measuring sexual abuse Mortality data provide virtually no measure of sexu- al abuse. In contrast to physical abuse, sexual abuse is defined on the basis of reports by the child or adult victim and not generally confirmed by physi- cal examination. At the same time, whereas sexual abuse is included in many national and regional child abuse registers, it is difficult to ascertain what proportion of the "true" level of sexual abuse comes to the attention of those agencies or individ- uals maintaining such registers. Estimates of the prevalence or incidence of sexual abuse are de- rived from surveys of adult populations, child abuse registers, or populations referred for evalua- tion and treatment following the disclosure of sex- ual abuse. Data from adult surveys may vary widely according to the methodology used and the man- ner of formulating the interview questions. The methodological problems are further compound- ed by the time elapsed since the event, and the operational definition of sexual abuse that is used. Estimates of the magnitude of the problem based on referrals for evaluation and treatment are not reliable since the majority of child victims of sexual abuse do not seek care. At the same time, allega- Rapp. trimest. statist. sanit. mond., 46 (1993) ~ Ta ble 5 -T ab le au 5 ::: ,- Pr es um ed c hil d ab us e m or ta lity fo r i nfa nts b as ed o n the IC D cla ss ific ati on 8 55 a nd 8 56 fo r s ele cte d co un trie s re po rtin g bo th 85 5 an d 85 6 an d ha vin g at lea st 50 D OD b irth s pe r y ea r d ur ing th e pe rio d §: 19 85 -1 99 0 "' 63 ' M or tal ite in fan tile p ar m alt ra ita nc e pre su me e su r la ba se d es ru br iqu es E 55 e t E 56 d e la lis te de b as e de la C IM p ou r c er ta ins p ay s a ya nt no tifi e a l a f ois le s ru br iqu es E 55 e t E 56 e t a ya nt eu a u m oin s ~ ,.... 50 O OO n ais sa nc es p ar an a u co ur s de la p eri od e 19 85 -1 99 0 . c , ai ~ ~ Co un try an d re gio n Bi rth s pe r y ea r (i n t ho us an ds ) p er 10 0 O OO Ho mi cid e de ath s - ag e l es s t ha n 1 y ea r Ho mi cid e ra te for in fan ts les s t ha n Nu mb er of de ath s f ro m in jur y o f Pr es um ed ch ild a bu se d ea th ra te - . , . liv e bir ths le ss th an 1 ye ar 1 y ea r p er 10 0 OO O liv e bir ths un de ter mi ne d or igi n - ag e l es s of inf an ts un de r o ne ye ar pe r j tha n 1 y ea r 10 0 OO O l ive b irth s Pa ys et re gio ns Na iss an ce s p ar an (e n m illie rs) po ur 1 O D O OO De ce s p ar inf an tic ide - no ur ris so ns Ta ux d 'in fan tic ide ch ez le s n ou rri ss on s No mb re de d ec es p ar tra um at ism es Ta ux de d ec es p ar m alt ra ita nc e na iss an ce s v iva nte s de m oin s d 'un an de m oin s d 'un an p ou r 1 00 OO O d'o rig ine in de ter mi ne e - no ur ris so ns pre su me e ch ez le s n ou rr iss on s na iss an ce s v iva nte s de m oin s d 'un an de m oin s d'u n an p ou r 1 00 OO O na iss an ce s v iva nte s AM ER IC AS -A ME RI QU ES Ar ge nti na - Ar ge nti ne 69 8.9 36 5.2 52 12 .5 Br az il - Br es il 26 47 .5 54 2.0 12 9 6.9 Ca na da 37 1.2 8 2.2 2 2.7 Ch ile - Ch ili 26 9.9 5 1.9 12 1 46 .7 Co lom bia - Co lom bie 78 3.7 0 0.0 0 0.0 Co sta R ica 80 .5 2 2.5 1 3.7 Cu ba 18 2.1 0 0.0 0 0.0 Ec ua do r - Eq ua teu r 33 8.4 4 1.2 0 1.2 Me xic o - Me xiq ue 24 14 .7 69 2.9 47 4.8 Pa na ma 56 .6 2 3.5 2 7.1 Pu er to Ri co - Po rto R ico 75 .3 3 4.0 8 14 .6 Un ite d St ate s o f A me ric a - Et ats -U nis d 'Am er iqu e 39 45 33 5 8.5 51 9.8 Ur ug ua y 56 .6 1 1.8 1 3.5 Ve ne zu ela 54 0.2 6 1.1 11 3.1 EA ST ER N ME DI TE RR AN EA N - ME DI TE RR AN EE O RI EN TA LE Eg yp t - Eg yp te 17 35 0 0.0 24 8 14 .3 I ra n- cit ies - I ra n- vil les 45 4.9 1 0.2 10 .5 2.5 Ku wa it - Ko we "it 52 .9 1.3 2.5 0 2.5 W ES TE RN P AC IFI C - PA CI FIQ UE O CC ID EN TA L Au str ali a - Au str ali e 14 5.4 8 5.5 0 5.5 Ho ng K on g 77 .6 1.6 2.1 0 2.1 Ja pa n - Ja po n 12 09 .4 50 4.1 39 7.4 . . . . . . (. ,) . . . . . Ta ble 5 -T ab lea u 5 (co ntin ue d - su ite ) ~ Co un try an d re gio n Bi rth s pe r y ea r {i n t ho us an ds ) p er 10 0 OO O Ho mi cid e de ath s - ag e l es s t ha n 1 y ea r Ho mi cid e ra te for in fan ts les s t ha n Nu mb er of de ath s f ro m inju ry of Pr es um ed c hil d ab us e d ea th ra te liv e bir ths le ss th an 1 ye ar 1 y ea r p er 10 0 OO O l ive b irth s un de ter mi ne d or igi n - ag e l es s of inf an ts un de r o ne ye ar pe r tha n 1 y ea r 10 0 OO O liv e bir ths Pa ys et re gio ns Na iss an ce s p ar an {e n m illie rs) po ur 10 0 O OO De ce s p ar inf an tic ide - no ur ris so ns Ta ux d 'in fan tic ide ch ez le s n ou rris so ns No mb re de d ec es p ar tra um at ism es Ta ux d e d ec es p ar m alt ra ita nc e na iss an ce s v iva nte s de m oin s d 'un an de m oin s d 'un an p ou r 1 00 OO O d 'o rig ine in de ter mi ne e - no ur ris so ns pre su me e ch ez le s n ou rri ss on s na iss an ce s v iva nte s de m oin s d'u n an de m oin s d 'un an p ou r 1 00 OO O na iss an ce s v iva nte s Ne w Ze ala nd - No uv ell e- Ze lan de 57 .6 46 9 0 6.9 Re p. Ko rea - Re pu bli qu e de G ore e 66 4.2 2 0.3 0 0.3 Sin ga po re - Sin ga po ur 50 .4 1 2.0 1 4.0 SO UT H EA ST A SIA - AS IE DU S UD -E ST Sr i L an ka 43 3.3 8 1.8 7 3.5 Th ail an d - Th a"i lan de 84 3.4 6 0.7 3 1.1 EU RO PE Au str ia - Au tric he 92 .1 3 3.3 1 4.3 Be lgi um - Be lgi qu e 11 6.1 5 4.3 0 4.3 Bu lga ria - Bu lga rie 10 7.2 4 3.7 1 4.7 Cz ec ho slo va kia - Tc he co slo va qu ie 20 7.4 14 6.8 7 10 .1 De nm ark - Da ne ma rk 62 2 3.2 3 8.1 Fin lan d - Fin lan de 64 .2 3 4.7 1 6.2 Fr an ce 75 0.7 13 1.7 10 3.1 Ge rm an y - Al lem ag ne 90 1.7 25 2.8 7 3.5 Gr ee ce - Gr ec e 10 4.2 0 0.0 0 0.0 Hu ng ary - Ho ng rie 12 2.7 75 7 0 5.7 Ire lan d - lrla nd e 50 .8 0 0.0 0 0.0 Ita ly - lta lie 56 7.2 1 0.2 1 0.4 ~ Ne the rla nd s - Pa ys -B as 19 2.4 4 2.1 0 2.1 i5 S" No rw ay - No rve ge 59 .9 1 1.7 0 1.7 ::!" Po lan d - Po log ne 55 2.5 8 1.4 5 2.4 tJl .... Sp ain - Es pa gn e 41 4.6 0 0.0 1 0.2 I Sw ed en - Su ed e 11 3.9 1 0.9 0 0.9 . . . . ~ Sw itz erl an d - Su iss e 81 .9 2 2.4 2 4.9 :: , US SR - Ru ss ie 14 8 3.0 27 5 8.7 ;::. , 48 68 .1 ~ Un ite d Ki ng do m - Ro ya um e-U ni 77 5.5 8 1.0 22 3.9 ?- t i Table 6-Tableau 6 . · 1986 f cumulative rate through age 4 of presumed child abuse mortality of the cohort of children born in 1985 and or Czechoslovakia, Hungary and the United States of America , Risque cumulatif de mortalite par maltraitance j~squ'a l'ag~ de 4 ans dans une cohorte d'enfants nes en 1985 et 1986 aux Etats-Unis d'Amerique, en Hongrie et en Tchecoslovaqu1e Country, year of birth Presumed child abuse death rate of infants under 1 year per 100 OOO live births Cumulative presumed child abuse death rate up to age 5 years per 100 OOO live births Pays et an nee de naissance Taux de deces par maltraitance presumee chez les nourrissons de mains d'un an pour 100 OOO naissances vivantes Risque cumulatif de mortalite par maltraitance iusqu'a 5 ans pour 100 OOO naissances vivantes Czechoslovakia - Tchecoslovaquie Hungary - Hongrie United States of America - Etats-Unis d'Amerique 1985 1986 1985 1986 1985 7.6 5.9 12.0 12.6 6.8 tion of sexual abuse is neither always true nor easily substantiated. In a prospective study based on the mandatory reporting system in New York State, about 40% of reports of sexual abuse were substan- tiated (10). Reports that were not mandated had a significantly lower rate of substantiation. The presence of a sexually transmitted disease (STD) in a child has been suggested as an objective measure of sexual abuse ( 11). While the isolation of a microorganism, such as Neisseria gonorrhoea, from the genital or anal tract of a child may be construed as evidence of sexual abuse, other infections may be less specific and cannot be taken as presumptive evidence (12). Furthermore, in instances where large registers of child sexual abuse have been maintained, the diagnosis of an STD usually occurs in no more than 1-2% of cases or cultures taken (3, 13, 14, 15). In order to use age-specific infection rates for country comparisons and to take account of the variation in STD patterns between such countries, some authors have proposed using the ratio of pediatric gonococcal (GC) infection cases to 1 OOO adult male GC cases ( 11). The overall ratio was 4.6 in that study. The incidence rate for GC in children 1 month through 9 years was 11 per 100 OOO (18.2 for girls and 4.1 for boys). Using the figure of 1 % of sexual abuse cases having a positive isolation of GC, the overall annual incidence rate of sexual abuse in the latter population would be around 1%. Surveys of adults in several industrialized coun- tries suggest that 10 to 15% of children are victims of sexual abuse ( 16). The surveys of adults report- ing sexual abuse rarely provide an indication of the age at which abuse occurred. However, several of the community-based registers and larger commu- nity-based studies describe a bimodal distribution with peak occurrences from 2 to 4 and from ~2 t~ 15 years of age (3,10,11,12). While all reports md1- cate that the majority of victims of sexual abuse are Wld hlth statist. quart, 46 (1993) 13.6 11.0 17.1 19.3 18.7 girls, this difference is less pronounced in the younger age group. Discussion The use of "presumed child abuse mortality" data, though available and easily defined and assuming that further research establishes its validity, pro- vides a picture of only the severest form of child abuse and neglect. Alone, such data are insuffi- cient to define the nature of the problem in any community, or to monitor progress in pro- grammes designed to address the problem. Child abuse deaths are rare events. With the presumed child abuse mortality rates for infants in most coun- tries at around 6 to 7 per 100 OOO live births, such data provide a global estimate and a notion of the size of the "tip of the iceberg." The size of the "hidden" portion of the problem is still ill-defined and may vary from setting to setting. The observa- tion that the presumed child abuse mortality (PCAM) rate for infants rose from 6.8 to 9.8 per 100 OOO live births in the United States, but fell from 4.2 to 0.9 per 100 OOO in Sweden from 1985 through 1989 could be interpreted as improved reporting, an increase in the case-fatality ratio, or an overall increase in the problem in the United States, and in Sweden as a lowering of the case- fatality rate or a decline in the overall problem. Until the case-mortality can be related to the inci- dence of child abuse, use of presumed child abuse mortality rates will not provide an accurate mea- sure of the magnitude of child abuse and neglect in general. Summary Child abuse and neglect include four distinct conditions: physical abuse, neglect, emotional abuse and sexual abuse. The magnitude of the problem is not well defined. 75 The lack of epidemiological data limits the extent to which sound public health and social welfare policies and intervention programmes could be developed, im- plemented and evaluated. In recent years two ap- proaches have been developed to document the mag- nitude and nature of child abuse and neglect: regional or national case registers; and a screening instrument for suspected cases of child abuse and neglect (SCAN) for use in health service facilities. We are proposing an additional approach for monitoring presumed child abuse and neglect-related mortality. Applying this ap- proach to regions or groups of countries for which there are sufficient data, the expected under-5 rate of pre- sumed child abuse and neglect would be between 13 and 20 per 100 OOO live births. These estimates are higher than those made either from community-based registers or forensic reporting systems. Differences in these estimates will need to be resolved through further research. Injury and injury-related mortality can be classified as intentional, unintentional or resulting from varying de- grees of neglect. Death from physical abuse represents a willful act or series of actions. Death from neglect may arise from wilful behaviour but may also arise from ignorance and irresponsible behaviour. These include failure to recognize hazardous circumstances or chil- dren's nutritional, health and developmental needs, and leaving infants and children unattended or inade- quately supervised. Mortality data provide virtually no measure of sexual abuse. In contrast to physical abuse, sexual abuse is defined on the basis of facts reported by the child victim or an adult which are not generally confirmed by physical examination. Estimates of either the prevalence or incidence of sexual abuse are derived from surveys of adult populations, child abuse registers or populations referred for evaluation and treatment following the disclosure of sexual abuse. Data are pre- sented on the levels of presumed child abuse and neglect mortality for 64 countries and territories for which recent data are available. For several countries, time trends are presented in the cumulative 5-year rate of presumed child abuse and neglect of mortality. The methodological issues in assessing the levels of child abuse and neglect are discussed. Resume la maltraitance des en/ants: mesurer un probleme mondial La maltraitance comprend quatre categories distinctes: les violences physiques, le manque de soins, les violen- ces psychologiques et les abus sexuels. On connait mal l'ampleur du probleme et le manque de donnees epide- miologiques ne permet pas de bien formuler, appliquer et evaluer des politiques de sante publique et de protec- tion sociale et des programmes d'intervention valables. Ces dernieres annees, deux methodes ont ete elabo- rees pour documenter l'ampleur et la nature de la maltraitance: les registres regionaux ou nationaux de cas et un instrument de depistage des cas suspects de maltraitance a !'usage des etablissements de sante. Nous proposons une nouvelle approche pour determi- ner la mortalite par maltraitance presumee Si l'on appli- 76 que cette approche aux regions ou groupes de pays pour lesquels on possede des donnees suffisantes, le taux previsible des cas de maltraitance chez les enfants de moins de 5 ans se situe entre 13 et 20 pour 100 OOO naissances vivantes. Ces estimations sent superieures a celles qui ont ete faites a partir soit des registres communautaires, soit des rapports de medecins legis- tes, et des recherches plus poussees devront etre entreprises pour expliquer ces differences. La mortalite directement ou indirectement liee aux trau- matismes peut etre classee comme intentionnelle, acci- dentelle ou resultant d'un manque de soins a des degres divers. La mort par violence physique provient d'un acte ou d'une serie d'actes intentionnels, tandis que la mort par manque de soins peut etre la resultante aussi bien d'un comportement intentionnel que de !'ignorance ou de l'irresponsabilite - on ne sait pas reconnaitre les situations dangereuses, on ne connait pas les besoins de l'enfant au niveau de la nutrition, de la sante et du developpement, on laisse les nourrissons et les enfants seuls ou mal surveilles. Les donnees sur la mortalite ne fournissent pratiquement aucune indication de !'impor- tance des abus sexuels qui, contrairement aux sevices physiques, sent definis sur la base de faits relates par la jeune victime ou par un adulte et qui ne sent pas confirmes de fac;:on generale par l'examen physique. Les estimations de la prevalence ou de !'incidence des abus sexuels sent derivees d'enquetes sur les popula- tions adultes, des registres sur les enfants maltraites ou de l'examen et d'un traitement des personnes en cause apres la divulgation d'abus sexuels. Des donnees sur le niveau de la mortalite presumee par maltraitance dans 64 pays et territoires pour lesquels on dispose de chiffres recents sent presentees dans cet article. L'evo- lution sur une certaine periode est egalement indiquee pour plusieurs pays ainsi que le risque cumulatif de mortalite par maltraitance a l'age de 5 ans. Entin, les problemes de methodologie que pose !'evaluation de l'ampleur de la maltraitance sent analyses. References/References 1. Lynch. M. Child Abuse before Kempe: An historical literature review, Child abuse and negkct, 9: 7-15 (1985). 2. Kempe, C.H. et al. The battered child syndrome. Journal of the American medical association, 181: 17-24 ( 1962). 3. Creighton, S.J. Child Abuse Trends in Engl.and and Wales 1988- 1990: And an Overview from 1973-1990, National Society for the Prevention of Cruelty to Children, London, 1992. 4. National Committee for Prevention of Child Abuse. World Perspectives on Child Abuse: An International Resource Book, National Committee for Prevention of Child Abuse, Chicago, Illinois, 1992. 5. WISbner,A.R. etal. Interpersonal violence-related injuries in an African-American Community in Philadelphia, American journal of public health, 81: 1474-1476 (1991). 7. Pless, I.B. etal. A reappraisal of the frequency of child abuse child abuse seen in pediatric emergency rooms, Child abuse and negkct, 11: 193-200 (1987). 8. Briefing, V.B. et al. Injuries due to deliberate violence in areas of Denmark. V. Violence against women and children. Copenhagen Study Group. Forensic science intemationa~ 41: 285-294 (1989). 9. Adelson, L. Pedicide revisited. The slaughter continues, American journal of forensic medicine and pathology, 12: 16-26 (1991). Rapp. trimest statist. sanit. mond., 46 (1993) 10. Menick, J. Child abuse and the lack of care. 2. An epidemiologic and social pediatric study of fatal child abuse and neglect in Denmark in 1970-1979, Ugeskr. Laeger, 151: 874-877 (1989). 11. Eckenrode, J. et al. The nature and substantiation of official sexual abuse reports, Chi/,d abuse and neglect, 12: 311-319 (1988). 12. Desenclos, J-C. A. et al. Pediatric gonococcal infection, Florida, 1984to 1988,Americanjoumalofpublichealth, 82: 426- 428 (1992). 13. Estteich, S. &: Forster, G.E. Sexually transmitted diseases in children: Introduction, Genitourinary medicine, 68: 2-8 (1992). Wld hlth statist. quart., 46 (1993) 14. Cupoli, M.C. &: Sewell, P.M. One thousand fifty-nine children with a chief complaint of sexual abuse, Chil.d abuse and neglect, 12: 151-162 (1988). 15. Dube, R. &: Hebert, M. Sexual abuse of children under 12 years of age: A review of 511 cases, Chil.d abuse and neglect, 12: 321-330 (1988). 16. Menick, J. Child abuse and the lack of care. 1. An epidemiologic study from the Danish forensic officers, Institute ofForensic Medicine and the Medico-legal Council during 1970-1979, Ugeskr. Laeger, 151: 870-874 (1989). 17. Feldman, W. et al. Is childhood sexual abuse increasing in prevalence? An analysis of the evidence, Pediatrics, 88: 29-33 (1991). 77 Violence against women: the hidden health burden Lori Heisea Introduction The health consequences of violence against wo- men may be a serious problem worldwide, as gen- der violence is a significant cause of female morbi- dity and mortality, and represents a hidden obsta- cle to economic and social development. By sap- ping women's energy and confidence, gender violence can can deprive society of their full partici- pation. As the United Nations Fund for Women (UNIFEM) recently observed, "women cannot lend their labour or creative ideas fully if they are burdened with the physical and psychological scars ofabuse" (1). In recent years, the world community has taken some tentative, yet important, steps toward urging greater attention to the issue of gender-based abuse. Various United Nations bodies, including the Commission on the Status of Women, the Eco- nomic and Social Council, and the Committee on Crime Prevention and Control, have passed resolu- tions recognizing violence against women as an issue of grave concern. Negotiations are underway through the Organization of American States to draft a Pan American treaty against violence against women. This international attention comes on the heels of over two decades of organizing by women's groups around the world to combat gender-based abuse. Women have started crisis centres, have had laws passed, and have worked to change the cultur- al beliefs and attitudes that undergird male vio- lence. A recent directory published by the Santia- go-based ISIS International, lists 379 separate orga- nizations working against gender violence in Latin America alone (2). These grassroots efforts need to be supported and amplified by strong governmental commit- ments to prevent violence and assist survivors of abuse. Some argue that to date, few governments have taken violence against women seriously, fail- ing to recognize either the extent of the problem or its implications for health and development. In part, this reflects active denial; but it is a denial facilitated by the lack of solid data documenting the pervasiveness and health consequences of abuse. Furthermore, ignorance is often an excuse for inaction. a Lecturer, The State University of New Jersey, Centre for Women's Global Leadership, New Brunswick, New Jersey 78 In order to draw attention to and marshall greater support for violence-related programmes, this article will seek to: (i) summarize the existing information on gender-based abuse; (ii) identify data gaps and priority areas for research; and (iii) discuss methodological issues related to the study of the health consequences of gender violence. Definition of gender violence In September 1992, the United Nations Commis- sion on the Status of Women convened a special working group to prepare a draft declaration against violence against women. This declaration - to be voted on by the Commission in the autumn of 1993 - includes for the first time a proposed defini- tion of gender-based abuse. This draft definition of "violence against women" includes "any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations ofliberty, wheth- er occurring in public or private life (3)". Among the specific acts listed in the declaration are: Physical, sexual and psychological violence occur- ring in the family and in the community, including battering, sexual abuse of female children, dowry- related violence, marital rape, female genital mutila- tion and other traditional practices harmful to wom- en, non-spousal violence, violence related to exploi- tation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution, and violence perpe- trated or condoned by the State. This article accepts the Commission's defini- tion as a point of departure; for the sake of brevity, it explores only a subset of the above-mentioned abuses. Wife abuse The most endemic form of violence against women is abuse of women by intimate male partners. Stud- ies have documented severe and ongoing abuse of women in almost every culture, save for a handful of small-scale societies where wife beating occurs only rarely. Levinson's analysis of ethnographic data from 90 peasant and small-scale societies indi- cates that in 86% of these, there is violence against wives by husbands. Only 16 of the societies studied "can be described as essentially free or untrou- bled by family violence" (4). In an analysis of ethno- graphic research on 14 cultures by female anthro- Rapp. trimest. stlltist. sanit. mond., 46 (1993) pologists using female informants, Counts et al. identified only one society, the Wape of Papua New Guinea, that have little or no woman abuse (5). In the United States of America, for example, experts estimate that 2-4 million women are battered each year (6). Similarly, between one-third and one-half (or more) of women surveyed in many developing countries report being beaten by their partner (Box 1). The health consequences of such violence are considerable. In the United States, wife abuse is the leading cause of injury among women of reproduc- tive age (See, for example, 7,8,h); moreover, be- tween 22 and 35% of women who visit emergency rooms are there for symptoms related to abuse (6). Wife abuse also provides the primary context for many other health problems. Battered women are 4-5 times more likely to require psychiatric treatment and 5 times more likely to attempt sui- cide than are other women.c,d They are also at increased risk of alcohol abuse, drug dependence, chronic pain, and depression (9, 10). In one study of health care utilization in the United States, a history of rape and/ or assault was a stronger pre- dictor of physician visits and outpatient costs than a woman's age or other health risks, such as smok- ing (11). Similar data are beginning to emerge from the developing world. A United Nations case study on wife abuse in China reports that domestic violence causes 6% of serious injuries and death in Shanghai.d In Papua New Guinea, 18% of all urban wives surveyed had received hospital treatment for injuries inflicted by their husbands (12). A matter of life and death Since it often results in forced suicide and murder, gender violence is an important cause of female mortality. After reviewing evidence from the Unit- ed States, Stark & Flitcraft conclude that "abuse may be the single most important precipitant for female suicide attempts yet identified" ( 10). One out of every four suicide attempts by women is preceded by abuse, as are half of all attempts by African American women ( 10). Starkb reports that 26% of all female suicide attempts presenting to Yale University Hospital in 1979 were associated with abuse as were 50% of attempts made by Afri- b Stark, E. The battering syndrome: social knowledge, social therapy and the abuse of women. Ph.D dissertation, Department of Sociology, Suny-Binghamton, 1984. c Observation about psychiatric treatment from: Koop, C.E. Violence against women: a global problem. Address by Surgeon-General Koop at the Pan American Health Organization, Washington, DC, May 22, 1989. d Wu, H. Proceedings of the Expert Group meeting on violence in the family with a special emphasis on its effects on women. United Nations Case Study of China. Vienna, Austria. UN Doc. BAW/EGM/86/CS.15, 1986. Wld hlth statist. quart., 46 (1993) can American women. The battered women also accounted for 42% of all traumatic attempts and were significantly more likely to attempt suicide more than once (20% vs. 8%). A cross-cultural survey of suicide by Counts draws the same conclu- sion, citing evidence from Africa, Peru, Papua New Guinea and several Melanesian islands (13). The relationship between domestic violence and homicide may be even stronger. In Canada, 62% of women murdered in 1987 died as a result of domestic violence (14), and in Papua New Guinea, almost three-fourths of women murdered were killed by their husbands ( 12). In India, in- creased commercialization of dowry has led to a dramatic rise in dowry-related murders and sui- cides. Increasingly, dowry is being seen as a "get- rich-quick" scheme by prospective husbands, with young brides suffering severe abuse if ongoing de- mands for money or goods are not met. A frequent subterfuge is to set the woman alight with kerosene and then claim she died in a kitchen accident- this crime is known as bride-burning. In 1990, the police officially recorded 4 835 dowry deaths in all of India, but the Ahmedabad Women's Action Group estimates that 1 OOO women may be burned alive annually in Gujurat State alone ( 15). In both urban Maharashtra and greater Bombay, 1 out of every 5 deaths among women aged 15-44 year is due to "accidental bums". For the younger age group, 15-24, the pro- portion is 1 out of 4 ( 16). This suggests that a significant number of homicides and suicides are being recorded as "accidents" instead of inten- tional injuries. Violence may also be responsible for a sizeable, although yet unrecognized, portion of maternal deaths, especially among young unwed mothers. Fauveau & Blanchet report that in Matlab Thana, Bangladesh, homicide and suicide - motivated by stigma over unwed pregnancy, or resulting from beatings or related to dowry- accounted for 6% of all maternal deaths between 1976 and 1986.e The figure rises to 22% if one includes deaths due to botched abortions, many of which are also related to shame over pregnancies out of wedlock. Rape and sexual abuse In recent years, it has become increasingly recog- nized that rape and sexual abuse are far more common than was thought earlier. An island-wide survey of women in Barbados revealed that 1 in 3 women had been sexually abused as children/ In e The World Health Organization (WHO) defines maternal mortality as a death during pregnancy or within 42 days afterward, from causes related to or aggravated by the pregnancy or its management. f Handwerker, W.P. Gender power difference may be STD risk factors for the next generation. Paper presented at the 90th Annual Meeting of the American Anthropological Association, Chicago, Illinois, 1991. 79 Box 1 Prevalence of wife abuse, studies in selected countries Country Sample size Sample type Findings Remarks Barbados 264 women and 243 Island-wide national 30% of women 50% of women and (Handwerker, 1991) men aged 20-45 years probability sample battered as adults men report their mother being beaten Antigua 97 women aged 20-45 Random subset of 30% of women 50% of women and (Handwerker, 1993) years national probability battered as adults men report their sample mother being beaten Kenya 733 women from Kissi District-wide cluster 40% "beaten Taken from (Raikes, 1990) District sample regularly" contraceptive prevalence survey Papua New Guinea Rural: 736 men and Rural survey in 19 60% rural women Almost perfect (Toft, 1987) 715 women villages in all regions "beaten"" agreement between Urban low income: and provinces 56% urban low- % of women who 368 men and 298 Urban survey with income women claim to have been women oversample of elites "beaten" beaten and % of Urban high income: 62% urban elite men who admit to 178 men and 99 women "beaten" abuse women Sri Lanka 200 mixed ethnic, low- Random sample from 60% had been beaten 51 % of women said (Sonali, 1990) income women from low-income husbands used Colombo neighbourhood weapons India 109 men and 109 50% sample of all 75% of scheduled 75% of scheduled- (Mahajan, 1990 women from a village scheduled caste caste men admit to caste wives report in Juliundur District, households and 50% beating their wives: being beaten Punjab of non-scheduled 22% of higher caste "frequently" caste households men admit to beatings Malaysia 713 women and 508 National random 39% of women Annual figure: 15% (Raj-Hashim, 1993) men over 15 years of probability sample of reported having been of adults consider age Peninsular Malaysia "physically beaten" by wife beating conducted by a large a partner in the last acceptable (22% market research firm year among Malays) in South-East Asia Colombia 3 272 urban women National probability 20% physically Part of Colombia's (Profamilia, 1992) 2 118 rural women sample abused; 33% OHS survey psychologically abused; 10% raped by husband Costa Rica 1 388 women Random sample of 50% reported being Sponsored by (Chacon et al., 1990) women attending child physically abused UNICEF/PAHO welfare clinics Costa Rica 1 312 women aged Random probability 51 % reported being (1990) 15-49 years sample of urban beaten up to several women times per year: 35% reported being hit "regularly" Guatemala 1 OOO women Random probability 49% abused; 74% by Includes physical, (Coy, 1990) sample of women in an intimate male emotional and sexual Sacatepequez partner abuse in adulthood; study sponsored by UNICEF/PAHO 80 Rapp. trimest. statist. sanit. mond., 46 (1993) Mexico (Jalisco) 1 163 rural women Random household 56.7% of urban Experienced some (Ramirez & Vasquez, and 427 urban women survey of women on women and 44.2% of form of 1993) in Jalisco State DIF register rural women reported "interpersonal physical abuse violence" Mexico 342 women from Random, probability 33% had lived in a (Valdez Santiago & Nezahualcoyotl sample of women "violent relationship" Cox, 1990) from city adjacent to Mexico City Ecuador 200 low-income Random convenience 60% had been 37% of those beaten (CEPLAES, 1992) women sample of Quito barrio "beaten" by a partner were assaulted every day up to once a month Chile 1 OOO women in Stratified random 60% have been 70% of those abused (Larrafn, 1993) Santiago, aged 22 to probability sample abused by a male are abused more 55 years, involved in a with a maximum intimate; 26.2% have than once a year relationship of 2 years sampling error of 3% been physically or more abused (more severe than pushes, slaps or having object thrown at you) Norway 150 women aged 20 Random sample 25% had been Does not include (Schei & Bakketeig, to 49 years in selected from census physically or sexually less severe forms of 1989) Trandheim data abused by a male violence like partner pushing, slapping or shoving New Zealand 2 OOO women sent Random probability 20.1 % report being (Mullen et al. 1988) questionnaire; sample selected from "hit and physically stratified random electoral rolls of five abused" by a male sample of 349 women contiguous partner; 58% of these selected for interview parliamentary women (> 10% of constituencies sample) were battered more than 3 times United States of 2 143 married or co- National random 28% report at least America habiting couples probability sample one episode of (Straus & Gelles, physical violence 1986) United States of 6 OOO women state- State-wide random 39% have been > 12% have been America wide from Texas probability sample abused by male sexually abused by (Grant, Preda & partner after age 18; male partner after Martin, 1991) 31 % have been age 18 physically abused United States of 3 OOO rural women in Random probability 40.2% have been 22% abused within America Texas sample of abused after age 18; the last 12 months (Teske & Parker, communities with 31 % have been 1983) 50 OOO people or less physically abused Sources Barragan Alvarado, L. et al. Proyecto educativo sobre violencia de genera en la relaci6n domestica de pareja. Centro de Planificati6n y Estudios Sociales. CEPLAES. Quito, Ecuador 1992. Chacon, K. et al. Caracteristicas de la muier agredida entendida en el patronato nacional de la infancia (PANI). In: Batres Gioconda & Claramunt, Cecilia. La violencia contra ta mujer en la familia costarricense: un problema de satud pub/ica. San Jose, Costa Rica: ILANUD 1990. Coy, Frederico. Study cited in: Castillo, Delia et al. 1992 Violencia hacia la mujeren Guatemala. Report prepared for the First Central American Seminar on Violence Against Women as a Public Health Problem, Managua, Nicaragua, March 11-13, 1990. Grant, Robert et al. Domestic violence in Texas: a study of statewide and rural spouse abuse. Wichita Falls, Texas: Bureau of Business and Government Research, Midwestern State University, 1989. Handwerker, Penn. Gender power difference may be STD risk factors for the next generation. Paper presented at the 90th Annual Meeting of the American Anthropological Association, Chicago, Illinois, 1991. Handwerker, Penn. Power, gender violence, and high risk sexual behaviour: AIDS/STD risk factors need to be defined more broadly. Private communication, Department of Anthropology. Humboldt State University, Arcata California, February 10, 1993. Wld hlth statist. quart., 46 (1993) 81 Larrain, Soledad. "Estudio de frecuencia de la violencia intrafamiliar y la condici6n de la mujer en Chile•" Santiago, Chile: Pan American Health Organization, 1993. Mahajan, A. "Instigators of wife battering".ln: Violence against women, pp. 1-10. Sushma Sood, ed. Janipur, India: Arihant Publishers. PRO FAMILIA. Encuestra de prevalencia, demografia y salud. (OHS) Bogota: Colombia, 1990. Raj-Hashim, Rita. "Summary of a Survey Research Malaysia (SRM) study on women and girlfriend battery". Asia-Pacific Resource and Research Centre for Women, Kuala Lumpur, Malaysia, 1993. Raikes, Alanagh. Pregnancy, birthing and family planning in Kenya: changing patterns of behaviour: a health utilization study in Kissi District. Copenhagen: Centre for Development Research, 1990. Ramirez Rodriguez, J.C. & Uribe Vasquez, G. "Mujer y violencia: un hecho cotidiano" .Satud Publica de Mexico. Cuernavaca: lnstituto nacional de salud publica. (In press). Schei, B. & Bakketeig, LS. "Gynecological impact of sexual and physical abuse by spouse: a study of a random sample of Norwegian women". British journal of obstetrics and gynecotogy 96: 1379-1383. 1989. Sona Ii, Oeraniyagala. "An investigation into the incidence and causes of domestic violence in Sri Lanka". Women in need (WIN), Colombo, Sri Lanka. 1990. Shrader Cox, E. & Valdez Santiago, R. "La violencia hacia la mujer Mexicana como problem a de salud ptiblica: la incidencia de la violencia domestica en una microregi6n de Ciudad Nexahualcoyotl". Mexico City: CECOVID. 1992. Straus, M.A. & Gelles, R.J. "Societal changes and change in family violence from 1975 to 1985 as revealed by two national surveys". Journal of marriage and the family, 48:465-479. 1986. Teske, R. Jr. & Parker, M. "Spouse abuse in Texas: a study of women's attitudes and experiences". Austin, Texas Department of Human Resources. 1983. Toft, S. (ed). Domestic violence in Papua New Guinea. Law Reform Commission Occasional Paper No. 19, Port Moresby, Papua New Guinea. 1986. Seoul, Republic of Korea, 17% of women surveyed reported being a victim of an attempted or com- pleted rape.g In the United States, 78 adult women - and at least as many girls and adolescents - are raped each hour ( 17). Contrary to popular perception, the majority of rape survivors know their assailants, a reality con- firmed by studies in Malaysia, Mexico, Panama, Peru and the United States (Tab/.e 1). A large per- centage of rapes (36-58%) is perpetrated against girls 15 years or younger, with a substantial propor- Table 1 Statistics on sexual crimes, selected countriesa Tableau 1 Statistiques des agressions sexuelles, echantillons de paysa Lima, Peru - Lima, Perou Malaysia - Malaisie Mexico City - Mexico Panama City Papua New Guineae - Papouasie- Nouvelle-Guineee United States of America - Etats-Unis d'Amerique Percentage of perpetrators known to victim - Pourcentage d'agresseurs connus de la victime 60 68 67d 63 78 tion against girls under 9 years. Rape survivors exhibit a variety of trauma-induced symptoms, in- cluding sleep and eating disturbances, depression, feelings of humiliation, anger and self blame, night- mares, fear of sex, and inability to concentrate.h Survivors also risk becoming pregnant or contract- ing sexually transmitted diseases (STDs), including HIV I AIDS. A rape crisis centre in Bangkok, Thai- land reports that 10% of their clients contract STDs and 15-18% become pregnant as a result of rape, a figure consistent with data from Mexico and Percentage of survivors 15 years and under - Pourcentage de survivants de 15 ans et moins 58 36 40 47 62g Percentage of survivors 10 years and under Pourcentage de survivants de 10 ans et mains 18b 18C 23 131 29 a Studies include rape and sexual assaults such as attempted rape and molestation except for United States data which includes only completed rapes. - Les eludes ont porte sur les viols et agressions sexuelles telles que tentative de viol et attentat a la pudeur sauf aux Etats·Unis d'Amerique oil seuls ont ete pris en compte les viols effectifs. b Percentage of survivors age 9 and younger. - Pourcentage de survivants de 9 ans et moins. c Percentage of survivors age 6 and younger. - Pourcentage de survivants de 6 ans et moins. d Data from Carpeta basica. 1991. Mexico City: Procurador de Justicia del Districto Federal de Mexico. - Donnees fournies par Carpeta basica. 1991, Mexico City: Procurador de Justicia del Districto Federal de Mexico. • Bradley, C. Why mate violence against women is a development issue: Reflections from Papua New Guinea. Paper for United Nations Fund for Women (UNI FEM), 1990. t Percentage of survivors age 7 and younger. - Pourcentage de survivants de 7 ans et moins. g Percentage of survivors age 17 and younger. - Pourcentage de survivants de 17 ans et moins. Sources: Malaysia - Malaisie (20), Panama City (21 ). Peru - Perou (22), Mexico City (23), United States - Etats-Unis (17). g Shim, Y-H. Sexual violence against women in Korea: a victimization survey of Seoul women. Paper presented in St. Petersburg, Russia at the Conference on "International Perspectives: Crime, Justice and Public Order", June 21-27, 1992. 82 h Kilpatrick, D. Testimony before the house select committee on children, youth and families. Washington, DC, March 28, 1990. Rapp. trimest. statist sanit. mond., 46 (1993) Korea.iJ,k In countries where abortion is illegal in case of rape, victims often resort to illegal abortions, greatly increasing their chance of future infertility or even risking death. Response of the health sector Violence against women has only recently begun to be recognized as a health problem by the medical and public health establishment. In the United States, the American Medical Association (AMA) launched a major campaign in 1991 to educate the public and physicians about family violence ( 18). Similarly, the Joint Commission on Hospital Ac- creditation issued new standards requiring all hos- pitals to develop protocols and provide training to their staff on how to respond to different forms of abuse. After training and protocols were intro- duced, the percentage of women found to be bat- tered rose from 5.6% to 30% at the emergency department of the Medical College of Pennsylvania ( 19). Once identified, the women can be referred to shelters, counselling and other potentially life- saving services. On the international front, violence is slowly becoming recognized as an obstacle to women's health and development. In 1991, the Pan Ameri- can Health Organization (PAHO) sponsored a conference in Managua, entitled "Violence against women: a problem of public health". The Ministry of Health of Colombia issued an action agenda on women's health which included a programme on the "prevention of abuse and at- tention to victims of violence." In 1992, the United Nations Fund for Women (UNIFEM) published Battered dreams: viol.ence against women as an obstade to deve!,opment ( 1). Measurement and research issues As with any issue similarly underreported and fraught with problems of measurement, deriving accurate statistics on violence against women rep- resents a great challenge. However, to assume that women will not disclose abuse would be a mistake for researchers; it has been observed by most re- searchers to date that women are remarkably will- ing, indeed eager, to share their experiences. As i Thai data from "Ban Thanom Rak", a home for rape survivors run by the Friends of Women, Bangkok, Thailand as quoted in Archavanitkui, K. & Prarnualratana, A. Factors affecting women's health in Thailand. Paper presented at the workshop on Women's Health in Southeast Asia. Population Council,Jakarta, October 29-31, 1990. j Mexican data from COVAC, 1990. "Evaluaci6n de proyecto para educaci6n, capacitaci6n y atenci6n a mujeres y menores de edad en materia de violencia sexual, Enero a Diciembre 1990." Mexico City: Asociaci6n mexicana contra la violencia a !as mujeres; and CAMVAC, 1985. "Carpeta de inforrnaci6n basica para la atenci6n solidaria yfeminista a mujeres violadas." Mexico City: Centro de apoyo a mujeres violadas. k Korean data from Shim, Y-H., see footnote g_ Wld hffh statist. quart., 46 (1993) was the case with abortion, once researchers have created a safe space for discussion, women have proved willing to discuss abuse. Indeed, it is impor- tant for researchers to consider the sensitive nature of violence when designing research strategies. Perhaps most important is ensuring the physical and emotional safety of the women being inter- viewed. Not only for the woman's safety, but also for the sake of accuracy, it is essential for women to be interviewed away from their partners or other family members who may be perpetrators. Also, prior to initiating research, there is an ethical obli- gation to investigate the psychological and legal resources available locally to support women who disclose having suffered abuse or violence. Priority data needs on violence against women • Better definitions of rape, child sexual buse, wife abuse, and other forms of gender violence to facilitate measurement and comparison across populations. • Better data on the incidence and prevalence of gender-related violence in representative popu- lations of women. • Data on the percentage of women presenting in different contexts ( e.g. emergency rooms, fami- ly planning clinics, etc.) who have been raped and/ or abused. (This will help convince health care providers of the prevalence of abuse as well as help define the potential of using different settings as points of identification and referral for victims.) • Data on health care and social costs of domestic violence and sexual assault/abuse. Estimates of cost of emergency services, indirect costs of pro- ductivity losses, costs associated with increased utilization of primary care services, etc. • Data on the mental health consequences of violence: relative risk among victimized and non-victimized women for suicide attempts, al- cohol and drug abuse, depression, somatic health complaints, anxiety, sexual dysfunction, etc. • Data on the impact of domestic violence and/ or sexual assault/abuse on birth outcomes: rates of miscarriage, low birth weight, pregnan- cy complications, etc. • Studies that analyse the relationship between gender violence and other development issues such as Safe Motherhood, child survival, pros- pects for AIDS prevention, family planning etc. • Descriptive profiles of the typical presenting symptoms of rape and abuse victims (location of injuries, somatic complaints, etc.) so as to facili- tate identification by health care providers. Suggestions for the researc.~, community While existing data are sufficient to capture the severity of the problem, research is still needed to .83 improve our understanding of gender violence and to help design better interventions, using the list of priority issues for research, above. In addi- tion, the following suggestions could greatly facili- tate future work on violence: • WHO and other agencies could sponsor cross- cultural research on violence against women. Donors could convene meetings of researchers and women's advocates working on gender violence to begin exploring methodological is- sues with respect to studying violence against women and girls. (All research efforts can draw on the experience ofNGOs that have worked to combat gender violence and provide services for victims.) • On-going research efforts, such as focus groups and surveys being conducted on sexuality for the purposes of developing HIV I AIDS preven- tion programmes, can use these opportunities to explore the role that violence and coercion play in women's sexual and reproductive de- cision-making. • All crime statistics should be broken down by gender (for both the perpetrator and the vic- tim). Information should be recorded on the relationship between the perpetrator and the victim, to help identify the gender-specific na- ture of much of violent crime. Governments and the international community should recognize that it is important for women to live free from physical and psychological abuse. Gender violence is damaging, both physically and mentally. A health research agenda that values women can no longer ignore this regrettably fre- quent reality of women's lives. Summary Violence against women is a major health problem around the world. It often goes unnoticed and undocu- mented partly due to its taboo nature. A number of recent studies have explored the extent and patterns as well as the health consequence of violence in different cultures. The studies cited indicate that violence against women is widespread and an important cause of mor- bidity and mortality among women. Injuries due to vio- lence have only recently been recognized as an impor- tant public health problem. More research is needed to improve our understanding of gender violence, and to design better interventions. Resume La violence contre les femmes: un probleme de sante cache La violence contre les femmes est un probleme majeur de sante dans le monde entier, mais elle est souvent inaper9ue et inobservee, en partie parce qu'elle consti- tue un tabou. Recemment, un certain nombre d'etudes 84 ont porte sur l'ampleur et les schemas de la violence dans differentes cultures ainsi sur les consequences pour la sante. Ces eludes indiquent que la violence contre les femmes est tres repandue et constitue une importante cause de morbidite et mortalite. Ce n'est que recemment que les traumatismes dus a la violence ont ete reconnus comme un important probleme de sante publique. De nouvelles recherches sont done necessai- res pour ameliorer notre comprehension de cette violen- ce et mettre au point de meilleures interventions. References - References 1. Carrillo, R. Battered dreams: violence against women as an obstade to devewpment. New York, UNIFEM, 1992. 2. Violencia enamtra de la mujer en America Latina y El Caribe: directorio de programas. ISIS internacional, Santiago, Chile, (1990). 3. United Nations. Repurt of the working group on violence against women. Economic and social council, Vienna, United Nations, E/CN.6/WG.2/1992/L.3, 1992. 4. Levinson, D. Violence in cross-cultural perspective. Newbury Park, Sage Publications, 1989. 5. Counts, D. et al. Sanctions and sanctuary: cultural perspectives on the beating of wives. Boulder, Colorado, Westview Press, 1992. 6. Council on Scientific Affairs. Violence against women: relevance for medical practitioners. Journal of the American medical association, 267(23): 3184-3189 (1992). [Citing three studies: Journal of the American medical association, 51: 3259-3264 ( 1987); Annual Emergency Medicine, 18: 651-653 (1987); Wife abuse in the medical setting: An introduction for health personnel. Office of Domestic Violence, Washington, D.C., monograph No. 7, 1981.] 7. Grisso,J. et al. A population-based study ofinjuries of innter- city women. American Journal of Epidemiology, 134( 1): 59-68 (1991). [Studybasedonaswveillance programmeof68103 people in 17 Census tracts in Western Philadelphia.] 8. National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. New York, Oxford University Press, 1989. 9. Plitcha, S. The effects of woman abuse on health care utilization and health status: a literature review. W o men 's health, 2(3): 154-161. 10. Stark, E. &: Flitcraft, A. Spouse abuse. In: Rosenberg M. & Finley, A., eds. Violence in America: a public health approach. New York, Oxford University Press, 1991. 11. Koss, M. etal. Deleterious effects of criminal victimization on women's health and medical utilization. Archives of internal medicine, 151: 342-347 (1991). 12. Bradley, C. The problem of domestic violence in Papua New Guinea. In: Guidelines for police training against women and child sexual abuse. London, Commonwealth Secretariat, Women and Development Programme, 1988. 13. Counts, D. Female suicide and wife abuse: a cross cultural perspective. Suicide and life threatening behavior, 17 (3): 194- 205 (1987). 14. Homicide in Canada 1987: a statistical perspective. Department of Supply and Services, Canadian Centre for Justice Statistics, Ottawa, 1988. 15. Kelkar, G. Stopping the violence against women: issues and perspective from India. In: Margaret Schuler, ed. Freedom from Violence: Women's strategies from around the world, OEF International, Washington, DC, 1991 [available through UNIFEM, New York]. 16. Karkal, M. How the other half dies in Bombay. Eamomic and political wt.ekly, 1424 ( 1985) . 17. Kilpatrick, D. R.apeinAmerica: a report to the nation. Arlington, VA, The National Victim Center, 1992. 18. Perrone,J. AMA sounds call for coalition of doctors to fight family violence. American medical news,Jan. 6, 1992. Rapp. trimest. statist. sanit. mond., 46 (1993) 19. McCleerS.V.&:Anwar,R.Astudyofwomenpresentinginan emergency department American journal of public hea!J.h, 79: 65-67 (1989). 20. Rape in Malaysia. Consumer's Association of Penang, Penang, Malaysia, 1988. 21. Perez Marquez A. Aproximaci6n diagnostica a las viofo.ciones de mujeres en los distritos de Panama y San Miguelito. U niversidad de Panama, Centro para el Desarrollo de la mujer, 1990. Wld hlth statist. quart., 46 (1993) 22. Portugal, A.M. Cr6nica de una violaci6n provocada? Revis- ta mujer/Fempress: Contmviolencia, Fempress-Ilet, Chile, 1988. 23. Evaluaci6n de pruyectlJ pam educaci6n, capacitaci6n y atenci6n a mujeres y menores de edad en materia de violencia sexuaL Enero a Diciembre 1990. Mexico City: Asociaci6n mexicana contra la violencia a !as mujeres. COVAC, Mexico City, 1990. 85

Implementation of the Global Strategy for Health for All by the Year 2000: Second Evaluation Eighth Report on the World Health Situation Volume 1: Global Review Some facts and figures from the book • Each year, some 50 million people die throughout the world, with 46.5 million deaths attributable to illness and disease. Of these 50 million, about 6.8 million deaths are registered in the developed market econo- mies, 4.2 million in Eastern Europe, 7 million in the group of the least developed countries, and 32 million elsewhere in the developing world. • Worldwide, life expectancy has increased by between one and two years over the past five years, with the global average currently 65 years. Females outlive males by seven years in the developed countries, but only by two years in the least developed countries. • In virtually all developed countries, average life ex- pectancy is now in excess of 70 years. The majority of least developed countries still have a life expect- ancy below 50 years. Some 18 developing countries, including Argentina, Cuba, Singapore, and Sri Lanka, are already enjoying a life expectancy of 70 years or more. • In all developed countries except South Africa, the infant mortality rate is below 20 for 1 OOO live births, as it is in five of the eight countries of Eastern Europe. On the contrary, infant mortality rates of 100 per 1000 or higher are still observed in the majority of least devel- oped countries. • Between 1985 and 1990, the number of infant and child deaths in the developing countries fell from 13 .5 million to 12.9 million. This decline was primarily due to the marked reduction in deaths from measles, pertussis, and neonatal tetanus, reflecting the success of the Expanded Programme on Immunization. Unfor- tunately, deaths from neonatal and perinatal causes and acute respiratory infections (mostly pneumonia) increased. • Of the 140 million babies born each year, almost four million die within hours or days from perinatal causes. Approximately 95% of these deaths occur in the de- veloping countries. • Acute respiratory infections are estimated to be the first cause of childhood mortality in developing coun- tries. They claim 4.3 million lives of children under the age of five annually. Almost 20%, or 800 OOO, of these deaths are due to pneumonia in the neonatal period. There are 2000 million episodes of acute respi- ratory infections in young children throughout the world. • Diarrhoeal diseases remain a major cause of morbidity and mortality in infants and young children in devel- aping counties. This results in 1500 million episodes of illness, and more than 3 million deaths each year in children under five years of age. • More than one-third of children under five ( 150 mil- lion) in the developing world, excluding China, are underweight. About 163 million children are stunted (below height-for-age) and 35 million are wasted (be- low weight-for-age). Millions of children suffer from cretinism and other permanent brain damage because their diets and those of their parents are deficient in iodine, or they go blind and even die from lack of vitamin A. • Over 500 OOO women die each year from causes related to pregnancy and childbirth. A woman in sub-Saharan Africa who becomes pregnant is 75 times more likely to die as a result than a woman in Western Europe. In countries where the risk is highest, such as Somalia and the Gambia, the difference is 100-fold. • Tropical diseases seem to have gone on a rampage, with cholera spreading to the Americas for the first time this century, yellow fever and dengue epidemics affecting even greater numbers, the malaria situation deteriorating, schistosomiasis establishing itself in new areas, and leishmaniasis and nonvenereal endemic syphilis increasing. • The seventh recorded cholera pandemic, after 30 years of westward spread from its origin in the Far East, reached the Americas at the beginning of 1991. A year later, cholera cases were recorded in 68 countries around the world. It is now feared that cholera may become endemic in Latin America and the Caribbean. • Schistosomiasis, causing liver and urinary tract dis- ease, including bladder cancer, is endemic in 76 coun- tries. Of the 600 million people exposed to the disease, 200 million are infected. • Dracunculiasis or guinea-worm disease has been a major health risk for millions of people in Africa and the Indian subcontinent. Effective national eradica- tion programmes have succeeded in reducing the esti- mated annual global number of cases from 10 million in 1985 to fewer than three million in 1991. The goal of global eradication by 1995 will be achieved if national commitment to the programme is maintained. • The elimination of leprosy as a public health problem is now within reach. Ofloxacin has been shown to be highly effective against Mycobacterium leprae, and to be well tolerated in combination with standard multi- drug therapy. The prospects ofreducing the length of treatment to one month are being assessed. • The malaria situation worldwide, far from improving, is in many places deteriorating compared with 10 years ago. More than 2000 million people, almost half of the world's population, are exposed to the disease in some 100 countries and areas. In recent years there were serious epidemics in normally low-incidence highland areas of Africa: Burundi, Ethiopia, Madagas- car, Rwanda, Swaziland and Zambia. • The AIDS pandemic is spreading globally, as also are genital herpes and sexually transmitted chlamydia! disease. Pulmonary tuberculosis is on the increase, partly stimulated by HIV co-infection. Pneumonia and hepatitis B remain serious threats. • Sexually transmitted diseases continue to be among the most frequent infectious conditions worldwide. The annual incidence of major sexually transmitted diseases is 250 million cases. In addition, over one million people a year are newly infected with HIV, and this number is increasing. As of mid-1991, at least 8-10 million HIV infections have occurred in adults since the beginning of the pandemic, and about one million children have been born infected with HIV. • Tuberculosis is the leading cause of death attributable to a single infectious pathogen. One-third of the world's population - 1700 million people - are at risk of developing the disease. Whereas in otherwise healthy people the risk of developing the disease is fairly low, certain conditions such as malnutrition, and especially HIV infection, greatly increase the probability. By the end of 1990, more than three million people were dually infected with tuberculosis and HIV, of whom 2.4 million were in African countries south of the Sahara. • National tuberculosis programmes are not functioning satisfactorily in many countries in the developing world; it is estimated that fewer than half of existing tuberculosis cases are detected and fewer than half of those detected are cured. • Despite the fact that safe and effective hepatitis B vaccines have been available since 1982, two out of every five persons are infected with the virus, which causes more than one million related deaths annually. More than 72 countries have included immunization against hepatitis in their regular health services. • The whole category of chronic noncommunicable dis- ease is increasing, especially in the developing world, where the number of cancer cases has for the first time overtaken that in the developed countries. • Every year about 7 million new cancer cases occur, half of them in developing countries. Currently, there are about 14 million cancer patients, roughly two- thirds of them terminal cases. Cancer incidence is expected to rise in practically all parts of the world, the main reasons being tobacco use and paradoxically, better health care. As people life longer, they stand a greater chance of developing cancer. Two-thirds of all cancers are attributable to life style and the environ- ment. At least one third of all cancer cases is prevent- able. • Cardiovascular diseases claim about 6 million lives every year in the developing world, as many as in the developed countries and eastern Europe combined. Similarly, cancer now claims more victims in devel- oping countries (2.7 million deaths per year) than in the developed world (2.4 million). Cardiovascular diseases in developed countries (except those in East- ern Europe) are on the wane with the spread of health education and promotion. • Diabetes is increasing everywhere, blindness (espe- cially cataract) is more common, alcohol-related dis- eases are up (especially in developing countries), as are mental problems and suicide (particularly in the developed countries). • There are 31 million blind people in the world, more than 90% of them in developing countries. The main global causes of blindness are cataract (around 50%), communicable eye diseases (25%), onchocerciasis and vitamin A deficiency (10%), glaucoma (10%), and other causes, such as diabetes and trauma (5%). • Well over 300 million people in the world suffer from a mental or neurological disorder. Schizophrenia and other psychoses affect 55 million. There are 43 million epilepsy sufferers in the world, eight million of them in developed countries. Senile dementias affect nearly 30 million elderly people. • For most developing countries, the combined effects of inflation and population growth have resulted in declining real public spending for health per capita. For many developing countries, particularly in Africa, economic reality in health has been one of shrinking government capability. • The demands placed on health systems and services may have to be met with lower levels of financial, human, and technical resources than were previously available. The quantity and quality of some, or all, elements of health care may inevitably decline. • AIDS alone has placed great additional burdens on the already strained health sector in many developing countries. In the developing world, the overall social and economic impact of the pandemic will be im- mense and the health and social support infrastructure will be inadequate to handle the clinical burden of HIV-related illness. Through the deaths of millions of young men and women, the elderly will be left without support, and 10 million children in sub-Saharan Africa alone will be orphaned by the year 2000. WHO• DISTRIBUTION AND SALES• 1211 GENEVA 27 • SWITZERLAND Publications of the World Health Organization 1993 WORLD HEALTH FORUM An international journal of health development (Separate editions in English, French, Spanish, Arabic, Chinese and Russian) World health/arum is a quarterly journal for policy-makers, health planners, administrators, health educators, and public health workers of all kinds. It provides a medium for the presentation and discussion of new concepts in public health and new approaches to health problems, and it is devoted to the improvement of health through the promotion of health services covering the entire population and the undertaking of a wide variety of public health measures, whether or not they are supported by WHO. The Farum is the main organ ofWHO's Member States for the international exchange of health information and an active instrument in technical cooperation among developing countries. Subscription ( 4 numbers) ............................................... . Price per copy ............................................................... . Sw. fr. 68.- Sw. fr. 20.- BULLETIN OF THE WORLD HEALTH ORGANIZATION The Bulktin is the principal scientific organ of WHO: its role is to review progress in medical and related sciences ("update" articles) and bring to light new knowledge by publishing original papers on scientific research in the laboratory and field. The Bulktin contains original articles in either English or French, with a summary in the other language. Bimonthly. Subscription (6 numbers) ............................................... . Price per copy ............................................................... . WEEKLY EPIDEMIOLOGICAL RECORD (Bilingual: English and French) Sw. fr. 145.- Sw. fr. 25.- Prepared for the guidance of health administrations and health authorities, the Weekly epidemilllogi.cal record contains notifications made under the International Health, Regulations and information concerning their application. The Record also contains epidemiological information on communicable diseases of international importance. Annual subscription ......................................................... . Sw. fr. 170.- WORLD HEALTH STATISTICS QUARTERLY The World health statistic., quarterly replaces (since 1978) the World health statistics report (published since 1967) and its forerunner the Epidemilllogi.cal and vital statistics report (published since 194 7). It deals with the detailed analysis of selected health topics of current intcresL The Quarterly contains articles in either French or English with a summary in both languages. Annual subscription ......................................................... . Price per copy ............................................................... . WORLD HEALTH STATISTICS ANNUAL (Bilingual: English and French) Sw. fr. l 00.- Sw. fr. 28.- The forerunner of this series was the Annual epidemiokigi.cal report of the Lealflll of Nations. It was followed by the Annual epidemilllogi.cal and vital statistics issued by the World Health Organization. Latest publications: l 988. Vital statistics and life tables, the health professions in the 1980s, causes of death (single volume), 513 pages ( out of stock) ...................... . 1989. Vital statistics and life tables, the WHO MONICA Project, causes of death (single volume), 443 pages .............................................................. . 1990. Vital statistics and life tables, international statistics on causes of disability, causes of death (single volume), 447 pages (out of stock) .................................................................... . 1991. Vital statistics and life tables, health and human development, causes of death (single volume), 371 pages ..................................................... . 1992. Vital statistics and life tables, imple-mentation of the Global Strategy for Healh for All by the Year 2000 (single volume), 480 pages ........................ . Sw. fr. 90.- Sw. fr. 90.- Sw. fr. 90.- Sw. fr. 100.- Sw. fr. 100.- Publications de /'Organisation mondiale de la Sante 1993 FORUM MONDIAL DE LA SANTE Revue internationale de developpement sanitaire (Editions separees en fran{ais, anglais, espagnol, arabe, chinois et russe) Forum mondialdelasanti est une revue trimestrielle destinee aux responsables des politiques sanitaires, aux planificateurs, administratcurs et cducateurs sanitaires, enfin aux travailleurs de la sante publique de toutes categories. Tribune pour la presentation et la discussion de nouveaux concepts en sante publique et de nouvelles approches des problemes de sante. Forum se consacre a. !'amelioration de la sante par la promotion de services de sante couvrant la population tout entiere et d 'une vaste gamme de mesures de sante publique, qu'elles soient ou non soutenues par l'OMS. II est le principal organe a la disposition des Etats Membres de !'OMS pour I' echange international d'infonnationssanitairesen meme tempsqu'un instrument de cooperation technique entre pays en developpemenL Abonnement (4 numeros) ............................................... . Le numero ····································································· Fr. s. 68.- Fr. s. 20.- BULLETIN DE L'ORGANISATION MONDIALE DE LA SANTE Le Bulktin est le principal organe scientifique de I 'OMS; ii a pour role de passer en revue les progres des sciences medicales etapparentees (articles de la rubrique «Le point») et de mettrc en lumiere les connaissances nouvelles en presentant dans des articles originaux lcs resultats de recherches scientifiques au laboratoire et sur le terrain. Le Bulktin contient des articles originaux en fran{ais ou en anglais, accompagnes d'un resume dans l'autre langue. Bimensuel. Abonnement (6 numeros) ............................................... . Le numero .................................................................... . RELEVE EPIDEMIOLOGIQUE HEBDOMADAIRE (Bilingue: fran~ais et anglais) Fr. s. 145.- Sw. fr. 25.- Destine aux administrations sanitaires et aux services de sante, le &leui epidbniokigi.que hebdomadaire contient les notifications exigees par le Reglement sanitaire international, ainsi que d'autres renseignements concernant l'application de ce reglemenL Le &kvecontient egalement des informations cpidcmiologiques concernant les maladies transmissibles d'une importance intemationale. Prix de l'abonnement annuel ........................................... Fr. s. 170.- RAPPORT TRIMESTRIEL DE STATISTIQUES SANITAIRES MONDIALES Le Rapport trimestriel de statistiques mondiaks, remplace (depuis 1978) le Rapport de statistiques sanitaires mondial.es (publie depuis 1967) et son precurseur le Rapportepidimiokigi.queetdemographique (publie depuis 1947). II prcsente des analyses detaillees sur des sujets specifiques d'interet couranl. Le Trimestriel presentc des articles originaux en fran(ais ou en anglais, accompagnes d'un resume dans les deux langues. Prix de l'abonnement annucl .......................................... . Le numCro .................................................................... . Fr. s. 100.- Fr. s. 28.- ANNUAIRE DE STATISTIQUES SANITAIRES MONDIALES (Bilingue: fran(ais et anglais) Cet annuaire remplace les Statistique, ipidemiokigiques et demographiques annuelks publiees par !'Organisation mondiale de la Sante et qui avaient, elles-memes, rem place le Rapport ipidhniokigi.que annuelpublie par la Societe des Nations. Publications recentes: 1988. Mouvementde la population et tables de survie, la situation des professions de sante dans les annees 80, causes de deces (1 seul volume), 513 pages (epuise) ················································ 1989. Mouvement de la population et tables de survie, le Projet MONICA de l'OMS, causes de deces ( l seul volume). 443 pages .................................. . 1990. Mouvement de la population et tables de survie, statistiques intemationales sur les causes d'incapacite, causes de deces (1 seul volume), 44 7 pages ( epuise) ............................................... . 1991. Mouvementde la population et tables de survie, la sante et le developpement humain, causes de deces (1 seul volume), 371 pages ....................... . 1992. Mouvement de la population et tables de survie, mise en reuvre de la Strategie mondiale de la sante pour tous d'ici l'an 2000 (1 seul volume). 480 pages .............................................................. . Fr. s. 90.- Fr. s. 90.- Fr. s. 90.- Fr. s. 100.- Fr.s. 100.- Violence and health The twin issues of safety promotion and injury control are gaining increased visibility in the public health field. While unintentional or accidental injuries have been included for some time on public health agendas, this is not the case for intentional injuries. which are still viewed exclusively as police or penal issues. However, a new conceptual fra- mework is being developed in public health, which accom- modates and integrates the various aspects of injuries. whether intentional or not. This new conceptualization of injury and safety offers a new approach to violence preven- tion by viewing the two types of injuries together. There are several reasons for advocating a public health view of safety based on the concept of injury rather than accident. What should matter in health is to what extent, and to what degree of severity health can be impaired by any external cause. "Injury". including poisoning, reflects this situation qualitatively, if not quantitatively; "accident" cannot. Acci- dent is not a scientific term and there is always some ambiguity in its use: are all accidents really accidental? It also brings with it irrational and sometimes cultural implica- tions. whereas injury is a neutral term. It is worthwhile considering unintentional and intentional injuries or violen- ce together since they share common features with regard to risk groups (such as youth}, risk factors (such as alcohol}, and a need for better surveillance networks and clearer indicators. In addition, although violence cannot be limited to physical injury, using the term injury can be an important first step in the conceptualization of a public health ap- Violence et sante La promotion de la securite et la prevention des traumatis- mes sont deux questions indissociables dont !'importance ne cesse de croTtre au regard de la sante publique. Si les traumatismes non intentionnels ou accidentels figurent depuis quelque temps deja a l'ordre du jour de la sante publique. ii n'en va pas de meme pour les traumatismes intentionnels qui sont toujours consideres comme relevant exclusivement de la police ou de la justice. On s'efforce pourtant de definir un nouveau cadre conceptuel de sante publique qui concilie et integre les differents aspects des traumatismes, intentionnels ou non. Cette nouvelle concep- tualisation des traumatismes et de la securite devrait ouvrir de nouveaux horizons a la prevention de la violence en proposant une seule et meme approche pour les deux types de lesions. Plusieurs arguments plaident en faveur d'une acception de la securite fondee du point de vue de la sante publique sur le concept des traumatismes et non d'accidents. L'important devrait etre de determiner le seuil de gravite a partir duquel la sante peut etre affectee par une cause externe. Le "traumatisme", y compris !'intoxication. repond a cette exigence du mains qualitativement sinon quantitativement; ii n'en va pas de meme pour !"'accident" L"'accident" n'est pas un terme scientifique et son utilisa- tion comporte toujours une part d'ambiguHe: tousles acci- dents sont-ils reellement "accidentels". II s'y attache aussi des implications irrationnelles, voire parfois culturelles, alors que "traumatisme" est un terme neutre. II importe de ne pas dissocier les notions de traumatisme ou de violence, intentionnels et non intentionnels, puisqu'ellesont des traits communs tel que les groupes a risque (par exemple les jeunes}, les facteurs de risque (notamment l'alcool}, et qu'elles appellent toutes deux des reseaux de surveillance ameliores et des indicateurs plus precis. En outre, bien que la violence ne puisse etre limitee aux traumatismes corpo- rels, !'utilisation meme du terme "traumatisme" peut cons- tituer un pas important vers la conceptualisation d'une nouvelle approche de la violence dans la perspective de la preach to violence, and may help in defining vague and controversial terms as objectively as possible. A previous issue of the Quarterly presented an analysis of accidents in children and youth. For the first time, in connection with the theme of World Health Day 1993, "Handle Life with Care: Prevent Violence and Negligence", this issue covers some aspects of violence in youth. The first chapter contains an overall review and an update of WHO data on violent deaths. As in the previous issue on accidents. the analysis of violence presented here makes it clear that national data collection systems and methods for reporting on injuries (intentional or unintentional} are still very weak. Basic to any efficient public health move towards injury control and violence prevention is the need for an appropriate sur- veillance system. There is no real difference between the surveillance/monitoring of any disease like poliomyelitis. malaria or other traditional health problems. and that of violence. Although limited progress has been made, for instance through compulsory hospital recording of E-code in some countries, the situation is still far from satisfactory regarding the reporting of mortality data, particularly for intentional injury. Moreover, surveillance of non-fatal cases and their resulting disabilities may be of even greater significance from the health, social, economic, and, of course, human standpoints. This dimension of the problem must receive more consideration in the future. • sante publique et peut aider a trouver une definition aussi objective que possible de ces termes vagues et controver- ses. Une livraison precedente du Trimestrielpresentait une analyse des accidents chez les enfants, les adolescents et les jeunes adultes. Pour la premiere fois, en relation avec le slogan retenu pour la Journee mondiale de la sante en 1993, "Attention I Vie fragile. Refusons la violence et la negligence", le present numero traite de certaines formes de violence chez les jeunes. Le premier chapitre brosse un tableau general du probleme et presente les donnees actualisees de l'OMS sur les cas de mart violente. Comme dans le precedent numero sur les accidents, !'analyse de la violence proposee ici ne laisse planer aucun doute sur les grandes lacunes qui caracterisent toujours les systemes nationaux de collecte des donnees ainsi que les methodes utilisees pour la declaration des traumatis- mes (intentionnels ou non). La mise en place, dans le cadre de la sante publique d'un dispositif efficace de prevention des traumatismes et de la violence passe inevitablement par un systeme de surveillance appropriee. II n'existe aucune difference reelle entre la surveillance d'une mala- die quelconque comme la poliomyelite, le paludisme ou d'autres problemes de sante courants et celle de la violen- ce. Meme sides progres modestes ont ete accomplis, par exemple !'obligation faite aux h6pitaux de certains pays d'enregistrer les cas relevant du Code Ede la Classification internationale des maladies, la situation laisse encore beaucoup a desirer en ce qui concerne la declaration des donnees de mortalite, notamment lorsqu'il s'agitde trauma- ti~mes intentionnels. En outre, la surveillance des cas non mortels et des incapacites qui s'y attachent est peut-etre plus importante encore d'un point de vue sanitaire. social et economique, sans parler bien entendu de la dimension humaine. A l'avenir cet aspect du probleme devrait retenir davantage !'attention.•