Half of all major incidents and two thirds of all deaths in major incidents are due to road traffic crashes. Interestingly, most RTCs were grouped in the high population density rural districts. Major RTCs were less common in the industrialized districts, whereas fires were the most frequent major incident in the major cities. However, the number of casualties due to fire incidents was significantly less than that of RTCs. After RTCs the second leading cause of mortality was violence (7.7%), which was specifically interpersonal violence including gunshots. Interpersonal violence in rural Punjab can include the use of firearms or the more traditional method of beating victims with wooden sticks or iron rods. This method leads to severe blunt trauma and head injuries, and in some cases is more lethal than firearm injuries. Mass lynching is also not unheard of in Punjab and was part of this 7.7% of major incidents.
Some other causes of major incidents appeared that may be particular to a developing country like Pakistan where buildings collapse (6.5%). This category included both well and wall collapses. Well collapses are indigenous to Southern Punjab where while digging wells for water the whole structure may suddenly collapse because of soft sand, and the men digging them may find themselves buried under tons of mud. Gas leakages and gas cylinder explosions resulted in 2.6% of major incidents. These explosions are often due to faulty pipes or old, non-calibrated gas cylinders. Drowning (3%) was also concentrated in three main districts; in fact 50% were only in the Sialkot district at one specific site. All drowning victims were young males on tourist excursions to dams and canals. With the recent increase in terrorism across Pakistan, bomb explosions were another cause of major incidents.
The high mortality associated with road traffic crashes has previously been demonstrated by other authors and other studies in developing countries. National Health Survey Pakistan (1994) has already established the high burden of injuries caused by RTCs in Pakistan [16–20]. In Pakistan, legal rules for traffic are laid down in three basic documents:
The driving codes include point penalties for speeding, driving while intoxicated, not using seat belts and helmets, and in some cases mobile phone use as well [21]. However, implementation and proper enforcement of these laws remain problematic [22].
A Fire and Safety Law is currently being drafted by policy makers that covers prevention and mitigation measures, including marking fire exits in buildings and having fire extinguishers. However, the rest of the major incident causes mentioned in this study have not received any official recognition or governmental support to date. Keeping the findings of this study in view, the value of injury prevention cannot be overemphasized in a low-income country such as Pakistan.
The high death rate of 10.4% on the scene -- that is, the mortality even before the arrival of the EMS -- implies that prevention rather than cure should be the aim. What is concerning about most of these incidents is that they were potentially preventable. In the developed countries, mechanisms of injury have been well studied, including road traffic injuries, injuries in the home, drowning, fires, violence and suicide; however, the same cannot be said for the developing world. The solution does not however lie completely in importing injury control techniques from developed to developing countries as they will not accomplish much because of the differing causes of injury and the different social and economic contexts in which they occur. Instead, there is a need for local adaptations and even the development of innovative strategies for which of course more directed research is needed [23].
The authors understand that there are certain limitations of the paper.
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Selection bias - possibly some of the incidents were not handled by the rescue service.
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Reporting bias - Incidents on the major roads are more likely to be reported. The victims of other incidents in urban areas are often picked up early by taxis or bystanders, and thus the need for calling 1122 is less.
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This is not a study from the entire province as the data were only collected from 24 out of 35 districts. At the time of this study, only 24 districts had the proper guidelines to report major incidents.