Contrary to common belief, disease is a rather fluid concept influenced by societal and cultural attitudes that change with time and in response to new scientific and medical discoveries.
Commonly also, a duality is introduced regarding one’s health status: one is either sick or healthy. The function of the health care systems (public health, hospitals, clinics, general practitioners, midwives) is predominantly seen as being active in the sphere of “treating” disease. However, the relation between health and disease is a complex entity and at least four different concepts are used.
In the first one, one is either sick or healthy. The categories are mutually exclusive; one is either sick or healthy and there is nothing in between. In a second concept, there is an additional kind of “neutral” area between health and sickness. One is either “sick”, “healthy” or “normal”. In a third concept, health and disease are distinctive categories, but not each other’s antagonists.
There is a kind of overlap, in which one can be sick and healthy. Finally, in a fourth concept, health and disease are extremes on a sliding scale. There is no absolute difference between disease and health, but only a gradual difference and there is a fluent transition from health into disease.
What is disease?
Disease is often defined as failure of the adaptive mechanism of an organism to counteract adequately, normally or appropriately the stimuli and stresses to which it is subject, resulting in a disturbance in the function or structure of some part of the organism. There is no doubt that from a political point of view too much stress has been directed at the management of the burden of disease, rather than on the promotion of health.
According to the World Health Organisation (WHO), health has been defined as “a state of complete physical, mental, spiritual and social well-being, and not merely the absence of disease and infirmity”. What can society do to promote health? According to the predictions of the WHO, trauma will be the biggest killer by 2020 since other causes such as infectious diseases and cardiovascular diseases will decline in the next decade.
Globally, trauma is a leading cause of childhood death between the ages of one and 18 and each year approximately one million children die from the three big killers: motor vehicle accidents, drowning and burns. South Africa, with approximately 40% of its population being children, is no exception. In South Africa each year at least 6 500 children between the ages of one and 14 die as a result of unintentional injuries. This is approximately 10 times more than in Western European countries.
Where generally the world is a dangerous place for children, this is even more so in low and middle income countries. Our own research shows that a child growing up in Cape Town has a 25 times higher chance of being admitted to hospital with an injury then a child growing up in Birmingham, UK. At the trauma unit approximately 10 000 children are treated annually, of which 3 000 are seriously injured and require to be admitted.
One of the most prominent activities of Childsafe was the support for the child-friendly new Firearms Bill which has reduced the number of gunshots in children treated in our hospital by 70% since 2000. It also had a drastic effect on national mortality as a result of gunshots, reducing it by 50%.
Childsafe furthermore contributed significantly to the World Report on Child Injury Prevention published by the WHO in December 2008. Whereas there are significant campaigns to increase vaccinations for infectious diseases, child accident prevention is seriously neglected in the third world. Too often it is forgotten that child health and safety is a matter for adults.
Children suffer more
South Africa suffers particularly heavily from negative consequences associated with the use of alcohol. Trauma is the leading cause of admission to hospitals in all South African provinces and the leading cause of childhood deaths between the ages of one and 18 years. A South African multi-centre study demonstrated that over half of all patients presenting to trauma units were victims of violent injuries. Across sites and for each respective year of the survey, between 35.8% and 78.9% of patients tested positive for alcohol.
It was concluded that efforts to combat the abuse of alcohol are paramount in reducing the burden of injuries on health care services. According to the third annual report of the national injury mortality surveillance system, over 50% of patients dying in a transport-related incident had elevated blood alcohol content. The majority of these cases (over 90%) were at levels greater than 0.05g/100ml. Pedestrians and drivers had the greatest percentage with positive blood alcohol levels.
Of all homicides – the most common cause of non-natural death (44% as opposed to 27% for transport-related injuries) — again more than 50% were alcohol-related. Of these, 89% had blood alcohol levels of more 0.05g/100ml. Of all firearm-related deaths, 43% were alcohol-related, with 77% of all deaths due to sharp objects having positive alcohol levels, compared to 54% for assaults with a blunt instrument, 26% for strangulation and 45% for burns.
Recently, the strong correlation between intimate partner abuse and alcohol abuse by a male partner has also been reported. Alcohol is also an important co-factor for risky sexual behaviour and HIV transmission, a wide range of social problems within the welfare system and violent crimes affecting all departments in the justice and protection cluster.
Do more than advertise
Since the effects of alcohol on the South African society are enormous, there is reason to believe that pressure from society can go long way to alleviate this scourge. For instance, research indicates that young children respond to advertising on an emotional level, and as a result do change their beliefs and expectations about alcohol.
The alcohol beverage industry is extremely sophisticated in developing marketing. Exposure to alcohol advertising and alcohol enjoyment in the media predict more frequent and heavier drinking among young people. Alcohol advertising continues to spread untruths: “Alcohol drinking is normal”; “Alcohol is used by attractive, successful and healthy people who are sexy, popular, charming, independent and strong”; “Drinking is safe; otherwise why would so many people drink?” and “Drinking is relaxing”.
However, it is sad to know that a great percentage of children who start drinking young will end up as alcoholics (especially when starting to drink before the age of 14), that alcohol-related accidents are one of the main killers of young people and that up to 70% of interpersonal and domestic violence is alcohol induced.
The success of efforts to curb the ill-effects of alcohol abuse on society- seems to depend on the ability of health professionals to step outside of their safety zones and reconcile rather than compromise scientific exactitude with the grim realities of South African society, in which the lives of many are under a continuous and great threat as a result of almost exclusively preventable causes.
Recently, there have been strong voices by the provincial minister, Theuns Botha, as well as the national Minister of Health, Aaron Motsoaledi, for a more integrated approach to injury prevention. The medical profession is often at the very forefront of treating the results of the persistent onslaught on the innocents (many of them children) within our society and therefore should also be at the forefront of a health promotion foundation.
A health promotion foundation will be able to make a major contribution, in a unified and organised voice, from health professionals as a broad-based and authoritative advocate for health and safety. It will be the key to elevate injury prevention from its dubious current status to its rightful place as a national health priority.
Professor Sebastian van As is head of the Trauma Unit at the Red Cross War Memorial Children’s Hospital in Cape Town and president of Childsafe South Africa www.childsafe.com
This article originally appeared in the Mail & Guardian newspaper as a sponsored feature