"The worst of both worlds": the management reform of the World Health Organization.

The governance and management of global health institutions, such as the World Health Organization (WHO), are under increasing critical scrutiny. This management case study explores the first year of transformation at the WHO under Director-General Dr. Gro Harlem Brundtland, focusing on the key stakeholders and the role of complexity in institutional change. This is a story about transition in a difficult, politically fraught, and management-resource-constrained environment. In the search for appropriate management paradigms, organizations such as the WHO may believe that the answers lie in harsh reengineering and the search for high-profile "success stories." Ironically, global business has moved away from such approaches and is far more focused on collaboration, empowerment, and knowledge sharing.

Health impact assessment.

There is growing concern about the environmental, social and health consequences of development projects. Environmental impact assessment (EIA), which aims to address this concern, is often conducted with little input from the health sector. Quantifying the health benefits and risks of a project or policy requires an innovative synthesis of socio-demographic, environmental health, epidemiological and health systems data. This article provides a simple framework for health impact assessment (HIA), a method for describing and measuring the impact of a project or policy on health and wellbeing, and designing appropriate interventions. The key components of HIA are: review of available data; research and identification of priority health issues through the use of rapid assessment methods; design of a health action plan with stakeholder consultation; implementation of interventions and the monitoring of long-term health impacts. HIA can assist in ensuring that development and policies are 'health promoting' and that the health sector plays a meaningful role in EIA.

Health for all: analyzing health status and determinants.

An analysis of health status and determinants is presented as a basis for health for all renewal and in order to provide a model linking the health for all vision with strategy and action. Equity and gender, at the core of health for all, directly concern health status and the distribution of health determinants. The role of the various transitions (demographic, epidemiological, health risk and technological) is described, the need to strengthen the link between data and decision-making for health is explained, and the range of health determinants--macroeconomic, demographic/nutritional, environmental, tobacco and alcohol and their implications for policy--is outlined.

PIP: Responding to efforts to renew the "health for all" vision and link it with strategy and action, this article explores the relationship between health status and proximal and distal determinants (macroeconomics, environment, sociodemographics, and education). Next, the pivotal relationship of equity and gender to health status and determinants is considered, and the challenges posed by transitions in health, demographics, epidemiology, health risk, and technology are reviewed. After noting the necessity to strengthen the links between health data and decision-making, the article summarizes current knowledge about global health status for 1990-2020. Following a brief explanation of the need to adopt a lifespan approach to health, the next section describes some key proximal and distal health determinants and their relationship to health status and illustrates this relationship with a model that traces the pathway connecting health status, determinants, and interventions. Finally, the article reviews the importance of sectoral health determinants and ways to enhance health decision-making and considers 1) the implications of the change in the distribution, intensity, and nature of the global burden of disease and injury; 2) the relationship between poverty, equity, and health status; 3) the importance of sectoral health determinants; and 4) the role of governments, the health sector, international organizations, and the World Health Organization.

Hours to hell and back: a social epidemiology of railway injury in a South African city, 1890-1995.

This paper describes fatal and non-fatal injury on the Cape Town metropolitan rail system between 1890 and the present day. This is examined from the perspective of the community, rail operators and authorities, in the light of the expansion of the rail system and the risk that exposure to sophisticated infrastructure has placed on the poor. Injury is discussed as a public health issue and historical data are juxtaposed against the current situation. The study identifies recurrent themes of limited safety enforcement by the rail operator, victim blaming and public concern.

Delays in the identification of non-natural mortality.

Rapid and accurate identification of non-natural deaths is an important component of a good forensic service. To study the identification process and quantify delays in the identification of non-natural deaths in Cape Town, South Africa, we conducted a retrospective review of identification rates between 1980 and 1995 and a descriptive study of time to identification stratified by manner and cause of death for 1995. The mean yearly number of unidentified cases between 1980 and 1995 was 137 (range, 75-280), constituting about 3% of total admissions. There has been no substantial change in the proportion of unidentified cases during this period. Suicides and homicides were most rapidly identified; 84% of suicides and 75% of homicides identified within 3 days. Pedestrian and railway deaths accounted for 72% of the unidentified accident admissions in 1995. Delays in the identification of various categories of deceased victims of violence and unintentional injury reflect the social impact of poverty and impose an unnecessary hardship on next-of-kin. Forensic pathologists should devote both scientific and administrative efforts to reducing such delays.

Fatal railway injuries in Cape Town, South Africa.

To describe the features of railway-related deaths in Cape Town, South Africa, we reviewed demographic, autopsy, and accident report data on all such deaths between 1 April 1992 and 30 September 1994. Of the 379 railway-related deaths, 27 were among pedestrians or commuters who were hit by a train while crossing the track, 38 were among commuters who fell from moving trains, 32 were suicides, 43 were the result of criminal violence on trains or at railway stations, and 38 were due to other causes. Most railway fatalities were among men between the ages of 25 and 44 years. About half of all railway fatalities occurred at peak commuting times, with high levels of violence (often robbery related) recorded during the evening peak. A blood alcohol concentration > 0.1 g/100 ml was found in 35% of the people who died from crossing the track or falling from moving trains. Fatal railway injury is characterized by extensive disruption of more than one body region. The high levels of fatal railway injury make a strong case for a range of injury control interventions, including ticket control, surveillance, law enforcement, and safety engineering.

Violence and injury mortality in the Cape Town metropole.

OBJECTIVE: To describe accurately the violence and injury mortality in a South African city and demonstrate the utility of secondary data sources to identify injury control priorities. DESIGN: Cross-sectional analysis of medicolegal laboratory (state mortuary), forensic and police data. SETTING: Metropolitan Cape Town, 1994. RESULTS: Non-natural causes (deaths due to homicide, suicide, accidents and undetermined causes) accounted for almost 4000 deaths, which comprised approximately 30% of all-cause mortality during 1994. The five main violence and injury mortality categories were: homicide (1789 cases; 46% of all non-natural mortality), transport accidents (1130 cases; 29% of all non-natural mortality), fire (295 deaths; 8% of all non-natural mortality), suicide (291 deaths; 7% of all non-natural mortality) and drowning (96 cases; 2% of all non-natural mortality). CONCLUSIONS: Priority issues in injury control include the increasing homicidal and suicidal use of firearms, road and rail commuter injury and the spatial distribution of injury. Surveillance, based on non-natural mortality, should be included in local, regional and national health information systems.

Meeting the challenge of railway injury in a South African city.

BACKGROUND: Efficient and safe transport infrastructure is vital for economic growth in developing countries. The city of Cape Town, South Africa, has an extensive rail network with high levels of injury and violence. We investigated the reporting and frequency of railway injuries and examined their reduction through a range of interventions. METHODS: We analysed railway injury and death reporting by Cape Town's rail utility, state mortuaries, and a regional trauma survey. The data were obtained over 2.5 years, and the use of more than one data source was necessary to increase the size of the data pool and to determine under-reporting. FINDINGS: There were 379 railway-related deaths and 505 serious injuries during the study period. Most death (190) were train-pedestrian collisions, and the fatality rate on the metropolitan lines was about 60 per 100 million passenger journeys. There was substantial under-reporting by the rail utility of both fatal (20% under-reported) and non-fatal injuries (at least 24%). Many injuries occurred during peak commuting times and alcohol played an important part, especially in pedestrian fatalities. INTERPRETATION: Our results demonstrate the importance of a comprehensive, sustainable railway injury surveillance system to promote safety engineering and law enforcement in a metropolitan rail system.

'Neither obscure nor mysterious'--infant mortality and the Kimberley Board of Health, 1898-1977.

Annual reports of the Kimberley Board of Health, established in 1883, provide rich insight into public health discourse on infant mortality. Commentaries on the determinants of infant mortality, especially prior to 1950, largely focus on poverty and interracial disparities, issues relevant to current health policy.

'A bothersome death'--narrative accounts of infant mortality in Cape Town, South Africa.

Traditional measures of health status such as mortality rates and cause-of-death information give limited insight into the role of caregivers and health care providers in infant illness and death. To the extent that the behaviours of these parties can be accurately mapped, they may reveal important sites for effective community interventions and the improvement of medical care. This possibility is explored in relation to infant mortality in Cape Town, South Africa, by analysing verbal histories provided by the caregivers of 70 infants in the course of obtaining police death certification. From these verbal histories it appears that acute respiratory infection and diarrhoeal disease caused the majority of deaths. Infants with a respiratory condition were likely to have been taken for medical attention prior to death. By contrast, the parents of infants with diarrhoeal disease, while more active towards these infants, were less likely to seek medical care--these infants typically being found dead in bed or dying en route to the hospital or clinic. A story of infant death at home following recent medical care was obtained in over half the cases. This study demonstrates a simple method for the examination of the content and structure of lay accounts of illness and death. The implications for health care of such accounts are discussed in terms of the behavioural antecedents of infant mortality due to acute respiratory infections and diarrhoeal disease.

Homicide-associated burning in Cape Town, South Africa.

To describe the features of homicide-associated burnings (HAB) and examine factors that distinguish between intentional and accidental fatal burn injury, we undertook a review of all burn cases admitted to the Salt River State Mortuary, Cape Town, South Africa, between January 1, 1991, and December 31, 1992. Of 358 burn-related deaths, 35 (10%) were homicides; five (14%) of these were described as "necklacings." No significant difference existed in age, sex, residential status, or extent of burn injury between the HAB and adult residential fire victims (ARFV). Of the HAB, 44% had soot in the trachea and main bronchi, whereas soot was present in 83% of the ARFV (p = 0.001). The median blood carbon monoxide saturation was 12% in the HAB and 30% in the ARFV (p = 0.001). Of the HAB, 48% had a blood alcohol concentration > 0.1 g/100 ml, whereas this concentration was noted in 70% of ARFV (p = 0.02). Evidence of either gunshot, stabbing, or blunt force injury was seen in 82% of the HAB. Although some significant autopsy parameters characterize HAB, we conclude that the forensic pathologist should diligently seek evidence of homicidal injury in all fatal burn cases.

Application of two secondary documentary sources to identify the underreporting of fatal occupational injuries in Cape Town, South Africa.

We reviewed 8,502 deaths registered at the Salt River state mortuary, Cape Town (medical examiner records) for an 18-month period (1/1/90-6/30/91). When fatal occupational injuries located from this data source were matched with the records of the occupational safety inspectorate of the Department of Manpower, it was found that 28% had not been reported in terms of statutory regulations. Unreported deaths accounted for 25% of all fatal occupational injuries in the construction industry. None of the fatal occupational injuries in agriculture and fishing had been reported. Falls constituted 45% of the unreported fatalities. High levels of unreported fatal occupational injury indicate deficiencies in current occupational safety surveillance and enforcement in South Africa.

Preventable mortality following sharp penetrating chest trauma.

We examined the determinants of outcome following sharp penetrating chest trauma (SPCT) in Cape Town, South Africa. During a 6-month period, 248 nonsurvivors (comprising 231 prehospital and 17 in-hospital deaths) and 474 survivors admitted to the Groote Schuur Hospital Trauma Unit were located. Most (77%) of the deaths resulted from cardiac or great vessel injuries. An unexpected finding was that in 47 (19%) of the prehospital deaths, the only injury at autopsy was a unilateral lung wound. There were no deaths in the 442 patients with this injury admitted to the hospital. The survival rate following equivalent injuries was unexpectedly better in patients from poorer socioeconomic areas, possibly because of increased use of private transport to reach the hospital. The key to improved outcome after survivable SPCT lies in rapid transportation to adequate emergency care by the quickest available means.

A time-series analysis of trends in firearm-related homicide and suicide.

In order to determine whether firearm use was an increasing component of the general pattern of homicide in Cape Town, South Africa, hidden Markov time-series models were used to examine a week-by-week count of firearm homicides, non-firearm homicides, firearm suicides and non-firearm suicides for the 6-year period from 1986 to 1991. Of several models fitted to the proportion of homicides that involved firearms, the one which incorporated a discrete upward shift in the middle of 1991 was the most successful. There was no evidence of a similar upward shift in the proportion of the suicides that involved firearms. The sharp increase in 1991 in the probability that a homicide involved the use of a firearm is consistent with a reported upsurge in violence related to the so-called 'taxi wars'. Hidden Markov models, as a general methodology for the analysis of discrete-valued time series, may be a useful and flexible means of identifying time trends or points of transition related to events or interventions in a wide range of public health contexts.

Imaginary constructions and forensic reconstructions of fatal violence against women: implications for community violence prevention.

The almost exclusive media focus on political violence in South Africa has deflected attention from the high levels of interpersonal violence in areas of socioeconomic deprivation. In order to explore the tension between an at-risk community's perspective and the current reality of violence against women, imaginary constructions of their own violent death produced by 45 African female interview respondents were examined in conjunction with forensic data relating to 73 African female homicide victims in Cape Town, South Africa. The prototypical account of an imagined homicide involved a female commuter being approached by a group of men, taunted and assaulted, raped and then killed. The majority of actual homicides occurred at or in the vicinity of the residence of the victim, with the attacker being known to the deceased. Whilst only 1 of the imagined homicide narratives depicted the use of alcohol by the victim, over half the actual homicides had elevated postmortem blood alcohol levels. These and other disjunctions and convergencies between lay and forensic constructions of violent female death should be viewed in the wider context of enmeshment in social circumstance, and could provide some understanding of how at-risk communities perceive violence against women, thereby providing a foundation for appropriate prevention programmes.