In the fifth paper, Dr Michael E Reichenheim, (Institute of Social Medicine, Rio de Janeiro State University, Brazil) and colleagues look at Brazil's heavy toll of traffic and violent injuries. One in 8 deaths in Brazil is caused by external causes, and, although there are signs of decline, murders and traffic-related related injuries together make up two thirds of all deaths from external causes in Brazil. This injury mortality pattern is different from most WHO member states, where half of all deaths from external causes are due to suicide. But other South American countries have patterns not that different from Brazil.
In 2007, there were around 48 000 murders and 38 000 traffic-related deaths in the country. Domestic violence is another major concern that, although it does not cause many deaths, is responsible for many injuries.
Young, black, and poor men are the main victims and perpetrators of community violence, whereas poor black women are the main victims of domestic violence. There is also a geographical distribution of domestic violence, with the poorer, less developed north having higher rates than the more economically developed southern regions.
Murder mortality rose from 27 per 100000 population in 1991 to 32 in 2003, but by 2007 had decreased back to the level seen in 1991. This is much higher than in China (1.2 per 100000) and Argentina (5), but lower than in South Africa (37) and Colombia (39). Men are 10 times more likely to be murdered than women; yet one woman is murdered every 2 hours, making Brazil the 12th worst country in the world in this regard. Murders of children aged 0 to 14 years accounted for most of the rising murder mortality in the 1980s, while in the 1990s adolescents aged 15-29 saw a sharp increase. In the new Millennium, murder rates have fallen in all age groups apart from those aged over 50 years. Murder with guns is also at a very high rate in Brazil (20 per 100000 population) compared with Canada, France, the USA and the UK (all under 3 per 100000). Alcohol and drug misuse, cultural clashes, economic stagnation in the 1980s and availability of firearms are among the reasons for Brazil's high murder rate. Violence generally is thought to cost the Brazilian economy more than US$30 billion (R$ 87 billion) per year. Quality of life improvements (including access to healthcare) could be behind recent falls in violence-related mortality. Examples of projects with positive results are the First Job programme and the Family Grant Programme.
The authors say: "Despite some successful experiences in recent years, public safety largely operates by confrontation and repression rather than sharing intelligence and prevention...Widespread corruption and impunity provide a culture of permissiveness that surrounds violence and its consequences."
At 28 per 100 000 population, Brazil's traffic-death rate is higher than the world average (19) and all low-to-middle income countries combined (20), as well as being higher than in high-income countries (13). The Brazilian transport system gives priority to roads and private-car use without offering an adequate infrastructure, and is poorly equipped to deal with infringement of traffic rules. But progress is taking place, such as the 2008 law that reduced the legal limit for alcohol in drivers to zero. But some cities still lack breathalysers needed to enforce such laws. The authors say: "The high-traffic related morbidity and mortality in Brazil have been linked to the chosen model for the transport system that has given priority to roads and private car use without offering adequate infrastructure."
Thanks to growing investment from national research agencies, the number of research groups dedicated to studying violence and injuries has increased from 7 in 2000 to 80 in 2009.
The authors conclude: "In response to the major problems of violence and injuries, Brazil has greatly advanced in terms of legislation and action plans. The main challenge is to assess these advances to identify, extend, integrate, and continue the successful ones."
Dr Michael E Reichenheim, Institute of Social Medicine, Rio de Janeiro State University, Brazil. T) +55 (21) 2334-0235 E) Michael@ims.uerj.br
Journal
The Lancet