Sot .%I rthfrd. Vol 14D. pp 361 to 367 0 Pcrgamon Press Ltd 19110 Prmled III Gredt Bntsm

0162-~002180/1201-0361 SC2 00/O

DEATHS DUE TO ACCIDENTS IN TAIWAN: A POSSIBLE INDTCATOR OF DEVELOPMENT

ROGER MARK SELYA

Department of Geography. University of Cincmnati

Abstract-m the pertod 196&1977 acctdenrs have gone from the 7th to 3rd leading cause of death m Taiwan. Thts change IS measured by the change in the number of accident related deaths, crude death rates per 100.000, and percent of deaths due to accidents. Three hypotheses are evaluated to explain the role of accidents in the epidemrological profile of Tatwan: the notion of the epidemtological transttton. Chmese character traits. and culture m disequilibrium. Hypothests evaluation includes specifying the person variables of age. sex. and occupatron as well as when and where accidents occur. Increased deaths due to accidents are related to a changed environment and risk taking. Imphcations of the role of accidents in Taiwan’s epidemiolo~cal profile include possible use of the ep~demioiog~cal transition to measure development. and the need for an intervention strategy. Interventton strategies include environ- mental modification and supplymg emergency medical care. The need of some Intervention IS indrcated by labor shortages and potential years of hfe lost.

fNTRODUCTlON

In the period 1960-1977 accidents have gone from the seventh to the third leading cause of death in Taiwan. In this report four aspects of this change are dis- cussed. First, the change is documented; second. it is described using basic epidemio~ogjcal variables; third, aftemative hypotheses are evaluated in an attempt to explain the change; fourth, some implications of the change are examined.

Data used in the report are taken from several pub- lications [I+. For all years studied, data are avail- able for motor vehrcle deaths (BE 47) and other acci- dental deaths (BE 48) in the abbreviated list of fifty leading causes of death. For 1967 and 1974-77 data on more specific causes of death are available (items A 138-146 m the 150 causes of death hst). Suictde was not included in the study. All calculations are by the author unless otherwise specified.

EVIDENCE FOR CHANGE

There are three pieces of evidence which can be used to document the changed position of accidents in Taiwan’s epidemiological profile.

First, the absolute number of deaths due to aca- dents has increased. From 196@1977 the total number of accidental deaths increased from 4061 to 9521. In the decade between 1967 and 1977 the number of male deaths due to accidents rose from 5539 to 7372; for females the analogous data are I547 and 2149.

Second, there has been a rise in the death rate per 100,000 due to accidents. In 1960 the rate was 38,9. in 1977 57.15.

Third, the percentage of total deaths due to acci- dents has risen. In 1960 5.59, of all deaths were due to accidents. By 1977 this figure had increased to 12.1”,.

It should be noted that these changes are real. not apparent, changes. For example using 1977 popula- tion as a standard. the total death rate for motor vehicle deaths (BE 47) went from 10.18 in 1967 to

44.87 in 1977; for non-motor vehicie deaths (BE 48) the change was smaller. from 32.09 to 32.28.

DESCRIPTIVE EPIDEMIOLOGY

The patterns of accidental death can be described using person, place, and time variables.

Person vuriahles

The age specific death rates for 1967 and 1977 for BE 47 and 48 are seen in Figs 1-4. A familiar pattern

361

362 ROGER MARK SELYA

000’001 Jad raw

Deaths due to acctdents m Tatwan 363

_ --Female

I “““““““” 0 5 IO 15 20 25 30 35 40 45 50 55 60 65 70 75 eO+AGE I, 0 I I I I I I I I, I/ I I

4 9 14 19 24 29 34 39 44 49 54 59 64 69 74 79

Fig 4. Age specfic death rates, 1977. non-motor vehicle acctdents (BE 48)

of reduced rusk after years G4 is seen. wtth increased risk beginning in the teen years. Males appear to be at greater risk than females for both classes of accidents. Note that for non-vehtcle accidents the two diagrams are nmilar, while for vehicle related accidents there is a major shift upward for both sexes between 1967 and 1977.

Table I shows the percentage of deaths due to acci- dents for selected occupations for 1977. Clearly males m agriculture and industry are at risk. A further breakdown of individual occupational types suggest that for males. farming. sales. teaching. medicine. management, and transportation are dangerous occu- pattons. For women. being at home appears to in- crease the risk of accidents. This observatton must be understood in context: fully 43”, of all women of working age are at home. The only age group which shows any substanttal deviation from this figure is X-24; 34”” of these women are at home. Women who are employed outstde the home are at greatest risk if they work in agriculture. sales. and educatton.

Place

Taiwan is divided admimstrattvely into 16 counties

and 5 citres. (Fig. 5). There is a high degree of spatial unrformny in acctdent rates. The only areas wtth ex-

ceptionally high death rates due to accidents are the northern port city of Keelung, and the east central coastal county of Hualien. Both have considerable topographic conditions which hamper road building and access [S].

Time

There is no marked seasonahty in the occurrence of accidental deaths in Taiwan. On the average for both

Table I. Acctdental desths by occupatton. 1977 (P, total deaths)

Occupatton BE 47 BE 48

Male Female Male Female

Professtonal 2.3 1.3 1.7 1.3 techmcal

Admunstrative 0.9 0.7 0.3 0. I managerial

Clertcal 2.7 2.6 2.5 1.8 Sales 5.6 I .89 3.92 I.2 Servtce 6.3 0.7 4.2 1.5 Farming 27. I 9.0 28.3 9.3 Industry 25.4 8.1 23.0 4.8

transportatton Students 4.2 3.9 6.9 5.6 Housewtfe - 55.8 - 50 3

ROGER MARK SELYA

TAIWAN LOCATION MAP

Fig. 5. Tawan locatton map.

males and females for both BE 47 and 48. 8.3% of HYPOTHESES FOR EXPLAINING THE CHANGE acctdental deaths occurred each month m 1977. For motor vehicle related deaths there is a slight increase Three hypotheses are explored: the epidemiological in the fall: for non-motor vehicle related deaths there transformation, Chinese character traits, and society- IS a slight increase in the summer. in-change.

Deaths due to accidents in Taiwan 365

Table 2. Selected Taiwan socio-economic indicators

Variable 1952 1964 1977

Crude birthrate/IO@ Crude death rate/l000 Per capita income (8) Percent GNP from industry Percent working population

in industry

46.6 34.5 23.8 9.9 5.7 4.8

48.05 168.48 1032.78 10.8 20.3 30.4 9.3 11.8 23.3

Source: Taiwan Stumtical Duta Book, I9 79. Taipei: Council for Economic Planning and Development, Execu- tive Yuan, 1979.

Epidemiological trunsformation

The notion of the epidemiological transformation can be summarized as follows:

This theory focuses on the shifting web of health and dis- ease patterns in population groups and their links with several demographic, social, economic, ecologic. and bio- logic changes. Many countries have experienced a signifi- cant change or transition from high to low mortality accompanying either social development.. or a combt- nation of medical development and early social change.. . Common to all these countries is a clear shift m the kinds of diseases and causes of death that are prevalent at a fixed point in time: the Old World epidemics of infection are progressively (but not completely) replaced by degenerative diseases, diseases due to stress, and man-made dis- eases. . . [6].

As can be seen in Table 2 the kinds of socio-econo- mic changes mentioned by Orman have taken place in Taiwan. In addition the old infectious causes of death-gastro-intestinal diseases, pneumonia, and tuberculosis, have been replaced by cerebrovascular disease, malignant neoplasms, accidents, and heart diesases as the leading causes of death. The years of transition between the two causal patterns appear to be 1960-1964, although Sullivan [7] surveying the 1957-1968 decline in mortality stiil saw infectious dis- eases as the major causes of death. Tsai has docu- mented the transition and the resulting modem pat- tern of mortality [S].

Given the socio-economic changes and the parallel changes in the epidemiological profile which have

resulted in accidents being the third leading cause of death in Taiwan, what specific changes could have lead to this situation? The answer to this question can be approached by consulting the data in Table 3. We see that two types of accidents stand out-motor ve- hicles and drownings. If we can explain these two types we can perhaps understand how accidents have come to be the third Leading cause of death in Taiwan.

Motor vehic!e related deaths

There are a number of reasons why this type of accident should be on the increase. First, there has been a rapid increase in the number of vehicles regis- tered for use. For example, between 1952 and 1977, the total number of registered motor vehicles in- creased from 10,710 to 3.167.559. Of thts total, notor vehicle registrations increased from 2002 to 2.718.055, sedan registration increased from 2579 to 255,667, and truck registration from 4024 to t61.309. Such in- creases alone would not necessarily account for the total increase in the accident rate. However. during the period under consideration (1952-1977) the total length of highways did not increase proportionately (from 15,619 km to 17,224 km). One major improve- ment in the road net was an increase in the percent of roads paved, from 6.7 to 66.5. This change, however, was not enough to compensate for the increase in traffic. We have then a basically rural-agriculturally oriented and design road system which is now serving an ur~n-industrial society. It is not uncommon to see. in both urban and rural areas, a traffic mix con- sisting of motorcycles, trucks, buses, cars, bicycles. pedestrians, argicultural power implements, and water buffalo drawn carts.

Other factors besides the increased number of ve- hicles using a rural road system contribute to acci- dents. Taiwan drivers, in general, display a series of driving habits which most likely increase the risk and probability of accidents. These include advancing on the yellow light at right angles to the driver’s direc- tion, cutting comers, and excessive speeding and sud- den stops. Taxi and truck drivers frequently work 12-18 hr non-stop shifts. In addition overloading is common: trucks frequently lose their loads as corners are turned, buses commonly are overloaded so as to

Table 3. Percent accidental deaths by type, 1977

Vehicle death Other vehicle

related Poisonings Falls Fires Drowning Firearms Industrial Other Total number

deaths due to accidents

Total number deaths

Males Females % all accidents % all deaths % all accidents “/:, all deaths

43.39 7.7 38.5 3.0 4.20 0.74 2.90 0.22

449 0.80 8.88 0.69 6.87 1.2 8.48 0.66 I,46 0.26 2.44 0.19

16.97 3.02 18.50 1.44 0.33 0.05 0.04 0.004 6.6 1.18 4.62 0.36

12.84 2.28 13.02 1.01

7590 2205

42,629 28.297

resemble a sardine can, and a family of three or IMPLICATIONS

four 1s often seen on a 5Occ motorcycle. Vehicles in We have seen that accidents have become a major genera1 are not maintained: preventive maintenance iS cause of death m Taiwan. Both a changed environ- rare. Finaliy. although data on the number of new ment and a changing society pressuring on mdivtd- drivers are not available, field observation suggests uals have made this so. What 3re some of the impii- that a minimum of driver preparation is common. cations of these findings?

First, we can no longer view Taiwan as an under-

~ro~~~iiz~s developed or developing country. She has an eplde- miological profile of a developed country. The risk

This is perhaps the most perplexing part of the factors associated with the leading causes .of death are accident profile until one recalls that in the U.S. similar to those in developed countries. In terms of drowning is the fourth leading cause of accidental public health this presents an anomoly: due to past deaths, and second for ages 5-24 after motor vehicles. and present use of night so11 in agriculture a moderate

Dietz and Baker [9] list the following activities as to heavy parasite burden will be found rn the general related to drownings: swimming, hunting or fishing, public. Nevertheless. epidemiological~y Tatwan playing near water. fishing from piers, wading, show- appears to be a developed country. In reaching this ing off. diving, walking near water, drinking near conclusion we have come to the same conclusion water, and bathing, In addition for Taiwan the follow- reached by others assessing modernization in more ing would increase the risk of drowning: irrigation than purely economic or structural terms 1211. A cor- facilities. typhoons. and unguarded construction sites. rolary of this conclusion is that the notlon of the The decline in age specific death rates for age O-4 and epidemiologica~ transition can be used as a measure an increase in the ages 15 and oiier would suggest that of development. in Taiwan drownings are not necessarily childhood Second an intervention strategy is needed to reduce problems. the number of deaths due to accidents. Regarding ve-

In summary. the evidence from motor vehicle acci- hicle accidents certain possibilities readily come to dents and drownings suggest that a changed environ- mind: roads can be improved. widened. redesigned: ment in Taiwan is a major reason for the increase in driver education can be improved; pedestrian over- all accidental deaths. The same argument can be passes can be constructed; cars can be periodically made for the other leading causes of death. For and regularly inspected. In regard to drownmg, swim- example. pollution has resulted from industrialization mer education and placing of guard rails at known [IO. Ii); changes in the Taiwan diet have water hazards would help. Many of these improve- occurred [ 121. In short development has created ments are already being implemented. Regarding bottlenecks and rusk factors which are associated with transportation development. improvements were in- the leading causes of death. stituted to reduce bottlenecks in the economy, not

reduce accidents. The role of better roads in reducing

Ckrrucwr traits accidents will be mixed: modern. limited access high- ways may reduce some types of accidents, especially

This hypothesis deals with the agent. Lin [i3] notes for children. but create new or increase risks for that the major character trait of the Chinese is the adults. Two areas beyond transportation and drown- acceptance of fate or fatalism. This is displayed in the ing which deserve attention are home and mdustrlai following behavior patterns: indifference. roguery. accidents. Improved education can serve to reduce the pacifism. and conservatism. Such a character profile former. While the latter is not as serious as it might may dispose the Chinese to take risks that in any be. there is the potential for a worsening situation environment would result in accidental deaths. which could best be prevented by improvements in

In addition Fan [14] and Chang and Chang [15] the work environment now. attribute childhood accidents to the carelessness of Another intervention strategy could focus on pro- inexperienced young mothers. vlding facilities for treating accidents in addition to

preventing them. The distribution of health facilities 1s

SOCi~t~-i/Y-ChUf?~~ not equal in Taiwan: urban areas have a greater con- centratlon of all forms of facilities, and rural clinics

The third hypothesis deals with the role that a lack are frequently understaffed [22]. It could be argued of a set of values in a changing society may play m that to transfer resources to the treatment of modern accidents. Kurokawa {16] has noted that children of causes of death would not be in the long term best non-acculturated oriental parents in the United States interests fo the health of the Taiwan population. This have two possible accident patterns: if the child is is arguable for two reasons: first the government has also unacculturated, his accident rate is very low com- a policy of disbursing industry away from urban pared with the general population his age; If the child centers and is trying to disburse urban population to is acculturated his accident rates is intermediate new industrial centers. Second. the most commonly between that of the unacculturated child and the gen- treated diseases in public-Taiwan hospitals are acute eral population. respjratory infections (A89). inflammatory diseases of

Taiwan is a society in change. Family ties and old the eye (A75), other diseases of skm and subcutaneous values are being challenged. stress and Insecurity are tissue (A120). other diseases of digestive system present. This is a frequent theme in much Taiwan (A104), bronchitis, emphysema. and asthma (A93), contemporary literature [17-201. This may create a and gastritis and duodenitis (A99). None of these are social environment where ~onst~~nts on ‘risk taking leading causes of death. Accidents rank t 1 th compris- are reduced and the possibtlity of accidents increased. ing 3.29o/0 of all cases treated. This discrepancy merits

366 ROGER MARK SELYA

Deaths due to accidents m Taiwan 367

further study. Why do accident victims so rarely receive treatment in hospitals? What about cancer and heart disease victims? Is diagnosis so late that treatment is not feasible? These issues *are being debated in Taiwan 123,241.

But regardless of which intervention strategies are used, there is fittle doubt that some strategy is needed. The continued growth of the Taiwan economy will require, in part, a skilled, educated workforce. Although economic planners frequently complain that the rate of natural increase in Taiwan is too high, Taiwan has gone through the demographic trans- formation [25]. Yet there are chronic shortages in the workforce 1261. Accidents may well contribute to this shortage. Using the method of Romeder and McWhinnie [27] the potential years of life lost (PYLL) for accidents was calculated for 1977. For males the PPYL was 270,949; for females, 78,218.S. The total PYLL for both sexes shows a 47.5% in- crease over the PYLL for accidents for 1967. Clearly a reduction in accidental deaths is not only called for from a public health point of view, but also to insure future economic viability and vitality.

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9.

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