|Year : 2015 | Volume
| Issue : 1 | Page : 36-43
Injuries in marginal workers and social trauma in female: Important cause of the paradigm shift in eye injury over a decade
Department of Ophthalmology, Bokaro General Hospital, Steel Authority of India Limited, Bokaro Steel City, Jharkhand, India
|Date of Web Publication||14-May-2015|
4C/3020 Bokaro Steel City 827 004, Jharkhand
Source of Support: None, Conflict of Interest: None
Background: Changing profile of work force can give rise different types of injuries. Purpose: To analyse causative factors (Host-Agent-Event) in ocular trauma over last 15 years. Methods: Hospital based prospective study during 1997-2012.Detailed information on nature of trauma; agent and setting were recorded. Results: Cohort included 12365 eye injuries, 1241 serious cases. Prevalence - 0.45 /10000 Mean age 45.8 with bi- modal pattern of incidence, 3:1 male-female ratio. 80% closed globe, 48% workplace injury (90% in marginal labourers with an exponential annual increase). 10% cases from garage mechanics.60% of eye injuries in female were related to "social violence". Multivariate analysis has detected new causative agents. Conclusion: Significant change in parameters of trauma (Host-Agent-Event) is resulting in paradigm shift in eye injury. Unorganised unaccustomed labour in workplace injury and "social trauma" in females has become an important cause of eye injury.
Keywords: Eye injury , marginal workers, paradigm shift, social trauma
|How to cite this article:|
Chowdhury S. Injuries in marginal workers and social trauma in female: Important cause of the paradigm shift in eye injury over a decade. Indian J Occup Environ Med 2015;19:36-43
|How to cite this URL:|
Chowdhury S. Injuries in marginal workers and social trauma in female: Important cause of the paradigm shift in eye injury over a decade. Indian J Occup Environ Med [serial online] 2015 [cited 2019 Jun 17];19:36-43. Available from: http://www.ijoem.com/text.asp?2015/19/1/36/157006
| Introduction|| |
The term "injury" from the Latin "in+jus" meaning "not right," refers to human damage from acute exposure to physical and chemical agents. Ocular trauma is a major cause for monocular vision impairment worldwide but does not usually give rise to bilateral visual loss, hence, blindness from injury often miss the epidemiologists' list. The impact of ocular trauma can be enormous as population at risk is usually the productive age groups and the potential person-day's loss of work associated with treatment of the sequel of the trauma. It has become more important as rapidly declining regular workforce is being replaced by contract/marginal worker worldwide. During last decade (2001-2011 census data), India gross domestic product (GDP) has become one of the fastest in world economy that involved participation by marginal laborers which has increased from 22% to 26% of total workers (120 million of total 480 million workforces in India).  They are less trained and by definition work for <6 months, so more prone to injuries often leading to more disastrous consequences both physically and economically.
With the industrialization and technological change, a major expansion took place in the development of transport and communication networks. Furthermore, over time due to population growth, there has been a massive shift in the labor force from rural to urban and from agriculture to industry accompanied by a heavy dependence on the service sector. As a result, more and more people are becoming exposed to injury producing agents such as mechanical, electrical, thermal or chemical energy. In the world today, mechanical energy has remained the most important cause of injury but the paradigm is changing as far as the host - agent factors are concerned.
Another category of ocular trauma, least addressed is injury in females which can be considered as a tip of the iceberg. 
Looking up into the literature, we could not find any study on ocular trauma in these categories.
Bokaro in Jharkhand is the most industrialized zone in India with biggest steel plant in Asia. In next 5 years, half of Indian steel will be produced here. Marginal labor in Jharkhand is highest in India. Ocular trauma in and around the steel plant has impact on this.
On this background, we conducted a prospective study on ocular trauma at our health service network which is an on-going project under the central government Public Sector Units.
| Methods|| |
A prospective interventional study on all cases of ocular trauma attending our healthcare network has been going on since 1995.
Detailed information on the nature of trauma, agent and setting are analyzed during 1997-2012. Serious cases are those who had visual impairment on presentation/advised rest for more than24 h/hospitalized for treatment.
All injuries are accidental in nature except those uncategorized injuries which are inflicted upon with an ulterior motive. This last group has never been studied or included in any literature.
Bokaro population includes all four categories of workers and catered by our 910 bedded super-specialty hospital, Occupational Health Service Centre, health centers and peripheral developmental centers. Thus, any study using this healthcare service system represents a proper worker profile who sustain ocular trauma during last 15 years.
A comprehensive ocular examination is carried out at the main hospital after obtaining necessary informed consent. We collected demographic, medical, and surgical history details from each participating subject before the ocular examinations. We obtained a history of ocular trauma in any eye from subjects participating in the study using the question "have you ever suffered from any eye injury in the past?" to elicit this information. We recorded details of the most recent event of trauma as recalled by the subject, including the type of injury, the age of trauma, the setting of injury, and place where treatment was sought for the trauma, if any. The ophthalmologist rechecked for a history of ocular trauma if signs of ocular trauma were evident on clinical examination, but history was not available for patient interviews. The ophthalmologist determined whether trauma was an underlying cause for decrease in visual acuity for subjects with visual acuity worse than 6/18 in any eye.
We defined vision impairment as best corrected visual acuity between 6/18 and 3/60 in the better eye, and blindness as best-corrected visual acuity worse than 3/60 in the better eye. We estimated the age-adjusted (adjusting to population of India as per census 2011) prevalence with 95% confidence intervals (CI) for blindness caused by trauma. CI for prevalence estimates and odds ratios (OR) from the regression analyses were calculated. The Chi-square and Fisher exact test is applied to look for significance between categorical variables as appropriate. We used the youngest age at trauma to determine the mean age at trauma and for analysis involving age at trauma for subjects with trauma in both eyes. We estimated the OR (95% CI) for factors associated with trauma and with blindness from trauma in a multiple logistic regression models that included gender, education, and occupation as variables. Mantel-Haenszel OR were estimated to determine whether the type of trauma, education of subjects or occupation determined the use of services from an eye specialist or a traditional healer. We considered P values 0.05 significant.
All analyses were conducted after applying the appropriate record weights. For each year (1997-2012), eye injury incidence rates were calculated both overall and according to gender and race, using denominators obtained from India census 2011. As everyone in the population was theoretically at risk for eye injury, this denominator is appropriate. Frequency distributions were created for injury type and cause. Poisson regression was used to calculate the trend in the rate of eye injury over the study period.
| Results|| |
During last 15 years (1997-2012), 12,365 eye injuries were registered in this prospective study, 1241 serious cases which needed hospitalization/rest from duty or visual impairment. Mean age is 45.8 with bi-modal pattern of incidence highest among third and sixth decade, 3:1 male-female ratio (n9273:N3012).
Totally, 5936 cases (48%) workplace injury included 5333 case or 90% in marginal laborers with an exponential annual increase. 595 cases or 10% cases from garage mechanics.
A total of 1862 cases or 60% of eye injuries in female were related to "social violence." Multivariate analysis has detected new risk factors [Table 1], [Figure 1] [Figure 2] [Figure 3] a and b].
|Figure 1: Incidence of eye injuries in different categories of workers over 15 years study period|
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|Figure 2: Increasing eye injuries in marginal workers (a) Social and occupational injustice?. (b) Ensuing occupational "epidemic"|
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|Figure 3: (a) Increasing injuries in females: Social trauma? (b) Increasing injuries in females: Social trauma? (statistical analysis)|
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What (types of injury)?
The most common injury were of nonserious category which had no visual impairment or did not require hospitalization or rest from duties (n111234). This category includes corneal abrasion, traumatic conjunctivitis, sub-conjunctival hemorrhages, hydraulic oil spillage. Of 1241 serious cases, 80% had closed globe injury. Open globe injuries included perforation with metal splinter, road traffic accident - roadside accident (stone flying from speeding wheels) [Figure 4] [Figure 5] [Figure 6].
|Figure 5: Less trained marginal workers with lax safety norms are at risk|
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|Figure 6: Marginal workers at construction particularly on road are highly predisposed to injuries|
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Pediatric age group (<16 years): No serious injury case is registered, but characteristic injuries include abrasion from fingernail and blouse hooks. Older children had more serious eye injuries mostly sports related (gilli danda, shuttle cork, cricket ball, cycle handles, etc.). Self-inflicted injuries were registered among school goers without serious consequences. 
Over the counter medicines in agricultural eye injuries had blinding corneal ulceration which leads to intractable panophthalmitis in 12 cases which led to evisceration in 80% cases [Figure 7]. 
|Figure 7: Deficient preemployment health check-up and lack of medical cover are the main reason for resorting over the counter medicines often leading to blinding ulcer|
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Mean yearly incidence of serious festivity injuries is 18.5, which include fireworks injury (unexploded firecracker, falling rocket sticks, etc.). During diwali, serious ophthalmia nodusum due to caterpillar while collecting banana trees for festivity. During holi, fall on hand pumping tub well-caused blinding open globe injury in 4 cases. Muharrum time injuries include perforating injuries by fluorescent tube lights, sharp weapons [Figure 8] and [Figure 9]].
|Figure 8: Slippery tube well area give rise to fall and subsequent blinding injuries while marginal workers take a break for foods|
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|Figure 9: Celebrations often lead to accidents and injuries. Marginal workers particularly younger age groups are more vulnerable, often from un-exploded crackers|
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Prevalence - 0.45/1000 (Bokaro population 2011:20 lakhs) 80% closed globe, mean yearly incidence of injury 824 cases/year which has not changed significantly during the study period (1997-2012). From the study population, calculated prevalence is 0.45/1000. Necessary correction was applied as this was not a population-based study.
Eye injury in marginal workers was increased from 280 cases in 1997-2000 to 680 in 2000-2012 which is highly significant statistically (P < 0.01).
Social injury in females has also shown a distressing and statistically signifying rise from 180 in 1997-2000 to 232 in 2000-2012
This can be explained by an increase in female marginal workers and social violence [Figure 10].
|Figure 10: Increasing violence against women for various reasons often give rise to blinding injuries which most of the time go unreported, more with marginal female workers|
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In the male: Incidence is rising due to marginal labor increase, increase in agricultural laborers (AL) as compared to cultivator (CL).
Household industry related injuries increased from 8 cases in 1997 to 24 in 2012 mainly due to unaccustomed laborer, use free distribution of "gifts" (bicycles which are poorly maintained) and preventive articles (mosquito nets for malaria, dengue without proper back up where strings are often very sharp).
Motor vehicle specially bikes related injury registered a leap from 12 in 1997 to 82 in 2012 due to untrained and unauthorized workshops. 50% of which result in visual impairment.
Fencing related injury has increased from 12 cases in 1997 to 24 in 2012 due to use of metallic sheets in place of hedge/bamboo [Figure 11].
|Figure 11: Marginal workers are often engaged at unaccustomed labor without any prior training which predispose them to various injuries. This is increasing due to rapid urbanization and migration from cultivation to marginal workers|
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Incidence of blinding eye injuries remain the study with 1.6 cases/year, however, outcome has improved in potentially blinding trauma due to better surgical infrastructures. ,, Significant reduction in excision of eyeball ,, has been seen (2.1 cases/year during half of this study period and only 1 case in the second half) [[Figure 12].
|Figure 12: Outcome of injuries in marginal workers are deplorable as they go often unreported and not covered by proper healthcare system|
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Complicated old injuries
Closed globe wound due to blunt trauma, firecracker gradually deteriorated to intractable glaucoma in 12 cases out of 1241 serious injuries whereas old perforating injuries progressed to retinal detachment and phthisis bulbi in 18 cases. ,
4.5 cases/year were the incidence of eye injury attributable to ocular comorbidities (post-PK, Aphakics,). 
| Discussion|| |
Ocular trauma is a major cause for monocular vision impairment and blindness worldwide but does not cause bilateral visual loss or, hence, blindness except in rare situations. , However, considering the impact of blindness, that the population at risk is usually the productive age groups, and the potential person-day's loss of work associated with treatment of the squeal of the trauma, the impact of ocular trauma can be enormous.  It has become more important as rapidly declining regular workforce, replaced by contract/marginalized laborer. During the last decade (2001-2011 census data), India GDP has become one of the fastest in world economy. However, participation by marginal laborers has increased from 22% to 26% of total workers (120 million out of total 480 million workforces) in India. As they are less trained and by definition work for <6 months, is more prone to injuries and more disastrous consequences both physically and economically. Executive report of census 2011 has highlighted following facts which is the probable explanation for this paradigm shift: 
Bokaro in Jharkhand is the most industrialized zone in India with biggest steel plant in Asia. In next 5 years, half of Indian steel will be produced here. Ocular trauma in and around the steel plant has impact on the economy. Hence, an on-going prospective interventional study is going on since 1997. Incidence and prevalence in this study are comparable to world literature. Eye injuries in marginal workers have increased significantly over the last decade which can explained from the census data of India registering a steady increase in marginal workers. 90% of work-related injuries were seen in this group of workers. However, as there is no published literature on this, our data cannot be compared. Jharkhand has the highest population of marginal laborers (26% of India) which can explain higher and increasing trend in eye injuries. 
- Broad categories of economic activities also known as four-fold classification of the workers are, CLs, AL, working in household industries (HHI) and other workers (OWs). The CLs and AL broadly show the workers engaged in the agricultural sector, except those engaged in plantation activities, which, over the censuses, have been considered as a part of "OWs"
- In census 2011, out of 481.7 million total workers, 118.7 million are CLs and another 144.3 million are AL. Thus, nearly 55% of the workers are engaged in agricultural activities compared to 58.2% in census 2001. About one-in-two males and 2 of every 3 females are engaged in agricultural activities either as a CL or an AL. Of the remaining workers, 18.3 million are in HHI, and 200.4 million are OWs
- During the decade 2001-2011, the census results show a fall of about 9 million in CLs and an increase of about 38 million in AL. The HHI have shown an increase of 1.4 million and OWs have increased by nearly 49 million
- The fall in the number of CLs, during the decade 2001-2011, was less pronounced among the male workers. In census 2011, the number of male workers decreased to 82.7 million from 85.4 million in census 2001. Among the females, the number of CLs has reduced to 36.0 million in census 2011 from 41.9 million in census 2001
- Among the states/union territories s, Uttar Pradesh has reported the highest numbers in all the categories of workers, with 19.1 million CLs, 19.9 million AL, and 3.9 million in HHI and 22.9 million as OWs.
It is well-known fact that every 15 s, a worker dies from a work-related accident or disease and every 15 s, 160 workers have a work-related accident every day, 6300 people die as a result of occupational accidents or work-related diseases - more than 2.3 million deaths/year. 317 million accidents occur on the job annually; many of these resulting in extended absences from work.  The human cost of this daily adversity is vast, and the economic burden of poor occupational safety and health practices is estimated at 4% of global GDP each year. The safety and health conditions at work are very different between countries, economic sectors and social groups. Deaths and injuries take a particularly heavy toll in developing countries, where a large part of the population is engaged in hazardous activities, such as agriculture, fishing and mining. Throughout the world, the poorest and least protected-often women, children and migrants are among the most affected.
Since long, injuries were considered synonymous with "accidents" implying that occurrence of such events was sudden and caused by external factors.  Assuming that these factors were random and uncontrollable acts of fate and luck, injuries remained a neglected field of research in the past. Some studies have been carried out in developed countries to estimate the magnitude, severity and consequences of injuries and accordingly appropriate safety measures, laws and regulations have been devised to prevent them. Recently, the epidemiologist of developed countries have expanded their area of etiology of diseases to include injury and have contributed toward the understanding of causal relationships among risk factors, events and the outcomes of injury. In contrast, so far not much attention has been paid to injury awareness, prevention and control in the developing countries. Not many efforts are made to learn from the experiences of developed nations, and a very few open fora are organized in the developing countries for the dissemination of research findings of the developed nations.
Pioneering work on defining agents of injury was done by Gordon; he suggested that injuries behaved like classic infectious diseases and were characterized by epidemic episodes, seasonal variation, and long-term trends and demographics distribution. He further argued that each injury was the product not of one cause, but of forces from at least three sources which are the host, the agent itself and the environment in which host and agent find themselves.  Our results can clearly be explained by Gordon's theory.
According to Haddon,  unlike disease, the exposure causing injury is sudden and the damage is quick and severe; besides energy induced or exposed, injury also results from absence of essentials such as lack of oxygen or heat. Haddon further expanded the work of Gordon by including the time dimension in injury-producing factors and created a landmark in the prevention measures of injury; often referred to in the literature as "the Haddon matrix." The matrix includes three phases of injury as "preevent," "event," and "postevent"- as rows and the interacting factors, which cause injury over time as columns, include host, agent (or vector) and environment (physical and socioeconomic).  The World Health Organization (1977) in its International Classification of Diseases tried to explain the typology of injuries in terms of external causes (agents) and associated pathological outcomes.  The classification has helped a great deal in addressing the issues of acute effects and long-term disability resulting from injury; however, it failed to provide adequate attention to the associated socioeconomic and psychological consequences.
Domestic violence is rooted in a dynamic of unequal power and control that escalates to physical, Sexual, or psychological abuse. In homosexual relationships,  this dynamic is often compounded by homophobia and the victim's fear that sexual orientation will be exposed. Domestic violence is the second leading cause of injury to all US women and is the leading cause of injury to American women 15-44 years old.  Approximately 25% to 45% of abused women are beaten during pregnancy. Of women seeking medical assistance at emergency departments 22-35% are there because of domestic abuse, and of these, only 5% have their situations correctly identified. Partner abuse observes no ethnic, geographic, religious, or socioeconomic boundaries.  Some studies suggest that abusers probably experienced violence during their own childhoods and probably abuse alcohol.
Our study result has shown disturbing in "social" eye injuries due to acid attacks, dowry exploitation, etc., This is very important finding of this study (hitherto unreported) as an intervention at this stage can prevent lethal consequences.
Furthermore, most of the social injuries in females and work injuries in marginal workers are not "notified" to appropriate administrative authorities. However, treated with secrecy from abuser/employer due to complex socioeconomic reasons. Hence, this study emphasizes bigger role of an eye care provider in days to come.
| Conclusion|| |
The greatest change in the paradigm of ocular trauma is yet to come: Understanding ever-changing pattern in "host-agent-event reaction" in eye injury will enable us to prevent, treat and rehabilitate the affected.
Increasing eye injuries in marginal workers and rising "social injury" to female eyes are indicators of socioeconomic imbalance. An accident is an opportune time for secondary prevention messages. Ocular trauma at workplace is a sentinel event, indicative of failure of protection in that system - an eye care provider should capitalize on this opportunity to send a strong message to the employer, administration and society (Dr. Frost). "Ophthalmologists have a huge role to play to dramatize the problem. They see the drama of failure. You can look at statistics, rate in graphs and charts, but one photo or description of the devastation of an eye injury to get people ponder blindness is very powerful. The horror of the medical outcome speaks very loudly."
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