Epidemiology and prevention of burns

for fuel leakage, which is especially common when stove reservoirs are being filled. Kerosene can leak onto clothing, or if heat or flames are present nearby during fueling, vapors can ignite. Ignorance of safe techniques in using fuel and appliances will also lead to catastrophic explosions if gasoline contaminates or is substituted for kerosene. In addition, these small, portable stoves are often very unstable, easily tipping over while being moved or even when resting in place. On occasion, the small stove is used as a weapon, thrown by the assailant at the victim, igniting his or her clothing on fire [165].

The essential issue is that families at greatest risk because of poverty, ignorance, and overcrowding, lack the resources needed to purchase stoves of safe and dependable design. The most affordable stoves in South Africa are little over US$3 each, but these flame or wick stoves are notorious for rapidly fluctuating flame size, instability, and explosions. In addition, the impoverished housing conditions lead to poor air circulation, and incomplete combustion of kerosene in flame stoves produces significant levels of toxicants such as carbon monoxide. Even in dwellings supplied with electricity, low-income families will often choose to use kerosene stoves for cooking because of cost savings.

War, mass casualties, and terrorism

Military personnel are at high risk for burn injury in wartime. In general, however, the distribution of burn size in combat is similar to that observed in the US community: 80 % of burns are less than 20 % TBSA in size [173]. Many burn casualties occur during combat at sea. In the Falkland Islands campaign (1982), for instance, 34 % of all British Navy casualties were burns [50]. Personnel in armored fighting vehicles are also at relatively high risk for burn injuries and fire deaths. For example, the proportion of burn casualties during the Yom Kippur War (1973) was nearly 11 %, higher than that of less than 5 % seen during the Israeli Six-Day War (1967) because there was greater saturation of the battlefield with tanks and anti-tank weaponry [156]. Subsequent to the Yom Kippur War, the Israeli army enforced use of flame retardant garments and installed automatic fire extinguishing systems within tanks. These changes led to a decrease in incidence to less than 9 % of military burn casualties

during the Lebanon War (1982). Those modifications have also been credited with reduction of burn size in those who were injured [71].

Fire, flames and explosions have caused mass burn casualties over the centuries. In 1190, a fire in Clifford’s Tower, York, UK, took the lives of 150 Jews who had been besieged by an anti-Semitic mob [63]. A theater fire in Canton, China, claimed the lives of 1670 in 1845. In Santiago, Chile (1863), between 2000 and 3000 lives were lost when a gas lamp near the main altar ignited veils on the walls of la Iglesia de la Compañía de Jesús (the Church of the Company of Jesus) [151]. On April 27, 1865, USS Sultana, a steamboat returning Union prisoners-of-war to their homes in the North, caught fire when one of its boilers exploded on the Mississippi River near Memphis and sank, taking with her approximately 1800 casualties from burns and drowning [101].

Throughout the twentieth century in the US, there have been several fire or burn disasters in which more than 100 people were killed, including the Iroquois Theater fire in Chicago (1903) with 602 fatalities and 220–250 injuries, forest fires near Cloquet and Moose Lakes in Minnesota (1918) with 800 fatalities and 85 injuries, and the Cocoanut Grove Nightclub fire in Boston (1942) with 492 fatalities and 166 injuries [31]. More recent examples include fire disasters at the Beverly Hills Supper Club in Kentucky (1977) with 165 fatalities, the MGM Grand Hotel in Las Vegas (1980) with 84 fatalities, the Alfred P. Murrah building explosion in Oklahoma City (1995) with 168 fatalities, and the attacks on the Pentagon Building and the World Trade Center (2001) with 189 and 2750 deaths, respectively. The last three mass-casualty incidents were the result of terrorism, and casualties were caused not only by smoke inhalation and thermal injuries, but by blast, crush and fall injuries.

Indeed, most of the mass-casualty terrorist attacks in the US have employed conventional explosives or incendiary agents (such as jet fuel). A bomb placed under the staircase in the 16 th Street Baptist Church in Birmingham, AL, in 1963 caused the death of four young girls; the motivation was anger over public integration of the races [203]. The first attack by foreign terrorists on American soil came in 1993 when a truck bomb with conventional explosives was detonated in the underground parking garage of the World Trade Center, taking the lives of six per-

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