Social Science & Medicine 66 (2008) 1699e1708

www.elsevier.com/locate/socscimed

Economic development as a determinant of injury

mortality e A longitudinal approach
Syed Moniruzzaman*, Ragnar Andersson
Division of Public Health Sciences, Department of Health and Environmental Sciences, Karlstad University, 651 88 Karlstad, Sweden
Available online 4 March 2008

Abstract

Cross-sectional studies have produced clear inverted U-shaped curves between injury mortality and economic development; yet,
this does not mean that single countries will necessarily follow similar curves as they grow richer over time. This study was con-
ducted to examine whether previous cross-sectional findings can be verified using a longitudinal approach. Data for both injury
mortality and gross domestic product (GDP) per capita were obtained from an official health database for the member countries
of the Organization for Economic Cooperation and Development (OECD) for the period of 1960e1999. Regression models
were then used to examine the longitudinal relationship between these two variables. Substantial improvements in injury mortality
were observed in all income categories in the selected countries. For higher and middle high-income countries, injury mortality
rates (all causes) increased until 1972, peaking in 1972 and then declining. For industrialized countries with relatively low
GDP, injury mortality rates increased until 1977 and then declined. Using cubic regression lines for injury mortality rates, for
all income categories, injury mortality rates increased up to a GDP per capita of $3000e$4000, then decreased significantly.
The rising trends of suicide and homicide rates were observed until countries attained a GDP per capita of around $13,000e
$14,000 for all income categories. It is noteworthy that compared to the intentional injury categories, mortality due to road traffic
accidents and injuries from falls declined earlier on in the economic development process. Longitudinal analysis among high-
income countries confirms earlier cross-sectional findings; that is, most injury categories seem to follow inverted U-shaped trend
lines, with declining trends after peaking at various stages of temporal and economical development. A comparison between time
and economy suggests that differences in peaking time between countries for the same injury category is partly a reflection of
temporal differences in economic development.
2007 Elsevier Ltd. All rights reserved.

Keywords: Economic development; Injury; Suicide; Homicide; Mortality; Organization for Economic Cooperation & Development (OECD);
Longitudinal

Introduction

Economic development has long been considered an

* Corresponding author. Tel.: 46 547002535; fax: 46 54 7002
220.
E-mail addresses: syed.moniruzzaman@kau.se (S. Moniruzzaman),
ragnar.andersson@kau.se (R. Andersson).
important determinant of changing patterns of disease,
disability, and mortality in populations (McKeowan,
Record, & Turner, 1975; Preston, 1975, 1978; Rogers
& Wofford, 1989). Throughout the last century,

0277-9536/$ - see front matter 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2007.12.020
1700 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708
important epidemiological changes accompanied eco-
nomic development in most countries, especially those
known today as high-income countries (HICs). Further,
both mortality and fertility rates declined enormously.
Rising standards of living in a population make a major
contribution to the shift in main causes of death, from
infectious and communicable diseases such as malaria,
diarrhea, and tuberculosis to non-communicable and
man-made conditions such as cancers, cardiovascular
diseases, and injuries resulting from road traffic
accidents (van Beeck, Looman, & Machenbach, 1998;
Murray & Chen, 1993; Murray & Lopez, 1997; Oppe,
1991; Thom, Epstein, Feldman, & Leaverton, 1985).
These major changes in disease patterns led to the for-
mulation of a theory called the health (epidemiologic)
transition theory (Omran, 1971). This health transi-
tion may have been completed in all high-income
countries, whereas in developing countries it is still
underway (Omran, 1971, 1983).
In high-income countries, the rising trends in cardio-
vascular diseases of the 1950s and 1960s were later
reversed in spite of growing economic development
(Uemura & Pisa, 1988). In the 1970s, such observations
inspired the graphic modeling of the health transition
process in the form of waves of health problems
replacing each other through the course of historical de-
velopment: first a declining wave of communicable dis-
eases (diseases of poverty), to be followed by a wave of
non-communicable diseases (diseases of civilization or
well-being), and thirdly (and tentatively) an upswing in
psycho-social health problems (Hjort, 1994).
Discerning secular trends and understanding health
transition processes are essential for the adoption of
adequate health policies and health planning in all
countries. The relationship between socio-economic
development and injury as a cause of mortality and mor-
bidity needs further clarification (Beaglehole & Bonita,
2004). In an attempt to examine the relationship
between economic development and injury mortality,
cross-sectional studies have produced diverging results.
Early studies on road traffic injury in a global perspec-
tive showed increasing injury mortality rates with
growing national economies (Soderlund & Zwi, 1995;
Wintemute, 1985). However, more recent and compre-
hensive studies on unintentional injury mortality
(UIM) in the span from low to high-income countries
have yielded more complex findings. These analyses
have consistently shown an inverted U-shaped pattern
in relation to economic development (Ahmed & Ander-
sson, 2000, 2002; Moniruzzaman & Andersson, 2005a;
Plitponkarnpim, Andersson, Jansson, & Svanstrom,
1999; Plitponkarnpim, Andersson, Horte, & Svanstrom,
1999). In parallel cross-sectional studies on intentional
injury mortality (suicide and homicide), similar in-
verted U-shaped patterns are also found in association
with GNP per capita (Moniruzzaman & Andersson,
2004, 2005b).
The main problem in previous cross-sectional stud-
ies where the association between injury mortality and
economic development was examined is that even if
cross-sectional studies produce clear inverted U-shaped
curves for mortality from low to high-income countries
at a specific point of time, this does not necessarily
mean that specific countries follow similar curves as
they grow richer over time. This is why further analysis
is required to examine whether previous cross-sectional
findings can be verified using a longitudinal approach.
Since high-income countries have generally ad-
vanced through most stages of epidemiological transi-
tion, as far is known today, this paper aims to explore
the longitudinal relationship between injury mortality
and economic development in high-income countries
over a long time span.
Method
Data sources and inclusion criteria
Mortality and GDP per capita e US$ adjusted with
purchasing power parity (PPP) data e were derived
from the official health database for the member coun-
tries of the Organization for Economic Cooperation and
Development (OECD) for the period of 1960e1999
(OECD, 2006). PPP-adjusted values are the rates of cur-
rency conversion that equalize the purchasing power of
different currencies. Thus, PPP-adjusted values elimi-
nate differences in price levels between countries.
Data for all OECD countries reporting to the mortality
database were reviewed. Age standardized mortality
data for 21 OECD countries were available for each
year from 1960 to 1999, except 1999 for which data
were missing from Belgium, Canada, Denmark, and
New Zealand. Some countries were also excluded due
to small population size (<1 million) in order to reduce
sampling variability. Data were acquired on cause-
specific mortality rates (per 100,000 in the population)
of UIM, fall injury, RTA, suicide, and homicide.
The 21 countries are grouped into three categories by
level of income in GDP per capita, US$ (PPP), based on
the number of countries in each category and significant
income differences between the categories: high-
income countries with high levels of GDP per capita
(higher high-income countries) ranging from $25,501
to $33,016: Australia, Austria, Ireland, Netherlands,
 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708 1701

Canada, Denmark, Switzerland, Norway, and the  Self-inflicted, in other words, suicide (E950eE959
United States (category 1); high-income countries for ICD-9, X60eX84, Y870 for ICD-10).
with medium levels of GDP per capita (middle high-  Interpersonal violence, in other words, homicide
income countries) ranging from $20,501 to $25,500: (E960eE969 for ICD-9, X85eY09, Y871 for
Finland, UK, France, Italy, Sweden, Germany, Bel- ICD-10).
gium, and Japan (category 2); and the lower income
level among high-income countries with GDP per cap- No corrections for inconsistencies between the two
ita (lower high-income countries) from $9386 to versions are made. However, potential impacts from
$20,500: Greece, Portugal, Spain, and New Zealand such inconsistencies are commented under the
(category 3) (Fig. 1). Discussion.
Intentional and unintentional injuries are defined by
a series of codes for external cause of death (WHO, Statistical methods
2001). Unintentional injuries are subdivided into road
traffic injuries, poisoning, falls, fires, drowning, and Means of age standardized mortality rates for injury
other unintentional injuries. Intentional injuries are sub- (all causes) and the four major causes of injury, that is,
divided into self-inflicted injuries (suicide), interper- RTA, falls, suicide and homicide, were calculated for
sonal violence (homicide), war-related injuries, and each income category of countries and year. In stratified
other intentional injuries. analyses, carried out for each of the three income
The International Classification of Disease (ICD), groups of countries, least squared regression lines
9th and 10th editions, was used to define specific causes were fitted to examine the longitudinal relationship
of injury mortality that are referred to in this study. between the cubed value of GDP per capita and injury
mortality. The cubic regression models provided an ad-
 All injuries (E800eE999 for ICD-9, V01eY90 for equate fit, which was better than alternatives using
ICD-10). lower order transformations of the GDP per capita vari-
 Road traffic injuries (E810eE819, E826eE829, able (van Beeck, Borsboom, & Mackenbach, 2000; Lee
E929 for ICD-9, V01eV89, V99, Y850 for ICD- & Shaddick, 2007). The regression lines are presented
10). below in graphs which illustrate the cubic relationship
 Falls (E880eE888 for ICD-9, W00eW19 for ICD- between mortality and GDP per capita predicted by
10). the models. Therefore, the data were best described
by an asymmetric curve. The longitudinal relationship
Country by income per capita between GDP per capita and injury mortality variables
United States 33016
was established for the three income categories. This
Norway 29876 helped to identify income-related differences in injury
Switzerland 28775 mortality by time and economic development. Two sta-
Denmark 27542
Category 1: tistics are presented: adjusted R2, and the associated p
Canada 26601
Netherlands 26581 $25 501 or more value. The adjusted R2 shows the extent to which the
Ireland 25981 two variables are related, and the p value indicates the
Austria 25644 significance of the regression model. The statistical sig-
Australia 25550
nificance levels were set at p < 0.01 and p < 0.05.
Japan 24801
Belgium 24776 Results
Germany 24592
Sweden 24342 Category 2:
Italy 24026 $20 501-$25 500
Injury mortality (all causes) and cause-specific in-
France 23831 jury mortality (i.e., RTA, fall injury, suicide, and homi-
United Kingdom 23741 cide) rates over time, for the three income categories of
Finland 23224
countries, are shown in Fig. 2. In recent decades,
New Zealand 19258
substantial improvements in injury mortality have
Spain 19018 Category 3: been observed in all income categories. More specifi-
Portugal 16854 $20 500 or less cally, for income categories 1 and 2, injury mortality
Greece 15753
rates (all causes) first increased up until 1972, with rates
Fig. 1. Country categories by GDP per capita, US$ (PPP), 1999 of mortality peaking in 1972 e at 73 per 100,000 pop-
(Source: Data from OECD health database). ulation e then declined. For income category 3, the
1702 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708

Injury (all causes)

80

70

Rates/100 000
60

50

40

Cat 1
30 Cat 2
Cat 3
20
60

65

70

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85

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95

00
19

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Year

RTA Fall Injury

30 18
16
25
14
Rates/100 000

Rates/100 000
20 12
10
15
8
10 6
Cat 1 4 Cat 1
5 Cat 2 Cat 2
Cat 3 2 Cat 3
0 0
60

65

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Year Year

Suicide Homicide
18 3
Cat 1
16
Cat 2
2.5
14 Cat 3
Rates/100 000

Rates/100 000

12 2
10
1.5
8
6 1
4 Cat 1
Cat 2 0.5
2 Cat 3
0 0
0

85

95

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95

0
6

0
19

19

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Year Year

Fig. 2. Trends lines in age standardized injury mortality rates (per 100,000) by country category among high-income countries, 1960e1999
(Source: Data from OECD health database).

lower income countries, injury mortality rates increased countries. For categories 1 and 2, mortality rates due
until 1977 and then declined. to RTA increased until 1972, followed by a general de-
Similar inverted U-shaped trends in mortality due to cline in rates. For category 3, RTA mortality rates in-
road traffic accidents (RTA) and fall injuries were ob- creased until 1977, then leveled off until 1990, and
served for all income categories of the selected declined from 1990 onwards. Reversal trends were
 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708
also observed for fall injury mortality rates in all in-
come categories, resulting in an earlier rise and then
a downward trend in categories 1 and 2, and a late
downward trend in category 3.
The trends in mortality due to intentional injuries
such as suicide and homicide were more uncertain. In
general, suicide rates increased slightly until 1984 for
income categories 1 and 2, with the highest rates of
suicide at 17 per 100,000 in category 2 in 1984; for cat-
egory 3, no significant change in suicide rates was
observed.
Homicide trends were also more inconsistent over
time for all income categories with a slow upswing,
a leveling off, and then a decrease in mortality rates
from the early 1990s onwards. However, homicide
rates were generally higher throughout the time period
for category 1, followed by category 2 and then
category 3.
Fig. 3 shows the cubic regression lines for injury
mortality by cause over time from 1960 to 1999. The
cubic regression lines of injury mortality formed clear
and consistent inverted U-shaped curves over the study
period. Two major findings were observed in Fig. 3:
first, an earlier peaking time is observed for higher in-
come categories compared to lower income categories
for all injury types, and secondly, peaking was seen to
occur earlier in RTA (except for income category 3)
and fall injury (unintentional injury) mortality com-
pared to suicide and homicide (intentional injury).
Fig. 4 shows regression lines of injury mortality (all
causes) and cause-specific injury mortality rates by eco-
nomic development, measured as GDP per capita, US$
(PPP adjusted). Using cubic regression lines for injury
mortality rates for all income categories, injury mortal-
ity rates increased until reaching a GDP per capita of
$3000e$4000, and then decreased significantly from
the GDP level per capita of $4000. For RTA, for cate-
gories 1 and 2, the changes in mortality rate by GDP
per capita were similar to that for all causes of injury,
which increased up to GDP per capita $3000e$4000
followed by a significant decline above this level of
GDP per capita ($). For category 3, RTA rates increased
up to the GDP per capita of $8800, followed by a signif-
icant decrease when GDP per capita rose to more than
$9000. Similar reversal trends of mortality were found
for fall injury mortality and for injury mortality (all
causes) with an exception of the higher income category
(category 1); mortality due to fall injury increased up to
a GDP per capita of $3000e$4000 trailed by a decline
for categories 2 and 3, while mortality was more line-
arly related with GDP per capita for category 1. The
rise of trends in mortality of suicide and homicide rates
1703
were observed up to levels of GDP per capita around
$13,000e$14,000 for all income categories. It is note-
worthy that compared to the intentional injury cate-
gories, RTA and fall injury mortality declined earlier
in the economic development process. However, all of
our injury categories exhibited increasing and then
decreasing levels of mortality rates, as GDP per capita
increased over time, suggesting an inverted U-
relationship.
Table 1 shows the coefficient of determination (r2) of
the regression model for each income category of
countries and their significance levels indicating the
extent to which the two variables (GDP per capita and
injury mortality) are related.
Discussion
Data from 21 member countries of the OECD were
analyzed in this study. These countries are referred to
as the established market economies (Murray & Lo-
pez, 1997) or the industrialized countries (Soderlund
& Zwi, 1995). There were two major shifts of coun-
tries between the income categories since 1960;
New Zealands GDP per capita was similar to that
of Australia, Canada, and Denmark (category 1) in
1960 and Irelands GDP per capita was close to the
average for category 3 (Greece, Portugal, Spain, and
New Zealand) in 1970e1990. However, in our analy-
sis all countries remained within their income-based
categories as they were defined by 1999. The influ-
ence from these shifts on our overall results is consid-
ered to be limited. The current study provides
longitudinal evidence on the national income (GDP
per capita) e injury relationship among high-income
countries. Inverted U-shaped curves for injury mortal-
ity over time and over GDP per capita have been
found, as predicted in earlier cross-sectional studies
(Ahmed & Andersson, 2000, 2002; Moniruzzaman
& Andersson, 2004, 2005a, 2005b; Plitponkarnpim,
Andersson, Horte, et al., 1999; Plitponkarnpim, An-
dersson, Jansson, et al., 1999). Our results show that
in most countries, economic development has been ac-
companied by safety improvements since the early
1980s, but by increased injury risks in earlier years
of the study period. We also find variation in peaking
time and levels between income strata and injury cat-
egories, as well as the corresponding variation by eco-
nomic development. The comparison of injury
mortality over time versus by economic development
suggests that differences in peaking time seem in
part to be a matter of temporal differences in eco-
nomic development.
1704 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708

80 Injury (all causes)

70

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30 Cat 2
Cat 3
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00
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Year

30
RTA Fall Injury
18
16
25
14
Rates/100 000

Rates/100 000
20 12
10
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10 6
Cat 1 4 Cat 1
5 Cat 2 Cat 2
Cat 3 2 Cat 3
0 0
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Year Year

18
Suicide Homicide
3
16
2.5
14
Rates/100 000

Rates/100 000

12 2
10
1.5
8
6 1
4 Cat 1 Cat 1
Cat 2 0.5 Cat 2
2 Cat 3 Cat 3
0 0
0

65

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00

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00
6

9
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Year Year

Fig. 3. Cubic regression lines of cause-specific injury mortality rates (per 100,000) by country category among high-income countries, 1960e1999.

The underlying causes of these reversal trends of in- Andersson, Horte, et al., 1999), but rather separate ex-
jury mortality are little known or discussed. Differences planations for each category of injury. Unintentional in-
in peaking time (or economic levels) among different in- jury mortality among children starts to decline already at
jury categories and age/sex groups suggest that there is lower levels of economic development, which may be
no universal explanation (Ahmed & Andersson, 2000; explained by a combination of social changes (fewer
Moniruzzaman & Andersson, 2005a; Plitponkarnpim, children per family, increased school attendance, etc.),
 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708 1705

Fig. 4. Cubic regression analysis between mortality rates of cause-specific injury and economic development, measured GDP per capita, in three
income categories, 1960e1999.
1706 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708
Table 1
Coefficient of determination (r2) and associated p value of cubic
regression of injury mortality rates and level of GDP per capita by
country category among high-income countries, 1960e1999
Cause of mortality Category 1 Category 2 Category 3
HIC (high) HIC (medium) HIC (low)
Injury 0.98** 0.98** 0.94**
Unintentional
RTA 0.97** 0.94** 0.93**
Falls 0.98** 0.97** 0.95**
Intentional
Suicide 0.95** 0.91** 0.26ns
Homicide 0.89** 0.71** 0.82**
**p < 0.01; ns, not significance.
exposure changes (urbanization, shift from unprotected
to protected modes of traveling, decline in child labor,
etc.), and child safety programs (Bergman & Rivara,
1991; Plitponkarnpim, Andersson, Jansson, et al.,
1999). Among adults, where peaking occurs somewhat
later in the developmental process and where traffic
and occupational injuries play a larger part, structural
changes in these environments such as shifts in vehicle
fleets from two-wheelers to four-wheelers, improved
road infrastructure, shift from mechanized to automated
industrial production, transfer of dangerous jobs to low-
wage countries may account for the reversal trends in
this group (van Beeck et al., 2000; Berger & Mohan,
1996). Other factors include successful traffic and occu-
pational safety programs. Finally, among the elderly,
where unintentional injury is strongly dominated by
falls, for which many countries still experience increas-
ing rates, changes in life style (physical inactivity, etc.)
and improvements in health care and nursing, leading
to larger proportions of frail seniors with multiple illness
surviving into advanced ages, might be of key impor-
tance (Deeg, Potrait, & Lindeboom, 2002; Saari, Heikki-
nen, Sakari-Rantala, & Rantanen, 2007).
Inverted U-shaped curves are also observed in the re-
lationship between economic development and changes
in environmental health risks. Considerable literature
has dealt with the question of whether environmental
health risks tend first to rise and then fall with economic
development, as described for income inequality by No-
bel economist Simon Kuznets in the 1950s (Barbier,
1997). The empirical literature (Grossman & Krueger,
1995; Selden & Song, 1994; Stern & Common, 2001)
refers to inverted U-shape curves between environmen-
tal health risk factors and economic development; for
example, pollutant levels rise and then fall with increas-
ing national income (Smith & Ezzati, 2005). In the be-
ginning of economic development, however, little
weight is given to environmental concerns, causing
pollution to rise alongside industrialization (Smith &
Ezzati, 2005). After a certain threshold, when basic
physical needs are met, interest in a clean environment
rises, reversing the trend.
The incomeeinjury curves have some importance
from a national and global health policy perspective.
Up to a certain national income level, increasing
wealth may give rise to more injury deaths. Globally,
a limited number of countries have reached this level,
meaning that on a global scale, a considerable increase
in public health damage due to injuries could still be
expected in low-income and lower middle-income
countries, as has been reported previously (Murray &
Lopez, 1997). In richer countries, the secular trend
seems to be clearly declining. However, segments
of emerging injury risks may still appear as a conse-
quence of social changes, for example, aging popula-
tions or socio-political and economic crises (Kaasik,
Andersson, & Horte, 1998).
Since this study is based on existing data sources,
findings of this type should be interpreted with caution.
Possible registration bias caused by differences in cod-
ing of mortality between countries and over time must
be taken into account. It is increasingly recognized
that classification of death due to fall injury varies
over time and between countries (Janssen & Kunt,
2004; Jansson, 2005). Moreover, in the case of inten-
tional injuries, policies and/or practices involving
recording a death as suicide vary between countries
despite the use of a standard classification system
(Morrison, Stone, & EURORISC Working Group,
2000). For example, in Luxembourg, a suicide note is
required to register a death as suicide, whereas in other
countries (e.g., the UK, Ireland) a decision on intent is
made by a coroner. Social and cultural norms may also
be influential determinants for whether a death will be
identified and registered as suicide.
Another problem is the limited sample size for in-
come category and the category distribution, especially
for category 3. Three out of four countries in category 3,
are southern European countries which have consis-
tently lower mortality rates due to suicide than those
in northern European countries. Southern European
countries are predominantly Catholic, and religious
affiliation has long been regarded as an important factor
in suicide behavior and classification (Farberow, 1975;
WHO, 2002). Moreover, some single countries have
demonstrated deviating trends from the general patterns
of inverted U-shaped curves; for example, no reversal
trend was found in mortality due to homicide in the
United States regardless of the economic progress
 S. Moniruzzaman, R. Andersson / Social Science & Medicine 66 (2008) 1699e1708
achieved during the study period. Therefore, the study
design is also susceptible to aggregation bias; this
means that associations observed for pooled countries
do not necessarily apply to individual societies.
Aggregating data from countries of various sizes,
and calculating means, is the subject of another contro-
versy. However, since official data are normally com-
piled and presented at national levels, and since
nations to some degree represent separate sets of legal,
political and economic conditions, we assert that coun-
tries are relevant units to study and to compare regard-
less of their size. At a population (group, individual)
level, however, much more detailed analyses need to
be performed, taking intra-national differences into
account, such as inequalities between population sub-
categories, differences in social, economic, and indus-
trial development between domestic districts, and so on.
GDP per capita was used as the only indicator of eco-
nomic development. Other parameters could also be
used, such as the gross national product (GNP), levels
of exports or external debts, vehicle ownership, energy
or newspaper consumption, literacy, home ownership
and so on. Despite the limitations, the attainment of
a modest level of per capita GDP is a major landmark
or indicator for a countrys economic development
(Smith & Ezzati, 2005; World Bank, 1982).
Repeated and more comprehensive longitudinal
studies that use age- and sex-specific data are needed
to validate the relationships described here. As more
injury mortality data become available over time, longi-
tudinal studies will also be possible for LICs and MICs.
These are essential for examining associated changes in
both variables (dependent and independent) so that the
link between economic changes and injury mortality
can be better documented and understood.
Conclusion
Longitudinal analyses among high-income countries
confirm earlier cross-sectional findings, where most in-
jury categories seem to follow inverted U-shaped trend
lines, with declining trends after peaking at various
stages of temporal and economic development. Injury
mortality rates increased up to a certain level of GDP
per capita in all income country categories, and then de-
creased significantly up to the highest level of GDP per
capita. The comparison of injury mortality between
time and economy suggest that differences in peaking
time between countries for the same injury category
seem in part to be a matter of temporal differences in
economic development. Further research on causation,
mechanisms, broader indicators, and data quality, is
1707
needed to fully understand the dynamics of the relation-
ship between economic development and injury
mortality.
Acknowledgements
We wish to thank Karen Leander for English check-
ing and the Swedish Rescue Services Agency, for their
financial support.
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