Bener, Abdulbari PhD, ITMA, MFPHM, FRSS*; Al-Mulla, Fatima H BSc†; Al-Humoud, Suhail M Q BSc, MSN‡; Azhar, Abdulaziz MD, FRCS(A&E)‡
Accidents and injuries are a large and growing health problem, although our knowledge of their epidemiology is inadequate.1,2 Trauma is a prominent cause of death among children aged 0 to 15 years in most countries. Statistics on mortality resulting from accidents or injuries by age and sex are available for most developed and developing countries. Some of this information has been presented by the World Health Organization2 and United Arab Emirates.1 Data on morbidity resulting from accidents is far less satisfactory. A system for registration of accidents is unavailable in most countries, even in industrialized ones.1
There are numerous sports and recreational and occupational activities that are related to camels. By tradition, camel racing is one of the most popular sports in Qatar. It is a tourist attraction sport. Tour companies organize the ideal outing to watch racing camels training at Al Shahaniya race track for animal lovers in Qatar. Massive sums of money are spent on the animals and races. In Qatar, camel races take place every year during January, February, and March, which is between winter and spring. Around the Middle East, child slaves are often used as camel jockeys. Before the camel races, children go without food for 1 week, not as a punishment but to keep their weight down, so the camels will run faster. Camel riding and handling is risky and very dangerous. Observation of racing events and that of patients treated indicates that they are poorly nourished and from families of poor social and financial background. Camel racing injuries are common in Arabian Gulf countries.
The descriptive data on camel racing injuries provide important information on the nature and distribution of these injuries. The study findings highlight the causes of these injuries and help in bringing public and political attention to injury prevention priorities. Nearly 100,000 people in the Arabian Gulf countries ride camels. Different studies have tried to analyze the injury pattern and define factors that affect camel-related injuries3-5 and camel race-related injuries.6,7 Camel-related fatal accidents and injuries are causing increasing concern. Studies from Saudi Arabia reported that camels were more often associated with injury than other types of accidents, and an analysis of the causes showed that most were preventable.4,5 Mortality rates have been consistently lower and falling in the United States8 and Canada,9 but in the United Kingdom and New Zealand, hospital admission rates due to children's injuries are increasing.10-13
The authors are not aware of any study that has defined the severity of camel racing injury morbidity and mortality and factors that affect them. The aim of this study is to determine the frequency and severity of camel racing injuries among young camel jockeys aged 5 to 15 years in the State of Qatar.
Study Design and Participants
This is a case series retrospective study design that included all accidents, injuries, and deaths among children camel jockeys aged 5 to 15 years for the period between January 1992 and December 2003. A total of 275 subjects with camel racing injuries who were seen at the Accident Emergency Department, Critical Care, and Physiotherapy Departments of the Hamad General Hospital were studied. Hamad General Hospital is the main tertiary care center and serves as a teaching hospital for Weill Cornell medical college in the country, and all injury cases are treated in this hospital. Data were obtained from the Medical Records Department, plus the ward, intensive care unit, and operating theater records. The medical records comprised 2 parts:
* General factors: date of birth (age), sex, nationality, date of admission, arrival time, date of discharge and outcome of treatment
* Specific factors: the frequency and severity of injuries (among pediatric camel jockeys), distribution of injuries by body region
The data of this study covered all the injuries of children who were involved in camel racing for the analysis. Severity of injury was graded according to the Abbreviated Injury Scale (AIS).14,15
The statistical analyses were performed using the Statistical Package for Social Sciences.16 Data were expressed as mean and SD unless otherwise stated. The Student t test was used to ascertain the significance of differences between mean values of 2 continuous variables. One-way analysis of variance and nonparametric Kruskal-Wallis analysis of variance was employed for comparison of several group means and to determine the presence of significant differences between group means. The level P < 0.05 was considered as the cutoff value for significance.
Between January 1, 1992, and December 31, 2003, 275 camel racing injuries were reported among children aged 5 to 15 years. Of these, 165 boys (60%) were hospitalized and 110 boys (40%) had only superficial injuries. The final status of the inpatients indicated that 82 patients (50% of the subjects) saw improvement through physiotherapy; 17 patients (10%) were disabled due to a fractured femur, fractured pelvis, fractured spine, and intracranial hemorrhage; and 66 (40%) did not require any physiotherapy.
Table 1 shows the sociodemographic characteristics of the injured children. All camel racing injuries occurred among males because only boys were employed as camel jockeys. The majority (91.3%) of these children were Sudanese. The patient population had a mean (SD) age of 8.1 (2.23) years, but the age range was higher for those between 5 and 8 years (59.3%), followed by 9 to 12 years (33.5%) and 13 to 15 years (7.3%). The mean (SD) hospital stay was 5.98 (7.61) days.
Table 2 shows the distribution of injuries by anatomic location and mean length of hospital stay. As can be seen from this table, the main location of injuries among children were upper limb (23.2%), lower limb (21.1%), head (20.7%), chest (8.4), abdomen (7.2%), and neck (6.6%), followed by other types of injuries. Head injuries had the maximum hospital stay compared with other injuries (9.9 ± 7.5).
Table 3 gives injuries scored by the AIS. A little more than a third of the injuries (34.4%) were considered to be minor, 22.1% moderate, 18.1% serious, 11.6% critical, and 6.5% maximal-fatal.
There was a statistically significant correlation between the duration of hospital stay and the AIS (ρ = 0.820; P = 0.001) and between age and AIS (ρ = 0.241; P = 0.0028).
Figure 1 shows the trend of camel racing injuries reported from 1992 to 2003. It is worth noting that the number of camel racing injuries increased gradually from 1997 until 2002, and there was sudden decrease in the year 2003.
The current study in Qatar has shown that camel racing injuries were higher in Sudanese boys because most of the camel jockeys were brought from Sudan. The possible reason for this significant problem could be their poor financial background or their willingness to come to work in Qatar. Sudanese children tend to be lightweight and thus are deemed quite suitable as camel jockeys. Because all the subjects were boys (due to the nature of the sporting event), our study could not show a gender effect on injury severity.
As far as the authors have surveyed, this is the first study involving camel racing injuries among children in an oil-rich Arabian Gulf country. One of the reasons for publishing our data was to raise the level of awareness of both the frequency and severity of camel-related children's trauma in Qatar. This situation may be applicable to other Arabian Gulf countries including the United Arab Emirates, Kuwait, Saudi Arabia, and the Sultanate of Oman. These injuries appeared to be associated with limitations in the legality, education, and level of compliance with basic safety measures, especially with regard to riding helmets and other safety equipment.
This study demonstrated that the injury severity caused by the camel racing significantly affected the length of hospital stay. Head injuries had the maximum stay in the hospital compared with other injury locations, followed by neck injuries.
Similar to other reports, most of the injuries were caused by falls from the camel.4-7 Nearly a quarter of our patients had head injuries, with a high number of skull fracture and brain injuries (31.6%). Of the patients with neck injuries (n = 18), 5 children ended up with permanent spinal cord disabilities. Arms of horse riders are usually extended when they fall from the animal. This may explain the high prevalence of upper limb injuries.17 Previous research has shown that the frequency of fractures was high in hospitalized patients.18
Different studies have demonstrated that head injuries were the main cause of death in horse-related injuries.12,19 The camel racers tend to wear the traditional cloth covering the head without helmets. Head injuries occurred in a quarter of our patients. There was a high proportion of missing information regarding helmet use. Ingemarson et al19 have shown that equestrian riders using recommended helmets have significantly lower head injuries than those using classic ones. The use of proper riding helmets has dramatically reduced the number of severe and fatal head injuries.19,20
Although most of the patients had minor, uncomplicated injuries that did not need hospitalization, our study focused on those with serious (18.1%) and severe injuries (11.3%), and those who needed hospitalization with critical (7.3%) and maximum (6.5%) injuries. Of the 18 patients with maximal injuries, 3 deaths were fatal and recorded. The rest of the children were taken abroad to Germany or the United Kingdom or other countries for further management, and the final outcome of these patients were unknown. Camel racing has the highest mortality of all sports in this region and can be more dangerous than motorcycle or car racing.3-12 The mortality of hospitalized patients in our study was much less than 1% (3 deaths), most probably due to excellent medical and rehabilitation services, though it is possible that more patients may have died before arriving at the hospital.
In the present study, we observed that the patients who were thrown from camels and subsequently had a camel fall on them tended to have more serious injuries. A camel can weigh more than 750 kg, and serious injury may be inflicted if the camel rolls over the rider. The outcome of the treatment of the injured patients indicated that half of them realized good improvement through physiotherapy, but 10% of them were totally disabled. The injuries in this study were measured in AIS, which is limited to anatomic injuries by body regions. Due to the lack of data, we could not use the Injury Severity Score.
There is a need to do further research in this area. The study has to be repeated after implication of new laws. Additionally, some deaths occurring outside of the hospital setting should also be measured and included.
Furthermore, more recently, a committee21 was established for further investigation, and as a result, the State of Qatar issued a decree that bans the import, recruitment, training, or involvement of children in camel racing. Otherwise a very severe penalty will be imposed, and that person would be deported from the country immediately. The committee wants to make Qatar the first Gulf country to tackle this problem in an effective manner. The practice of employing child camel jockeys, some as young as 5 or 6 years, has come under a cloud over the past few years, with human rights forums urging an end to it. This is quite evident from Figure 1: there was a sudden decrease in the number of injuries in the year 2003. There have been no camel race-related injuries reported to accident and emergency services since January 2005. Camel race clubs are planning to use robots instead of children in the future, and these are currently being tested.
Finally, we have demonstrated in our current study that severity of injury had a significant effect on the duration of hospital stay. A wider appreciation of the potential dangers of camel riding and a greater awareness of the serious injuries that can occur, especially in racing events, may help to make it safer. Improved personal protective equipment and teaching riders safe falling techniques may reduce hospital admissions and severity of injuries.20
Camel racing injuries involving children in Qatar account for a considerable number of disabilities and, although not measured in this study, deaths. In summary, safety in all potentially dangerous sports should be foremost in the minds of those who administer, supervise, and participate in such games, because camel racing injuries in children account for a considerable number of disabilities and, although not measured in this study, deaths.
In the present study, there are certain limitations in the data obtained from the hospital. First is the reliability of reported levels of injury severity by casualty doctors. Some misclassification between levels is possible. Second is underreporting of injuries, especially for minor injury falls. There may be differences in distribution between minor injuries from falls that are reported and those that are not. This may result selection bias. Lastly, mortality rates have likely been underestimated in this study because those children who died on site would not have been brought to the hospital.
The present study has provided insight into the nature and frequency of camel racing injuries affecting children and youth in Qatar. Camel racing-related injuries significantly affected the duration of hospital stay and the injury severity. Upper and lower limb were the most common location of injuries found in the injured subjects. At present, the government is serious about this problem, and there is a draft of proposed legislation intended to prevent the employment of children below the age of 12 as camel jockeys.
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