Patterns of violence‐related skull trauma in neolithic southern scandinavia

This article examines evidence for violence as reflected in skull injuries in 378 individuals from Neolithic Denmark and Sweden (3,900–1,700 BC). It is the first large‐scale crossregional study of skull trauma in southern Scandinavia, documenting skeletal evidence of violence at a population level. We also investigate the widely assumed hypothesis that Neolithic violence is male‐dominated and results in primarily male injuries and fatalities. Considering crude prevalence and prevalence for individual bones of the skull allows for a more comprehensive understanding of interpersonal violence in the region, which is characterized by endemic levels of mostly nonlethal violence that affected both men and women. Crude prevalence for skull trauma reaches 9.4% in the Swedish and 16.9% in the Danish sample, whereas element‐based prevalence varies between 6.2% for the right frontal and 0.6% for the left maxilla, with higher figures in the Danish sample. Significantly more males are affected by healed injuries but perimortem injuries affect males and females equally. These results suggest habitual male involvement in nonfatal violence but similar risks for both sexes for sustaining fatal injuries. In the Danish sample, a bias toward front and left‐side injuries and right‐side injuries in females support this scenario of differential involvement in habitual interpersonal violence, suggesting gendered differences in active engagement in conflict. It highlights the importance of large‐scale studies for investigating the scale and context of violence in early agricultural societies, and the existence of varied regional patterns for overall injury prevalence as well as gendered differences in violence‐related injuries. Am J Phys Anthropol, 2013. © 2012 Wiley Periodicals, Inc.     

Cranial trauma in iron age Samnite agriculturists, Alfedena, Italy: implications for biocultural and economic stress

The Samnites are an Iron Age protohistoric people from the central region of Italy. The skeletal remains are from the Alfedena necropolis, 6th through 5th centuries B.C. Macchiarelli et al. (Antropologia Contemporanea 4 (1981) 239-243) were the first to report on cranial trauma for this population, presenting four cases with extreme injuries. We re-examined this well documented skeletal population for additional examples of trauma. Previously unexamined remains from Alfedena, excavated at the turn of the 20th century, are also included in our analysis (Mariani. 1901. "Aufidena", ricerche archeologiche e storiche del Sannio settentrionale. Roma: Acc Naz Dei Lincei). Of the 209 adult crania examined, 12.9% of them exhibited trauma. Analysis of location and frequency of cranial trauma revealed that cranial injuries to the head appear to originate from all directions. The high rate of cranial trauma underscores the violent circumstances experienced during the Iron Age protohistoric period of central Italy. Males are much more likely to exhibit cranial injury than females (P = 0.009). We conclude that the injuries received by Samnite male farmer-warriors occurred while defending pastoral-agricultural resources. Trauma rates are similar for some Iron Age populations and not for others. Behavior associated with violence during the Iron Age period can not be generalized for all populations found in Italy.     

Bioarchaeological investigation of ancient Maya violence and warfare in inland northwest Yucatan,Mexico

This study investigates evidence of changes and continuities in ancient Maya violence and warfare in inland northwest Yucatan, Mexico from the Middle Preclassic (600–300 BC) to the Postclassic (AD 1050–1542) through bioarchaeological analysis of cranial and projectile trauma. It is hypothesized that the frequency of violence increases before the Classic Maya collapse and remains high during the Postclassic period. It is also hypothesized that the flat, open terrain was conducive to warfare and resulted in higher trauma frequencies than in other parts of the Maya area. Results show that the frequency of cranial trauma decreases before the Classic collapse and increases in the Postclassic, partially matching the expected chronological trends. The frequency of cranial trauma does not differ significantly from other Maya regions but the pattern does: for all periods, males have more healed injuries than females and they are concentrated on the left side of the anterior of the skull. Some injuries appear to be from small points hafted in wooden clubs. In addition, projectile trauma is evident in a scapula with an embedded arrowhead tip, the first such case reported in a Maya skeleton. Overall, these results suggest greater reliance on open combat and less on raids in this region compared with other parts of the Maya area, possibly due to the flat, open terrain, though the identification of perimortem trauma in both women and men indicates surprise raids on settlements were also practiced. Am J Phys Anthropol 154:140–151, 2014. © 2014 Wiley Periodicals, Inc.     

Warfare related trauma at Orendorf, a middle Mississippian site in west-central Illinois

Skeletal evidence of nonritual interpersonal trauma in the central Illinois valley is currently limited to the terminal prehistoric period in the region. Sixteen percent of the entire Norris Farms Oneota skeletal sample died violently, presumably because they intruded upon small groups of Mississippians who had not yet abandoned the region. Archaeological evidence of palisades, however, suggests that the region was embroiled in conflict before the Oneota arrived though the skeletal evidence supporting more than ritualized or geographically sporadic cases of scalping or embedded projectiles has been elusive. This study examines the frequency and nature of interpersonal trauma at Orendorf, a Middle Mississippian (AD 1150-1250) site at the northern periphery of the region. Nine percent (N = 25) of all 268 individuals documented at Orendorf suffered warfare-related trauma, including 13 cases of scalping, six instances of decapitation, five individuals with healed cranial blunt force trauma, three projectile point impacts, and eight cases of projectile injuries inferred by the burial context. All of the traumatized individuals were at or above the age of 15 years and males and females were victimized equally. The trauma rate among adults is 16%, which is less than that of the Norris Farms Oneota (34%) but higher than other Mississippian groups in the Southeast. The nature of the injuries is more consistent with attacks by outsiders than codified or ritualized intragroup violence.     

Traumatic injuries and imperialism: the effects of Egyptian colonial strategies at Tombos in upper Nubia

As circumstances of conquest change, leaders of empires must adapt their colonial strategies in order to be successful. One example of such modification in approach is the shift from Middle Kingdom to New Kingdom Egyptian colonial activities in Nubia. During the Middle Kingdom (2050-1650 BC) Egypt used aggressive military campaigns to subdue the strong Nubian polity at Kerma, resulting in the construction of fortresses and many victory stelae. In the subsequent New Kingdom period (1550-1050 BC) during which the Egyptian administration succeeded in occupying nearly all of Nubia, changes were necessary in conquest strategies. Diplomacy and cooperation may have replaced military action as mechanisms of control. This article investigates changes in imperial policy through the examination of traumatic injuries in human skeletal remains. Patterns of injuries in a sample from the site of Tombos, an Egyptian colonial cemetery in Nubia dating to the New Kingdom period, are compared with data on the patterns of injuries from Kerma, a cemetery dating to the Middle Kingdom period, published by Judd (2004). Analysis indicates a decrease in the level of traumatic injuries from Kerma to Tombos supporting the idea that through time the Egyptian administration modified their colonial strategy toward more nonviolent means. This article presents data on differences in the patterns of injury at Tombos and Kerma and explores possible explanations for this variation.     

Traffic Deaths—A Preliminary Study of Urban and Rural Fatalities in California

An analysis by the California Department of Public Health of California Highway Patrol reports for 1961 showed that traffic accidents injured one and one-half times as many people per 1,000 population in rural California counties (under 50,000 people) as in urban counties (over 500,000 people), also persons injured in rural counties were almost four times as likely to die of their injuries as those injured in urban counties.A death certificate study was undertaken of 782 traffic deaths (excluding pedestrians) occurring in rural and urban California counties during 1961. Accidents occurring in rural counties tended to be single vehicle accidents which resulted in less severe injuries, while those in urban counties tended to be two vehicle and multiple vehicle accidents resulting in more serious injuries. The anatomic distribution of injuries was the same for both urban and rural accidents. However, people dying in rural accidents more frequently died at the scene of the accident, died sooner after injury, and died of less serious injuries than did those injured in urban accidents. For injuries where theoretically few lives should be salvaged by prompt emergency care, the time between injury and death was about the same in urban as in rural counties. Where such care should delay or prevent death because the injury was possibly or probably salvageable, those injured in rural counties died more quickly.Thirty-two per cent of fatalities in rural counties happened to urban and out-of-state residents, while only 12 per cent of fatalities in urban counties were to rural or out-of-state residents, suggesting that traffic accidents to non-residents may place an excessive load upon medical care resources in rural areas.     

Trauma and violence in the Wari empire of the Peruvian Andes: warfare, raids, and ritual fights

This study examines bioarchaeological evidence for violence during the period of Wari imperialism in the Peruvian Andes through analysis of skeletal trauma from three populations dating to AD 650-800. The samples are from contemporaneous archaeological sites: Conchopata, a Wari heartland site in central highland Peru; Beringa, a community of commoners in the Majes valley of the southern Wari hinterland; and La Real, a high status mortuary site, also in the Majes valley. Given the expansionist nature of Wari and its military-related iconography and weaponry, it is hypothesized that Wari imperialism was concomitant with greater levels of violence relative to other prehispanic groups in the Andes. It is also hypothesized that differential articulation with the Wari empire (e.g., heartland vs. hinterland groups) affected the frequency and patterning of trauma. Results show that cranial trauma frequency of the three Wari era samples is significantly greater than several other Andean skeletal populations. This suggests that Wari rule was associated with high levels of violence, though it may not have always been related to militarism. The three adult samples show similar frequencies of cranial trauma (Conchopata = 26%; Beringa = 33%; La Real = 31%). This may suggest that differential positioning in the Wari empire had little effect on exposure to violence. Sex-based differences in cranial trauma frequencies are present only at La Real, but wound patterning differs between the sexes: females display more wounds on the posterior of the cranium, while males show more on the anterior. These data suggest that Wari rule may have contributed to violence.     

Paleoepidemiolgical patterns of trauma in a prehistoric population from central California

Skeletal trauma was investigated in a large collection of human remains from central California (N = 162 aged and sexed adults). Lesions investigated included cranial and long bone fractures, projectile wounds, and dislocation. Long bone fractures were found in 10.5% of individuals; overall, incidence by element was 2.3%. In addition, cranial injuries were found in 4.4% of complete adult crania. Projectile wounds were seen unambiguously in four individuals (with embedded obsidian fragments) and strongly suggested in two other individuals with partially healed lesions. Finally, one case of traumatic hip dislocation was also observed. In both incidence and patterning of injuries, this population is similar to other archeological groups from California. This evidence further supports earlier reports indicating that interpersonal aggression was quite common in prehistoric California.     

Bone fractures as indicators of intentional violence in the eastern adriatic from the antique to the late medieval period (2nd-16th century AD)

To test the historically documented hypothesis of a general increase in deliberate violence in the eastern Adriatic from the antique (AN; 2nd–6th c.) through the early medieval (EM; 7th–11th c.) to the late‐medieval period (LM; 12th–16th c.), an analysis of the frequency and patterning of bone trauma was conducted in three skeletal series from these time periods. A total of 1,125 adult skeletons—346 from the AN, 313 from the EM, and 466 from the LM series—were analyzed. To differentiate between intentional violence and accidental injuries, data for trauma frequencies were collected for the complete skeleton, individual long bones, and the craniofacial region as well as by type of injury (perimortem vs. antemortem). The results of our analyses show a significant temporal increase in total fracture frequencies when calculated by skeleton as well as of individuals exhibiting one skeletal indicator of deliberate violence (sharp force lesions, craniofacial injuries, “parry” fractures, or perimortem trauma). No significant temporal increases were, however, noted in the frequencies of craniofacial trauma, “parry” fractures, perimortem injuries, or of individuals exhibiting multiple skeletal indicators of intentional violence. Cumulatively, these data suggest that the temporal increase in total fracture frequencies recorded in the eastern Adriatic was caused by a combination of factors that included not only an increase of intentional violence but also a significant change in lifestyle that accompanied the transition from a relatively affluent AN urban lifestyle to a more primitive rural medieval way of life. Am J Phys Anthropol 2012. © 2012 Wiley Periodicals, Inc.     

Possible relationship of cranial traumatic injuries with violence in the south‐east Iberian Peninsula from the Neolithic to the Bronze Age

The main aim of this study was to analyze the presence and distribution of cranial trauma, as possible evidence of violence, in remains from the Neolithic to Bronze Age from the SE Iberian Peninsula. The sample contains skulls, crania, and cranial vaults belonging to 410 prehistoric individuals. We also studied 267 crania from medieval and modern times for comparative purposes. All lesions in the prehistoric crania are healed and none of them can be attributed to a specific weapon. In all studied populations, injuries were more frequent in adults than in subadults and also in males than in females, denoting a sexual division in the risk of suffering accidents or intentional violence. According to the archeological record, the development of societies in the SE Iberian Peninsula during these periods must have entailed an increase in conflict. However, a high frequency of cranial traumatic injuries was observed in the Neolithic series, theoretically a less conflictive time, and the lowest frequency was in crania from the 3rd millennium B.C. (Copper Age), which is characterized by the archeologists as a period of increasing violence. The relatively large size and the high rate of injuries in Neolithic crania and the practice of cannibalism are strongly suggestive of episodes of interpersonal or intergroup conflict. The number and distribution of injuries in Bronze Age is consistent with the increase in violence at that time described by most archeologists. Am J Phys Anthropol, 2009. © 2009 Wiley‐Liss, Inc.     

Interpersonal violence in prehistoric San Pedro de Atacama, Chile: behavioral implications of environmental stress

The prehistoric population of San Pedro de Atacama lived through periods marked by prosperity and interregional interaction, as well as times of severe drought, social stress, and widespread poverty. A sample of 682 crania was analyzed for evidence of cranial trauma in order to assess changing patterns of interpersonal violence during the occupation of the oasis. It was hypothesized that the level of traumatic injuries in this population would parallel some of the changes seen in the archaeological record. Low fracture rates would be expected in periods of affluence and environmental stability, while periods characterized by environmental extremes and state collapse would yield elevated rates of aggression. This analysis found that rates of trauma escalated from 5.1% (5/99) in the earliest period, to 10.9% (10/92) in the Middle Horizon (AD 600-950). Although it may reflect problems related to increasing population density in the oasis, this increase is surprising, given that the early period witnessed the shift to permanent settlements, and the middle period was one of prosperity and plentiful resource availability. Trauma rates peaked at 35.6% (16/45) in an early Late Intermediate period (AD 950-1400) cemetery, with other Late Intermediate cemeteries demonstrating similarly high rates of traumatic injury. The elevated trauma rates during this period correlate with major droughts, the concentration of settlements on the oasis' east side, fortified structures, and material poverty, all reflected in the archaeological record. As the Late Intermediate waned and environmental conditions improved, trauma concomitantly decreased (7.0%), and remained low throughout the Inka occupation (AD 1400-1532). This indicates that while the Atacama was not peaceful, violence became commonplace only during periods of great social change and resource stress.     

Fractures in late medieval skeletal populations from Serbia

Bone fractures were analyzed from skeletal remains of 861 adult individuals from six cemeteries dating to the Late Medieval period in Serbia. Results of the study were compared to other cemetery populations (635 individual skeletons) of the same date and region in an attempt to understand fracture patterns. The association of types of fractures and their prevalence with sex, age at death, cemetery site, and information deriving from historical sources are discussed. Results showed that the long bone fracture frequency was 0.7%, and the majority of the fractures were the result of direct force. This rate is similar to some studies of contemporary British skeletal samples. However, it is much lower than for some other Old World sites. Cranial vault fractures had a rate of 6.7%, and of the facial skeleton, 1.3%; the frontal bone was the most affected of bones of the cranial vault. Injuries were more common on the upper extremities (0.8%) compared to the lower (0.6%). However, the fibula was the most fractured bone (2.8%), followed by the ulna (2.4%). This pattern is similar to three of six Late Medieval urban sites in Britain. These findings suggest that this rural community was exposed to a low risk of trauma, probably related mostly to accidents sustained during farming, and rarely to interpersonal violence.     

Biocultural interpretations of trauma in two prehistoric Pacific Island populations from Papua New Guinea and the Solomon Islands

Two Pacific Island skeletal samples originating from the inland site of Nebira, Papua New Guinea (1230–1650) and a coastal site on the small island of Taumako, Solomon Islands (1530–1698) were examined for evidence of skeletal trauma using a biocultural approach. The types of trauma identified were cranial trauma, postcranial fractures, and piercing and sharp force trauma. Both samples exhibit trauma (Nebira, n = 9/28, 32.1%; Taumako, n = 17/133, 12.8%). Postcranial fractures are significantly higher in males from Nebira (Fisher Exact P value = 0.025). The prevalence of cranial trauma (n = 6/28, 21.4%) is significantly higher in Nebira individuals (Fisher Exact P value = 0.007). There is no conclusive evidence of piercing trauma at Nebira unlike Taumako, which has four individuals with evidence of piercing or sharp force trauma. Both samples show evidence of interpersonal violence and warfare. The results suggest the environment may have contributed to the pattern of trauma at these sites. These patterns are discussed within their cultural and environmental contexts. Am J Phys Anthropol 142:509–518, 2010. © 2010 Wiley‐Liss, Inc.     

Investigating health at Kerma: sacrificial versus nonsacrificial individuals

This analysis examines heterogeneity in risks by assessing the health status of individuals in two distinct burial contexts from the Nubian site of Kerma: sacrificial (n = 100) and nonsacrificial (n = 190) burial areas dated to the classic Kerma period ( approximately 1750-1500 BC). Indicators of physiological stress that were examined include cribra orbitalia, dental enamel hypoplasia, tibial osteoperiostitis, and femur length. The analysis presented here shows that the people interred in the sacrificial and nonsacrificial burial contexts at Kerma in Upper Nubia had similar health profiles that were comparable with other contemporaneous samples from the region. If sacrificial individuals did not experience the same risk of death as nonsacrificial individuals, it was not evident in the frequencies of nonspecific stress indicators. However, this differential risk of death may be blurred by our inability to examine nonadults for childhood disease. This research demonstrates the complexities involved in understanding the multiple factors that result in heterogeneity in skeletal samples.     

Fracture trauma in a medieval British farming village

Farming is among the three most hazardous occupations in modern society and perhaps also held a similar position during the medieval period. The goal of this study was to determine if there is a significant difference in frequencies and patterns of longbone fracture trauma observed between rural and urban activity bases that distinguish farming as a particularly dangerous occupation during the medieval period. The longbones of 170 individuals excavated from Raunds, a rural medieval British site (10th–12th centuries AD) were examined for fractures and compared to data collected from four contemporary British medieval sites, one rural and three urban. The fracture frequency for the Raunds individuals (19.4%) was significantly different from the urban sites (4.7–5.5%). Female fractures were characterized by injury to the forearm, while the males were predisposed to diverse fracture locations. Clinical research provided a source of documented farm-related trauma from North America and Europe where the crops and animals raised, the manual chores performed, and the equipment used in traditional or small-scale farms have changed little in form or function since the medieval period. Nonmechanized causes of injury contribute to approximately 40% of all modern farm-related injuries and are attributed to falls from lofts and ladders, animal assaults and bites, and falls from moving vehicles. These hazardous situations were also present in the medieval period and may explain some of the fracture trauma from the rural sites. A high fracture frequency for both medieval males and females is significantly associated with farming subsistence when compared to craft-orientated urban dwellers. Am J Phys Anthropol 109:229–243, 1999. © 1999 Wiley-Liss, Inc.     

Lethal Interpersonal Violence in the Middle Pleistocene

Evidence of interpersonal violence has been documented previously in Pleistocene members of the genus Homo, but only very rarely has this been posited as the possible manner of death. Here we report the earliest evidence of lethal interpersonal violence in the hominin fossil record. Cranium 17 recovered from the Sima de los Huesos Middle Pleistocene site shows two clear perimortem depression fractures on the frontal bone, interpreted as being produced by two episodes of localized blunt force trauma. The type of injuries, their location, the strong similarity of the fractures in shape and size, and the different orientations and implied trajectories of the two fractures suggest they were produced with the same object in face-to-face interpersonal conflict. Given that either of the two traumatic events was likely lethal, the presence of multiple blows implies an intention to kill. This finding shows that the lethal interpersonal violence is an ancient human behavior and has important implications for the accumulation of bodies at the site, supporting an anthropic origin.     

Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS)

Background

Rural induced abortion service has declined in Canada. Factors influencing abortion provision by rural physicians are unknown. This study assessed distribution, practice, and experiences among rural compared to urban abortion providers in the Canadian province of British Columbia (BC).

Methods

We used mixed methods to assess physicians on the BC registry of abortion providers. In 2011 we distributed a previously-published questionnaire and conducted semi-structured interviews.

Results

Surveys were returned by 39/46 (85%) of BC abortion providers. Half were family physicians, within both rural and urban cohorts. One-quarter (17/67) of rural hospitals offer abortion service. Medical abortions comprised 14.7% of total reported abortions. The three largest urban areas reported 90% of all abortions, although only 57% of reproductive age women reside in the associated health authority regions. Each rural physician provided on average 76 (SD 52) abortions annually, including 35 (SD 30) medical abortions. Rural physicians provided surgical abortions in operating rooms, often using general anaesthesia, while urban physicians provided the same services primarily in ambulatory settings using local anaesthesia. Rural providers reported health system barriers, particularly relating to operating room logistics. Urban providers reported occasional anonymous harassment and violence.

Conclusions

Medical abortions represented 15% of all BC abortions, a larger proportion than previously reported (under 4%) for Canada. Rural physicians describe addressable barriers to service provision that may explain the declining accessibility of rural abortion services. Moving rural surgical abortions out of operating rooms and into local ambulatory care settings has the potential to improve care and costs, while reducing logistical challenges facing rural physicians.     

Frequency and patterning of bone trauma in the late medieval population (13th-16th century) from Dugopolje, southern Croatia

The aim of this paper is to test the hypothesis of an increased level of interpersonal violence in Dugopolje during the late medieval period as testified by written sources. In order to accomplish this, an analysis and comparison of frequencies and patterning of long bone and craniofacial fractures between sex and age categories in the Dugopolje skeletal sample was performed. In total 209 excellently preserved adult skeletons were analysed: 111 males and 98 females. The total long bone fracture frequency is 1.5% (29/1910) with a significantly higher frequency in males compared to females. Most of the long bone injuries occurred as a result of accidents, probably due to rugged mountainous terrain, while a certain portion of trauma resulted from deliberate violence. Significantly higher fracture frequencies in males could be a result of a strict sexual division of labour where males performed more physically demanding and risky tasks, as witnessed by historical sources. 26 out of 119 complete adult crania (21.8%) exhibit skeletal trauma with significantly higher frequencies in males. Perimortem trauma was observed in one individual while antemortem healed sharp force lesions were registered in five individuals (all males). The predominance of frontal craniofacial injuries, as well as the presence ofperimortem trauma and sharp force lesions, suggests the presence of deliberate violence in this community. Although the indicators of deliberate violence were recorded predominantly in males, suggesting that intentional violence in Dugopolje was exclusively males' prerogative, the presence of nasal fracture in a female skeleton might point to a male towards female violence. Presented bioarchaeological data are in accordance with the written documents thus corroborating the claims of an increased level of deliberate interpersonal violence in the late medieval population from Dugopolje.     

Post-Cranial Traumatic Injury Patterns in Two Medieval Polish Populations: The Effects of Lifestyle Differences

Traumatic injuries can be used as general indicators of activity patterns in past populations. This study tests the hypothesis that contemporaneous (10th–12th century) rural and urban populations in medieval Poland will have a significantly different prevalence of non-violent fractures. Traumatic injuries to the post-cranial skeleton were recorded for 180 adults from rural Giecz and for 96 adults from urban Poznań-Śródka. They were statistically analyzed by body region and individual skeletal element. Results reveal that Giecz had a significantly higher rate of trunk fractures than Poznań-Śródka (Fisher’s exact, p<0.05). In particular, rib and vertebral fractures were more common in Giecz males and females than in their Poznań-Śródka counterparts. Traumatic injuries in the extremities were comparable between the two samples, suggesting similar risks of trauma to these regions. These results indicate that in early medieval Poland, activities associated with a rural lifestyle resulted in more injuries. These stress or accidental fractures, which are related to a high-risk setting, were not consistent with an urban lifestyle. Overall, agricultural populations like Giecz were engaged in a laborious lifestyle, reflected in a variety of injuries related to repetitive, high-risk activities. Although urban populations like Poznań engaged in craft specialization participated in repetitive activities, their lifestyle resulted in lesser fracture-risk.     

Mortality from unintentional injuries in California, 1985.

In 1985 unintentional injuries were the fourth leading cause of death among California residents, causing 10,380 deaths. They were the leading cause of potential life lost, accounting for 278,109 years lost. This was more than twice the number of years lost due to heart disease and 1 1/2 times the number lost due to cancer. Motor vehicle traffic accidents were the leading cause of unintentional injury deaths, accounting for half (5,158) the deaths. The next two leading causes were poisoning (especially for men aged 25 to 44 years) and falls (especially among persons aged 75 and older). Drowning was second to motor vehicle accidents as a cause of death in children aged 1 to 14 years. California''s age-adjusted injury mortality rates in 1985 were lower in coastal and urban counties than in inland and rural counties, and these rates were generally lower in counties having organized systems of trauma care.