Reduced Violence-Related Burden and Mortality at Higher Altitudes: Examining the Association between High Altitude Living and Homicide Rates in Ecuador.

Esteban Ortiz-Prado, Juan Sebastian Izquierdo-Condoy, María G. Dávila-Rosero, Jorge Vásconez-González, Ana M. Diaz, Carla E. Moyano, Vanessa Arcos-Valle, Ginés Viscor, and Joshua H. West. Reduced Violence-Related Burden and Mortality at Higher Altitudes: Examining the Association between High Altitude Living and Homicide Rates in Ecuador. High Alt Med Biol. 00:000-000, 0000. Background: Homicides are a major public health concern and a leading cause of preventable deaths worldwide. The relationship between altitude and homicides remains unclear, and evidence of the possible effects of living at high altitudes on homicide rates is limited. This research aimed to investigate the mortality rates resulting from various types of aggression that culminated in homicides in Ecuador and to explore potential differences associated with altitude. Methods: An ecological analysis of homicide rates in Ecuador was conducted from 2001 to 2022. Homicide cases and the population at risk were categorized based on their place of residence according to two altitude classifications: a binary classification of low (<2,500 m) and high altitude (>2,500 m), and a detailed classification according to criteria by the International Society for Mountain Medicine, which includes low (<1,500 m), moderate (1,500-2,500 m), high (2,500-3,500 m), and very high altitude (3,500-5,500 m) categories. Both crude and directly age-sex standardized mortality rates were calculated for each altitude category. Results: We analyzed a total of 40,708 deaths attributed to aggressions (ICD-10 codes X85-Y09). The total homicide rate for men was 21.29 per 100,000 (95% confidence interval [CI]: 9.55-32.37), whereas for women, it was 2.46 per 100,000 (95% CI: 1.44-3.27). Average rates across the 22 analyzed years were higher at low altitudes (men: 13.2/100,000 and women: 1.33/100,000) as compared with high altitudes (men: 5.79/100,000 and women: 1.05/100,000). Notably, the male-to-female rate difference was more pronounced at low altitudes (898%) than at high altitudes (451%). Conclusions: Our study revealed a higher prevalence of homicides in certain provinces and significant disparities in mortality rates between men and women. Although we cannot establish a direct relationship between altitude and homicide rates, further research is needed to explore potential confounding factors and a better understanding of the underlying causes for these variations.