Wicked problems and the recovery of meaning: critical systems thinking for injury care in low- and middle-income countries

Abstract

Injuries cause 6 million deaths and 40 million disabilities annually. Over 90% of deaths occur in low-and-middle-income-countries (LMICs), and nearly half are preventable. This Commentary examines the possibilities and limitations of data to support injury care in LMIC settings. We frame injury care as a wicked problem with complex causality, contested goals, unintended consequences, and an incomplete evidence base. We use critical realism (CR) to address conceptual complexity and data scarcity using depth ontology and retroduction. Using exemplars (drug-related admissions, intimate-partner violence, and ambulance delays), we apply a pragmatic approach to: (1) describe patterns/distributions; (2) identify who/what may be missing or misrepresented; (3) triangulate with frontline/community intelligence to infer mechanisms and constraints, translating interpretations into feasible actions and accountabilities. CR broadens interpretation to include institutional and structural drivers (e.g. mistrust, referral fragmentation, gender norms). Routine data are indispensable but are partial. Used uncritically, they can reproduce disparities, leaving health systems to manage complex demands with limited insight. CR supports holistic analysis of how interventions interact with actors, interests, institutions, and political-economic conditions. Focusing on why disparities persist and linking routine metrics to triangulation and dialogue, CR readings can guide service adaptation and wider structural reform.