Trauma is well known as a major cause of death and disability in the developed world, but has been inadequately studied in developing nations. We reviewed 539 trauma patients admitted from 1987 through 1991 to a rural African hospital, the Holy Family Hospital (HFH) in Berekum, Ghana, and compared these results with 14,270 patients admitted during the same period to a level I trauma center, the Harborview Medical Center (HMC) in Seattle, Washington. At HFH, 59% of patients were seen > 24 hours after injury, compared with 4% of HMC patients (p < 0.001). Only 25% of HFH patients received prehospital care, compared with 82% of HMC patients (p < 0.001). Mean ISS was higher at HMC (10.0 +/- 6.3) than a HFH (6.7 +/- 6.5) (p < 0.001), but trauma mortality rates were identical (6%) at both institutions. Neurologic injuries were the leading cause of death at both HFH (62%) and HMC (54%). There was no significant difference between institutions in mortality for patients with ISS 1-8 (HMC: 0.7% n = 6390; HFH: 0.3%, n = 342). There was a marked decrease in mortality for patients with ISS 9-24 at HMC (3%, n = 3709) compared with HFH (10%, n = 146) (p < 0.001). There was a less pronounced decrease in mortality for patients with ISS > 24 at HMC (41%, n = 1520) compared with HFH (73%, n = 26) (p < 0.01). The type and the severity of injuries causing fatalities in this developing nation suggest that no inexpensive hospital-based changes would improve outcomes.(ABSTRACT TRUNCATED AT 250 WORDS)