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 at 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. The lack of prehospital care and the long delays in transport to the hospital indicate areas in which less costly interventions might decrease mortality from trauma.