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Reducing the Burden of Injury: Advancing Prevention and Treatment 1 The Injury Field Injury morbidity and mortality have been persistent problems in the United States. Recent findings report that in 1995 alone, injuries were responsible for 147,891 deaths, 2.6 million hospitalizations, and more than 36 million emergency room visits (Fingerhut and Warner, 1997). It has been estimated that injury accounts for 12 percent of all medical spending (Miller et al., 1994). In 1995, approximately $260 billion was spent on injury and its consequences (E. MacKenzie, Johns Hopkins University, personal communication, 1998).1 Unintentional injury and violence account for about 30 percent of all lost years of productive life before age 65, exceeding losses from heart disease, cancer, and stroke combined (CDC, 1991; Waller, 1994). Yet, the federal investment for injury research has not been sommensurate with the problem (Figure 1.1). STUDY BACKGROUND In 1966, the National Academy of Sciences' Division of Medical Sciences and the National Research Council (NRC) issued Accidental Death and Disability: The Neglected Disease of Modern Society, recommending that the nation's public and private resources be mobilized to reduce accidental death and injury in an effort equivalent to the recent assaults on polio and cancer (NRC, 1966). The recommendations in the report focused mainly on improving emergency 1 The 1985 estimates of the costs of injury in the United States were updated to 1995 separately by type of cost. Direct costs were inflated using the appropriate component of the Consumer Price Index (hospital and related services, physicians' services, prescription drugs, professional medical services, and medical care services). Indirect costs were inflated using the index of hourly compensation in the business sector.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Figure 1.1 Years of potential life lost versus the federal research investment. Note: Age-adjusted years of potential life lost (YPLL) before age 75 in 1996 was calculated per 100,000 population. Injury includes unintentional injury, homicide, and suicide. The research support for injury is for FY 1995; research support for cancer, heart diseases, and stroke is NIH support for FY 1996. Sources: NCIPC (1997); IOM (1998); NCHS (1998). medical care, but the committee also addressed trauma research and injury prevention, recommending creation of a National Institute on Trauma at the National Institutes of Health (to sponsor and conduct a program of injury treatment research) and a National Council on Accident Prevention in the executive branch (to coordinate and advise federal regulatory agencies and to provide support for research and program development). Nearly 20 years later, the Committee on Trauma Research established by the NRC and the Institute of Medicine (IOM) conducted a new study at Congress's direction and issued what has become a landmark report, Injury in America (NRC, 1985). That committee recommended a major national program of research to address "serious, but remediable, inadequacies in the understanding of and approach to injury as a health problem." The significance of Injury in America lies both in its intellectual contribution and in its influence on national policy. Intellectually, the committee set forth the rationale for conceptualizing "injury prevention and control" as a distinct field of interdisciplinary research, drawing together what had been separate strands of scientific study within the framework of public health. In terms of public policy, the committee recommended a major investment in injury research, commensurate with the magnitude of the problem, and proposed creation of a center for injury research within the Centers for Disease Control, now the Centers for Disease Control and Prevention (CDC). The committee envisioned that the new center would (1) conduct and support research in biomechanics, injury epidemiology and prevention, and
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Reducing the Burden of Injury: Advancing Prevention and Treatment treatment and rehabilitation; (2) establish injury surveillance systems and support prevention activities; (3) promote professional education and training; (4) establish interdisciplinary injury research centers; and (5) serve as clearinghouse, coordinator, and lead agency on injury prevention and control among federal agencies and private organizations. Soon after Injury in America was released, Congress appropriated funds for a pilot program for injury control at CDC, and two years later, a new IOM-NRC committee reviewed its progress. In Injury Control (NRC, 1988), the committee concluded that the program had been sufficiently successful to warrant permanent support. It commended the CDC program for establishing five interdisciplinary research centers; sponsoring a new program of extramural research; and building staff expertise for intramural research, database development, coordination, and technical assistance. However, the committee expressed disappointment that the program had been given inadequate resources to carry out its broad mission and noted that the program had underemphasized acute care and biomechanics during its start-up phase. During the intervening years, there have been several efforts to determine priorities for injury prevention and treatment (e.g., National Committee ; NCIPC ; NIH ; IOM ). In 1997, the current Committee on Injury Prevention and Control was established by the IOM with funding from the Robert Wood Johnson, W.K. Kellogg, and John D. and Catherine T. MacArthur foundations, to review the present status and direction of the field in light of earlier IOM-NRC reports and to make appropriate recommendations for advancing the field and for reducing the burden of injury in America. The committee's charge, however, is broader than those of the earlier IOM-NRC committees, encompassing "opportunities and barriers" for practice as well as research (Injury in America focused exclusively on research) and "the response by public and private agencies," not only the activities of the CDC program. Recognizing the breadth of its charge, the committee decided not to replicate the work of its predecessors, choosing instead to focus on areas that had not received attention in prior reports and on current issues or challenges confronting the injury field as a whole. This report characterizes the injury problem in the United States, assesses the current response by the public and private sectors, and presents recommendations for reducing the burden of injury in America. To introduce the issues addressed by the committee, this chapter outlines the history of the injury field, discusses the public health approach to injury prevention and treatment, and assesses progress in the development of the injury field. ORIGINS OF THE INJURY FIELD For centuries, human injuries have been regarded either as random and unavoidable occurrences ("accidents" or "acts of God") or as untoward consequences of human malevolence or carelessness. From this perspective, the main
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Reducing the Burden of Injury: Advancing Prevention and Treatment strategies for prevention are prayer and human improvement. With the advent of industrialization in the nineteenth century, the environmental risk factors for injury became more discernible, and the challenges of "accident prevention" and industrial safety began to receive sustained attention. Railroad, textile, and mining industries began recording work-related injuries in the early 1800s (Loimer et al., 1996). Political movements for worker protection developed in Europe in the mid-nineteenth century and later in the United States. Early developments include the creation of the National Safety Council in the United States in 1913 and the Royal Society for the Prevention of Accidents in England in 1916. Although interest in worker safety, child safety, and driver safety grew over the course of the twentieth century, systematic scientific inquiry was rare, and the ameliorative efforts undertaken by interested private constituencies were episodic and unconnected. This situation changed dramatically during the 1960s and 1970s when two developments converged to establish the intellectual and programmatic foundation for a new field of research and social action: (1) a substantial social investment in injury prevention, spurred by a burst of federal regulatory action and (2) the emergence of injury science as a distinct interdisciplinary field of research within the domain of public health (Baker, 1989; also, see the following discussion). The Highway Safety Act of 1966 signaled a national commitment to reducing injuries and deaths on the nation's highways. In this path-breaking legislation, Congress empowered a federal agency, the National Highway Safety Bureau (now the National Highway Traffic Safety Administration [NHTSA]), to set motor vehicle safety standards and to make grants for research and programs promoting highway safety. Four years later, the federal Occupational Safety and Health Act established a regulatory agency (Occupational Safety and Health Administration) to set and enforce workplace safety standards, and a separate research agency (National Institute for Occupational Safety and Health). This period of federal regulatory innovation was consummated with the enactment of the Consumer Product Safety Act and companion legislation in 1972 that established the Consumer Product Safety Commission. Throughout this formative period, diverse initiatives were undertaken by a variety of other federal agencies, state governments, foundations, and citizen activists to promote safety and ameliorate the burden of injury. Examples include Kellogg Foundation grants for home accident prevention in the 1950s and 1960s, the founding of the American Trauma Society in 1968, the establishment of 600 poison control centers in the 1960s and 1970s, the creation of a federal program on emergency medical services in the 1970s, the funding of state injury prevention programs by the Division of Child and Maternal Health of the Department of Health, Education, and Welfare in 1979, and the founding of Remove Intoxicated Drivers in 1978 and Mothers Against Drunk Driving in 1980. Although these activities were not coordinated, they reflected a common aspiration and a shared recognition of the potential benefits of concerted social action to reduce injury. Taken together, they substantially increased the number of individuals and
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Reducing the Burden of Injury: Advancing Prevention and Treatment organizations engaged in injury prevention research and practice, and thereby began to build the infrastructure for a new field. For additional historical information, see the time line in Appendix B. Modern injury science began to take shape as a distinct field in the mid-1960s. Perhaps the key conceptual development was the recognition that patterns of injury distribution and causation can be analyzed using the epidemiological tools of public health and that the etiology of injury includes environmental factors and interactions between human and environmental factors. The formulation of the prevailing scientific paradigm for studying the causes and prevention of injury is generally attributed to William Haddon, a public health physician. Building on the work of John Gordon (1949) and James Gibson (1961), Haddon (1968) observed that all injury events are attributable to the uncontrolled release of one of five forms of physical energy (kinetic, chemical, thermal, electrical, and radiation). From a preventive or ameliorative standpoint, interventions can be made during three temporal phases in relation to the injury event: (1) a pre-event phase, during which the energy becomes uncontrolled; (2) a brief event phase in which the uncontrolled energy is transferred to the individual, resulting in injury if the energy transfer exceeds the tolerance of the body to absorb it; and (3) a post-event phase, during which attempts can be made to restore homeostasis and repair the damage. This three-phase conceptualization of injury causation can be combined with the traditional public health categorization of risk factors and intervention opportunities—host (the potential injured person), agent (the energy and the vehicle through which it is transferred), and environment (both physical and social)—to create a 12-cell matrix that can be modified to apply to any circumstance of injury (Figure 1.2). Using this model to identify risk factors and potential interventions during all three temporal phases, Haddon summarized the range of interventions as follows: (1) preventing or limiting energy buildup; (2) controlling the circumstances of energy use to prevent uncontrolled release; (3) modifying the energy transfer phase to limit damage; and (4) improving emergency response, treatment, and rehabilitative care to limit disability and promote recovery. Figure 1.2 Haddon matrix. Source: Adapted from Haddon (1980).
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Reducing the Burden of Injury: Advancing Prevention and Treatment INJURY AS A PUBLIC HEALTH PROBLEM The subtitle of Injury in America was ''A Continuing Public Health Problem" (NRC, 1985). What exactly does it mean to say that injury is a public health problem? Injuries constitute a major public health problem because, in the aggregate, they produce such an enormous toll of disability and premature death, draining health care dollars and weakening the nation's productive capacity. Fortunately, these consequences can be reduced or ameliorated by using the analytic tools and preventive perspectives of public health. Indeed, because the public health paradigm can embrace all etiologic factors bearing on prevention, it has been widely accepted by analysts in all disciplines, even though many of the interventions lie outside the expertise and capacity of public health agencies. This is not to say that the public health approach is the only useful perspective for thinking about injuries. Some perspectives are remedial rather than preventive and normative rather than empirical. Conceptually, issues concerning the remediation of injuries (compensation of injured persons, corrective justice or the punishment of persons or entities responsible for "causing" or failing to prevent injuries) are extrinsic to issues of prevention. Operationally, however, they may converge (e.g., punishment of wrongdoers or imposition of liability can achieve preventive effects through deterrence) or diverge (e.g., the risk of tort liability faced by companies often reduces hazards, but sometimes creates disincentives to disclose safety information and may thereby retard safety innovation). To say that injury is a public health problem should not be understood to mean that the social response should be mounted primarily or exclusively by public health agencies; nor does it imply that a public health response is superior to other forms of response. Public health agencies lack expertise and command over most of the interventions suggested by the Haddon matrix. Injuries represent a complex set of social problems. Prevention and remediation of these problems are and should be the responsibility of a wide variety of social institutions, including medicine, alcohol control, fire safety, mental health, criminal justice, the tort system, and many others. As discussed in Chapters 7 and 8, public health agencies should be playing a much more substantial role in injury prevention than they are now, but their role should be understood as a contributory one, in collaboration with other agencies. THE MISSION AND BOUNDARIES OF THE INJURY FIELD The mission of the injury field is prevention, amelioration, and treatment of injury and the reduction of injury-related disability and death. The field is defined by its focus on the injury, whatever the mechanism by which it was immediately caused and regardless of the contributing role of human intent. This understanding, which emerges clearly from Injury in America, has profoundly important implications for the boundaries of the field because, by drawing no
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Reducing the Burden of Injury: Advancing Prevention and Treatment distinction between unintentional and intentional injuries (i.e., homicide, assaultive injuries), it broadens the reach of prevention research and practice beyond the traditional domain of "accident prevention." From "Accident Prevention" to "Injury Prevention" Injury in America (NRC, 1985) explicitly recognized that the public health paradigm could be usefully applied to the prevention of intentional injuries as well as unintentional ones. The report identified knowledge about assaultive injuries as a major gap in current research: "Nonfatal assaultive injuries and homicides have been subjected to little prevention-oriented research. Typically, they have been regarded as a 'crime problem,' rather than as a health problem, and blame and punishment of the perpetrators have been emphasized, rather than measures to reduce the frequency and severity of such injuries." After identifying several potentially useful interventions for the prevention of firearm-related injuries, the report noted that "assaultive injuries involving other weapons or personal force are virtually unresearched." Similarly, although Injury in America recognized that much research had focused on the diagnosis and treatment of depressed or suicidal people, the report observed that little attention had been paid to public health approaches, such as modifying products or environments to reduce the lethality of means of suicide. It encouraged research into the "validity of the widespread assumption that nonfatal suicide attempts represent a lack of desire to kill oneself, and therefore involve the choice of less lethal means" and on "reducing the lethality of common means of committing suicide.'' Despite its emphasis on the need for greater attention to assaultive and self-inflicted injuries, Injury in America focused mainly on unintentional injuries, primarily those caused by motor vehicle crashes. Three years later (with the publication of Injury Control), the IOM-NRC committee reviewed the status and progress of the injury control programs at CDC; that report reiterated the need to intensify the study of intentional injury: "The study of intentional injury can be characterized as a neglected but potentially productive research field. . . . The nation now has hundreds of programs aimed at reducing the incidences of suicide, homicide, and other intentional injuries, but there is no commensurate effort to evaluate the effectiveness of the programs" (NRC, 1988). A Broader Field Ten years have elapsed since the publication of Injury Control. Over this period, research and program development within the injury field have been expanded to give greater attention to the study of intentional injuries, reflecting a broader movement within medicine and public health embracing the cause of
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Reducing the Burden of Injury: Advancing Prevention and Treatment violence2 prevention (see, e.g., Surgeon General's Workshop on Violence and Public Health [U.S. DHHS, 1986;]; Violence in America: A Public Health Approach [Rosenberg and Fenley, 1991]; Understanding and Preventing Violence [NRC, 1993]; Violence in Families: Assessing Prevention and Treatment Programs [NRC, 1998]). The salience of intentional injuries in the collective consciousness of public health has also drawn the attention of injury scientists to the mechanisms of these injuries, principally firearms (see, e.g., Karlson and Hargarten ). However, these developments have exposed some critical tensions within the injury field about its identity, mission, and future direction. Some believe this trend to be a deviation from the core scientific mission of the field and worry about the diversion of limited resources from the chronically neglected problems of unintentional injuries to areas in which the potential contributions of the field are limited. They also believe that it is a strategic mistake for the injury field to take on the daunting, complex, and highly politicized subject of violence. Others believe that the scientific and programmatic advantages of integrating the field, and its potential contributions to the cause of violence prevention, require steadfast continuation of the present course. From the internal perspective of the injury field, the issue can be posed either as one of boundaries or as one of priorities: Does the prevention of intentional injuries lie within the domain of the field? If so, how should the priorities for research and action be set within such a diverse array of important social problems? From a societal perspective, the argument raises questions about the added value of public health to the prevention of suicide and violence, problems traditionally understood to lie within the respective domains of mental health and criminal justice. This controversy signifies an important stage in the development of the injury field. Arguments for disaggregating the prevention of violence and suicide from the prevention of unintentional injuries have some force, especially in light of the greater importance of motivational factors and individual vulnerabilities in understanding and responding to violence and suicide and of the traditional roles played by criminal justice and mental health disciplines in these areas. However, despite the important differences associated with intentionality, the committee strongly endorses and reaffirms continued integration of all injury prevention activities within a common framework of research and program development for several reasons. First, the surveillance systems that undergird injury prevention collect data on all injuries regardless of intent and 2 In this report the committee uses the term violence to denote interpersonal violence. A major 1993 report defined violence as "behavior by persons against persons that intentionally threatens, attempts, or actually inflicts physical harm. . . . [The definition] excludes consideration of human behavior that inflicts physical harm unintentionally. Also excluded are certain behaviors that inflict physical harm intentionally: violence against oneself, as in suicides and attempted suicides . . ." (NRC, 1993, pp. 35–36).
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Reducing the Burden of Injury: Advancing Prevention and Treatment focus on the mechanism of injury because the information regarding intent may be subjective and unavailable. Second, even though differences in intentionality are often associated with different risk factors and different targets of intervention, responsibilities for carrying out preventive interventions in the field often converge on the same programs and agencies, particularly in public safety, emergency medical and other health care, and public health. Finally, epidemiologic evidence highlights the powerful etiological role of several factors that cut across all injury categories, whatever the mechanism and regardless of intention. Prominent examples are alcohol use and adolescent impulsivity. Reflecting this, some interventions tend to reduce the incidence and severity of both unintentional and intentional injuries. Examples of interventions shown to have a broad impact include reducing alcohol availability (Chiu et al., 1997; Landen et al., 1997), home visitation for first-time new mothers (Kitzman et al., 1997; Olds et al., 1997), and eliminating the carbon monoxide content of domestically used coal gas (Hassall and Trethowan, 1972). Viewed in this way, injury prevention is necessarily a collaborative undertaking. The main contributions of injury science lie in its population-based perspective; its capacity to identify and frame interventions for a broad array of risk factors, particularly environmental ones; and its tools for measuring outcomes. However, injury scientists and prevention practitioners need partners in order to mount any successful preventive intervention. Interventions targeted at product design and the physical environment require collaboration with product manufacturers, safety engineers, and so forth. Interventions targeted on human behavior or the social environment require collaboration with schools, family service agencies, mental health agencies, and alcohol control agencies, among others. Interventions aiming to reduce self-inflicted injuries, assaults, and various types of unintentional injuries require different collaborators, but the basic approach is the same: The injury field provides the wide-angle lens, while the specific focus is provided by specialists from pertinent disciplines in adjacent fields. In summary, by proclaiming that "violence is a public health problem," leaders in medicine and the public health establishment have summoned a growing body of researchers and practitioners to the cause of violence prevention. Perhaps an analogous effort will be undertaken for suicide prevention. However, it is important to clarify the implications of this declaration for the future of the injury field. Conceptually and scientifically, the prevention and treatment of injury (whether intentional or unintentional) may be productively studied and understood from a public health perspective. However, organizing a successful social response to injury is not a conceptual and scientific challenge; it is a political one. To say that violence is a public health problem is not necessarily to say that the public health community should be at the center of the social response to violence. Nor is it to say that the public health infrastructure has any comparative advantage in organizing the social response to violence. What is required is a coordinated effort to harness social energies for a more effective
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Reducing the Burden of Injury: Advancing Prevention and Treatment program of studying and preventing violence. The tools and resources of public health should be allocated prudently to this effort. Boundaries The recent emphasis on violence prevention has raised some additional questions about the conceptual boundaries of the injury field. At issue are the subtle but important differences between its defining mission—preventing and ameliorating traumatic physical injury—and the more sweeping aims of violence prevention. Physical injuries are among the most serious consequences of violence. However, definitions of violence (and "abuse") focus on the behavior (typically, force or threats of force) rather than the outcome. Moreover, the ultimate harm associated with violent relationships—including psychological distress and developmental harm—is more diffuse than physical harm, affecting both the immediate victim and those who witness the violence (Osofsky, 1995). This difference in focus has two implications for the mission and boundaries of the injury field. First, violence prevention is a broader mission than prevention of the injury inflicted. The focus of the injury field should remain on preventing injuries, and in identifying and modifying risk factors for injuries. The committee recognizes that targeting abusive relationships and styles of violent interaction can often be effective means of reducing injuries (in the short term and across generations), but the challenge for the injury field is to promote collaboration with violence researchers and intervention agencies without losing sight of its own primary mission. In the final analysis, the value of the injury field's investment will be determined by the impact on injury morbidity and mortality. Second, the focus of the injury field should be on physical injury rather than emotional or developmental harms. One could say that all harmful outcomes from traumatic exposures, including emotional and developmental harm, are "injuries" within the domain of the injury field. However, in the committee's view, the tasks of measuring, understanding, and preventing these psychological harms are best viewed as being within the domain of mental health. This is not to say that psychological trauma is irrelevant to the injury field—emotional sequelae to physical injuries have a direct bearing on treatment, for example, and on the measurement of outcomes; but these concerns call for collaboration between injury and mental health, not for an extension of the boundaries of the injury field. In sum, although the perspectives and tools of the injury field have much to contribute to the study and prevention of violent injuries, the prevention of violence and the amelioration of its consequences comprise a much larger domain. Keeping this distinction in mind helps to shape the priorities of the injury field.
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Reducing the Burden of Injury: Advancing Prevention and Treatment VOCABULARY OF THE INJURY FIELD In reports of this kind, choices of terminology often signify positions on disputed issues of perspective or policy. Although the vocabulary of the injury field is less contentious than in many fields, a few terms are laden with policy significance and require clarification. Injury and Accident Architects of the injury field in the United States have made a concerted effort to displace the term "accident," which implies random events and bad luck, with the term "injury," implying predictability in the epidemiological sense and therefore amenability to prevention. Injury, moreover, refers to the health outcome being addressed. By focusing the attention on result or outcome, the term "injury'' is neutral with respect to causation, intentionality, and fault. The terminology has thereby facilitated scientific communication and helped disentangle issues of description from assumptions about etiology and fault. Erasing the term "accident" from the vocabulary of the field has not erased it from everyday speech, however, and the general public and policy makers seem to understand the phrase "accident prevention" much better than they understand "injury prevention." Moreover, as noted by Bijur (1995), abandoning the term accident has left the field without a generic term for the events that may or may not result in bodily injury. Instead, many such terms are used to describe specific events (e.g., crash, collision, fire, poisoning, fall, shooting, fight). Interestingly, the phrase "accident prevention" continues to be used in the United Kingdom without the implications of fatalism feared by the field in this country, and Avery (1995) has proposed that this term be revived throughout the field to refer to interventions aiming to reduce events that present a significant risk of injury. However, the committee agrees with Bijur (1995) that this approach is inadvisable, not only because of its inescapable etiological connotations but also because it leaves no room for injury events that are intentionally caused (and are in no sense accidents). Intentionality Although the injury field focuses on preventing and treating a condition (the "injury") and ameliorating its consequences, intentionality (e.g., the actor's purpose and awareness of the risk of injury) is an important variable in studying the causes and prevention of injuries. According to the standard practice, injuries are divided into two categories: The term "unintentional" is used to refer to injuries that were unplanned ("accidents" in the earlier terminology), whereas the term "intentional" is used to refer to injuries resulting from purposeful human action (whether directed at oneself or others). This nomenclature is embodied in the
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Reducing the Burden of Injury: Advancing Prevention and Treatment adequately, and adding the term "control" can only sow confusion because it implies a preference for coercive interventions. The phrase "injury field" (rather than "injury control") is used to refer to the entire domain of injury prevention and treatment. DEVELOPMENT OF THE INJURY FIELD The committee was assigned the task of reviewing the progress of the injury field since publication of Injury in America and Injury Control and making recommendations to further develop the field and reduce the burden of injury. The entire report is meant to be responsive to this charge. However, in light of the role of previous IOM-NRC committees in nurturing the development of the field over the past 30 years, the committee wanted to comment on measures of growth and maturity. Based on its public and scientific workshops and on discussions with researchers and practitioners, the committee has concluded that the field has grown in size, has achieved a significant degree of cohesion, and has matured in perspective. However, further development of the field has been hampered by inadequate opportunities for training and scientific communication (see Chapters 4, 7, and 8). Growth and Cohesion The authors of Injury in America (NRC, 1985) envisioned an interdisciplinary field of science and practice with five components: (1) epidemiology, (2) prevention, (3) biomechanics, (4) acute care, and (5) rehabilitation. In the follow-up report, Injury Control (NRC, 1988), the IOM-NRC committee referred to these components as the "five core disciplines" of injury control. The current committee has found it helpful to distinguish between the applications of knowledge (prevention and treatment) and the scientific disciplines that provide the methods and analytic tools for acquiring such knowledge. From this perspective, the range of contributing disciplines is far broader than one might infer from Injury in America. In addition to epidemiology, biomechanics, acute care, and rehabilitation, for example, contributing disciplines include psychology, criminology, economics, health outcomes research, and other social and behavioral sciences. TABLE 1.1 Mission and Vocabulary of the Injury Field Injury Prevention Injury Treatment Pre-Event Event Acute Care Rehabilitation Preventing injury-causing event Preventing injury orminimizing severity of injury Minimizing severity of outcome Restoring optimum functioning
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Reducing the Burden of Injury: Advancing Prevention and Treatment Increasing numbers of individuals, from a wide variety of disciplines and occupational settings, identify themselves as participants in the field of injury prevention and treatment rooted in the intellectual perspectives and methods of public health. When the CDC and the Johns Hopkins University convened the First National Conference on Injury Control in 1981, it was attended by approximately 25 individuals, representing about half of all of those working in the field at the time. In comparison, more than 900 people participated in the November 1997 Safe America Conference. The National Directory of Injury Prevention Professionals lists 1,234 individuals in its 1992 edition (Children's Safety Network, 1992). It also appears that the injury field has achieved a significant degree of cohesion, notwithstanding the diversity of disciplines and the variety of specialized spheres of interest. The field has drawn together specialists interested in various domains of prevention (e.g., highway safety, fire safety, product safety, occupational safety, child injury, and violence and suicide prevention) as well as basic scientists and clinicians interested in various types of trauma (e.g., burns, orthopedic injuries, and head injuries). As has occurred in the cancer field, these specialists have come to see scientific, programmatic, and political advantages to characterizing injury as a single "disease." The growing cohesion of the field (within public health) is evidenced by the growth of the Injury Control and Emergency Health Services section within the American Public Health Association, and the development of the field is reflected in, and symbolized by, the 10 multidisciplinary injury control research centers (ICRCs) established over the past decade by the CDC (see Chapter 8). Links between researchers and practitioners are also developing. National conferences in the field draw together science and practice in both prevention and treatment. The ICRCs have played an important role in this effort, holding conferences for practitioners and facilitating the implementation and evaluation of interventions. In addition, several journals are now devoted exclusively to the field, including the Journal of Safety Research, Injury Prevention, Accident Analysis and Prevention, and the Journal of Trauma, and an increasing amount of space is devoted to injury-related articles in journals with general professional readerships, including the American Journal of Public Health, Pediatrics, the Journal of the American Medical Association , and the New England Journal of Medicine. Another intriguing aspect of the emergence and composition of the injury field has been the close collaboration of prevention and treatment. An analogous development has occurred in the fields of cancer and heart disease. One might say that these partnerships can be explained entirely as expressions of political self-interest. Voices raised in support of injury prevention (including fire prevention, violence and suicide prevention, etc.) and in support of trauma care and rehabilitation are most likely to be heard if they are raised in unison. But the committee believes that much more than political strength would be lost if the
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Reducing the Burden of Injury: Advancing Prevention and Treatment prevention and treatment communities were to lose their sense of common identity. Injury epidemiology straddles prevention and treatment, serving as a bridge and source of information and insight in both directions. Designing strategies for protecting people from the effects of injury-causing events requires ongoing scientific communication between scientists in biomechanics, molecular biology, and clinical pathology. Implementation of public education and other prevention programs requires participation of surgeons and rehabilitation specialists to convey information about consequences. Although the task of drawing together specialists in injury prevention and treatment is unfinished, remarkable progress has been made. A recent example is the Crash Injury Research and Engineering Network (CIREN) established by NHTSA in 1996. CIREN links trauma center clinicians and crash investigators in a nationwide computerized network. This enables engineers to better understand injury-producing mechanisms and to develop better criteria for vehicle safety design, while informing clinicians about emerging injury patterns, and thereby facilitating triage, diagnosis, and treatment of crash injuries. Of course, not all people interested in preventing or treating injuries (e.g., violence and suicide prevention, highway engineering, fire safety, emergency medical services) identify themselves with the injury field. All of these groups have an interest in safety, which is more a common cause than a recognizable field of scientific study or professional practice. However, many people within these specialized spheres have increasingly recognized their common interests with specialists in the injury field and have embraced its conceptual paradigms, intellectual perspectives, and methods. One of the challenges facing the field in the coming years is to develop and implement strategies for injecting injury science into the training curricula of the many disciplines that participate in and contribute to the injury field. The injury field (including the many specialized spheres of interest within it) overlaps with other fields whose knowledge and practice affect injury prevention and treatment. These adjacent fields include substance abuse, disability prevention, criminal justice, child development, and mental health. Another important challenge facing leaders of the injury field in the coming years is to facilitate collaboration with scientists and practitioners from these many overlapping and adjacent fields. Maturity A vibrant interdisciplinary field, encompassing biomedical, engineering, and social and behavioral sciences cannot thrive in the face of intellectual orthodoxy. In the injury field, the challenge has been to open a discourse between environmental and behavioral perspectives. Until the 1960s, the predecessor field of accident prevention was dominated by a behavioral perspective, and proposed
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Reducing the Burden of Injury: Advancing Prevention and Treatment interventions relied heavily on changing individual behavior, primarily through education and persuasion. Partly in reaction to the perceived failure of health education, Haddon (1968) and others highlighted the importance of mechanical and environmental factors. What Haddon had in mind was an extension of injury prevention from one cell of the matrix in Figure 1.2 (pre-event, individual behavior) to all the cells. However, during the late 1960s and early 1970s, the pendulum swung in the other direction, and the developing injury field was characterized by a strong emphasis on environmental intervention (and passive protection) and a deep skepticism about the efficacy of behavioral intervention. This perspective has long been regarded as axiomatic in the literature, and behavioral perspectives (e.g., of economists or health educators) have often been discounted or strongly criticized. In recent years, however, this intellectual tension has receded and behavioral perspectives are now increasingly viewed as complementary rather than antagonistic to environmental perspectives. Since 1985, knowledge about human judgment and decision making has made significant advances, integrating the perspectives of cognitive psychologists and economists. People have also recognized that behavioral interventions may sometimes be cheaper and more cost-effective than environmental ones even if they are more circumscribed in scope. Moreover, educational efforts have increasingly focused on changing the behaviors of those with opportunities to influence policy, such as legislators and the media, rather than on merely educating for the purpose of changing individual behavior. Like other fields in public health, such as infectious disease control and substance abuse prevention, the injury field is defined by a preventive mission. Injury specialists are not "neutral" about whether injuries occur or whether their impact is ameliorated. However, this mission must be pursued in a social and cultural context where the message (that injuries are preventable) competes for attention with other concerns and where people have widely divergent attitudes about what risks are acceptable or what interventions are appropriate. One sign of the maturation of the injury field is the growing appreciation of the ethical and cultural context of injury prevention and treatment. Injury prevention is not free. All preventive interventions have costs, including possible trade-offs with other important social values. In the early years of the field, injury specialists were almost reflexively inclined toward regulation, particularly of consumer products and environmental risks. This orientation was understandable in light of the weaknesses of legal regulation at the time. In recent years, however, the field has begun to incorporate the perspectives of economists, particularly the need to consider all of the behavioral effects of an intervention, to measure costs, and to seek a reasonable balance between benefits and costs. A complementary phenomenon has also occurred within the allied disciplines, as some economists and public policy experts have embraced the perspectives and vocabulary of public health (Cook, 1991; Zimring and Hawkins, 1997).
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Reducing the Burden of Injury: Advancing Prevention and Treatment A related development is recognition of the need to embrace different perspectives on the weighing of risks. A developing literature on risk analysis has described the factors that affect people's judgments about what risks are acceptable (e.g., whether they are voluntarily assumed) and how different types of risks are compared with one another, and has helped to highlight the ways in which the benefits and burdens of risk-taking behavior are differentially distributed (Fischhoff et al., 1981). Those contributions have enriched our understanding of the ethical dimensions of preventive interventions and have located the injury field in the larger landscape of risk regulation. Controversies in the Field Because the injury field is mission driven and action oriented, some controversies concerning the ethics and politics of prevention tend to recur. A continuing challenge for participants in the public debate, and particularly for leaders of the field, is to develop rhetorical strategies for promoting public consensus on controversial issues. Regulation and Freedom Injury prevention interventions often aim at protecting people from the consequences of their own risk taking. In some instances, critics may characterize these interventions as "paternalistic" because they curtail people's freedom "for their own good," rather than to protect other people. The most clear-cut examples are mandatory motorcycle helmet laws and other regulations requiring that people use safety precautions to protect themselves. More ambiguous examples include prohibiting manufacturers from selling products thought to be too risky (e.g., three-wheel all-terrain vehicles [ATVs]) or requiring manufacturers to protect adult consumers from their own negligence (e.g., machine guards) when doing so increases the product's cost or reduces its utility. The argument that an intervention is impermissibly paternalistic can be contested on a variety of grounds. First, it might be argued that the intervention is designed to offset irremediable deficits in information that prevent people from appreciating the risks they face or otherwise making informed risk-benefit judgments. Everyone would agree that such information deficits, if proven, provide an ethically appropriate basis for regulation. The disagreement arises when the government restricts peoples' choices (by banning three-wheel ATVs for use by adults or requiring adult car occupants to wear safety belts) on the ground that people sometimes do not make "rational" choices based on the information at hand. Libertarian critics would find this argument unpersuasive because it substitutes the government's values and preferences for the individual's. Proponents might also defend supposedly paternalistic regulation by arguing that the person
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Reducing the Burden of Injury: Advancing Prevention and Treatment injured as a result of his or her own risk taking rarely "internalizes" the cost of the injury and that everyone therefore has a stake in reducing the social costs of injury. Finally, some might argue that even if the intervention is paternalistic, it still may be justified as long as some other criterion is met (e.g., that the aggregate social benefits of the intervention outweigh its costs). Recent studies have shown, for example, that mandatory helmet laws and mandatory safety-belt use laws substantially reduce injury costs (Graham et al., 1997; Max et al., 1998). In the final analysis, opposition to mandatory safety-belt laws virtually evaporated in the face of unequivocal evidence that the safety gains (lives saved and disability avoided) far outweigh the costs of enforcement and the slight reduction in freedom. Regardless of one's views on the issue of paternalism, injury prevention interventions always require attention to costs and benefits, and a restriction of individual freedom must sometimes be "weighed" as one of the "costs" of the intervention. One example is the argument that reducing the blood alcohol level (BAL) that constitutes conclusive evidence of drunk driving (from 0.10 g/dL to 0.08 g/dL) will curtail the opportunity for social drinking in bars and restaurants by many people who would not have posed a higher crash risk. How does one quantify the "costs" of this reduced freedom to drink and weigh them against the safety gains effected by the 0.08 BAL laws? Another contentious example is the argument that reducing access to handguns in the home poses a trade-off between the value of the lives that would be saved by reduced access and the value of a reduced sense of security for homeowners. One of the important challenges facing the field is to promote rational discourse about the empirical issues and value judgments raised by these recurrent conflicts between safety regulation and personal freedom (see Chapter 5). Federalism and Priority Setting As in many areas of public health, an ongoing dispute concerns the role of the federal government in priority setting. Some argue that the most useful role of the federal government in the sphere of injury prevention is to support states and communities in their efforts to set and implement local priorities. The counterargument is that limited federal dollars should be used to generate new knowledge and to spur states and communities to implement policies and programs that have been identified as federal priorities. This dispute is evident in debates between those who want federal money to be used for capacity building in state health departments and those who prefer that the money be used to support the implementation and evaluation of programs identified as federal priorities. Another dimension of this controversy is the degree of pressure that should be brought to bear on states to implement federal priorities. Sometimes Congress uses the "carrot," making grants available for the specific purpose of implement-
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Reducing the Burden of Injury: Advancing Prevention and Treatment ing a new program. In other contexts, however, Congress uses a "stick," withholding funding for ongoing federally supported state activities, such as highway construction. For example, a provision of the National Highway System Act of 1995 directed the Department of Transportation to withhold federal highway construction monies from states that failed to enact "zero tolerance" laws for drivers under 21 by 1998. The dispute over the use of "conditional" federal funding was evident in the 1998 congressional debate over the .08 BAL laws, when the battle lines were drawn between those who wanted to withhold federal highway monies from noncomplying states and those who wanted to offer an incentive for adoption rather than use a penalty. Science and Advocacy In any value-laden field where research is highly susceptible to political bias, special efforts are required to preserve the integrity of the scientific process through peer review of proposals and publications and through the corrective effects of replication and reinterpretation of scientific findings. (The distortion of tobacco research is described by Bero and colleagues .) Research can never be value free, of course. Inevitably, a researcher's values influence the topics he or she chooses to investigate and the discussion of the possible implications of study findings. Yet every reasonable effort should be made to minimize the influence—and the appearance—of bias on the study methods and the analysis of results. It is also important for investigators to avoid becoming so invested in a particular policy position that they compromise public confidence in the objectivity and integrity of the scientific process. Some investigators try to do this by eschewing advocacy altogether, and the committee believes that the injury field would benefit from a stronger cadre of "pure scientists" who try to maintain an objective stance on their work. However, it would go too far to insist that all injury scientists abstain from advocacy. As noted in Chapter 7, advocacy on behalf of injury prevention is a key component of public health practice, and injury scientists may properly want to assume the burdens—and risks—of advocacy. How to balance the demands of science and advocacy is one of the ongoing challenges for the field. ORGANIZATION OF THE REPORT It is customary to summarize the knowledge, activities, and challenges of the injury field by categorizing injuries according to mechanism (motor vehicle, firearm, fall, fire, etc.), intentionality (unintentional, assaultive, and self-inflicted), or context (transportation, residential, recreational, and occupational). The committee decided not to use any of these customary devices to organize
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Reducing the Burden of Injury: Advancing Prevention and Treatment this report. For one thing, other reports and reviews have recently synthesized knowledge and opportunities in the component parts of the field (see, e.g., National Committee ; IOM ; Rivara et al. [1997a,b]). More importantly, the committee's charge was to assess the injury field as a whole and to make 'recommendations for advancing the field as a whole. Rather than compiling particular recommendations for each of the component areas, the committee wanted to highlight the potential contributions of injury science and practice to a diverse, collaborative effort to achieve a safer society. Chapter 2 describes the magnitude and costs of injury in the United States. Chapter 3 reviews existing injury data systems and makes recommendations for improving injury surveillance as a necessary foundation for further advances in risk analysis, prevention research, and program evaluation. Chapter 4 highlights opportunities for strengthening injury prevention research. Chapter 5 presents two case studies of injury prevention—motor vehicles and firearms—in an effort to identify the successful components from motor vehicle injury prevention that may be applied to reducing firearm injuries. Chapter 6 reviews progress in trauma systems development. Chapters 7 and 8 present recommendations for strengthening society's capacity to prevent and treat injuries. Chapter 7 focuses on state and community action, with a particular emphasis on the implementation of injury prevention programs. Chapter 8 addresses the federal response, with a series of recommendations for strengthening federal support for research and program development and for coordinating the federal effort. Chapter 9 provides the main conclusions of this report and discusses future opportunities for reducing the burden of injury in America. Finally, there are four appendices in the report: Appendix A provides a list of those individuals who shared their insights and knowledge with committee members, attended meetings, and the public or scientific workshop. Appendix B provides a timeline of selected historical events in the injury field. Appendix C details the agenda for the committee's public workshop. Appendix D contains a list of acronyms used in the report. REFERENCES Avery JG. 1995. Accident prevention—injury control—injury prevention—or whatever? Injury Prevention 1(1):10–11. Baker SP. 1989. Injury science comes of age. Journal of the American Medical Association 262(2):2284–2285. Bero LA, Glantz SA, Rennie D. 1994. Publication bias and public health policy on environmental tobacco smoke. Journal of the American Medical Association 272(2):133–136.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Max W, Stark B, Root S. 1998. Putting a lid on injury costs: The economic impact of the California motorcycle helmet law. Journal of Trauma 45(3):550–556. Miller TR, Lestina DC, Galbraith MS, Viano DC. 1994. Medical-care spending—United States. Morbidity and Mortality Weekly Report 43(32):581–586. National Committee (National Committee for Injury Prevention and Control). 1989. Injury Prevention: Meeting the Challenge. New York: Oxford University Press. Published as a supplement to the American Journal of Preventive Medicine 5(3). NCHS (National Center for Health Statistics). 1998. Health, United States, 1998 with Socioeconomic Status and Health Chartbook. Hyattsville, MD: NCHS. DHHS Publication No. (PHS) 98-1232. NCIPC (National Center for Injury Prevention and Control). 1993. Injury Control in the 1990s: A National Plan for Action. A Report to the Second World Conference on Injury Control. Atlanta, GA: Centers for Disease Control and Prevention. NCIPC (National Center for Injury Prevention and Control). 1997. Inventory of Federally Funded Research in Injury Prevention and Control, FY 1995. Atlanta, GA: NCIPC. NIH (National Institutes of Health). 1994. A Report of the Task Force on Trauma Research. Bethesda, MD: NIH. NRC (National Research Council). 1966. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy Press. NRC (National Research Council). 1985. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press. NRC (National Research Council). 1988. Injury Control: A Review of the Status and Progress of the Injury Control Program at the Centers for Disease Control. Washington, DC: National Academy Press. NRC (National Research Council). 1993. Understanding and Preventing Violence. Washington, DC: National Academy Press. NRC (National Research Council). 1998. Violence in Families: Assessing Prevention and Treatment Programs. Washington, DC: National Academy Press. Olds DL, Eckenrode J, Henderson CR Jr, Kitzman H, Powers J, Cole R, Sidora K, Morris P, Pettitt LM, Luckey D. 1997. Long-term effects of home visitation on maternal life course and child abuse and neglect. Journal of the American Medical Association 278(8):637–643. Osofsky JD. 1995. The effects of exposure to violence on young children. American Psychologist 50(9):782–788. Rivara FP, Grossman DC, Cummings P. 1997a. Injury prevention. First of two parts. New England Journal of Medicine 337(8):543–548. Rivara FP, Grossman DC, Cummings P. 1997b. Injury prevention. Second of two parts. New England Journal of Medicine 337(9):613–618. Rosenberg ML, Fenley MA, eds. 1991. Violence in America. A Public Health Approach. New York: Oxford University Press. U.S. DHHS (Department of Health and Human Services), Department of Justice. 1986. Surgeon General's Workshop on Violence and Public Health. October 27–29, 1985. Rockville, MD: DHHS, Public Health Service. DHHS Publication No. HRS-D-MC-86-1.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Waller JA. 1994. Reflections on a half century of injury control. American Journal of Public Health 84(4):664–670. Zimring FE, Hawkins G. 1997. Crime Is Not the Problem: Lethal Violence in America. New York: Oxford University Press.
Representative terms from entire chapter: