Injury Prevention

Charles C. Branas

Although tragic, the 1997 Paris car crash death of Diana, Princess of Wales, is an excellent opportunity to reflect on the basics of injury prevention. Five fundamental opportunities for prevention were overlooked and very likely resulted in the crash itself and its three deaths, including the princess’. First, the princess, in the rear right passenger seat, was not wearing a seat belt, along with two other occupants. The one occupant who did survive the crash was in the front passenger seat and was wearing a seat belt. Second, the princess’ car was being pursued by photographers and was traveling at high speed, far beyond typical urban speed limits. Third, the chauffeur of the princess’ car had been drinking alcohol before getting behind the wheel and was above the proscribed level of intoxication. Fourth, the princess’ car drove into a tunnel where it hit a pillar that was very close to the road and then crashed into a wall. The aging urban roadway they had been driving on had not been updated with modifications such as guardrails or flared barriers. Fifth, a medically trained bystander who arrived minutes after the crash reported that the princess was conscious. Although emergency medical services quickly responded to the scene of the crash, it took as much as 90 minutes to then transport the princess to a hospital, which was only a few miles away. This tragic event is a helpful case study for new injury prevention strategists and will serve to reinforce an understanding of the topics discussed in this chapter—injury as disease, the history of injury prevention, the magnitude of the injury problem, and injury prevention strategies.

THE BIOMEDICAL DISEASE OF INJURY

Injury, or trauma, occurs when at-risk people, unsafe environments, and hazardous objects converge. As such, injuries are often thought of as simply unavoidable social accidents, not worthy of systematic study and, by extension, thoughtful prevention efforts. But injury clearly deserves attention as a leading cause of death and disability in the United States and around the world. Injury also deserves attention because it occurs as part of a unique disease process: violence, suicide, falls, and automobile crashes are all disease-generating events that can very suddenly kill or disable otherwise healthy people. This is in contrast to other leading diseases, which generally become noticeable only after months or years of risk exposure. Therefore, injury develops in a fraction of a second, often after a similarly sudden exposure to one or more risk factors, making its prevention especially challenging.

Injury is a biomedical disease process brought about by a fast-acting, external force. The external force in question is created by the transfer of thermal, mechanical, electrical, or chemical energy onto the human body. This transfer of energy often occurs very rapidly and the pathologic damage that results is quickly recognizable. More recent definitions of injury have also included a damaging transfer of psychological energy (for instance, as with post-traumatic stress disorder).¹ The risk factors that precede this transfer of energy can occur almost simultaneously to the event itself or accumulate in the near or far past. The repercussions of this energy transfer also occur almost simultaneously to the event itself but with both immediate and long-term consequences. Given this fundamental disease paradigm, injury reduction strategists typically eschew the notion of injuries as unavoidable social accidents and instead rely on rational, scientific approaches to prevention.

HISTORY OF INJURY PREVENTION

The pluralism of injury prevention, as evidenced by its close ties to at least three different cabinet-level agencies in the United States—Health and Human Services, Justice, and Transportation—has made it one of three areas cited by the Institute of Medicine as highly suitable for interdisciplinary study.² In this way, the 20th century has been rife with
landmarks in injury prevention. Some of these events are accomplishments at singular points in time although many formed the basis of activities that continue today. The traffic safety movement of the 1920s and the home safety movement of the 1950s are two such examples³,⁴,⁵ (see Table 1).

TABLE 1 A SELECT CHRONOLOGY OF TWENTIETH CENTURY INJURY PREVENTION ACCOMPLISHMENTS

1924—Cadillac offers the first car with safety windshield glass standard

1933—Congress charters the National Safety Council

1934—National Firearms Act passed as the first major federal gun legislation

1942—Hugh de Haven, a World War I pilot and crash survivor-turned-physiologist, publishes landmark article on importance of injury biomechanics

1949—Seat belts introduced by Nash Motors

1949—John Gordon suggests that injuries behave like classic infectious diseases and can be studied using epidemiologic methods

1951—First medical evacuation by helicopter during Korean War

1956—United States Public Health Service establishes an Accident Prevention Program

1965—Ralph Nader publishes Unsafe at Any Speed documenting the resistance of car companies to seat belts and the three Es of road safety: engineering, enforcement, and education

1966—National Research Council report, Accidental Death and Disability, is released

1972—First live product demonstration of Dupont Kevlar bulletproof vest that was invented by Richard Davis after he was shot at in an attempted robbery

1973—Congress passes the Emergency Medical Services Act

1974—General Motors produces first air bags

1986—Injury Prevention Act signed into law paving the way for the National Center for Injury Prevention and Control at the CDC

CDC, Centers for Disease Control and Prevention.

Given its landmark achievements in injury prevention thinking and study, the 20th century has also witnessed some noteworthy reductions in injury. In fact, motor vehicle safety has been cited as one of the top ten public health achievements in the United States over the last century. This is largely based on reductions in traffic deaths due to safer vehicles and highways, increased use of safety belts, child safety seats, and motorcycle helmets, as well as decreased drinking and driving.⁶

However, it is worth noting that in the last century mortality reductions from injuries of all causes (not simply motor vehicle crashes) have been far less than those of other diseases, such as influenza, tuberculosis, and gastroenteritis⁷ (see Fig. 1). This relatively low level of success may be related to the fact that the federal research investment in injury prevention has been, and continues to be, very low proportional to the public health burden posed by the disease of injury⁸ (see Fig. 2). Certain mechanisms of injury have been limited or even proscribed in terms of receiving resource support from certain federal agencies. For instance, since 1997 the Centers for Disease Control and Prevention (CDC) have not been legally permitted to fund “activities designed to affect the passage of specific Federal, State, or local legislation intended to restrict or control the purchase or use of firearms.”⁹ Correspondingly, the National Institutes of Health (NIH), the largest public health research agency in the United States, has only granted one major research award per million firearm injury cases per decade in the last 30 years¹⁰ (see Table 2). Therefore, federal public health support of firearm injury research has been in short supply relative to the magnitude of the problem.¹¹

MAGNITUDE OF THE INJURY PROBLEM

Around the world, injury is the leading cause of death for the first half of the human life span and a regular source
of disability and disfigurement.¹²,¹³,¹⁴,¹⁵,¹⁶,¹⁷,¹⁸ As a leading cause of death, injury is fourth behind heart disease, cancer, and stroke (see Fig. 3). As an actual cause of death injury also ranks quite high; this is especially true for certain mechanisms of injury such as motor vehicles and firearms¹⁹ (see Table 3).

Figure 1 Twentieth century mortality reductions from injuries of all causes have been far less than those of other diseases. (Taken from Baker SP, Ginsburg MJ, O’Neill B. The injury fact book, 2nd ed. New York: Oxford Publishing; 1992.)

Figure 2 Years of potential life lost (YPLL) versus federal research investment. (Taken from Bonnie RJ, Fulco CE, Liverman CT, eds. Reducing the burden of injury: advancing prevention and treatment. Washington, DC: National Academy Press; 1999:19.)

Injury and its repercussions have a significant impact on health and well-being. Each day in the United States more than 320,000 men, women, and children are injured severely enough to seek medical care. Approximately 200 of these people will sustain a long-term disability due to their injuries and an additional 400 will die.²⁰,²¹,²²,²³ Globally, approximately 16,000 people die from injuries each day and this incidence is growing.²⁴

Only gold members can continue reading. Log In or Register to continue