The Burden of Injury
Injury is a continuing public health problem that has reached epidemic proportions. Injury is the fourth leading cause of death in both the United States and West Virginia and is the leading cause of death among those under the age of 45. Unintentional injury accounts for nearly two-thirds of these deaths nationwide and in West Virginia, while intentional (homicide and suicide) injuries account for about one-third of injury deaths in the U.S. and slightly over one-quarter in West Virginia. In modern America, injury takes a high toll on the lives of our citizens and is a major cause of premature death, especially among our children. Over 12% of the 143,948 persons who died from injuries in the U.S. in 1999 were children and teenagers. Forty-three percent of these youthful deaths were a result of MV crashes, 19% were homicides, and 11% were suicides. In West Virginia, over 10% of the 1,220 injury-related deaths in 1999 occurred to children and teenagers; 31% from MV crashes, 19% from suicide, 10% from falls, and 8% from homicides. About 10% of all U.S. residents, or 31 million people, visited emergency departments in 2000 for treatment of nonfatal injuries. In West Virginia, injuries account for about 4 in 10 visits to emergency departments and nearly 10% of all hospital discharges had a first-listed injury diagnosis.
Injury Pyramid
The distribution of injury mortality and morbidity has often been characterized as an “injury pyramid or injury triangle,” as shown below. In a classic monolithic injury pyramid, the number of injury deaths represents the smallest proportion of cases or the capstone or the “tip of the iceberg.” Greater and increasing proportions of the pyramid are thought to be self-care and no treatment modalities. It is often implied that these latter injuries and treatment modalities are the most numerous and form the foundation of any injury pyramid.
U.S. WV
146,941 *
Deaths
1,220 §
2,540,000 **
Hospital Discharges
17,250 #
129,284,000 ***
Ambulatory care visits: ED, outpatient treatments, physician office visits
225,000
???
Injuries not requiring formal medical treatment, self-care, no treatment
???
* National Center for Injury Control and Prevention: Injury Mortality from Wisqars, 1998 ** National Center for Health Statistics: National Hospital Discharge Survey, annual summary for 1998 *** National Center for Health Statistics: Ambulatory Care Visits to Physician Offices, Outpatient Departments, and Emergency Departments, U.S., 1996 § WV Office of Epidemiology and Health Promotion, 1999 # WV Health Care Authority, 1996-2000
Many nonfatal injuries result in serious financial, social and personal costs.
5 Estimates currently place the cost of injuries in the U.S. at 224 billion dollars annually, with costs continuing to rise each day. One in four Americans is injured seriously enough to seek medical attention each year. In fact, injuries have become such a public health problem that they now result in more years of potential life lost than either heart disease or cancer.
Injury Control and Prevention Strategies
Although the numbers suggest that the burden of injury may be at epidemic proportions, public health professionals are only beginning to adequately address the topic of injury control. Conceptually injury control consists of three elements: Prevention - the means by which the number of injuries can be reduced and the severity of outcome lessened; Acute care - how injuries are treated; whether there are sufficient personnel, in the right places, with adequate training and; Rehabilitation - how victims of injury who suffer functional disabilities are treated and retrained physically, mentally, socially, and occupationally. Injury prevention encompasses a broad spectrum of programs and policies aimed at reducing the frequency or severity of injuries. These interventions can be grouped in different ways. For example, one approach divides these elements into four broad categories, sometimes referred to as the 4 E’s of injury prevention: Enforcement and legislation legislation covers the creation of laws and regulatory standards to reduce the risk and severity of injury. Enforcement sees that these laws are applied as intended; Engineering and product design - engineering and product design should ensure that products and equipment are designed in such a way to protect the user/consumer from known hazards; Education and behavioral change - education and behavioral change refer to what we can do as individuals to alter our own behavior, attitudes and actions and to educate others about how injuries are caused; and Economic and other incentives - strategies are used to focus part of the public mind on the cost and economic burden of injury at the individual, community, and state levels. Conversely, the dollars to be saved when specific injuries are prevented should be of general interest to citizens. These four strategies are not mutually exclusive from each other but interrelated. Legislation, for example, can change public awareness, personal behavior and product design. Product design can become a selling feature, as in the case of air bags, and influence public awareness and personal purchasing choices. Another approach recommended by the Institute of Medicine’s Committee on Injury Prevention and Control groups the elements of injury prevention and intervention into four interrelated categories:
• Individual Behavior
Many injury interventions require changes in human behavior, either to reduce the exposure or vulnerability of potential victims to injury-causing events or to reduce the risk that one person will become the agent or instrument of harm to another. Behavior change can be achieved by incentives and deterrence, education, and persuasion – usually through a combination of these.
• Agent
6 The agent of injury is often a product obtained by a consumer in the marketplace (e.g., motor vehicles, firearms, etc.). Product alterations, such as childproof caps on medicines, center-high mounted brake lights on automobiles, have been shown to reduce the risk of an injury causing event or to ameliorate its effects. Research on the safety features of products is conducted primarily by manufacturers, regulatory agencies, or watchdog consumer organizations.
• Physical Environment
Engineered safety interventions (e.g., guard rails and rumble strips on highways, window guards to prevent childhood falls, smoke detector and sprinkler systems) are often unnoticed factors in the environment that have been proved highly successful. Other environmental changes such as improved lighting in parking lots and locating ATM machines in well-lit, high-traffic areas are readily recognizable means of reducing robberies.
• Socioeconomic Environment
Interventions designed to reduce injuries occur in the context of broad economic and social forces --- such as employment rates, wealth distribution and poverty status, social norms about health and safety, and population demography --- that also fundamentally influence injury rates. Economic conditions, and social and cultural practices constitute the context for all these other factors and the prospect of altering them. For example, changes in attitudes towards alcohol-impaired driving has been associated with changes in driver behavior and with consequent reductions in injury rates.
Injury Control - Who Should Do It?
Injury prevention and control can be facilitated through a variety of constituents. Sometimes, prevention can be accomplished by a simple act of an individual while at other times, prevention may require the combined efforts of the entire community. Ultimately, we are all involved to some degree. An important first step is to ask, “how do we do it?” Here are some basic ideas: Law Enforcement Learn and practice basic life-saving techniques, such as first-aid and CPR. Enforce laws designed to reduce injury and protect the citizens of our state. Let local and state legislators know your opinions about effective policies and interventions and those that don’t work. Legislators Find out how injury affects your constituents. Learn about how injuries can be prevented, support injury control legislation, support data collection, injury surveillance, and related injury control research. Educators Become aware of the injury problem. The causes of injury are multifaceted. You
7 can teach your students about injury prevention through physics, social studies, mathematics, political science, driver safety, anatomy, criminology, and a number of other subjects. Researchers Publish and disseminate information which describes who is being injured, how badly, where, by what mechanisms, at what cost, and other related contributing factors. Develop intervention evaluations to determine the most effective programs. Investigate technological interventions which can reduce injury frequency or severity. Medical Personnel Keep track of what causes injuries and describe it in your chart notes. Set up your own local surveillance system. Advocate for including E-codes on all hospital discharge forms. Visit your legislators and tell them about the extent and effects of injury that you see in your patients. Employers Learn how injuries affect your industry. Discover whether programs or devices have been developed which can reduce the risk of injury to your employees. Look at your work force and evaluate whether they are following safe working practices. Provide general and task-specific training, as appropriate. All of Us Don't wait for an injury to happen. Become informed about personal injury prevention. Buckle your seat belt, don't drink and drive, wear motorcycle/bicycle helmets, buy cars with air bags and anti-lock brakes, don’t use a cell phone while driving, speak up about domestic and family violence and change the batteries in your fire alarms. Identify and address the risk of falling in your home. Keep poisons out of the reach of children. Become part of the solution for reducing death and injury from handguns. Talk to your kids, ask your physician about injury prevention, voice your opinions to your legislators and vote for injury control legislation when you get the chance. Injury prevention can also take place on a variety of levels. The following list provides a few brief examples: National - establish standards for vehicle safety and interstate highway speed limits; State - pass legislation establishing minimum blood alcohol content levels for drivers; County - develop a program to introduce bicycle safety to all public school children; Community - remove visual obstructions at a dangerous intersection; Workplace - require personal protective gear including hard hats and safety glasses;
8 Family - use child safety seats; Individual - use a seat belt, don’t drink and drive, observe the speed limit. Many different interventions are proposed or implemented. All should be evaluated to see if they make a difference in reducing the frequency and severity of injuries. Specific examples of a wide variety of strategies are presented in each of the cause-specific chapters which follow.
References
Institute of Medicine (Committee on Injury Prevention and Control, Division of Health Promotion and Disease Prevention). Reducing the Burden of Injury: Advancing Prevention and Treatment. Bonnie RJ, Fulco CE, and Liverman CT (eds). National Academy Press: Washington, DC, 1999. Centers for Disease Control and Prevention. National Injury Estimates of Nonfatal Injuries Treated in Hospital Emergency Departments – United States, 2000. Morbidity and Mortality Weekly Report May 4, 2001;50(17):340-6. Fingerhut LA, Warner M. Injury Chartbook: Health, United States, 1996-97. National Center for Health Statistics: Hyattsville, MD, 1997. Christoffel T, Gallagher SS. Injury Prevention and Public Health: Practical Knowledge, Skills, and Strategies. Aspen Publications, Inc.: Gaithersburg, MD, 1999. National Center for Health Statistics. Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 1996. Vital and Health Statistics, Series 13, No. 134, Table 6. February 1998. National Center for Health Statistics. National Hospital Discharge Survey: Annual Summary, 1998. Vital and Health Statistics, Series 13, No. 148, Table 7. September 2000. National Center for Injury Control and Prevention. Leading Causes of Death, 1998. WISQARSTM (Web-based Injury Statistics Query and Reporting System). National Center for Health Statistics. National Vital Statistics Report, Vol 49, No. 8. September 21, 2001. National Center for Injury Prevention and Control. Injury Fact Book 2001-2002. Atlanta GA: Centers for Disease Control and Prevention; 2001.