National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

Reducing the Burden of Injury

ADVANCING PREVENTION AND TREATMENT

Richard J. Bonnie, Carolyn E. Fulco, and Catharyn T. Liverman, Editors

Committee on Injury Prevention and Control

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1999

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W. Washington, DC 20418

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

Support for this project was provided by the W.K. Kellogg Foundation, the John D. and Catherine T. MacArthur Foundation, and the Robert Wood Johnson Foundation. The views presented are those of the Institute of Medicine Committee on Injury Prevention and Control and are not necessarily those of the funding organization.

Library of Congress Cataloging-in-Publication Data

Reducing the burden of injury : advancing prevention and treatment / Richard J. Bonnie, Carolyn E. Fulco, Catharyn T. Liverman, editors ; Committee on Injury Prevention and Control, Division of Health Promotion and Disease Prevention, Institute of Medicine.

p. cm.

Includes bibliographical references and index.

ISBN 0-309-06566-6 (pbk.)

1. Accidents--United States--Prevention. 2. Wounds and injuries--United States--Prevention. I. Bonnie, Richard J. II. Fulco, Carolyn. III. Liverman, Catharyn T. IV. Institute of Medicine (U.S.). Committee on Injury Prevention and Control.

HV676.A2 R44 1999

363.11'5--dc21

98-40288

Copyright 1999 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

COMMITTEE ON INJURY PREVENTION AND CONTROL

RICHARD J. BONNIE* (Chair), John S. Battle Professor of Law and Director,

Institute of Law, Psychiatry, and Public Policy, University of Virginia

DIANA D. CARDENAS, Professor,

Department of Rehabilitation Medicine, University of Washington

KATHERINE KAUFER CHRISTOFFEL, Director,

Violent Injury Prevention Center, Children's Memorial Hospital, Chicago, and

Professor of Pediatrics and Preventive Medicine,

Northwestern University Medical School

PHILIP J. COOK, ITT/Sanford Professor of Public Policy, and Director,

Sanford Institute of Public Policy, Duke University

SUSAN S. GALLAGHER, Director,

Children's Safety Network, and

Senior Scientist,

Education Development Center, Inc., Newton, Massachusetts

HERBERT G. GARRISON, Director,

Eastern Carolina Injury Prevention Program, and

Associate Professor of Emergency Medicine,

East Carolina University School of Medicine

BERNARD GUYER,* Professor and Chairman,

Department of Maternal and Child Health, Johns Hopkins University School of Hygiene and Public Health

HOPE HILL, Professor of Psychology,

Howard University

LENWORTH M. JACOBS, JR., Professor and Chairman,

Department of Traumatology and Emergency Medicine, and

Professor of Surgery,

University of Connecticut School of Medicine;

Director,

EMS/Trauma Program, Hartford Hospital, Hartford, Connecticut

ELLEN MACKENZIE, Director,

Center for Injury Research and Policy, Department of Health Policy and Management, Johns Hopkins University School of Hygiene and Public Health

SUE MALLONEE, Chief,

Injury Prevention Service, Oklahoma State Department of Health, Oklahoma City

ELIZABETH MCLOUGHLIN, Director of Programs,

Trauma Foundation, San Francisco General Hospital, San Francisco, California

GORDON REEVE, Corporate Epidemiologist,

Occupational Health and Safety, Ford Motor Company, Dearborn, Michigan

PATRICIA WALLER, Director,

Transportation Research Institute, and

Professor of Health Policy and Administration,

University of Michigan School of Public Health

ALLAN F. WILLIAMS, Senior Vice-President for Research,

Insurance Institute for Highway Safety, Arlington, Virginia

FLAURA WINSTON, Director,

TraumaLink, Children's Hospital of Philadelphia, University of Pennsylvania

CRAIG ZWERLING, Director,

Injury Prevention Research Center, University of Iowa

Board on Health Promotion and Disease Prevention Liaison

ELENA O. NIGHTINGALE,* Scholar-in-Residence,

Institute of Medicine

*

Member, Institute of Medicine.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

Staff

CAROLYN E. FULCO, Study Director

CATHARYN T. LIVERMAN, Study Director

SANDRA AU, Project Assistant/Research Assistant

KATHLEEN STRATTON, Director,

Division of Health Promotion and Disease Prevention

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

Acknowledgments

The committee's efforts were supported by the work and dedication of the project staff and consultants and numerous individuals named in Appendix A who shared their thoughts and expertise with the committee. The committee benefited from the project staff's direction and commitment to the study; Carolyn Fulco and Cathy Liverman contributed constructively to the committee's deliberations and provided necessary guidance in informing the committee of our responsibilities in developing the report. Sandra Au provided the committee with excellent attention to detail, exceptional concern for the study process, and dedication to the production of the report. Institute of Medicine summer intern, Ann St. Claire, in consultation with many individuals, produced an informative timeline of the development of the injury field and provided assistance with numerous other activities; we appreciate her efforts on our behalf. We also thank Kysa Christie for her diligent work on producing the camera-ready copy of the report.

We are indebted to Kathleen Stratton for her insight, assistance, and guidance as we negotiated our way through various difficult issues, and especially to Elena Nightingale for her thoughtful comments that kept us true to our task. They both contributed constructively to the committee's deliberations and provided guidance to make the report responsive to the charge.

Miriam Davis, consultant to the committee, provided exceptional background information and research for our deliberations and extensive written material for the committee's consideration. Lois Fingerhut, National Center for Health Statistics, provided considerable technical assistance and information on injury statistics and injury surveillance systems and we are very grateful for her help. Finally, we appreciate the careful editing by Florence Poillon who has enhanced the readability of the report, and to all the reviewers whose thoughtful comments have improved the quality of our work.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report:

Susan Baker, Johns Hopkins University School of Hygiene and Public Health;

Barbara Barlow, Columbia University, Harlem Hospital Injury Prevention Program;

Enriqueta Bond, Burroughs Wellcome Foundation;

James Ebert, Marine Biological Laboratory, Johns Hopkins University;

Lois Fingerhut, National Center for Health Statistics;

John Graham, Harvard University School of Public Health;

Robert Haggerty, University of Rochester School of Medicine;

David Hoyt, University of California, San Diego, Medical Center;

Alexander Kelter, California Department of Health Services;

Mark Moore, Harvard University;

Barry Myers, Duke University;

Fred Rivara, University of Washington; and

Gerald Strauch, American College of Surgeons.

While the individuals listed above have provided constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the institution.

The committee expresses its appreciation to the sponsors of this study: the W.K. Kellogg Foundation, the John D. and Catherine T. MacArthur Foundation, and the Robert Wood Johnson Foundation.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

Preface

The Committee on Injury Prevention and Control was appointed by the Institute of Medicine in March 1997, with funding from the Robert Wood Johnson, W.K. Kellogg, and John D. and Catherine T. MacArthur foundations, and was directed to "make recommendations intended to further develop the field of injury prevention and control and to reduce the burden of injury in America." In carrying out this charge, the 17-member committee was standing on the shoulders of two predecessor committees of the Institute of Medicine (IOM) and the National Research Council (NRC), whose efforts laid the foundation for the field of injury prevention and treatment, as distinct spheres of specialization within public health and clinical medicine, more than a decade ago. Accordingly, the reports of these earlier committees—Injury in America (NRC, 1985) and Injury Control (NRC, 1988)—have been taken as the starting point for this work. William H. Foege, who chaired both of these committees, correctly observed that future historians would regard this formative period as a "turning point" for the field, ''when science began defining injury, measuring determinants [and] devising interventions" and public and private efforts were galvanized to address injury problems. Although much has been accomplished since the publication of Injury in America, the aspirations of the previous IOM-NRC committees have not yet been fully realized.

Injury prevention and treatment encompass a vast terrain and touch on the interests of numerous disciplines and constituencies. To open the process to as many voices as possible, the committee convened a public hearing in Washington, D.C., conducted three scientific workshops, invited written comments and suggestions from hundreds of organizations and individuals, and conducted surveys of researchers and practitioners about the needs of the field. The level and intensity of the response provide compelling evidence of the growth and

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

vitality of the injury field and of a heightened public awareness of injury problems.

The committee encountered the customary pattern of special pleading for one cause or another (e.g., suicide, drunk driving, firearms, head injury), a reflection of a general drift toward interest-group politics in biomedical research and health policy making. Focusing attention on particular problems arouses public interest, brings more energy into the field, and probably hastens the application of advances in the laboratory to solutions of real-world issues or diseases. However, preoccupation with special causes can obscure common goals and lead to fragmentation of effort. While the committee applauds the energetic efforts of an increasing number of "interest groups" in the injury field to draw public attention to their particular concerns, what is most needed at this stage of the field's development is for all these groups to collaborate in a common effort to advance injury science and strengthen the nation's investment in injury prevention and treatment.

The committee was constituted to reflect the disciplines ordinarily identified with the injury field (including biomechanics, psychology, epidemiology, and medicine) as well as a number of disciplines adjacent to the field, such as criminology, economics, and law. This committee's experience holds a lesson for the field as a whole. Certain ideas have been regarded as axiomatic in the injury field, including a general preference for "passive protection" and a general skepticism about behavioral strategies. Until recently, these biases have been accompanied by tendencies to neglect the use of incentives and to overlook or disregard the costs of regulatory interventions. Future success of the injury field depends on its ability to broaden its base—by recruiting researchers and collaborators from the behavioral and social sciences—and to incorporate and integrate different ideas and perspectives, while preserving its intellectual bearings and distinct grounding in public health.

The historical record will show that this committee was conceived at a moment of confusion (if not crisis) in the field (Thompson, 1998). Two related questions had been raised. One is whether the priorities of injury policy makers, researchers, and practitioners have become distorted by an undue emphasis on firearms, and perhaps by a bias in favor of gun control. The second is whether prevention of violence is being overemphasized in comparison with the field's traditional focus on unintentional injuries. The committee explored these problems frankly and open-mindedly. We explored the similarities and differences between firearms and other mechanisms of injury, including the role of intentionality, and their implications for designing and implementing intervention strategies. We explored the relation between violence prevention and injury prevention. We also seriously considered proposals to refocus the preventive agenda of the injury field on unintentional injuries, leaving primary responsibility for assaultive injuries and suicide to criminal justice and mental health. In the end, however, the committee decided, unanimously, to reaffirm the views expressed in Injury in America and Injury Control regarding the scope and mission

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

of the injury field. Despite important differences associated with intentionality, the committee strongly endorses the continued integration of all injury prevention activities within a common framework of research and program development. The injury field has much to contribute to scientific understanding of firearm injuries and to the prevention of violence, complementing the contributions made by criminal justice, mental health, and other approaches. The public health investment in these areas should be strengthened, not abandoned or diminished.

Strengthening "the injury field" is but one element of a strategic plan for reducing the burden of injury in America. Achieving a safer society requires coordinated efforts by many public and private agencies in numerous spheres of research and social action. Public health agencies and affiliated constituencies comprise only a segment of the vast array of agencies and groups aspiring to build a safer America. The challenge set forth in Injury in America was to establish injury prevention and treatment as a recognized interdisciplinary field of scientific study. For the most part, this goal has been achieved. The challenge confronting us today is to enhance the impact and effectiveness of the field. Doing so requires a broad matrix of collaboration with other agencies and constituencies, and careful priority setting within the field in order to focus efforts and resources on areas of research and action that optimize the specialized contribution of public health.

This report takes its place alongside several other recent IOM-NRC reports highlighting the need to rejuvenate and strengthen the infrastructure of public health (IOM, 1988, 1996). Our society's failure to invest in injury prevention is symptomatic of a more general tendency to underinvest in programs designed to prevent social problems. This is ultimately a political challenge that must be addressed by "marketing" the virtues of prevention in the forum of public opinion. "A key struggle for [public health leaders] is making the benefits of community-based, population-wide public health activities and initiatives more recognizable" (IOM, 1996). Another key challenge in public health is to take maximum advantage of the changing incentives in the emerging structure of health care delivery and financing. In large capitated systems with limited enrollee turnover, successful prevention can result in larger profit margins downstream. Partnerships between public health agencies and managed care organizations offer rich opportunities for institutionalizing injury prevention and assessing outcomes (Lasker and Committee on Medicine and Public Health, 1997; Mechanic, 1998).

This report emphasizes, as did Injury in America and Injury Control , that the nation's current investment in injury research is not commensurate with the magnitude of the problem. Throughout the report, the committee has recommended additional funding for surveillance, research, and program evaluation supported by a variety of federal agencies. Abundant opportunities for scientific advances in all aspects of the field fully justify a substantially higher level of funding for injury research. Trauma research (basic and applied) should receive a higher share (compared with current allocations) of increases in the National

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

Institutes of Health (NIH) budget, and funding outside NIH (e.g., Centers for Disease Control and Prevention, Agency for Health Care Policy and Research) for extramural research in all aspects of injury prevention and treatment should be increased. The committee also concluded that there is a yawning gap between what we already know about preventing or ameliorating injuries and what is being done in our communities, workplaces, and clinics. Thousands of lives could be saved every year if interventions already known to be successful were more widely implemented. Funding for prevention program support, emergency medical services and trauma systems, and public health infrastructure should be significantly increased. Although the committee has not attempted to develop cost estimates for its recommendations, carrying them out will clearly require the investment of new funds. The committee has provided adequate support for the programmatic goals and objectives of its recommendations; additional funds and resources must be forthcoming from the Congress for the relevant federal agencies and the states. Echoing Dr. Foege's prefatory claim in Injury in America, adequate investment in injury research and program implementation "could yield an unprecedented public health return." It is time for the country to make the necessary investment.

Richard J. Bonnie, LL.B.

Chair

Committee on Injury Prevention and Control

REFERENCES

IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, DC: National Academy Press.

IOM (Institute of Medicine). 1996. Healthy Communities: New Partnerships for the Future of Public Health. Washington, DC: National Academy Press.


Lasker RD, Committee on Medicine and Public Health. 1997. Medicine and Public Health: The Power of Collaboration. New York: New York Academy of Medicine.


Mechanic D. 1998. Topics for our times: Managed care and public health opportunities. American Journal of Public Health 88(6):874–875.


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.


Thompson B. 1998. The science of violence: Guns, politics, and the public health. Washington Post Magazine. March 20.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×
Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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TABLES, FIGURES, AND BOXES

Tables

1.1

Mission and Vocabulary of the Injury Field

30

2.1

Leading Causes of Injury Death, Trends, 1985–1995

46

2.2

Leading Causes of Years of Potential Life Lost

54

3.1

U.S. Federal Data Systems for Injury Surveillance, Research, and Prevention Activities

66

4.1

Examples of Effective Unintentional Injury Prevention Interventions

87

6.1

Chronology of Trauma System Legislation

144

6.2

Essential Criteria to Identify Regional Trauma Systems

150

7.1

State and Local Government Agencies and Organizations

184

8.1

Federal Agencies Involved in Injury Prevention and Treatment

206

9.1

Leading Causes of Death and Disability in the United States

263

Figures

1.1

Years of potential life lost

19

1.2

Haddon matrix

22

2.1

Ten leading causes of death, 1995

42

2.2

Burden of injury: United States, 1995

44

2.3

Leading causes of injury death by manner of death, United States, 1995

45

2.4

Age-adjusted death rates for leading causes of injury: United States, 1985–1995

47

2.5

Hospital discharge rates for injury by age and sex: United States, 1993–1994

51

5.1

Motor vehicle traffic injury deaths in the United States, 1950–1996

116

6.1

Reimbursement profile for all service areas

163

Boxes

1

The Federal Response

11

2

Summary of Recommendations

15

4.1

Harlem Hospital Injury Prevention Program

85

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

4.1

Harlem Hospital Injury Prevention Program

85

5.1

Brief Overview of Federal Firearm Laws and Regulations

127

6.1

The Continuum of Care

140

6.2

Levels of Trauma Centers

141

7.1

Child Passenger Safety Seats: An Example of the Lessons Learned

179

7.2

Examples of Nonprofit Organizations

181

7.3

Examples of Professional Organizations

183

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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Reducing the Burden of Injury

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Injuries are the leading cause of death and disability among people under age 35 in the United States. Despite great strides in injury prevention over the decades, injuries result in 150,000 deaths, 2.6 million hospitalizations, and 36 million visits to the emergency room each year.

Reducing the Burden of Injury describes the cost and magnitude of the injury problem in America and looks critically at the current response by the public and private sectors, including:

  • Data and surveillance needs.
  • Research priorities.
  • Trauma care systems development.
  • Infrastructure support, including training for injury professionals.
  • Firearm safety.
  • Coordination among federal agencies.

The authors define the field of injury and establish boundaries for the field regarding intentional injuries. This book highlights the crosscutting nature of the injury field, identifies opportunities to leverage resources and expertise of the numerous parties involved, and discusses issues regarding leadership at the federal level.

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