INJURY: A NEW PERSPECTIVE ON AN OLD PROBLEM Lisa M. Chatman, Melodie D. Billups, Carl C. Bell, MD, and Marlon L. Priest, MD Birmingham, Alabama, and Chicago, Illinois
Injury-related morbidity and mortality have finally been acknowledged as major public health issues facing this country today. While injuries represent a serious problem for society as a whole, the rates are significantly higher among African-Americans, especially black males between 20 and 29 years of age. Moreover, injury and death resulting from acts of interpersonal violence are not only increasing, but are also significantly higher among blacks. Because injury-producing events have been shown to conform to the same biological laws that govern the expression and behavior of many infectious and chronic diseases, it has now been determined and verified that such events are largely predictable, and, in many instances, preventable. Because of the significant racial disparity in the incidence of injury-producing events, the authors encourage establishment of vigorous injury prevention, control-oriented curricula, and training opportunities in predominantly black medical schools. The authors assert that such institutions of higher learning represent an ideal point of introduction for innovative injury prevention and control strategies specifically aimed at the African-American population. Key words * injury * accidents * interpersonal violence
From the Minority Enrichment Program, UAB School of Medicine, CDC-sponsored Injury Prevention Research Center, Birmingham, Alabama, and the University of Illinois School of Medicine, Chicago, Illinois. Requests for reprints should be addressed to Ms Lisa M. Chatman, c/o Allen Bolton, MPH, MBA, Injury Prevention Research Center, UAB Station, CH-1 9, Birmingham, AL 35294. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
"Injury is the leading public health problem in America today; it affects, primarily, the young and will touch one out of every three Americans this year."'I Once we come to appreciate the meaning of these words, this compelling message will serve as the foundation for our learning. The most common concept of injury reflects a rather narrow definition along the general lines of detrimental physical effects resulting from accidents. However, injuries are far more than this, and the term "accident," although commonplace and visually descriptive, for all practical purposes, is inappropriate because accidents don't "just happen." Risk factors can be reduced or eliminated, injuries prevented, and their consequences minimized.2'3 While all people are seemingly created equal, the risks of being injured or killed are not the same for everyone. For example, black males are at a significantly greater risk of being injured or killed than either their white male or black female counterparts.4-6
MAGNITUDE OF THE INJURY PROBLEM As a direct result of medical science's ability to prevent and successfully treat infectious diseases-the leading killers before the antibiotic era-the importance of injury has increased to a point where today, injury is the most prominent cause of death for more than half of the human life span. In the United States alone, this modern epidemic's annual toll includes the loss of nearly 150 000 lives and permanent disablement of nearly 1 million people.2'7'6 Among all age groups combined, injuries sustained in motor vehicle crashes account for the most deaths (49%), followed by the home (22%), public places, (20%) and the workplace (12%). Motor vehicle crashes, drownings, and fires claim the lives of most young children. The majority of teenage and young adult deaths are associated with motor vehicle crashes, firearms, and drowning. Among the elderly, deaths 43
INJURY: A NEW PERSPECTIVE
TABLE. PERCENTAGE OF LEADING CAUSES OF DEATH BY AGE GROUP Heart Age Disease All Other Group Injuries and Stroke Cancer Causes 1-4 46 4 7 43 5-14 55 3 14 28 15-24 79 3 5 13 62 25-34 6 10 22 35-44 31 21 20 28 7 45-64 36 32 25 65+ 2 48 19 31 Adapted from MMWR.3
resulting from falls, fire, and suffocation are more frequent than those associated with motor vehicle crashes.1"2-17-21 Injury is the leading cause of death in people between 1 and 44 years of age (Table). In fact, each year 22 million children under the age of 14 (1 out of 4) sustain significant physical injuries, and approximately 10 000 die. Moreover, nearly half of all deaths in children between ages 5 and 14, and approximately 80% of deaths in young people between ages 15 and 24 are the direct result of injuries. Yet, the fact that deaths resulting from injuries outnumber deaths from all other causes for people through 44 years of age does not mean that injury is a lesser problem for the elderly.'-3"1822-29 In fact, the injury death rate is higher among older Americans,t a factor that will become increasingly important as the average age of the US population continues to increase. Injury is the fourth leading cause of death for all age groups combined, being exceeded only by heart disease, cancer,1'2 and stroke. Each year, over 4 million years of future worklife are lost to injury compared to 2.1 million years lost to heart disease and 1.7 million years to cancer. Injuries severe enough to require medical attention or resulting in some degree of disability strike nearly one in three Americans annually."7-'1629 For example, a National Health Survey estimated that between 1979 and 1981, an average of 69.2 million injuries occurred each year.2",29 Of these, over 18 million or 26% were termed "bed disabling." Added to this staggering figure are catastrophic brain or spinal cord injuries, each having long term medical, social, and economic consequences, together affecting between 75 000 and 80 000 persons annually." 8'2',25'29 Injury victims occupy one of every eight hospital beds in the United States, imposing a significant burden on the health care delivery system. For example, during a 44
recent 12-month study period, injuries were found to be responsible for more than 21 million hospital days. That figure exceeds the number of days required by all obstetric and heart patients combined, and was four times higher than required by all US cancer patients in the same time frame. Viewed another way, these statistics reflect a bed usage rate equal to 575, 100-bed hospitals operating at 100% capacity, 365 days a year. 1,3,29,30
In keeping with their auspicious distinction of being the leading killer of persons up to 44 years of age, injuries are also the leading cause of physician contact and the most common reason for costly hospitalizations among all persons under age 45.3,29,311 Injuries accounted for 99 million visits in 1980, a figure 27% higher than visits for heart disease, the next highest category. Plus, each year, more than one out of four people who visit hospital emergency rooms seek treatment for injuries.1-3 An analysis of 1982 figures revealed that when events resulting in deaths or disabling injuries were combined with non-injury-producing motor vehicle crashes and fires, they cost the nation at least $88.4 billion. The 1984 estimate of direct and indirect costs associated with nearly 150 000 injury-related deaths and another 70 + million nonfatal injuries approached $100 billion, an amount roughly equal to one-half the federal deficit.7-16,29 As noted by the National Academy of Science in their 1988 analysis of the status and progress of the Center for Disease Control's injury prevention and control initiative, "the eventual direct costs and lost revenues resulting from deaths due to unintentional injuries in 1984 ranged from $22-$26 billion for the federal government and between $10 and $12 billion for state and local governments." Some of the larger costs are incurred by those suffering permanent brain or spinal cord disabilities because recent advances in medical care have resulted in many catastrophicallyinjured persons now having near normal life expectancies. Regretfully, however, few victims of severe neurological injuries ever return to meaningful employment, and most remain totally dependent upon family and society.31 Intentional injury is also worthy of special emphasis, especially as it impacts on African-Americans. Previously treated as a criminal justice issue, intentional injury is now recognized as an interdisciplinary problem requiring a great deal of input from health professionals. In fact, epidemiologic evidence demonstrates that intentional injuries are predictable and JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
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preventable and therefore, subject to sound intervention strategies.3 Injuries resulting from interpersonal violence and self-inflicted acts are gaining acceptance as public health concerns (JAM & PWO, unpublished data, 1988). For example, more than 50 000 homicides and suicides are documented each year in the United States. Homicide ranks as the 11th leading cause of death, and the actual risk of homicide victimization is greater now than at any other time in our nation's history. Moreover, intentional injury data suggest that for every homicide, more than 90 people are injured in criminal assaults (JAM & PWO, unpublished data, 1988).32 Geographically, homicide rates are highest among residents of the southeastern United States, eg, 11.5327.43/100 000 population.2 Mortality and morbidity rates from intentional injuries among AfricanAmericans and children are also disproportionately high. For example, young black males have a homicide rate 7 to 12 times higher than the general population.1'4.5'32,3334 In fact, the lifetime risk of death from homicide for black males is 1 in 21 compared with 1 in 164 for white males. By contrast, black females' risk is approximately 1 in 370 (JAM & PWO, unpublished data, 1988).4,5,32 Regarding children, the greatest increase in homicide rates since 1968 has been in the 1 to 19 age category, an increase of 40%. Alarmingly, but not surprisingly, nearly 75% of these fatal assaults on children are inflicted by family members.2 Despite the startling reality that these statistics reflect, lack of awareness about the magnitude of the injury prevention problem remains a serious issue in both the lay and professional communities. For example, during the 1988-1989 academic year, a pilot injury prevention and control curriculum developed jointly by EDC, Inc of Boston, Massachusetts, and the Johns Hopkins University Injury Prevention Research Center, was field-tested in 10 medical schools or hospital residency programs, in 7 public health schools, 2 nursing schools, and 7 non-academic settings in the United States and Canada. While pilot data are still being evaluated, studies from one sample of state university medical students suggest some rather convincing preliminary impressions. Prior to their exposure to the injury prevention and control curriculum, the students did not realize the significance of injuries compared to other health problems. Furthermore, when asked to rate the ease with which injuries can be predicted, predicting the occurrence of lung cancer and sexually-transmitted diseases was believed easier than predicting either JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
unintentional or intentional injuries, with intentional injuries appearing last on their list. Moreover, it was found that student knowledge of basic epidemiology was poor.34 Since low levels of awareness about the magnitude of the injury phenomenon were detected in highly motivated medical students, it seems reasonable to conclude that college students, in general, are even less aware of the importance of injuries as health problems. It follows that even lower levels of awareness would be found in high schools, middle, and elementary schools. There are other misconceptions about the "injury phenomenon," not the least of which pertains to the use of the term "accident," implying varying degrees of uncertainty, unavoidability, unpredictability and inevitability.3'35 In fact, rigorous study of the injury phenomenon clearly reveals that injury-producing events conform to the same sort of natural laws that govern the behavior of other biologic events (including infectious and chronic diseases). Moreover, these inquiries reveal that injury-producing events are often characterized by the same sort of patterns and trends as infectious and chronic diseases. In addition, not only are given populations at different risks of being injured or killed, but the occurrence of these injury-producing events are also far more predictable than previously
believed.3 For example, while observing emergency department care being administered by one of the co-authors, we witnessed the treatment of a young black female gunshot wound victim. When asked about the circumstances and events resulting from her injury, the patient stated, nonchalantly, she was "playing around . . . drunk," and admitted having shot herself. At that moment, the "preventability" of the incident was apparent. Our impression from this experience was that unless increasing emphasis is placed on prevention and control, injuries will continue to account for an ever-increasing and disproportionate amount of morbidity and mortality, especially among AfricanAmerican youths. As alluded to previously, data show that blacks are at greater risk of being injured or killed than whites. For example, of the four primary categories (homicide, residential fires, drowning, and pedestrian injuries) where there was a significant racial difference in mortality rates, homicide was the most common etiology and reflected the most dramatic statistics.36 Figure 1 illustrates the dramatic differences in death rate ratios (ie, number of black deaths per 100 000 divided by the number of white deaths per 100 000) 45
INJURY: A NEW PERSPECTIVE
6.0 5.27
Influenza
200 i, 15 0
5.0 4.0
M
3.20
150
0 CL_
3.0
2.0
Tuberculosis
a Injury
1.76
100
_
1.60
1.0
50..!.} 1!I
Motor-
Vehicle
Homicide Residential Drowning Pedestrian Fire
0 191fl
1945
1050
Figure 1. Population-adjusted rate ratios of blacks compared to whites for selected injury fatalities, United States, 1984.
Figure 2. Death rates by selected causes, 1910-1980. Adapted from Baker, 1984.2
between blacks and whites for several injury categories. For every one motor-vehicle related death in the white population, in a black population of equivalent size there are 0.77 motor-vehicle deaths. On the other hand, after performing the required adjustment to accommodate for the size differential in the black and white "at risk populations," for every white homicide victim, there are 5.27 black victims. More importantly, blackon-black homicide has emerged as a major threat to the wellbeing of black Americans because, 90% of blacks who are murdered, are murdered by other blacks.4'5,37 We believe that if the incidence of intentional injury is to be significantly reduced in the black community, the problem must be confronted directly by black medical leadership.4'5'38 If attention to this problem continues to be relegated to politicians and government, it will remain primarily a law enforcement issue. Inspection of crime statistics quickly reveals that law enforcement agencies, despite their good intentions, have been poor custodians of the mandate to reduce the violence-related death rate in general, and also in the black community. ' Black medical leaders such as Woodrow Meyers, Debra Prothrow-Stith, and the past president Vivian W. Pinn-Wiggins, must be joined by others to help raise consciousness about the issue of black-on-black violence.4-6'33'37'38 We must realize that the statistics indicate that we are our own worst enemies.33 As Bell concluded, "the victim(s) of crime inevitably become the perpetrator(s) of crime . . . and we must break this vicious cycle" (People, March 21, 1988:80).
Anglo-Saxon, middle class, Protestant males." While
teaching is on the treatment of "young, white,
THE PRESENT AND THE FUTURE To date, very little is taught about African-American medical problems in medical schools or residency training programs, either in primarily black or white institutions.39 Typically, the focus of medical school 46
that group may predominate the demographic landscape in this era, as it has in the past, the reality is that "America is a cultural and ethnic mosaic that is destined to become even more diverse in the future."39 While it may be dominated by white, middle class males, it is not totally inhabited by this group. Thus, if medical schools will teach medicine accordingly, the more diverse segments of our society will have an opportunity to benefit from the change. Nowhere is sensitivity to this diversity more important than in the areas of injury prevention and control because as we have shown, while injuries are a serious problem for all of society, the incidence of injuries is disproportionately high for African-Americans and the poor.4'5'37 There is no vaccine for violence, but there is a cure: knowledge coupled with appropriate intervention.3 However, black Americans must become more aware and appreciative of the intentional injury problem if that cure is to be affected. Certainly, few would argue that economic disenfranchisement exacerbates the intentional injury phenomenon, especially among the young. Their intentional injury death rates reflect this conclusion with dramatic clarity. Thus, if "at risk" populations are to be successfully "immunized" against the victimization contagion, the community of health care professionals, led by black medical educators in cooperation with organizations of practicing black physicians, must become the agents of change. Unless and until this happens, blacks will continue to damage and destroy one another with alarming frequency.33 Because black-on-black homicide is a major threat to the well-being of all black Americans, physicians who treat black patients should be aware of the need for research in injury prevention and control techniques. Moreover, these same physicians will benefit from being taught how to identify potentially violent individJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
INJURY: A NEW PERSPECTIVE
uals and how to "treat" people who have exhibited violence towards others.4'5'33'37'38 For reasons such as these, we are hopeful predominantly black medical schools will consider placing increased emphasis on injury prevention and control, with special attention being paid to the prevention and control of interpersonal violence despite the acknowledged scarcity of resources. It was of little surprise that our review of medical school curricula at the predominantly black Howard, Meharry, Morehouse, and Charles Drew medical schools revealed no courses focusing on the science of injury prevention and control. We did, however, identify peripheral topics as components of more general coursework. For example, Meharry offers a first year, inter-departmental course entitled "Behavioral Sciences I" that includes "leading causes of death and disability at each stage of the life cycle and descriptive epidemiologic rates" as a topic in the descriptive epidemiology component of the course. Furthermore, in each medical school catalog reviewed, we noted that if there was any reference to an injury prevention-related topic, it was typically part of either a department of community, occupational health or family medicine course description.40'41 However, if one considers that injuries are the leading cause of death and disability for persons less than age 44, and the fourth overall leading cause of death for all age groups combined, it seems reasonable that injury prevention and control are deserving of more attention and emphasis than a lecture or two buried in a more general course. For example, if tropical diseases, which are not even in the top 15 causes of death in this country,42 are offered as electives (as at Howard and Charles Drew), it seems reasonable that injury, which Foege calls the leading public health problem in this country and the leading cause of death for African-American youth, should be deserving of far more attention than presently given.40 In fact, using magnitude and impact as criteria for resource allocation, it seems entirely warranted to require course work in injury prevention and control for all black and minority medical students.2'3'36 Figure 2 shows that over a period of the past 70 years, death rates for influenza have declined by 85%, and by 99% for tuberculosis. However, during this same period, injury death rates have declined only by 30%.2 Given this disparity and the consequences of injuries, it is reasonable to conclude and to hope that injury prevention research and education must receive increased emphasis from black medical leadership.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
Acknowledgements The authors greatly appreciate the assistance in the preparation of this manuscript and the encouragement and careerdeveloping work experience provided by Philip R. Fine, PhD, MSPH, Director of the UAB Injury Prevention Research Center and Allen Bolton, MPH, MBA, Assistant Director of the Center. They are also grateful to Michele Wilson-Morris for typing and proofing this manuscript. Literature Cited 1. National Research Council and The Institute of Medicine, Committee on Trauma Research. Injury in America. Washington, DC: National Academy Press; 1985. 2. Baker SP, O'Neill B, Karpf R. Unintentional Injury. In: Baker SP, O'Neill B, Karpf R, eds. The Injury Fact Book. Lexington, MA: DC Heath and Company; 1984:1-313. 3. Morbidity & Mortality Weekly Report. Table V: Years of potential life lost, deaths, and death rates, by cause of death and estimated number of physician contacts by principal diagnosis, United States. 1982;31:599. 4. Bell CC. Coma and the etiology of violence, Part 1. J Natl Med Assoc. 1986;78:1167-1176. 5. Bell CC. Coma and the etiology of violence, Part 2. J Natl Med Assoc. 1987; 79:79-84. 6. Report of the Secretary's Task Force on Black and Minority Health, Executive Summary. US Department of Health and Human Services, DHHS Publication. No. (PHS) 0-487-637. Government Printing Office; 1985. 7. Cline DM. Observation and head trauma patients at home: A prospective study of compliance in the rural south. Ann Emerg Med. 1988;1 7:127-131. 8. Kalsbeek WD, McLaurin RL, Harris H, Miller JD. The national head and spinal cord injury survey: Major findings. J Neurosurg. 1 980;53(suppl):S1 9-S31. 9. Olson DK, Gerberich SG. Traumatic amputation in the workplace. J Occup Med. 1986;28(7):480-485. 10. Ommaya AK, Grubb RL, Naumann RA. Coup and contre-coup injury: Observations on the mechanics of visible brain injuries in the rhesus monkey. J Neurosurg. 1971;35:502516. 11. Perlof JD, LaBailley SA, Kletka PR, et al. Premature death in the United States: Years of life lost and health priorities. J Public Health Policy. 1984;5:167-184. 12. Petro JA, Salisbury RE. Rehabilitation of the burn patient. Clin Plast Surg. 1986;1 3(1):145-149. 13. Rintala DH, Willems EP. Behavioral and demographic predictors of post discharge outcomes in spinal cord injury. Arch Phys Med Rehabil. 1987;68(6):357-362. 14. Rintala DH, Hanover D, Alexander JL. Team care: An analysis of verbal behavior during patient wounds in rehabilitation hospital. Arch Phys Med Rehab. 1986;67(2):118-122. 15. Robinett LS, Vondran MA. Functional ambulation velocity and distance requirements in rural and urban communities. Phys Ther. 1988;68(9):1371-1373. 16. Viano DC. Thoracic injury potential. In: Proceedings of the International Conference on the Biokinetics of Impact. Bron, France: International Research Committee on Biokinetics of Impacts, Secretariat; 1978. 17. The National Committee for Injury Prevention and Control. Injury Prevention: Meeting the Challenge. Am J Prev Med. 1989;5(3):1-303. 47
INJURY: A NEW PERSPECTIVE
18. Haddon W, Jr. Exploring the options, In: Research Directions Toward the Prevention of Injury in the Young and Old. DHEW Publication No. (NIH) 73-124. US Dept of Health, Education and Welfare. 1973:38-59. 19. Haddon W Jr, Suchman EA, Klein D. Accident Research: Methods and Approaches. New York, NY: Harper & Row; 1964. 20 Wintemute GJ. The size of the problem. In: Wintemute GJ, Baker SP, Mohan D, Teret SP, eds. Injury Prevention in Developing Countries. Baltimore, MD: The Johns Hopkins University Press; 1984. 21. National Safety Council. Accident Facts. Chicago, IL: National Safety Council; 1983. 22. National Center for Health Statistics. Current estimates from the National Health Interview Survey, United States, 1985. Washington, DC: Government Printing Office; 1986. 23. American Academy of Pediatrics, Alabama Chapter. Childhood Injury Prevention Handbook. 1988:1-6. 24. Haddon W, Jr. Advances in the epidemiology of injuries as a basis for public policy. Pub Health Rep. 1980;95:411-421. 25. Baker SP, Dietz PE. Injury Prevention, In: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Back papers. DHEW Publication No. (PHS) 79-55071A. US Department of Health, Education and Welfare; 1979:53-80. 26. Kraus JF, Black MA, Hessol N, et al. The incidence of acute brain injury and serious impairment in a defined population. Am J Epidemiol. 1984;1 19:186-201. 27. Kraus JF, Franti CE, Riggins RS, et al. Incidence of traumatic spinal cord lesions. Joumal of Chronic Diseases. 1 975;28:471 -492. 28. Marshall JF, Becker DB, Bowers SS, et al. The national traumatic coma bank: Design, purpose, goals and results. J Neurosurg. 1983;59:276-284. 29. National Center for Health Statistics. Current Estimates from the National Health Interview Survey, United States. Series 10, No. 141, 1981. DHHS Publication No. (PHS) 82-1569. US Department of Health and Human Services; 1982.
48
30. National Center for Health Statistics. Physician's Visits, Volume and Interval since last visit. United States, 1980. Data from the National Health Survey. Series 10, No. 144, 1983. DHHS Publication No. (PHS) 83-1572. US Department of Health and Human Services; 1984. 31. Committee to Review the Status and Progress of the Injury Control Program at the Centers for Disease Control. Injury Control. Washington, DC: National Academy Press; 1988. 32. O'Carroll PW, Mercy JA. Patterns and recent trends in black homicide. In: Hawkins DF, ed. Homicide Among Black Americans. Lanham, NY: University Press of America; 1986. 33. Bell CC, Prothrow-Stith D, Smallwood C. Black-on-black Homicide, The National Medical Association's responsibilities. J Natl Med Assoc. 1986;78:1 139-1141. 34. Educating Health Professionals in Injury Control: Preliminary Evaluation Highlights. Education Development Corporation, Inc; 1989. 35. Langley JD. The need to discontinue the use of the term "accident" when referring to unintentional injury events. Accid Anal Prev. 1988;20(1):1-8. 36. Morbidity and Mortality Weekly Report. Report on selected Racial/Ethnic groups. Massachusetts Medical Society. 1988:37(SS-3). 37. Bell CC. Impaired black health professionals: Vulnerabilities and treatment approaches. J Natl Med Assoc. 1 986;78:925-930. 38. Bell CC, Hildreth Cl, Jenkins EJ, et al. The need for victimization screening in a poor outpatient medical population. J Natl Med Assoc. 1987;88:853-860. 39. Bell CC, Fayen M, Mattox G. Training psychiatric residents to treat blacks. J Natl Med Assoc. 1988;80:638-641. 40. Howard University College of Medicine Catalog. 19861988. 41. Meharry Medical College General Catalog. 1986-1988. 42. National Center for Health Statistics. Monthly Vital Statistics Report. 1 987;36(suppl 5).
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
Injury-related morbidity and mortality have finally been acknowledged as major public health issues facing this country today. While injuries represent a serious problem for society as a whole, the rates are significantly higher among African-Americans, especially black males between 20 and 29 years of age. Moreover, injury and death resulting from acts of interpersonal violence are not only increasing, but are also significantly higher among blacks. Because injury-producing events have been shown to conform to the same biological laws that govern the expression and behavior of many infectious and chronic diseases, it has now been determined and verified that such events are largely predictable, and, in many instances, preventable. Because of the significant racial disparity in the incidence of injury-producing events, the authors encourage establishment of vigorous injury prevention, control-oriented curricula, and training opportunities in predominantly black medical schools. The authors assert that such institutions of higher learning represent an ideal point of introduction for innovative injury prevention and control strategies specifically aimed at the African-American population. Key words * injury * accidents * interpersonal violence
From the Minority Enrichment Program, UAB School of Medicine, CDC-sponsored Injury Prevention Research Center, Birmingham, Alabama, and the University of Illinois School of Medicine, Chicago, Illinois. Requests for reprints should be addressed to Ms Lisa M. Chatman, c/o Allen Bolton, MPH, MBA, Injury Prevention Research Center, UAB Station, CH-1 9, Birmingham, AL 35294. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
"Injury is the leading public health problem in America today; it affects, primarily, the young and will touch one out of every three Americans this year."'I Once we come to appreciate the meaning of these words, this compelling message will serve as the foundation for our learning. The most common concept of injury reflects a rather narrow definition along the general lines of detrimental physical effects resulting from accidents. However, injuries are far more than this, and the term "accident," although commonplace and visually descriptive, for all practical purposes, is inappropriate because accidents don't "just happen." Risk factors can be reduced or eliminated, injuries prevented, and their consequences minimized.2'3 While all people are seemingly created equal, the risks of being injured or killed are not the same for everyone. For example, black males are at a significantly greater risk of being injured or killed than either their white male or black female counterparts.4-6
MAGNITUDE OF THE INJURY PROBLEM As a direct result of medical science's ability to prevent and successfully treat infectious diseases-the leading killers before the antibiotic era-the importance of injury has increased to a point where today, injury is the most prominent cause of death for more than half of the human life span. In the United States alone, this modern epidemic's annual toll includes the loss of nearly 150 000 lives and permanent disablement of nearly 1 million people.2'7'6 Among all age groups combined, injuries sustained in motor vehicle crashes account for the most deaths (49%), followed by the home (22%), public places, (20%) and the workplace (12%). Motor vehicle crashes, drownings, and fires claim the lives of most young children. The majority of teenage and young adult deaths are associated with motor vehicle crashes, firearms, and drowning. Among the elderly, deaths 43
INJURY: A NEW PERSPECTIVE
TABLE. PERCENTAGE OF LEADING CAUSES OF DEATH BY AGE GROUP Heart Age Disease All Other Group Injuries and Stroke Cancer Causes 1-4 46 4 7 43 5-14 55 3 14 28 15-24 79 3 5 13 62 25-34 6 10 22 35-44 31 21 20 28 7 45-64 36 32 25 65+ 2 48 19 31 Adapted from MMWR.3
resulting from falls, fire, and suffocation are more frequent than those associated with motor vehicle crashes.1"2-17-21 Injury is the leading cause of death in people between 1 and 44 years of age (Table). In fact, each year 22 million children under the age of 14 (1 out of 4) sustain significant physical injuries, and approximately 10 000 die. Moreover, nearly half of all deaths in children between ages 5 and 14, and approximately 80% of deaths in young people between ages 15 and 24 are the direct result of injuries. Yet, the fact that deaths resulting from injuries outnumber deaths from all other causes for people through 44 years of age does not mean that injury is a lesser problem for the elderly.'-3"1822-29 In fact, the injury death rate is higher among older Americans,t a factor that will become increasingly important as the average age of the US population continues to increase. Injury is the fourth leading cause of death for all age groups combined, being exceeded only by heart disease, cancer,1'2 and stroke. Each year, over 4 million years of future worklife are lost to injury compared to 2.1 million years lost to heart disease and 1.7 million years to cancer. Injuries severe enough to require medical attention or resulting in some degree of disability strike nearly one in three Americans annually."7-'1629 For example, a National Health Survey estimated that between 1979 and 1981, an average of 69.2 million injuries occurred each year.2",29 Of these, over 18 million or 26% were termed "bed disabling." Added to this staggering figure are catastrophic brain or spinal cord injuries, each having long term medical, social, and economic consequences, together affecting between 75 000 and 80 000 persons annually." 8'2',25'29 Injury victims occupy one of every eight hospital beds in the United States, imposing a significant burden on the health care delivery system. For example, during a 44
recent 12-month study period, injuries were found to be responsible for more than 21 million hospital days. That figure exceeds the number of days required by all obstetric and heart patients combined, and was four times higher than required by all US cancer patients in the same time frame. Viewed another way, these statistics reflect a bed usage rate equal to 575, 100-bed hospitals operating at 100% capacity, 365 days a year. 1,3,29,30
In keeping with their auspicious distinction of being the leading killer of persons up to 44 years of age, injuries are also the leading cause of physician contact and the most common reason for costly hospitalizations among all persons under age 45.3,29,311 Injuries accounted for 99 million visits in 1980, a figure 27% higher than visits for heart disease, the next highest category. Plus, each year, more than one out of four people who visit hospital emergency rooms seek treatment for injuries.1-3 An analysis of 1982 figures revealed that when events resulting in deaths or disabling injuries were combined with non-injury-producing motor vehicle crashes and fires, they cost the nation at least $88.4 billion. The 1984 estimate of direct and indirect costs associated with nearly 150 000 injury-related deaths and another 70 + million nonfatal injuries approached $100 billion, an amount roughly equal to one-half the federal deficit.7-16,29 As noted by the National Academy of Science in their 1988 analysis of the status and progress of the Center for Disease Control's injury prevention and control initiative, "the eventual direct costs and lost revenues resulting from deaths due to unintentional injuries in 1984 ranged from $22-$26 billion for the federal government and between $10 and $12 billion for state and local governments." Some of the larger costs are incurred by those suffering permanent brain or spinal cord disabilities because recent advances in medical care have resulted in many catastrophicallyinjured persons now having near normal life expectancies. Regretfully, however, few victims of severe neurological injuries ever return to meaningful employment, and most remain totally dependent upon family and society.31 Intentional injury is also worthy of special emphasis, especially as it impacts on African-Americans. Previously treated as a criminal justice issue, intentional injury is now recognized as an interdisciplinary problem requiring a great deal of input from health professionals. In fact, epidemiologic evidence demonstrates that intentional injuries are predictable and JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
INJURY: A NEW PERSPECTIVE
preventable and therefore, subject to sound intervention strategies.3 Injuries resulting from interpersonal violence and self-inflicted acts are gaining acceptance as public health concerns (JAM & PWO, unpublished data, 1988). For example, more than 50 000 homicides and suicides are documented each year in the United States. Homicide ranks as the 11th leading cause of death, and the actual risk of homicide victimization is greater now than at any other time in our nation's history. Moreover, intentional injury data suggest that for every homicide, more than 90 people are injured in criminal assaults (JAM & PWO, unpublished data, 1988).32 Geographically, homicide rates are highest among residents of the southeastern United States, eg, 11.5327.43/100 000 population.2 Mortality and morbidity rates from intentional injuries among AfricanAmericans and children are also disproportionately high. For example, young black males have a homicide rate 7 to 12 times higher than the general population.1'4.5'32,3334 In fact, the lifetime risk of death from homicide for black males is 1 in 21 compared with 1 in 164 for white males. By contrast, black females' risk is approximately 1 in 370 (JAM & PWO, unpublished data, 1988).4,5,32 Regarding children, the greatest increase in homicide rates since 1968 has been in the 1 to 19 age category, an increase of 40%. Alarmingly, but not surprisingly, nearly 75% of these fatal assaults on children are inflicted by family members.2 Despite the startling reality that these statistics reflect, lack of awareness about the magnitude of the injury prevention problem remains a serious issue in both the lay and professional communities. For example, during the 1988-1989 academic year, a pilot injury prevention and control curriculum developed jointly by EDC, Inc of Boston, Massachusetts, and the Johns Hopkins University Injury Prevention Research Center, was field-tested in 10 medical schools or hospital residency programs, in 7 public health schools, 2 nursing schools, and 7 non-academic settings in the United States and Canada. While pilot data are still being evaluated, studies from one sample of state university medical students suggest some rather convincing preliminary impressions. Prior to their exposure to the injury prevention and control curriculum, the students did not realize the significance of injuries compared to other health problems. Furthermore, when asked to rate the ease with which injuries can be predicted, predicting the occurrence of lung cancer and sexually-transmitted diseases was believed easier than predicting either JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
unintentional or intentional injuries, with intentional injuries appearing last on their list. Moreover, it was found that student knowledge of basic epidemiology was poor.34 Since low levels of awareness about the magnitude of the injury phenomenon were detected in highly motivated medical students, it seems reasonable to conclude that college students, in general, are even less aware of the importance of injuries as health problems. It follows that even lower levels of awareness would be found in high schools, middle, and elementary schools. There are other misconceptions about the "injury phenomenon," not the least of which pertains to the use of the term "accident," implying varying degrees of uncertainty, unavoidability, unpredictability and inevitability.3'35 In fact, rigorous study of the injury phenomenon clearly reveals that injury-producing events conform to the same sort of natural laws that govern the behavior of other biologic events (including infectious and chronic diseases). Moreover, these inquiries reveal that injury-producing events are often characterized by the same sort of patterns and trends as infectious and chronic diseases. In addition, not only are given populations at different risks of being injured or killed, but the occurrence of these injury-producing events are also far more predictable than previously
believed.3 For example, while observing emergency department care being administered by one of the co-authors, we witnessed the treatment of a young black female gunshot wound victim. When asked about the circumstances and events resulting from her injury, the patient stated, nonchalantly, she was "playing around . . . drunk," and admitted having shot herself. At that moment, the "preventability" of the incident was apparent. Our impression from this experience was that unless increasing emphasis is placed on prevention and control, injuries will continue to account for an ever-increasing and disproportionate amount of morbidity and mortality, especially among AfricanAmerican youths. As alluded to previously, data show that blacks are at greater risk of being injured or killed than whites. For example, of the four primary categories (homicide, residential fires, drowning, and pedestrian injuries) where there was a significant racial difference in mortality rates, homicide was the most common etiology and reflected the most dramatic statistics.36 Figure 1 illustrates the dramatic differences in death rate ratios (ie, number of black deaths per 100 000 divided by the number of white deaths per 100 000) 45
INJURY: A NEW PERSPECTIVE
6.0 5.27
Influenza
200 i, 15 0
5.0 4.0
M
3.20
150
0 CL_
3.0
2.0
Tuberculosis
a Injury
1.76
100
_
1.60
1.0
50..!.} 1!I
Motor-
Vehicle
Homicide Residential Drowning Pedestrian Fire
0 191fl
1945
1050
Figure 1. Population-adjusted rate ratios of blacks compared to whites for selected injury fatalities, United States, 1984.
Figure 2. Death rates by selected causes, 1910-1980. Adapted from Baker, 1984.2
between blacks and whites for several injury categories. For every one motor-vehicle related death in the white population, in a black population of equivalent size there are 0.77 motor-vehicle deaths. On the other hand, after performing the required adjustment to accommodate for the size differential in the black and white "at risk populations," for every white homicide victim, there are 5.27 black victims. More importantly, blackon-black homicide has emerged as a major threat to the wellbeing of black Americans because, 90% of blacks who are murdered, are murdered by other blacks.4'5,37 We believe that if the incidence of intentional injury is to be significantly reduced in the black community, the problem must be confronted directly by black medical leadership.4'5'38 If attention to this problem continues to be relegated to politicians and government, it will remain primarily a law enforcement issue. Inspection of crime statistics quickly reveals that law enforcement agencies, despite their good intentions, have been poor custodians of the mandate to reduce the violence-related death rate in general, and also in the black community. ' Black medical leaders such as Woodrow Meyers, Debra Prothrow-Stith, and the past president Vivian W. Pinn-Wiggins, must be joined by others to help raise consciousness about the issue of black-on-black violence.4-6'33'37'38 We must realize that the statistics indicate that we are our own worst enemies.33 As Bell concluded, "the victim(s) of crime inevitably become the perpetrator(s) of crime . . . and we must break this vicious cycle" (People, March 21, 1988:80).
Anglo-Saxon, middle class, Protestant males." While
teaching is on the treatment of "young, white,
THE PRESENT AND THE FUTURE To date, very little is taught about African-American medical problems in medical schools or residency training programs, either in primarily black or white institutions.39 Typically, the focus of medical school 46
that group may predominate the demographic landscape in this era, as it has in the past, the reality is that "America is a cultural and ethnic mosaic that is destined to become even more diverse in the future."39 While it may be dominated by white, middle class males, it is not totally inhabited by this group. Thus, if medical schools will teach medicine accordingly, the more diverse segments of our society will have an opportunity to benefit from the change. Nowhere is sensitivity to this diversity more important than in the areas of injury prevention and control because as we have shown, while injuries are a serious problem for all of society, the incidence of injuries is disproportionately high for African-Americans and the poor.4'5'37 There is no vaccine for violence, but there is a cure: knowledge coupled with appropriate intervention.3 However, black Americans must become more aware and appreciative of the intentional injury problem if that cure is to be affected. Certainly, few would argue that economic disenfranchisement exacerbates the intentional injury phenomenon, especially among the young. Their intentional injury death rates reflect this conclusion with dramatic clarity. Thus, if "at risk" populations are to be successfully "immunized" against the victimization contagion, the community of health care professionals, led by black medical educators in cooperation with organizations of practicing black physicians, must become the agents of change. Unless and until this happens, blacks will continue to damage and destroy one another with alarming frequency.33 Because black-on-black homicide is a major threat to the well-being of all black Americans, physicians who treat black patients should be aware of the need for research in injury prevention and control techniques. Moreover, these same physicians will benefit from being taught how to identify potentially violent individJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
INJURY: A NEW PERSPECTIVE
uals and how to "treat" people who have exhibited violence towards others.4'5'33'37'38 For reasons such as these, we are hopeful predominantly black medical schools will consider placing increased emphasis on injury prevention and control, with special attention being paid to the prevention and control of interpersonal violence despite the acknowledged scarcity of resources. It was of little surprise that our review of medical school curricula at the predominantly black Howard, Meharry, Morehouse, and Charles Drew medical schools revealed no courses focusing on the science of injury prevention and control. We did, however, identify peripheral topics as components of more general coursework. For example, Meharry offers a first year, inter-departmental course entitled "Behavioral Sciences I" that includes "leading causes of death and disability at each stage of the life cycle and descriptive epidemiologic rates" as a topic in the descriptive epidemiology component of the course. Furthermore, in each medical school catalog reviewed, we noted that if there was any reference to an injury prevention-related topic, it was typically part of either a department of community, occupational health or family medicine course description.40'41 However, if one considers that injuries are the leading cause of death and disability for persons less than age 44, and the fourth overall leading cause of death for all age groups combined, it seems reasonable that injury prevention and control are deserving of more attention and emphasis than a lecture or two buried in a more general course. For example, if tropical diseases, which are not even in the top 15 causes of death in this country,42 are offered as electives (as at Howard and Charles Drew), it seems reasonable that injury, which Foege calls the leading public health problem in this country and the leading cause of death for African-American youth, should be deserving of far more attention than presently given.40 In fact, using magnitude and impact as criteria for resource allocation, it seems entirely warranted to require course work in injury prevention and control for all black and minority medical students.2'3'36 Figure 2 shows that over a period of the past 70 years, death rates for influenza have declined by 85%, and by 99% for tuberculosis. However, during this same period, injury death rates have declined only by 30%.2 Given this disparity and the consequences of injuries, it is reasonable to conclude and to hope that injury prevention research and education must receive increased emphasis from black medical leadership.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
Acknowledgements The authors greatly appreciate the assistance in the preparation of this manuscript and the encouragement and careerdeveloping work experience provided by Philip R. Fine, PhD, MSPH, Director of the UAB Injury Prevention Research Center and Allen Bolton, MPH, MBA, Assistant Director of the Center. They are also grateful to Michele Wilson-Morris for typing and proofing this manuscript. Literature Cited 1. National Research Council and The Institute of Medicine, Committee on Trauma Research. Injury in America. Washington, DC: National Academy Press; 1985. 2. Baker SP, O'Neill B, Karpf R. Unintentional Injury. In: Baker SP, O'Neill B, Karpf R, eds. The Injury Fact Book. Lexington, MA: DC Heath and Company; 1984:1-313. 3. Morbidity & Mortality Weekly Report. Table V: Years of potential life lost, deaths, and death rates, by cause of death and estimated number of physician contacts by principal diagnosis, United States. 1982;31:599. 4. Bell CC. Coma and the etiology of violence, Part 1. J Natl Med Assoc. 1986;78:1167-1176. 5. Bell CC. Coma and the etiology of violence, Part 2. J Natl Med Assoc. 1987; 79:79-84. 6. Report of the Secretary's Task Force on Black and Minority Health, Executive Summary. US Department of Health and Human Services, DHHS Publication. No. (PHS) 0-487-637. Government Printing Office; 1985. 7. Cline DM. Observation and head trauma patients at home: A prospective study of compliance in the rural south. Ann Emerg Med. 1988;1 7:127-131. 8. Kalsbeek WD, McLaurin RL, Harris H, Miller JD. The national head and spinal cord injury survey: Major findings. J Neurosurg. 1 980;53(suppl):S1 9-S31. 9. Olson DK, Gerberich SG. Traumatic amputation in the workplace. J Occup Med. 1986;28(7):480-485. 10. Ommaya AK, Grubb RL, Naumann RA. Coup and contre-coup injury: Observations on the mechanics of visible brain injuries in the rhesus monkey. J Neurosurg. 1971;35:502516. 11. Perlof JD, LaBailley SA, Kletka PR, et al. Premature death in the United States: Years of life lost and health priorities. J Public Health Policy. 1984;5:167-184. 12. Petro JA, Salisbury RE. Rehabilitation of the burn patient. Clin Plast Surg. 1986;1 3(1):145-149. 13. Rintala DH, Willems EP. Behavioral and demographic predictors of post discharge outcomes in spinal cord injury. Arch Phys Med Rehabil. 1987;68(6):357-362. 14. Rintala DH, Hanover D, Alexander JL. Team care: An analysis of verbal behavior during patient wounds in rehabilitation hospital. Arch Phys Med Rehab. 1986;67(2):118-122. 15. Robinett LS, Vondran MA. Functional ambulation velocity and distance requirements in rural and urban communities. Phys Ther. 1988;68(9):1371-1373. 16. Viano DC. Thoracic injury potential. In: Proceedings of the International Conference on the Biokinetics of Impact. Bron, France: International Research Committee on Biokinetics of Impacts, Secretariat; 1978. 17. The National Committee for Injury Prevention and Control. Injury Prevention: Meeting the Challenge. Am J Prev Med. 1989;5(3):1-303. 47
INJURY: A NEW PERSPECTIVE
18. Haddon W, Jr. Exploring the options, In: Research Directions Toward the Prevention of Injury in the Young and Old. DHEW Publication No. (NIH) 73-124. US Dept of Health, Education and Welfare. 1973:38-59. 19. Haddon W Jr, Suchman EA, Klein D. Accident Research: Methods and Approaches. New York, NY: Harper & Row; 1964. 20 Wintemute GJ. The size of the problem. In: Wintemute GJ, Baker SP, Mohan D, Teret SP, eds. Injury Prevention in Developing Countries. Baltimore, MD: The Johns Hopkins University Press; 1984. 21. National Safety Council. Accident Facts. Chicago, IL: National Safety Council; 1983. 22. National Center for Health Statistics. Current estimates from the National Health Interview Survey, United States, 1985. Washington, DC: Government Printing Office; 1986. 23. American Academy of Pediatrics, Alabama Chapter. Childhood Injury Prevention Handbook. 1988:1-6. 24. Haddon W, Jr. Advances in the epidemiology of injuries as a basis for public policy. Pub Health Rep. 1980;95:411-421. 25. Baker SP, Dietz PE. Injury Prevention, In: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Back papers. DHEW Publication No. (PHS) 79-55071A. US Department of Health, Education and Welfare; 1979:53-80. 26. Kraus JF, Black MA, Hessol N, et al. The incidence of acute brain injury and serious impairment in a defined population. Am J Epidemiol. 1984;1 19:186-201. 27. Kraus JF, Franti CE, Riggins RS, et al. Incidence of traumatic spinal cord lesions. Joumal of Chronic Diseases. 1 975;28:471 -492. 28. Marshall JF, Becker DB, Bowers SS, et al. The national traumatic coma bank: Design, purpose, goals and results. J Neurosurg. 1983;59:276-284. 29. National Center for Health Statistics. Current Estimates from the National Health Interview Survey, United States. Series 10, No. 141, 1981. DHHS Publication No. (PHS) 82-1569. US Department of Health and Human Services; 1982.
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30. National Center for Health Statistics. Physician's Visits, Volume and Interval since last visit. United States, 1980. Data from the National Health Survey. Series 10, No. 144, 1983. DHHS Publication No. (PHS) 83-1572. US Department of Health and Human Services; 1984. 31. Committee to Review the Status and Progress of the Injury Control Program at the Centers for Disease Control. Injury Control. Washington, DC: National Academy Press; 1988. 32. O'Carroll PW, Mercy JA. Patterns and recent trends in black homicide. In: Hawkins DF, ed. Homicide Among Black Americans. Lanham, NY: University Press of America; 1986. 33. Bell CC, Prothrow-Stith D, Smallwood C. Black-on-black Homicide, The National Medical Association's responsibilities. J Natl Med Assoc. 1986;78:1 139-1141. 34. Educating Health Professionals in Injury Control: Preliminary Evaluation Highlights. Education Development Corporation, Inc; 1989. 35. Langley JD. The need to discontinue the use of the term "accident" when referring to unintentional injury events. Accid Anal Prev. 1988;20(1):1-8. 36. Morbidity and Mortality Weekly Report. Report on selected Racial/Ethnic groups. Massachusetts Medical Society. 1988:37(SS-3). 37. Bell CC. Impaired black health professionals: Vulnerabilities and treatment approaches. J Natl Med Assoc. 1 986;78:925-930. 38. Bell CC, Hildreth Cl, Jenkins EJ, et al. The need for victimization screening in a poor outpatient medical population. J Natl Med Assoc. 1987;88:853-860. 39. Bell CC, Fayen M, Mattox G. Training psychiatric residents to treat blacks. J Natl Med Assoc. 1988;80:638-641. 40. Howard University College of Medicine Catalog. 19861988. 41. Meharry Medical College General Catalog. 1986-1988. 42. National Center for Health Statistics. Monthly Vital Statistics Report. 1 987;36(suppl 5).
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