In June 2004, the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control will celebrate its 12th anniversary. The vision of the Injury Center, which was founded in 1992 in response to an Institute of Medicine report, is to apply public health methods toward prevention and control of injuries. The anniversary provides an opportunity to review some of the accomplishments in this field and a discussion of the challenges that remain.
Causes of unintentional injuries include falls, drowning, improper use of firearms, driving-related wrecks, playground injuries, and accidental poisoning. Other injuries relate to violence, such as rape (including date rape), domestic violence, homicide, and suicide. Accidental injuries remain the number one cause of death in children and adults between one and 44 years of age. Suicide is a major cause of death in teenagers and young adults, and homicide is second only to accidental injuries in persons 15 to 24 years of age.1 A major challenge is to convince policymakers, the medical community, and the public that injuries are preventable and that prevention is worth the effort.
While driving, a 25-year-old mother enters an intersection that has a four-way stop sign. A teenaged driver who has been drinking beer does not notice the stop sign and hits the passenger side of the woman’s car. Her five-year-old child, unrestrained in the rear passenger-side seat, sustains a severe skull fracture. In the emergency department, the chief resident says, “What an unfortunate accident…”
Was this an accident? Could the child’s skull fracture have been prevented? Studies have shown that injuries are not purely the result of random events.2 They occur in predictable ways, with distinct patterns of risk and protective factors. The list of interventions that have been proven to prevent injuries is growing, and more disciplines and professions are recognizing their role in reducing the burden of injuries.
Each year, more than 40,000 persons die in motor vehicle crashes.3 Although some interventions for increasing safety, such as those related to automobile design, are out of the control of the health care professional, family physicians do have a role to play. Driving while impaired by alcohol dramatically increases the risk of death and injury, not only for the driver but also for passengers and those in other cars. For example, nearly two thirds of children killed in motor vehicle crashes were riding with a driver who had been drinking.4 Family physicians can help reduce traffic deaths by identifying and addressing problem drinking and counseling parents to appropriately restrain their children, preferably in the back seat of the vehicle.
Physicians face a complex counseling issue in attempting to reduce deaths and injuries among older drivers. Adjusted for the amount driven, death rates for drivers 85 years and older are nine times higher than rates for drivers 25 to 69 years of age.5 Nevertheless, many older drivers give up walking before they give up driving; taking away their car keys can have a profound impact on their mobility and quality of life. Better tools are needed to assist physicians and family members who are struggling with questions about when to stop an older adult from driving.
Family violence presents its own range of challenges for physicians, who must be alert to clues that a problem is occurring and be prepared to make appropriate diagnoses and referrals. Family violence includes child abuse and neglect, intimate partner violence, and elder abuse. In addition to injuries from the violence itself, victims of family violence seek health services for a wide range of conditions such as failure to thrive and behavior problems among children,6 and gastrointestinal disorders and conditions characterized by chronic pain among adult women.7 Even if the presenting injury or illness is not an emergency, the abuse may lead to one, and it needs to be addressed accordingly. Major challenges in family violence prevention range from the need to develop better methods for detection to the need for evidence-based approaches to prevention.
In the year 1900, the leading causes of death in this country were pneumonia, influenza, tuberculosis, and diarrhea. Societal changes such as better living conditions, improved sanitation, and better medical care contributed to reducing the mortality from these conditions. The United States mobilized to fight infectious diseases and has been remarkably successful. Another multifaceted, comprehensive effort should be launched against injuries, making use of environmental interventions, implementing safety programs, increasing awareness of the issue of injury prevention, and involving health care professionals. We challenge family physicians to be part of this movement.