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15. Unintentional Injuries The harm, disability, and death resulting from injury can be reduced by coordinated community prevention and control measures and individual awareness of risk factors for injurer, according to many testifiers. (#368; #378) Injuries are not accidents or random events. They are predictable and therefore preventable. Injury prevention can be effective, but there are many players, and little direction," states Patricia West of the Colorado Department of Health. (~368) Frederick Rivara, Director of the Harborview Injury Prevention and Research Center in Seattle, believes that "injurer control is coming of age, and will have a significant impact on the morbidity and mortality due to trauma in the coming decade." (#334) Steven Macdonald of the University of Washington quotes the 1985 National Academy of Sciences report Injury in Amenca, which states that ninjury is the principal public health problem in America today. Macdonald echoes this view and calls for a concerted local, state, and national approach: "Linking injury epidemiology and health policy is the key." (~322) Over the past decade, adds Rivara, the increasing attention paid to controlling injury has allowed this attitude of preventability to take root. It is likely that aggressive goals in injury control can be set and reached by the year 2000. (~334J Forty-eight testifiers addressed unintentional injuries and sug- gested objectives to reduce injury from motor vehicle accidents, falls, fires, poisoning, drowning, and violence. The Year 2000 Health Objectives distinguish between intentional and unintentional injuries. Speakers gave specific objectives for each category and outlined many prevention strategies. For a few testifiers, separation of the two categories in the Year 2000 Health Objectives is problematic. Not only is the intentionality of many injuries hard to assess, says Macdonald, but if trends and prevention measures are to be reliable, injury reporting must include all injuries, regardless of cause. (#322) Because of the nature of much of the testimony and many of the suggested prevention strategies, this chapter presents injury prevention goals popularly grouped under Unintentional" injuries. Chapter 16 deals with injury prevention as it relates to violence, homicide, suicide, child abuse, and so on, which come under the heading of ~intentional" injury in the Year 2000 Health Objectives outline. Disabling injuries, especially as they affect children and teens, are seen by many witnesses as deserving special attention, as are implementation problems related to manpower and organization and to surveillance and data collec- tion. MOTOR VEHICLE INJURIES The American Automobile Association (AAA) reports that 44,241 people died nationwide in 1984, from motor vehicle crashes. Of these fatalities, about half were alcohol related.2 ~008) Trauma from motor vehicle crashes is the fourth leading cause of death in the United States, the leading cause of death for ages 5 to 34, and the second leading cause of death for ages 1 to 4. The vehicular-crash-related death rate for a 15-year-old male is many times that of polio at its worst. (~011) In terms of potential years of life lost, motor vehicle fatalities rate above both cancer and heart disease. To reduce the number of motor vehicle deaths, says Karen Tarrant of the Michigan Department of State Police, the problem must be seen as an impor- tant public health priority. (~425) Traffic injuries are more than just a "highway safety problem," echoes James Saalberg of the CUNA Mutual Insurance Group, and individuals must be encouraged to think of them as a health problem. (~190) According to Tarrant, prevention and control of motor vehicle accidents involve five components: drinking and driving, proper restraint, speed, roadway design, and vehicle design. Of these five, drinking and driving, proper restraint, and compliance with speed limits reflect individual attitudes. Although law enforcement agencies can take measures to increase compliance with traffic rules, health promotion efforts in the community are necessary to bring about significant and long-lasting reductions in injury rates. Such programs should teach the importance of "buckling up," not driving after or while drinking, and obeying speed limits. (~425) Robert Haggerty of the William T. Grant Foundation reports that driver competence (or incompetence) is also a factor in some motor vehicle accidents, (e.g., older drivers with vision or hearing deficiencies) and should be Unintentional Injuries 129

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addressed through both increased compliance and health promotion efforts. (#784J Richard Austin, chairman of the Michigan State Safety Commission, adds that education on traffic safety has to indude personal decisions about interact- ing with other vehicles as pedestrians, bicyclists, or drivers. (#011) Such education Is especially impor- tant for children. As pedestrians and bicycle riders, many children do not have a proper understanding of how a car operates or how long it takes to stop. (#058) For five to nine year olds, pedestrian and bicycle injury is the most important cause of trauma that leads to death.3 (#334J Education, however, is not sufficient by itself to reduce fatalities from motor vehicle crashes. David Sleet of San Diego State University says that failure to use seat restraints may be the single most impor- tant preventable risk factor for motor vehicle trauma. This trend must be countered and reversed through policy and legislation, as well as through health promotion and incentives. "With 100 percent safety belt use in front seats, an additional 10,000 lives could have been saved and 120,000 injuries prevented in 1986," he says. (#285) Leo Gossett of the Texas Department of Public Safety also sees the proper use of occupant restraints as The most identifiable and measurable factor" in the reduction of motor vehicle injures and deaths. (#296) State and local police should enforce seat belt use and be strict with alcohol-related offenses. According to Gab Trietsch of the Texas Department of High- ways and Public Transportation, public awareness programs coordinated with a law enforcement pro- gram, including new safety belt and driving-while- into~ncated (DWI) laws, have contributed to a decline in traffic deaths to a 10-year low in Texas. (#563) Health professionals also should be involved in the effort to increase seat belt use and to strengthen legislation requiring such use at all times. (#190) The successful implementation of laws in all 50 states and the District of Columbia requiring the use :3f child safety seats is a notable victory, achieved through the efforts of state and local traffic enforce- ment agencies, health professionals, organizations, and communities. Joseph Hill of the Detroit Department of Health, however, reports that the number of injuries to infants and small children Is still unaccept- ably high due to lack of compliance and incorrect use of the seats. Continuing public awareness campaigns are still of vital importance. (#404) One method of increasing compliance with child safety seat use, says Sleet, is to require that all 130 Healthy People 2000: Citizens Chart the Course newborns leave the hospital in child safety seats. (~285) Auto insurance companies also could offer free child safety seats to policy holders who have children. According to Saalberg, League General Insurance Company of Michigan offers such a pro- gram to its policy holders. Begun in 1979, this program is now available in live states and has distributed 17,000 seats. A four-year evaluation of this program showed increased restraint use and a substantial drop in injuries.4 (~190J Mandatory helmet laws for motorcyclists in all states were encouraged. (~296) Enforcement of speed limits is another component of traffic safety, cited by Trietsch as one factor (along with safety belt and DWI laws) in the success of the Texas program. He underlines the role of police training and coordination between state and local levels in bringing about compliance. f#563J To help provide safer conditions for all who use the roadways, an effective management system must be in place, according to the Highway User's Federa- tion. A comprehensive management system would include road upkeep, pavement improvement, roadside obstacle removal, and pedestrian and bicycle access. (~517J Finally, vehicle manufacturers themselves have a role to play. According to the Highway User's Federation, improved technology is making cars more crash resistant. Manufacturer changes include brake enhancement, side impact protection, use of on-board electronics, improved vehicle stability, and automatic restraints. Laboratory testing and field experimenta- tion on better restraint systems are occurring, which include "improved belt designs, passive belts, air bag applications, and electronic accident avoidance tech- nology.n (~51 7) OTHER CAUSES OF INJURY Beyond automobile accidents, witnesses identified falls, fires, and drownings as key preventable causes of Injury. Falls Children and elderly adults have the highest risk of death or injury due to falling, according to William King and colleagues of the Children's Hospital of Alabama. (~266) To reduce injury and mortality from falls, Michael Oliva of Aurora, Colorado urges funding for fall prevention programs for older people. Providers of health care should recognize, he says,

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that many falls are not unexpected events. For example, you can identity those who have a high risk of falling when they get up at night to use the bathroom. They may have had prior falls, and their disabilities and medications may increase their risk of falling. Fall prevention in the elderly is closely related to their health problems and it should be included in their plan of care. (#378) Fires Residential fires took 3,900 lives in 1984. This makes fires the second leading cause of death in the home after falls.5 From a public health perspective, a critical intervention to reduce residential fires is the installation of smoke detectors in all homes. Rivara says that smoke detectors should be installed in all households, but particularly in the households of the poor. fit is the poor who are at greatest risk of fire deaths, he says, "particularly poor children." (~334) West writes, HI would like to see legislation at the national level, but also state legislation that says that all new housing will have smoke detectors built in. But I think that any housing units that receive federal funding-and this is, specifically, low income housing~lso should have smoke detectors in theme (#368J Rivara points out that approximately one-half of residential fires are started by cigarettes.6 Thus, development of a self-extinguishing cigarette would be an effective countermeasure. (~334J Sleet indicates that cigarette lighters in the hands of children cause between 120 and 200 childhood deaths annually, primarily to children under five years of age.7 He stresses the need for federal standards to require that all cigarette and novelty lighters be child proof. (#285) Poisoning Poison control centers can reduce the number of emergency room visits made by poison victims. These centers should be set up regionally, says Lewis Schwarz of Morristown Memorial Hospital in New Jersey, and should be reachable through a standard toll-free number, publicized nationally. By keeping a data base on the many and frequently updated drugs and products on today's market, poison control centers can offer up-to-date information over the telephone. By monitoring calls nationally, they also will be able to provide data for analysis of use and misuse patterns. (~446) The use of child-proof caps for medicines and household products has also proved to be a successful passive prevention technique, according to Haggerty. (#784) Drowning In 1983, over 5,000 persons died from drowning. More than half of the persons were under 25,8 and 82.4 percent of those drowned were male.9 To pursue the goal of no more than 1.5 drowning deaths per 100,000 people, Rivara encourages the use of multiple strategies and more studies; for example, "it is not known whether toddler and child swim classes are ~ positive or a negative risk factor for drowning." He also points out that "interventions for pool drownings may not be applicable to those occurring in natural bodies of water." (~334J DISABLING INJURIES Most injuries are nonfatal, according to Macdonald, but some severely disabling injuries are "perceived as worse than death." Of the eight 1990 objectives dealing with accident prevention and injury control, only one measures nonfatal injuries, and that is "based on unreliable data. Macdonald calls for the year 2000 objectives to measure the incidence of severe injuries, the prevalence of disability, and the rates of disability days. (~322) Samuel Stover of the Univer- sity of Alabama at Birmingham refers to "this epidem- ic of injuries with permanent disabilities and con- cludes that "we really don't pay much attention to them.n (~674) In 1983, for instance, nearly 8,000 children age 15 or under died from injuries sustained in accidents,~ and many more were permanently disabled, according to Martin Eichelberger of the Children's Hospital National Medical Center. (#058) Injuries to the spinal cord, head, or brain are especially disabling. Approximately 8,000 new cases of spinal cord injury occur yearly, and these are concentrated in the late-teen, young-adult age group. There is a lack of information on the effects of immediate treatment and rehabilitation on patients with spinal cord and head injuries, says Stover, and more applied research is critical to increase the rehabilitation rates of these patients. (~674) Even mild or moderate head injury victims ex- perience significant cognitive, emotional, and social disabilities, according to Thomas Boll of the Univer- sity of Alabama Hospital. As yet, no systematic Unintentional Injuries 131

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program exists in the United States for the diagnosis and treatment of noncatastrophic brain injury. The importance of primary prevention, however, is mani- fest, says Boll: many head injuries in childhood could be prevented if children always used restraint devices in vehicles, including school buses. (#264) Several speakers were concerned with reaching children through injury prevention education. Jill Floberg of Olympia Physical Therapy SeIvice writes: I often stand and wonder at how today's youth survive to adulthood with an apparent false sense of invincibility. High-tech toys with high- tech risks and the viewing of unreal responses to injury in various media, lead to an expectation that no matter what happens, someone can fix it. An important intervention, Floberg says, is to assess the Recklessness profile of 6 to 15 year olds. Col- lecting such information could help to design effective educational efforts in the schools on personal protec- tion. (~317) Eichelberger sees a need for nationwide education efforts on the preventability of childhood injury. "Instill a conviction among Americans," he says, "that most childhood accidents can be prevented-and that this country has a respon- sibility to take the steps necessary to prevent them.n (~058) IMPLEMENTATION Manpower and Organization The sweep of environmental and control factors involved in injuries, and the necessary crosscutting strategies that must be undertaken to curb them, mandate a combination of local and statewide preven- tion efforts with individual and professional awareness efforts. Public health approaches, with an emphasis on social marketing and broad-based collaboration, are appropriate for implementing injury prevention, according to West. Collaboration between different groups reduces fragmentation of effort and increases use of the same message throughout a community. (#368) Law enforcement officers, public health officials, and health professionals all have roles to play in ~ . . .. . . . . . enforcing or puollclzlng Injury prevention measures and in educating the public on individual risk factors. Trietsch underscores the usefulness of interdisciplinary "teams" in the Texas effort to reduce traffic injury 132 Healthy People 2000: Citizens Chart the Course rates. For example, the Texas Department of High- ways and Public Transportation provides funds directly to the Texas Department of Health for the promotion of safety belts, child safety seats, and DWI reductions. In return, the Department of Health "activates its extensive network of health professionals, clinics, and outreach programs to provide training, education, and materials where needed. (#563) According to Saalberg, health professionals also are invaluable in identifying, treating, and controlling those who suffer from alcoholism and problem drinking; expanding the availability of emergency medical services; and making further advances in trauma treatment. !~190; West strongly urges the development of statewide programs for injury control, which could serve as umbrella organizations for the activities of different sectors of society. The minimum criteria for a statewide injury prevention and control program are 1. establishment of a statewide plan for injury prevention and control that encompasses (a) technical assistance to communities; (b) surveillance and data collection; (c) a broad-based coalition; and (d) a comprehensive focus that includes prehospital and acute care, as well as rehabilitation; 2. maintenance of statewide poison control ser- vices; 3. enforcement of existing legislation; 4. development of other legislative/regulatory approaches as needed; and 5. integration of injury prevention and control content into the education and training of a variety of populations, including health care providers and the media. (i368) Roughly 50 percent of injury deaths are im- mediate," says Macdonald. Of the remaining 50 percent, 30 percent occur within the first four hours after injury. This presents a compelling need to provide quality prehospital emergency services and trauma care as an important tertiary prevention strategy. (i'329) Many testifiers supported Macdonakl's argument, claiming that the quality and immediacy of intervention can determine mortality rates. f#257) Surveillance and Data Collection It is essential to ongoing injury control to have a statistical data base capable of producing comprehen- sive and reliable injury information. ('tot 9) To establish and improve information collection for such data bases, speakers unanimously encouraged a more standard format of injury reporting and a regional

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collection system for this information. Currently, says the National Safety Council, "knowledge in this field is characterized by proliferating and redundant efforts in some areas and near absolute neglect in others." (~019) One step in making reporting procedures more standard would be to have hospitals, emergency medical service units, trauma centers, and police reports record the same types of information with the same or similar coding schemes. (#322) Several witnesses called for the use of the ICD-9 External Cause of Injury codes, or E-codes, to identify risk factors from the physical environment. Without such coding, "head injuries from motor vehicle crashes cannot be distinguished from those due to falls," points out Rivara; with them, however, "the existing systems would serve as a feasible and extremely useful surveillance tool for injuries requiring medical care." (#334) Currently, only four states (Maryland, New REFERENCES York, Pennsylvania, and Virginia) require hospitals to use E-codes. However, even the use of E-codes may not be enough, according to Macdonald, because they "do not allow for identification of risk factors that are behavioral (such as alcohol use or seatbelt non-use) or those from the social environment (such as occupa- tional or recreational settings)." He advocates the incorporation of an "activity code" into the fifth digit of the ICD-10 version of the E-oodes as a further refinement of the system. (#322) Schwarz's recom- mendation for regional poison information centers with a national 800 number is another example of how to collect the necessary data. (~446) Testifiers believe that having such information and control measures in place and available through a central organization, at either a state or a national level, could significantly increase the opportunities for large- scale prevention measures. 1. National Research Council, Committee on Trauma Research: Injury in America: A Continuing Public Health Problem. Washington, D.C.: National Academy Press, 1985 2. U.S. Department of Transportation, National Highway Traffic Safety Administration: Fatal Accident Reporting System, 1988. A Review of Information on Fatal Traffic Crashes in the United States in 1988 (DOT Publication No. HS 807 507), 1989 3. Fingerhut LA, Kleinman JC, Malloy MH, et al.: Injury fatalities among young children. Public Health Rep 103(4):399-405, 1988 4. Saalberg JH: Second Evaluation of the League General Insurance Company Child Safety Seat Distribution Program. U.S. Department of Transportation, National Highway Traffic Safety Administration, 1985 5. National Safety Council: Accident Facts, 1985 Edition. Chicago, 1985 6. Baker SP, O'Neill B. Karpf RS: The Injury Fact Book. Lexington, Ma.: Lexington Books, 1984 7. Ibid. 8. U.S. Department of Health and Human Services: Disease Prevention/Health Promotion: The Facts. Palo Alto, Cal: Bull Publishing Company, 1988 9. National Safety Council: op cit., reference 5 10. National SafeW Council: Accident Facts, 1986 Edition. Chicago, 1986 11. Young JS, Burns PE, Bower AM, et al.: Spinal Cord Injury Statistics: Experience of the Regional Spinal Cord Injury Systems. Phoenix: Good Samaritan Medical Center, 1982 Unintentional Injuries 133

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TESTIFIERS CITED IN CHAPTER 15 008 Anderson, Dave; American Automobile Association 011 Austin, Richard; Michigan Department of State Police 019 Benjamin, George; National Safety Council 058 Eichelberger, Martin; Children's Hospital National Medical Center (Washington, D.C.) 190 Saalberg, James; CUNA Mutual Insurance Group 257 Johnston, Carden; American Academy of Pediatrics 264 Boll, Thomas; University of Alabama at Birmingham 266 King, William; Kohaut, Edward C.; Johnston, F. Carden, et al.; The Children's Hospital of Alabama 285 Sleet, David; San Diego State University 296 Gossett, Leo; Texas Department of Public Safety 317 Floberg, Jill; Olympia Physical Therapy Service 322 Macdonald, Steven; University of Washington 334 Rivara, Frederick; Harborview Injury Prevention and Research Center (Seattle) 368 West, M. Patricia; Colorado Department of Health 378 Oliva, Michael; Aurora, Colorado 404 Hill, Joseph; Detroit Department of Health 425 Tarrant, Karen; Michigan Department of State Police 446 Schwarz, Lewis; Morristown Memorial Hospital (New Jersey) 517 Livingston, Charles; Highway Users Federation 563 Trietsch, Gary; Texas Department of Highways and Public Transportation 674 Stover, Samuel; University of Alabama at Birmingham 784 Haggerty, Robert; William T. Grant Foundation (New York) 134 Healthy People 20(70: Citizens Chart the Course