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The question of which group should be the leaders in injury prevention and control is one that raises important issues. The argument of this Dissent is that looking for a group to act as general leaders narrows our frame of reference and may well move us away from the practice and the forms of analysis that have been important in previous success in preventing injury.
Thinking of physicians trained in public health as the leadership group in injury confuses the concept of a leadership role with that of the leadership role. It also mixes the argument that physicians should increase their involvement in injury prevention and take a greater leadership role with the idea that that role should be pre-eminent.
What constitutes leadership in injury prevention?
If the challenge is to increase effective action on injury prevention what qualities in leadership are required to meet this challenge?
A primary requirement in leadership is drive and determination. A person who is not interested will not act. But motivation can come from many causes, social concern, commercial necessity, as well as professional interest, and the list of those with an actual or potential interest in injury prevention is long.
Leadership also needs direction. Effort must be directed at issues of moment in a way that gives some prospect of success. But it isn't necessary that leaders be technically adept, they simply need to understand the value of analysis and have the ability to seek advice and to take that advice into account.
A range of other skills will have an influence on whether leadership will be effective: the ability to build partnerships; the ability to integrate single interest programs into wider alliances; the ability to find information on what works and what does not; the ability to generate a high profile for issues or action; the ability to be creative and the ability to make connections with centres of power.
In looking for leadership we do not need to nominate any single profession, we need to look for people and organisations with leadership qualities.
Is knowledge of the health sector a key part of injury control?
One of the arguments for physicians as leaders is that they understand public health and the health sector, but how central are these attributes in the context of injury prevention?
The introduction of electrical safety switches in Australia illustrates another paradigm. Electricity authorities, industry, and organised labour worked out that electrocution deaths were a problem, they developed and implemented standards, practices, and regulations relating to the use of safety switches and, allowing for a little rhetorical flourish, electrical deaths started to fall well before the first injury prevention specialists become involved. Similarly, fire authorities built the case for smoke alarms and developed alliances with the media, with insurers, with building control authorities that resulted in an increase in the percentage of Victorian homes with smoke alarms from around 5% to above 75% in less than a decade.
On the basis of this experience public health people in general and physicians in particular are not the only potential injury prevention leaders. It is also questionable whether, on a range of matters including product safety, violence prevention, transport and pedestrian safety, and building standards and regulation, physicians are likely to make the best leaders.
Doesn't intersectoral collaboration imply that other sectors can lead?
Within injury prevention intersectoral collaboration is spoken of as a fundamental tenet of success. If this collaboration is real, rather than a comfortable fable we tell ourselves, then why shouldn't other sectors be leaders as well as followers?
Victorian bicycle helmet wearing programs and laws were developed on a 10 year plan by a cross sectoral group with bipartisan political support. Given the degree of intersectoral collaboration that was required to develop and implement this and other road safety programs that have been responsible for a substantial part of the reduction in injury deaths, there is no basis for thinking that the leadership skills available within public health are unique.
Doesn't deciding who are leaders independent of particular circumstances prejudge the issue?
One of the consistent lessons in successful injury prevention efforts is that analysis of injury issues needs to be made on a case by case basis. Deciding where leadership can or should come from, before making such analysis is not consistent with this experience. Just as the focus of action and the priorities for action vary from issue to issue and change over time the locus and style of leadership required is also likely to change.
The leadership required to get an issue on the agenda may be different from that required to develop or to implement an intervention. For example public health professionals played a key part in investigating and putting nursery product injuries on the public agenda in Australia, now that the case has been made, the leadership in preventive action is coming from an industry group convinced that there is commercial value and practical need for an industry code of safe practice.
Why is it poor practice to pick a leadership group?
In putting this dissenting view I am not arguing that public health physicians are unimportant or that they should not be more involved, or that they should not take leadership roles. The history of injury control shows their worth as partners and as leaders. The essence of the argument here is that leadership groups cannot be selected in advance or separated from an analysis of particular issues.
There is an aphorism, said to be a Russian proverb but I cannot vouch for this, that says “if the only tool you have is a hammer, then every problem is a nail”. In thinking of any one group as leaders we are that much less likely to think of alternatives and to overlook the other tools in the tool box. To the extent that this occurs the valuable lessons from Haddon and those who came after, that each situation has to be analysed according to its own circumstances, will be diminished.
Public health physicians have a leadership role to play in injury prevention and their interest and involvement should be encouraged. So too should all insurance brokers, plumbers, psychologists, engineers, economists, ergonomists, retailers, manufacturers, and so on who have leadership potential.
Ian Scott is the Director of Research and Policy for Kidsafe Australia, a national independent organisation directed at reducing unintentional injury. He chairs the National Injury Prevention Advisory Committee and trained in economics, statistics, and public policy.