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Our responsibility to children and adolescents
  1. Frederick P Rivara, Chair, ISCAIP
  1. Harborview Injury Prevention and Research Center, 325 Ninth Ave, Seattle, WA 98104, USA (tel: +1 206 521 1530, fax: +1 206 521 1562, e-mail: fpr{at}u.washington.edu)

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    A child falls from an open apartment window without a window guard and suffers a severe, disabling head injury. A teenager amputates his finger while operating machinery at work. A family of four small children are severely burned in a house fire because their rental tenement did not have a smoke alarm. Each of these patients is treated in a hospital; each is left with permanent disability.

    A child is admitted to the hospital with bloody diarrhea and develops renal failure secondary to the hemolytic uremic syndrome, and requires renal dialysis. This child's illness is caused by an infection with Escherichia coli 0157 H7, the source of which is unpasteurized apple juice sold at a local fair.

    In this latter instance, few physicians would hesitate for more than a millisecond in calling the local health authorities to report this source of contaminated juice once it was discovered. The local health authorities would also not hesitate to close down that producer until the source of the contamination was determined and the problem rectified. This is simply good “public health practice” and has resulted in dramatic reductions in morbidity and mortality from infectious diseases during this century.

    Should the same action occur for the injury problems described? Should physicians and hospitals give this information to health authorities, and should these authorities in turn investigate and take action? Is the threat to the public's health sufficient to warrant using patient identifying information? Is it the physician's responsibility to be concerned about hazards that result in injuries? Does the fact that the cases all involve minors make a difference in whether or not such information can and should be used?

    These questions have been pointedly raised in a recent debate in the pages of the BMJ. Lyons, Sibert, and McCabe discuss an injury surveillance system in Wales established by the local health authority based on data from accident and emergency department visits.1 High injury areas were identified from the data and community based programs were initiated. One common source of injuries was houses in multiple occupation. Local authority officers could potentially work with the landlord in various ways (collegial as well as adversarial) to correct the hazards. The identifying information in the surveillance system consists of postcodes that contain an average of 14 contiguous addresses. However, the director of public health objected because giving this information might violate patient confidentiality as protected by the “Data Protection Act”. Thus, as the authors state, “We are now left in a position of knowing where childhood injuries occur but of not being allowed to pass information on to public bodies”.1

    In accompanying articles, the public health director defends his actions,2 and is backed by articles from a solicitor3 and an ethicist.4 Their arguments are that (a) release of such information violates the Data Protection Act, (b) such action would jeopardize the tenants by placing them at risk for eviction by the landlord, (c) it wouldn't do much good anyhow because motor vehicle crashes and poisonings account for the vast majority of deaths, (d) it is not sufficiently in the public's interest to know the location of these injury hazards, (e) these kinds of environmental hazards are not the doctor's responsibility, and (f) where people live is largely a matter of their own choice.

    I believe these arguments embody why the International Society for Child and Adolescent Injury Prevention was established (and why a parallel or integrated society for adult injury prevention is needed). They ignore the now large body of scientific information accumulated over the last two decades that constitutes the injury field, the responsibilities of governments to apply this knowledge to prevent harm from trauma, and the special vulnerabilities of children and adolescents. These arguments are also not limited to the discussion of child injury prevention in the UK, but are relevant to the prevention of adult injuries in countries around the world.

    Injuries are cased by a complex interplay of agent, host, and environment. Environmental hazards are especially important in the etiology of child and adolescent injury where the limited experience and judgment of children and adolescents cannot counter the effects of environmental hazards such as open windows, unguarded machinery, or sleeping in a home without a smoke detector. Interventions focused on environmental modification have been some of the most powerful tools in the injury prevention armamentarium. They have played a large part in the reduction of deaths due to injury over the last few decades.

    These changes in the environment have not necessarily come easily, and have often required government intervention to insure their widespread use and protection of those most vulnerable in our society, namely poor children. Safety often costs money; the nature of business, on the other hand, is to maximize profits. New York City requires that windows in high rise housing be fitted with window guards to prevent falls. Labor regulations prevent teenagers under 16 from operating machinery in the workplace. In the US, nearly all jurisdictions require landlords to equip rental housing with functional smoke detectors. Few of us believe that motor vehicles would be as safe as they are today without government standards and regulation.

    Children, especially poor children, are the group most vulnerable to injury. Societies have generally recognized that these individuals do not decide for themselves where they live, and thus the hazards to which they are exposed. If their parents are unwilling or unable to provide for a safe environment, it is the responsibility of the state to insure that children are safe from harm. This is true whether the harm is from E coli 0157 H7, abusing parents, a sweatshop work environment, or firetrap housing.

    Physicians should and must look beyond individual health to the health of the public. Their responsibility for the health and welfare of patients, whether they be children or adults, does not end at the examining room door. Just as we send out public health officials to trace an infectious disease outbreak, we should send public health officials to trace the source and cause of high rates of injury in a specific group, whether that group be children and adolescents, the poor, or families on a specific street. Just as all politics is ultimately local, so too all injury prevention is ultimately finding a specific risk in a local community and changing it.

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