The continuing global challenge of injury

The UK is lagging behind

News p 1561

At the start of the 21st century injury prevention in most countries (including industrialised ones) is poorly targeted, inadequately funded, and seldom evaluated. Too many people—particularly children—continue to die or suffer unnecessarily. Unsurprisingly, the impact of this public health failure on health services is colossal: in the United States, for example, injuries were first out of 29 conditions ranked according to hospital days in 1994.1 The lack of interest in injury prevention is puzzling as there is evidence that when governments act much can be done to prevent this leading cause of premature death and disability.

Part of the problem is inadequate information on which to estimate the incidence and outcomes of most forms of injury. We know too little about the underlying causes, incidence, prevalence, long term consequences, and costs of injury. Most of what we do know relates to mortality. Of the 50.5 million deaths worldwide in 1990, 10% were due to injury,2 and such deaths are projected to increase from 5.1 million in 1990 to 8.4 million in 2020.3 Injuries are the leading cause of death under the age of 24 years in over half the countries that report statistics.4 This propensity for injuries to afflict young people results in their contributing disproportionately to the burden of disease as measured by potential years of life lost. Increasingly, young people are surviving previously fatal injuries,5 producing an extra (but largely unrecorded) burden of long term disability.

A recently published report from Unicef paints a mixed picture even in the richest countries. Although injury is the leading killer of children in each of the 26 nations in the Organisation for Economic Cooperation and Development (OECD), the number of such deaths fell by about half between 1970 and 1995.6

Because comparing data across countries is fraught with difficulty, the US sponsored International Collaborative Effort on Injury Statistics7 has, over the past few years, tried to improve the quality and reliability of injury statistics. Progress has been good, but much remains to be done merely to catch up with fields such as cancer, cardiovascular disease, and infection.

Lack of data is not the sole cause of patchy and often ineffectual efforts to prevent injury. Pless has highlighted a paradox: preventive efforts are often directed at diseases for which the means of prevention are of doubtful efficacy, while other conditions (including injuries) for which effective preventive measures are available are often ignored.8 Possible reasons include ignorance of the scale of the problem, the mistaken perception that many injuries are “accidental” and therefore unavoidable, the belief that prevention lies outwith the scope of health services, and an absence of political will.

In the end, effective injury prevention requires the wholehearted commitment of governments. Taking a lead from Sweden, the US, Australasia, and parts of Europe have recently pushed injuries higher up the political agenda.9 This has been achieved through political lobbying and seeking support from non-governmental sources, including the private and voluntary sectors. The publication of Injury in America in 1985 was widely regarded as a turning point in the US10 and was followed by a surge in funding for injury research and prevention. In 1999 the European Union launched an injury prevention programme, and the World Health Organization has played a part in keeping injury and violence prevention high on the international agenda (www.who.int/violence_injury_prevention/).

In contrast, the United Kingdom lags behind in its response to injuries. Although “accidents” have been a stated public health priority since the early 1990s, government commitment to injury prevention has been strong on rhetoric and weak on action. The UK compares well with other European countries in that it has the second lowest overall child injury death rate (after Sweden). These figures, however, conceal a poorer record on specific causes such as pedestrian injuries.11 Moreover, deaths are merely the tip of an injury iceberg that is largely invisible because of the lack of data on incidence, morbidity, and disability.

The political inertia in the UK was challenged in 1998 by a report, Action on Injury, published with the help of the Department of Health as a supplement to the journal Injury Prevention and supported by a national conference.12 The report was the initiative of a small group of activists working with the relevant royal colleges and faculties and the Child Accident Prevention Trust. Its aim was to raise the profile of injury prevention in the UK, and there is some evidence that it succeeded. For example, the white paper on public health in England, published in 1999,13 emphasises the need to reduce injuries and accepts that responsibility for strategic leadership lies with the health departments. These developments—along with the Department of Health's recently established task force for England—have heartened the injury prevention community, but they are only a start.

Further progress in the UK will depend mainly on four key measures: the creation of a dedicated agency to implement injury prevention and control programmes, improved injury surveillance, the encouragement of multidisciplinary research, and coordinated multisectoral action at local and national levels. Unless the UK acts to prevent injuries, more avoidable death and disability will be the inevitable consequence.