• leadership

Who should be the leaders in injury prevention and control? The purpose of this opinion piece is to suggest that the public health trained physician is uniquely qualified and can and should take a leadership role in injury prevention. Debate and discussion are welcomed. If there are other means that continued leadership can be generated in injury prevention and control, let us hear them. This opinion is not intended to create a sense of territorial ownership, but to emphasize the knowledge, skills, and experience of the public health trained physician and the benefit of their involvement as an enabling person in injury prevention and control.

The public health physician has training in epidemiology and in assessing the health of population groups—in contrast to the focus on the health of individuals or parts of individuals (like hearts or kidneys), which is the training of many physicians and health professionals. The focus on population groups means there is understanding of the benefits of surveillance and a constant emphasis on prevention and control measures including health promotion. The population approach in recent years has increasingly emphasized the variations in health, disease, and injury between population groups. It also emphasises the effects of the social determinants of health outside the health care delivery system such as education, poverty, employment, and early childhood development that influence a public health issue. He/she has knowledge of the health care system and how it operates, and they will have knowledge and experience in applying a public health approach to an issue. This public health approach includes the process of involving many sectors (intersectoral approach) in addressing issues and creating collaboration between those who have an interest and can make a difference in addressing an issue.

The challenge for those of us involved in injury prevention and control in all jurisdictions, in every country, is to increase the effective actions being taken towards injury prevention and control and to establish injury prevention as a significant public health goal for that jurisdiction. The jurisdiction may be anywhere from a national government or organization to the local community or group (like a sports team).

Every country has its own unique governance structure and hierarchical or non-hierarchical ways of making decisions and creating public health policy. To illustrate this—in Canada the British North America Act of 1867 made the provinces and territories primarily responsible for the delivery of health, education, and social services. From the beginning of this federation consisting of federal/provincial/territorial governments, the role of the national (federal) government has been one of providing cost shared or seed funding, advice, and consultation to support the development of health programs (with a few exceptions) by the provinces such as hospital insurance and Medicare.

At this time in Canada, all of the provinces and territories are undergoing some type of health “reform” in which there is decentralization and some would say devolution of the responsibility for health services, including preventive health services, to health regions. This is happening in many parts of the world.

To move ahead in developing actions for injury prevention and control, therefore, requires initiatives at the federal, provincial, and regional (local) level. At each level of governance there will be other players (stakeholders): national organizations, provincial organizations, and local organizations who play a part in injury prevention and control.

There is always at least one public health trained physician who has legislated responsibilities at the regional and provincial levels in Canada. This also applies in most developed countries. The national (federal) government has public health trained physicians in consultative roles. Our emphasis in Canada is to assist and support as much as possible activities at the regional and local level while at the same time ensuring that there is collaboration between the many stakeholders at the provincial level and national (federal) level.

When it comes to outbreaks of communicable disease, there is a public health physician who has the legislated mandate to take action to protect the health of the public. Most public health legislation was created to control such diseases as smallpox and polio, but today is used to support the control of such outbreaks as foodborne illness, meningitis, measles, and waterborne illness. For non-communicable diseases and injuries this “old” legislation can be applied under such terms as alleviating health hazards, but it rarely is. Because there is no clear decision making role and they may not have significant resources available to them, some public health physicians may be reluctant to be involved in injury prevention and control. This may be exacerbated by the restructuring of health delivery systems that cause those involved to have their time taken up with organizational management rather than public health issues. It would be rare to find a public health physician who does not believe, based on the burden of illness/injury, that progress needs to be made in injury prevention and control and that it is a significant public health problem.

In all the countries where the readers of this journal practice, significant public health policy decisions are made by elected officials or by boards/agencies appointed by elected officials. The public health trained physician will be involved in the development of those public health policies. Their input is invaluable because of their knowledge base, understanding of the health system, behavioural factors affecting health, focus on the health of the population and prevention measures. The public health physician, as well as many others involved in injury prevention and control, understands the pre-event factors of injury and injury prevention (for example Haddon's matrix and the four “Es”: education, engineering, enforcement, and evaluation). He/she will also have had experience in communicable disease epidemiology and addressing such issues as teenage pregnancy, heart disease, and other non-communicable diseases. The approach has been successful and will be successful in injury prevention and control. The challenges, however, in injury prevention and control are that there are many stakeholders and players, and those players that can most make a difference, for example those working in the transportation, water related injuries, home injuries, poisonings, agricultural injuries, violent injuries, etc, all have there own set of associated organizations that are hopefully collaborating to increase effective strategies to prevent injuries. The leadership of the public health physician can provide that necessary forum for collaboration. The public health physician has the knowledge of how to prevent injuries and how to access data on injuries and the skills and abilities to bring the many players together. What the public health physicians do not have is the means at their disposal to create some of the most effective engineering and other solutions for injury prevention. They do have, however, a good knowledge of health promotion and of ways of effecting public education and effecting behaviour change. The public health physician should increasingly take a leading role in injury prevention and control at all levels of government and in collaboration with agencies and the private sector.