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Reintegrating injury prevention
  1. Leon Robertson
  1. 160 Sharps Road, Globe, AZ 85501, USA

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    This could be a landmark year for the journal. The future inclusion of research on injuries to persons of all ages is a welcome move toward reintegration of all aspects of the field under one banner. The interdisciplinary cooperation necessary to advance injury prevention has too often been negated by turf wars. There is an unfortunate side effect of cooperation, however. Too much credence or resources may be devoted to approaches that are ineffective or counter productive.

    The classic article by Haddon reprinted in this issue reminds us that injury prevention is an integral part of a public health tradition that has often been ignored or misunderstood by those who think that injury is caused largely by misbehavior. Injury and illness are physical and biological processes that have numerous points for potential intervention. Since most people are behaving in some way or another when they are injured, behavior is obviously a factor as well. One of the more persistent fights of Haddonites is with behaviorists who resist the Haddon approach to injury prevention.

    If there is something in the water from the Broad Street Pump that is killing people, do we launch a campaign to persuade each individual to get their water elsewhere, or do we shut down the pump? The guard rail that prevents you from going over a cliff does not care whether you left the road because of inattention, drunkenness, distraction by others in the vehicle, adolescent hubris, or a wasp in the car. It just does its job. When high schoolers decide to play video games among their classmates with live ammunition, the death and injury toll is less a function of parental neglect, violent video games, or the hormones of the shooters than it is the nature of the weapons (caliber, bullet shape, number of rounds in a clip, capability of automatic or semiautomatic fire). Concentration on unchangeable host characteristics, such as age, gender, or behaviors that are difficult to change on an individual basis, is a prescription for unnecessary suffering.

    Most of the successful attempts at behavioral change are targeted at public behaviors that can be sanctioned by law enforcement, such as requiring seat belt use.

    Fragmentation is inevitable as researchers and practitioners develop specialties. This is particularly true in a field that involves several disciplines. The revitalization of interest in injury in the US was accelerated in government by Injury in America, a book prepared by a National Research Council/Institute of Medicine committee.1 As a member of that committee, I was amazed and gratified at the lack of turf defense among the disciplines represented—behavioral science, biomechanics, epidemiology, statistics, surgery, rehabilitation. Each member of the committee showed extraordinary respect for the contribution of disciplines other than their own and the need for monetary support of research in all the disciplines.

    Sadly, within three years after the report was released, as a modest amount of new money became available from the Centers for Disease Control (CDC), battles for the “pittance”, as Julian Waller aptly characterized it, formed largely along disciplinary lines. For example, a surgeon complained to me that the new Director of the CDC effort was an epidemiologist who was giving epidemiologists advanced information to help them with grant proposals. In fact, the allegation was easily shown to be unfounded as the Director had specialized in sexually transmitted diseases and was unknown to injury epidemiologists. Because of his lack of expertise in the field, many injury epidemiologists did not welcome his appointment. Psychologists complained that there were no psychologists on the National Research Council/Institute of Medicine committees, apparently unaware that my training was primarily in social psychology, albeit in a sociology department, or that Park Dietz had psychiatric training. The point of the consensus in the Injury in America committee is that disciplinary loyalty, ideology, or whatever you wish to call it, must be set aside when assessing needs regarding prevention.

    In subsequent efforts at consensus documents, attempts were made to appease those who claimed that their disciplines or emphases were being left out. Of six “challenges facing injury prevention programs” discussed in Injury Prevention: Meeting the Challenge, one said, “Our society glorifies risk taking; safety has a poor public image”.2 Changing attitudes by long term education was proposed as the solution. There is no entity with a brain called “society”. There are communications and entertainment media that portray risky behavior and conflict resolution with guns as common occurrences, appealing to the needs of some adolescents of whatever age for high levels of stimuli. Yet these are hardly representative of the behaviors or “attitudes” of the majority of the population. If John Snow were to find deaths associated with a water supply today, I fear that we might be urged to undertake a long term education campaign to change peoples attitudes toward that water supply, rather than remove the handle from the pump.

    Part of my training was in attitude measurement. It didn't take me long to learn that attitudes do not translate into actions. One of the most powerful effects on behavior is a desire for approval of others. Much inaction relative to attitudes and beliefs is the result of pluralistic ignorance—the often mistaken belief that the attitudes and beliefs of people whose approval is sought is different from one's own attitudes and beliefs. My first injury study compared people's attitudes toward seat belts and their use of them. The majority had positive attitudes but was observed sitting on the belts.

    The most recent attempt at a consensus assessment in the field was produced by a committee formed by the Institute of Medicine in the US, entitled Reducing the Burden of Injury: Advancing Prevention and Treatment.3 The document has several inaccuracies and unreferenced assertions. For example, US governmental authority to set safety standards for motor vehicles is attributed to the Highway Safety Act of 1966 which actually gives federal authority to assist states in highway safety programs. Safety standards were authorized by the Motor Vehicle Safety Act. The first airbags are attributed to General Motors in 1974. They were actually produced by Eaton, Yale, and Towne in the late 1960s.

    The notion that reduction of risk by safety standards and other environmental modifications is offset by changes in risky behavior is given credence without supporting references and despite a plethora of contrary evidence in the peer reviewed literature. Did the inaccuracies and mediocrity in that report, despite many highly competent committee members, occur because of pluralistic ignorance, compromise, or perhaps out of deference to an overworked staff?

    Too much death and disability occurs because what we know is not applied. We must be willing to confront governments and corporations whose policies and products fail to incorporate the science that we have developed. And those of us on consensus committees, funding review boards, or editorial boards, must confront colleagues and friends working in injury prevention who are ignorant of prior research on what works and what does not. We also need to confront those who put disciplinary loyalty above concern for the injured. It's a dirty job, but somebody has to do it.


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