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The comparative study of childhood injury fatality rates in five European countries by Ellsäβer and Berfenstam appearing elsewhere in this issue allows us to examine the reasons why childhood injury statistics vary among five relatively prosperous countries. Because of variations in data collection methods in the Netherlands, Sweden, Switzerland, Austria and Germany, the authors wisely eschew morbidity and hospitalization statistics, and instead examine mortality rates. While there has been a steady diminution in traffic related deaths in all five countries since 1980, the decrease in home and leisure trauma in Sweden is dramatic. The difference in drowning mortality is especially striking. As the authors state, “Despite the large number of lakes and inland waterways in the period studied (1995), the drowning mortality for children aged 1–4 years was three times higher in Germany than Sweden”.
The different organizational approaches to childhood injury prevention in the five countries are examined, as well as how the prevention efforts are funded. They conclude: “we are unable. ...to decide according to scientific criteria which country has the best national program or the most effective national structures for implementing safety policies”. That should not be surprising. The organizational structure of injury control activities, and even the financing, are less important than a country's cultural values and the presence of dedicated leaders.
Why does Sweden have such exceptional child injury statistics? In 1989 my colleague, Fred Rivara, and I went there and interviewed 25 individuals to try and answer the question.1 The characteristics of Swedish society are important, especially the homogeneity, relative prosperity, and receptivity to education. Other key factors are that Swedes place great value on protecting children and the elderly, and generally believe that government should be an active instrument to better their lives. Hence there is no controversy about spending money for traffic engineering that separates cars, cyclists, and pedestrians. Nor about a universal drowning prevention campaign where all schoolchildren are taught to swim, and where lifejackets are made available to all toddlers at little or no cost to wear whenever they are near water.
In other countries, like the United States, Canada, and the United Kingdom, there is a strong tradition of privacy and skepticism about government officials telling citizens how to behave. As one state senator told me when I was testifying on behalf of a mandatory bicycle helmet law, “doctor, next time you will be down here asking us for a law to mandate the wearing of overshoes in rainy weather in order to prevent catching colds”. Marketplace factors dominate discussions about product and traffic safety.
Strong personalities
Strong personalities and good fortune generally influence the success of a country's injury control efforts, more than the positions of government departments or expert committees. Examples in the United States are Seymour Charles and Robert Sanders who popularized the use of child auto restraints, and Kenneth Feldman and Murray Katcher who spearheaded efforts to lower water heater temperatures. The federal money that funds the National Center for Injury Prevention and Control became available because of a lucky break. Ayub Ommaya, a Washington DC neurosurgeon involved in trauma research, cared for the daughter of former Congressman William Lehman, who chaired the Transportation Appropriations Subcommittee. Ommaya told the congressman about the dearth of injury research, and like magic, the money became available.
What about Sweden? The official story is that Sweden's remarkable record in childhood injury control was achieved because of the work of a prestigious group established in 1954, the Child Accident Prevention Committee. This voluntary committee was superseded in 1980 by the government's Child Environment Council, and in 1993 by the Office of the Children's Ombudsman.2
The real story is that the committee served mainly to provide a shield of legitimacy for the efforts of three individuals who actually carried out the campaign. The trio consisted of Theodor Ehrenpreis, a renowned pediatric surgeon at Karolinska Institute, Ulla Bonde, administrator of the Save the Children Fund, an important institution involved with overseas relief, and pediatrician Ragnar Berfenstam, the “junior” author of the paper under discussion. Whereas the full committee met once or twice a year, with few exceptions the three activists met monthly for 25 years! What did they do? Mostly they cajoled. Rather than organizing one central campaign, their efforts were directed at influencing existing groups to pursue child safety within their own sphere of interest and expertise. Thus, for example, the Red Cross assumed responsibility for water safety; police and automobile associations assumed leadership in traffic safety; physicians and firefighters worked to improve pre-hospital care of trauma victims, and child welfare workers and public health nurses were trained and encouraged to take on the cause of home safety.
Dr Ehrenpreis and Ms Bonde have died. Blessedly, as evidenced by this article, Professor Berfenstam, now in his 90s, continues his productive work. This courtly and modest man can truly be described as the father of injury prevention. His guiding hand has been present in most of the world's major injury prevention research units. I vividly recall his advice when we were starting our center in Seattle. He stressed three points: (1) injury statistics gathered from surveillance, especially at the local level, are invaluable in gaining support for prevention efforts from politicians, the media, and the public, (2) organize coalitions, and get the groups to “carry the word” within their areas of interest, and (3) have infinite patience; success is a long time in coming.
The Berfenstam legacy is blurring the boundary between research and advocacy. Lives are not saved by writing scholarly treatises, but by getting out and influencing those who have the power to apply the research findings. The lives of countless children have been saved by the labors of Ragnar Berfenstam. The lives of countless more will be saved if his tactics are emulated.
Acknowledgments
Dr Bergman founded the Harborview Injury Prevention and Research Center at the University of Washington in Seattle and directs the Center's Section on Prevention.
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