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I I I EXECUTIVE SUMMARY "Closing the Gap" Health Policy Project Carter Center, Emory University. Unintentional Injuries: Intervention Strategies and Their Potential for Reducing Human Losses. by Gordon S. Smith, M.B. Ch.B., M.P.H. and Henry Falk, M.D., M.P.H. INTRODUCTION  Unintentional injuries are the third leading cause of death I I I ( (following all circulatory diseases and cancer) in the United States. ~ They kill more people between ages 5 through 44 than all other causes combined. Since injuries affect a greater proportion of younger people than most other major health problems, they have become the leading cause of premature death (years of life lost before age 65), excluding infant mortality (Figure 1). • Until recently, little attention has been given to this most preventable U.S. health problem. The gap between what we already know about prevention and what is being implemented is larger than that for any other disease entity. Although our mandate from the Carter Center has been to discuss only unintentional injuries, many of,the interventions we propose will also reduce intentional injuries. For example, reduction of the carbon monoxide content of domestic gas in I Britain not only dramatically reduced unintentional (accidental) poisonings, it also significantly reduced suicide by carbon monoxide poisoning without a corresponding increase in suicide from other means. N a N c.n a - B3 - .~ -J G ~

I. PROBLFM DEFINITIUN Many of the sources of data on injuries do not classify them on the basis of cause or intent. This includes the National Center for Health Statistics (NCHS) and the International Classification of Diseases (ICD) coding system, which codes only the type of injury and body part injured without regard to cause or intent. Consequently, much of the detailed data are available only for all injuries combined rather than for specific causes. Therefore, in selecting priority health problems, we used the ICD Supplementary Classification of External Cause'''•(ICD E codes) in which injuries are coded on the basis of cause and apparent intent. The leading causes of morbidity are often not the leading causes of mortality. For example, of the 10 leading causes of emergency room visits due to injuries, only 2 are in the 10 leading causes of death due to unintentional injuries. This discrepancy, combined with the lack of good morbidity and hospitalization data, made selection of the priority problems difficult. Because of the good quality of data available on mortality, we chose mortality rates as the basis for selecting the injuries for consideration. Analyzing the causes of these injuries, the prime consideration is the interaction of host (person injured), agent (various forms of energy, e.g., mechanical and thermal), and environment, including the socioeconomic environment (e.g., road design or the marketing of alcohol). How these affect the human body is determined by the type of energy involved, its distribution in time and space, and the ability of the human body to withstand the energy. -B4-

I I I I I I I I I I I I ~ I I ~ „~ II. IMPACT OF UNINTENTIONAL INJURIES The 12 leading causes of injury mortality are shown in Table 1. Motor vehicle-related injuries account for more than half of all deaths due to unintentional injuries, and they account for over 60% of all years of life lost before age 65 (Figure 2). They have been more intensively studied than any other injury, and consequently data is available on incidence (almost 4.4 million injuries annually), number of hospital days (over 3.5 million), disability days (over 145.5 million), and on the costs associated with auto injuries ($20,120 million). The direct costs of medical care amount to almost $6,700 million, and the indirect costs of lost wages and economic productivity amount to over $13,400 million. Despite the magnitude of the problems caused by other injuries, little is ~ - known about their true incidence and other variables of individual injuries (see Table 1). Only aggregate data for all other injuries can be shown for many variables. The second leading cause of death due to unintentional injuries is falls, which primarily affect the elderly. Drowning is the third leading cause, -- and, as is evident from the large number of years of life lost before age 65 -- it largely affects younger people (Table 1). Mortality rates for all injuries are highest in the elderly, primarily because of their decreased injury threshold and increased complications following trauma. In children under 5, the leading causes of death are motor vehicles, drowning, and fires. Among persons 15 to 21 years, half of all deaths result from unintentional injuries, primarily associated with motor vehicle crashes, firearms, and drowning. Males have over 2.5 times the ~ ~ fatality rate of females. Alcohol abuse is a major risk factor for U1 ..G i

injuries, increasing as a causative factor as the severity of injury increases. About 50% of drivers killed are -- by legal definition -- intoxicated, as are 25% of seriously injured drivers. Alcohol is also involved in about 30% of fatal injuries from other causes. III. INTERVENTIONS "'Passive" interventions, or those that work automatically and do not require repetitive active participation ("active" interventions), have proved more effective in controlling injuries. For example; seatbelts are an effective means of protection in crashes, but only about 13% of all drivers in the U.S. use them. Air bags, on the other hand, work automatically and are able to reduce fatalities an estimated 30%, without requiring any action on the part of individuals. Possible intervention strategies were analyzed by dividing them into those aimed at 1) preventing the injury-producing event's occurrence (pre-event phase, e.g., raising the legal drinking or driving age), 2) reducing the extent of injury (event phase, e.g., airbags) and 3) reducing the consequences of injury once it occurs (post-event, e.g., emergency services and rehabilitation). At each phase, we consider how to modify each of the following factors: a) human (e.g., health education), b) vehicles and equipment (e.g., crashworthiness of cars), and c) environment (e.g., breakaway poles or restriction of alcohol advertising). Many of the interventions involve legislation that regulates the production, design, or use of hazardous products. One single regulation often can save thousands of lives. For example, the 55-mile-per-hour -B6-

I I I I I I I I I I I I I I speed limit is estimated to save 5,000 lives annually, and the available (but unused) crashworthiness standards for automobiles could save 9,000 lives annually if implemented. A tragic example of the failure of legislation to control injuries was the widespread repeal of compulsory -motorcyle helmet laws, which has resulted in approximately 1,400 unnecessary deaths every year. Much of the need for legislation derives from the failure of manufacturers to assume corporate responsibility for manufacturing products that are designed to be as safe as possible within the limits of available technology. For example, cigarettes can be made that will self-extinguish when left, considerably reducing the 2,300 house fire deaths caused by cigarettes annually. The increasing number of product liability suits may well expand self-motivated responsibility within corporations. To date, prevention efforts directed at voluntarily changing human behavior have been disappointing and at times even detrimental. For example, fatalities in teenagers decreased when school driver education courses were eliminated. Attempts to increase seatbelt usage with insurance incentives and intensive television advertising have been unsuccessful. By contrast, those interventions aimed at reducing the hazards in the environment, such as childproof caps on poisons and breakaway poles on roadsides, have met with considerable success. A variety of promising but largely untested interventions are suggested for controlling alcohol consumption. Many of the other interventions proposed will also dramatically reduce the consequences of alcohol-related crashes and other injury-producing events. .. N CO N Ln CO ~ - B, - CV __J 0 i N

IV. IMPACT OF AVAILABLE INTERVENTIONS In considering the numerous interventions currently available, it became evident that those programs most likely to succeed used a mixed strategy with a number of different interventions directed at the same problem. We have identified four mixed intervention strategies that between them could prevent more than half of all injury related deaths. In planning intervention programs, we have assumed that every effort will be made to use all available technology for reduction of the risk of injury. ~ The gap is defined as the difference in injury rates between what we could expect if the programs were fully implemented and the present injury rates. A distinction must also be made between the total injury burden attributed to something (e.g., alcohol) and what we have the ability to prevent with currently available knowledge and technology. Because interventions are not mutually exclusive in their impact, it is not possible to sum all interventions to get an estimate of the total reduction in disease burden possible using all available resources. The four mixed intervention strategies are: 1. Motor Vehicle Safety_ Program, We estimate that a broad-based mixed strategy could reduce motor vehicle-related fatalities, injuries, and costs by about 75% as indicated in Table 2. Such a program would include installation of air bags, enactment and enforcement of laws requiring the use of seatbelts and child-seat restraints, control of vehicle speed, improved road design, and the maximum use of available technology in designing a safe, crashworthy vehicle. -B8- ~^-.~-.... ,.

I I I I U I U I I I I U I I I I I I 2. Home Injury Control Program. About 23,000 deaths per year result from unintentional injuries that occur in the home: 6700 from fatal falls, 4400 from burns and fires, 2400 from suffocation, 3100 from poisonings, 1100 from unintentional injuries caused by firearms, and 900 from drownings. We estimate that a targeted intervention program directed at these and other home injuries could reduce all home-based injuries by about 50% 3. Occupational Injury Control Program. Of the estimated 13,000 ~ occupational injury deaths that occur each year, a third are due to motor vehicle crashes, of which an estimated 75% are preventable. The causes of the other two-thirds include falls, industrial equipment, being struck by objects, electrocutions, and firearms. Using what little data are available, we estimate that 25% of the other occupational injury deaths • (that is, the two-thirds not related to motor vehicles) could be prevented. This percentage may be significantly increased if basie , principles and further injury control research are applied to the occupational setting. For all causes combined, we estimate that about 40% of the occupational injury deaths and serious injuries could be prevented, resulting in about 5,200 fewer deaths annually (Table 2). 4. Alcohol Intervention Program. The exact impact of alcohol on nonfatal injuries is not well understood (Table 1). If a broad-based societal approach were initiated against alcohol usage, we believe that by using only alcohol countermeasures we could expect about a 25% reduction in all fatal and serious injuries and a somewhat smaller reduction in less serious injuries in which alcohol plays a less significant role. It should be noted that many other injury control measures such as seatbelts and air bags will also reduce alcohol-related -B9-

injuries. A specific program, highly targeted at problem drinkers, is an essential component of an effective alcohol control effort. Any program that reduces unintentional alcohol-related injuries will also greatly reduce the incidence of other alcohol-related diseases. CONCLUSION We believe that the gap for unintentional injuries is larger than a the gap for any other disease entity. The extent to which each of the four proposed injury control programs could reduce the large number of deaths that occur annually is shown in Figure 3. Many of the interventions proposed are likely to encounter considerable political barriers from special interest groups. However, if we are to , significantly increase life expectancy and reduce the burden of diseases in the United States, the most effective means we have with current technology is through intensive injury control programs such as are outlined in the report. - B10 -

I W s a a= rL aL a a 4 i i, t8L A t f t a TABLE 1: Summary of Negative Impact Resulting From Unintentional Injuries Year of Data: 1980 SPECIFIC HEALTH Number of Number of Years Number of Number of Cost Associated Lost Before Hosiptal Disability with each specific PROBLEM Deaths Age 65 Days Days Health Problem Motor Vehicles 53,172 1,694,601 3,548,000 145,432,000 $20,120 million Falls 13,294 87,662 * * * Drowning 7,257 269,203 * * * Fire & Flames 6,016 150,950 * * * Poisoning 4,331 113,376 * * * Suffocation 4,121 88,255 * * * Natural/Environ- mental Factors 3,194 32,328 * * * Firearms 1,955 71,299 * * * Air Transportation 1,494 43,275 * * * Machinery 1,471 34,758 * * * Electric Current 1,095 36,660 * * * Struck by Falling Object 1,037 27,576 * * * Total 105,718 2,769,084 * * $45,472 million Injuries addressed by proposed intervention programs. Motor Vehicle- related Injuries 53,172 1,694,601 3,548,000 145,432,000 $20,120 million Home Injuries 23,000 * * 187,950,000 $8,191 million Occupational Injuries 13,000 * * 184,636,000 $11,570 million Alcohol-related Injuries 42,000 * * * * *Data not available 9 l Lzt,oSZoZ - B11 -

TABLE 2: Summary of Negative Impact Which Could be Reduced or Eliminated Through Implementation of the Intervention Strategies for Unintentional Injuries. Year of Data: 1980 NEGATIVE IMPACT WHICH COULD BE REDUCED OR ELIMINATED THROUGH IMPLEMENTATION OF THE INTERVENTION STRATEGY Targeted injuries for -Intervention Strategy Deaths Years of Life Lost Hospital Days Number (% Total) Number Number Disability Days Number Cost Million Motor Vehicle Related Injuries 40,000 (75%) 1,271,000 2,661,000 109,074,000 15,090 Home Injuries 11,000 (50%) * * 93,978,000 4,096 Occupational Injuries 5,200 (40%) * * 78,854,000 4,628 Alcohol Related Injuries 13,000 (25%) * * * * *Data not available. M-ZnllSM - B12 -