Injury and Injury Control

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The factual assertions used to demonstrate the importance of injuries as a public-health problem are well known: Injuries are the leading cause of death for the majority of the human life span; injuries deprive people of more potential years of life than any single disease; and the cost of injuries, whether measured in dollars or in human suffering, is staggering (Rice et al.). Injuries are generally defined by those working in the field of injury prevention as human damage due to the acute transfer of energy or the lack of essentials such as oxygen (as in asphyxiation) or heat (as in hypothermic injuries) (National Committee for Injury Prevention and Control).

Actions taken to control injury provide prototypical clashes between the personal liberty of the individual and the goals of public health. These conflicts—referred to in ethical terminology as conflicts between paternalistic beneficence and individual autonomy—are experienced in such public interventions as those that mandate helmet use by motorcyclists or that require the wearing of seat belts by drivers and passengers in automobiles. However, injury control also illuminates how public health makes progress by redefining the nature of the problem—in this case, by shifting from the term accident (which points to the individual who is injured or an "act of God" as the responsible agent) to injury (which suggests that equipment, environment, and those responsible for equipment and environment share responsibility).

Historical Development

Although injuries have plagued the human race since its earliest times, it is only in the twentieth century that science has been applied to this public-health problem. For most of history, and to some extent up to the present, injuries have been misperceived as the equivalent of accidents; that is, chance occurrences that are basically unpredictable, and therefore unpreventable. The notions that some people are accident-prone, and therefore we should expect them to be injured, and that people are injured as punishment for a prior moral offense, have substantially retarded the ability to approach injuries and injury prevention scientifically.

A turning point in the historical development of injury control occurred in the early 1960s, when scientists first recognized that injuries, like diseases, had agents that interacted with hosts in specific environments to produce human damage (Gibson; Haddon). By modifying the agent (which was recognized as transferred energy), the human host, or the environment, one could substantially reduce the likelihood and/or the severity of an injury. William Haddon is generally recognized as the individual who most clearly "moved injury prevention into the mainstream of public health research and policy" (Baker). He developed the conceptual tools for the analyses of injury etiology and prevention that form the foundation of modern injury control.

In the decades that followed, scientists applied epidemiologic methods to the investigation of injuries and developed a new body of knowledge on how, when, where, and to whom injuries occur. Data are now available to dispel definitively the notion that injuries occur at random. The clear patterns of injury, which include identified high-risk groups (e.g., elderly persons at risk for hip fractures), geographic patterns (e.g., the distribution of firearm fatalities in the United States), and temporal trends (e.g., the increasing rate of adolescent suicide), make injuries both predictable and, more important, preventable (Baker et al.). Interventions can be focused on high-risk persons and sites, and the effects of the interventions can be scientifically evaluated by comparisons of injury rates.

Shifting Conceptions: Environmental and Product Modification

Notwithstanding these significant advances in the science of injury control, the field remains troubled by popular misconceptions that impede effective prevention programs. The reduction of injuries is still considered a matter of common sense by many. Unlike disease prevention, which is generally recognized to depend upon expert knowledge, injury prevention is commonly misperceived as a matter of an individual's responsibility rather than of public policy, and the importance of expert advice in preventing injuries is often not acknowledged. Thus the false orientation that the only way to prevent injuries is to teach people to be careful remains a popular bias, even among key decision makers who are in a position to protect millions from injury. The exclusive focus on the behavior of individuals for the prevention of injuries characterizes what was once known as accident prevention. Accidents were understood as the result of imprudent behavior; the remedy was to teach people to be constantly careful and vigilant. An example of this is the early approach to reducing highway fatalities. The method relied upon was improvement of drivers' skills through education and frequent reminders to be careful delivered in public service announcements. By the mid-1960s, however, there was a growing awareness that lives could be saved by shifting the focus of attention from the driver to the highway and the automobile. Crashes were recognized as foreseeable events. By altering the construction of vehicles and highways, the human cargo of the vehicles would not have to suffer serious injuries if and when a crash occurred.

The U.S. Congress took notice of the increasing number of highway fatalities and the opportunity to reduce this toll by mandating "crashworthy" vehicles. In 1966, Congress passed the National Traffic and Motor Vehicle Safety Act, which provided for the creation of motor vehicle safety standards. These standards, which anticipated driver error and provided a more forgiving environment within the vehicle, have saved tens of thousands of lives (Robertson).

The idea of paying attention to products as well as behaviors has not been restricted to highway safety. Efforts to prevent childhood scald injuries from hot tap water provide an example of this trend toward product alteration. Hot water coming out of faucets in homes is often at a temperature that can cause a severe burn injury to a child's skin in a matter of a few seconds. Rather than relying on parents to keep young children away from faucets, efforts have been made to direct the parents to turn down the setting on their water heaters so that water will not be discharged at temperatures greater than 125°F (Katcher et al.). This prevention strategy, however, still relies upon motivating parents to reset the water heater. An even more effective strategy has been to influence appliance manufacturers to set the heaters at the proper level before they leave the factory, thus eliminating the need to modify parental behavior.

A general principle of injury control, illustrated by the prevention of scald injuries, is to shift the focus of prevention from the individual to the community (Beauchamp; Barry). Legislation and regulation that require safer products and environments are more effective in preventing injuries than are efforts to have individuals control their own behaviors. When safety legislation or regulation has been difficult to accomplish because of strongly resistant political influences, litigation has been used. An example of this is product liability litigation, which transfers the cost of injuries from a dangerous product back to the manufacturer, thus giving the manufacturer a strong incentive to improve the safety aspects of its product (Teret).

Altering Behaviors: Paternalism and Prevention

Sometimes product modification is not available to achieve a desired prevention strategy, and reliance upon altering behaviors is necessary. Such is the case with motorcycle helmet use. The effectiveness of helmet use in preventing or reducing the severity of head injuries is well established, but helmet use is not universally accepted by motorcyclists. Legislation requiring helmet use is effective both in increasing the use rates and in decreasing motorcyclist death rates. These laws, however, have been bitterly fought by some motorcyclists, and most states have passed and then repealed mandatory helmet use laws.

The debate over motorcycle helmet laws has raised many issues that apply to other areas of mandating safe behaviors. The propriety of governmental paternalism, the relevance of who pays the costs of injuries, and the constitutionality of laws that interfere with personal decisions are all included in the helmet issue. Assuming a definition of paternalism as institutional interference with individual action for the sake of some greater good, motorcyclists question whether their enforced safety is a good substantial enough to deny them their freedom of choice to ride without a helmet.

Opponents of helmet laws categorize such laws as hard legal paternalism, in that the laws regulate voluntary behavior that can harm only the motorcyclist (see Feinberg, p. 12, for distinction between hard and soft legal paternalism). Proponents of the laws point out that the increased harm inflicted on a helmetless motorcyclist eventually affects the public as a whole. The public pays about 85 percent of the costs of motorcyclists' injuries; helmet laws would reduce the human capital costs by about $400 million per year in the United States (Rice et al.). Arguments have been raised that the solution to the cost-of-injury problem is to require adequate medical insurance of those who choose to assume risks, but the flaws of this argument are apparent. Some motorcyclists will not purchase insurance, through lack of money or indifference; and it would be unacceptable to have the injuries of these motorcyclists go without medical attention (Dworkin).

The motorcycle helmet issue illustrates a problem that permeates the field of injury prevention. As a society, Americans will still permit the manufacture and marketing of some inherently dangerous products, and then rely upon limited efforts to control the behavior of the individuals to whom these products are distributed. Guns provide a striking example. There are about 38,000 firearm fatalities each year in the United States, and most of the policy to reduce this toll focuses on modifying the behavior of the individual who possesses a gun. There are few effective regulations governing the number and types of guns that can be manufactured in the United States (Webster et al.).

The future success of injury prevention appears to be highly dependent upon the willingness of government to regulate business. The products people use and the built environments in which they place themselves are highly determinative of the risk of injury. Since people do not always act in a prudent fashion, and since government is unwilling and unable to mandate such behavior, the greatest opportunity to reduce the incidence and severity of injury rests in the regulation of products and environments.

stephen p. teret

michael d. teret (1995)

bibliography revised

SEE ALSO: Autonomy; Paternalism; Public Health: History; Public Health Law


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