Chapter 3.

How Big is the Injury Problem?

By Mark Rosenberg, MD


Overview

The goal of this chapter is to provide you with a better sense of how big the scope of the injury problem is in this country, and to demonstrate how descriptions of different dimensions of the problem can be used to understand and ultimately change the problem's nature.

Perhaps the best way to introduce the material that we are going to cover is with a brief personal story: This summer, I asked my wife if she would walk over with me to a neighbor's house. The neighbors were good friends of ours and had a son who played soccer with our son. But the neighbor's 17-year -old son had just been killed in a car crash. I told my wife that the whole neighborhood was going over to offer some support, but she was reluctant to go, saying that she couldn't imagine what she could say to help them -- the loss was just too awful.

I certainly didn't know what I was going to say, but I urged her to come with me, and she reluctantly agreed. When we arrived, I reached out my hand to the father, and he said, "No, I'm not shaking any hands tonight, I'm just hugging people, I need people to hold me up, I need everyone close to me." We hugged him for several minutes, both somewhat relieved that we did not need to try to put our feelings into words. But as we stepped away he said, "you know, this is every parents' worst nightmare".

We were close enough to everyone in the room -- kids from the high school class, neighbors, friends, his family -- for them all to hear him, and everyone fell silent. He was right, he was living through every parent's worst nightmare. His son had called him at midnight and said, "Dad, I'm at the Waffle House, I'll be home in 20 minutes, we're on our way, don't worry." But in twenty minutes he was not home, and an hour later the father got a call that was from the hospital. He and his wife got to the hospital as quickly as they could, but when they arrived their son had already died.

Their experience made us all stop and wonder: Could this also happen to someone in my family? Are these types of tragedies really all that common? Unfortunately, the answer to both of these questions is an overwhelming yes.

How big is the scope of the injury problem?

 

Consider the statistics. This slide is a matrix that shows the 10 leading causes of death in this country by age group in 1994. If there is only one thing that you commit to memory from this entire course, I would like it to be the information on this chart. Just look at the colors, that's all that you'll really need to remember. If you look at that first row, everything that falls into the category of unintentional injuries is printed in blue. But to get the complete injury picture for each column, you must also add to the blue figures all of the numbers in red that represent homicides and in green that represent suicides.

The chart tells a story: that injuries dominate the pattern of death in the United States. For people ages 1 to 4, 5 to 9, 10 to 14, 15 to 24, 25 to 34, injury is the leading cause of death. And if you look at the 35 to 44 age group, and add together unintentional injuries with suicide and homicide, there too injury is the leading cause of death. So for people between the ages of 1 and 44 in this country, injury is the leading cause of death.

The total number of Americans who died from injuries in 1994 was about 151,000. About 43,000 of these deaths were from motor vehicle crashes, about 31,000 were from suicide, about 25,000 were from homicides, 10,000 were from falls, 9,000 were from poisonings, 4,000 were from fires and burns, and another 4,000 were from drownings.

But keeping track of deaths is just one way of measuring the injury problem. Another, and perhaps preferable way, is to calculate years of potential life lost. The calculation is based on an assumption that for most people, our productivity ends at age 65. So, if someone dies at age 64 from a heart attack, it would be registered as one year of potential life lost. But if a young person dies from a motor vehicle crash at age 20 then you should subtract 20 from 65, and you've lost 45 years of potential life. By comparing years of life lost from injuries to years of life lost from other public health problems, it becomes evident that injury is an even more severe problem than death rates alone would indicate.

This is not to say that measuring years of potential life lost is a perfect index. There is certainly no rule that says that people cannot be productive well past the age of 65. However, looking at years of life lost does help us to factor important information about when deaths occur into our understanding of the injury problem. If you look at years of potential life lost, injury accounts for more years of potential life lost than any other cause.

Another way to understand the scope of the injury problem is to look at nonfatal injuries. While we have much more accurate information about the number of deaths that occur in this country than about the number of nonfatal injuries, many more people suffer from nonfatal injuries each year than are killed as a result of injuries.

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This point is illustrated on this slide. The graphic shows that deaths are just the small tip of the injury pyramid, and that that there are many more nonfatal injuries than there are deaths. The ratio between nonfatal injuries and deaths does vary for different types of injuries. But it may be more important to recognize that as big a problem as injury deaths represent, the complete injury problem is much, much bigger.

Another way to measure the size of the injury problem is to assess the costs of injury. The financial costs of injuries are staggering. Our best estimates suggest that injuries cost the nation about $200 billion a year. At least one large company has estimated that injuries cost it $250,000 a day.

Nevertheless, not all costs can be measured in dollars. Perhaps the greatest cost of injuries in this country must be measured in terms of the human pain and suffering that is often not accounted for in figures.


Who is affected?

We can also look at demographic and geographic characteristics to get a clearer idea of exactly who is affected by the injury problem. We use age, gender and race to look more closely at particular injury problems.

Let's look first at age; take the example of suicide. In the early 1980's, when people first started looking at the problem of suicide, they looked at the overall death rate for suicide and they said, "oh, this line is just flat, it's not going anywhere, nothing significant is happening." But upon further inspection, they saw that the suicide rate for older people was coming way, way down, and the suicide rate for younger people was going way, way up. Stratifying by age helped people to recognize that what drove younger people to commit suicide was very different from what was causing the older people to commit suicide, and therefore that strategies designed to save the lives of these younger people needed to be very different from those designed to save the lives of the older people.

Age can also be a surrogate for other risk factors for injuries. For example, if you look closely at car crashes or other motor vehicle injury deaths to young people, it often turns out that they are not due to intoxication as often as you might think. Instead, many are caused by inexperience. On a wet or dark road, young people who had been driving for less than a year were not as good at controlling their car, and were much more susceptible to crashes. So this turned out to be a risk factor for younger drivers. Would it apply to older drivers if they had just started driving at a later age? Of course. But again, age held an initial clue to figuring out the role of inexperience.

Next, let's look at gender. Considering again suicide as an example, males seem to commit suicide at a much higher rate than females. But suicide attempts are much higher among females than among males. Recognizing these differences can help us to start exploring the underlying reasons for the differences, and ultimately can help us to devise more effective strategies to prevent suicide. So gender is very important in helping us to understand the problem of injury.

Injury pyramid

Race is also an important factor in understanding the nature of the injury problem. Let's consider the homicide rates of young men in this country. (part one) (part two) This slide compares death rates in the United States to those of other countries. The top red and yellow lines compare our rates to the rates in 22 other industrial countries. You can see that the rates start very low with Japan, England, and Wales less than one per 100,000 and the rates for the US are practically off of the chart. You can also see that our rates have declined from 1993 to 1995. But let's see what happens when you put race into the equation.

We're again looking at the same basic chart. But here, the second line is for white males, and the yellow line is the homicide rate for young black males in this country. (part 1) (part 2) (part 3) (part 4) (part 5) (part 6) (part 7) If you pay close attention to the numbers in the lower right hand corner , you will see that the rates for black males far, far exceed those for white males. What does this tell us? It tells us that the victimization rates are unequally distributed. Race can also sometimes be a surrogate measure. Here, the rates are not high because these young men are black. They are high because of differences in socioeconomic status. If you control for socioeconomic status, the difference in rates just about disappears.

The dynamic nature of the injury problem

So, what does the injury problem look like when compared to other causes of death? The best answer is that the picture is always changing. Let's revisit our
injury matrix. If you look again at column for the 34 to 44 year old age group, HIV appears in the slot as the number one cause of death for the year 1994. However, in 1980 HIV didn't even appear on this chart. It has rapidly moved its way up into position number one in this age group. Over time, the overall public health picture changes, and over time the injury picture can change. The important thing to remember is that we can all make the picture change. Injuries are preventable, and we can help move them down out of the top positions on the chart.

To summarize, injury is a very big problem in this country, but there are many ways that we can understand the problem, and these can provide us with clues to solutions. Finally, as you set out to describe the injury problems in your own particular community, don't forget that the figures and the epidemiological data tell only part of the story. The other part of the injury problem, and frequently the most compelling part, is written on the hearts, souls, and faces of the people who are injured and those who care about them. Tackle this problem with your mind and hearts and you can move us towards a safe America.

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Next: Chapter 4. A Systematic Approach to Injury Control and Violence Prevention

 


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