A World of Hurt: Global Injuries

In the developing world, children sustain injuries largely unfamiliar in high-income countries: They’re burned while cooking on unsafe stoves, they drown by falling into uncovered wells, and they’re poisoned by the kerosene used for lamp fuel.

“Globally, the high burden of injuries has been neglected,” says Adnan Hyder, associate professor in International Health. “Injury prevention has been difficult to integrate into public health in a meaningful way because it’s not considered a ‘disease.’” Additional obstacles to reducing injuries in developing countries include a lack of data and advocates, as well as a traditional perception of injuries as acts of fate beyond human control. The word “accident” itself implies a lack of control, which is why experts in injury prevention don’t like to use it. But injury ranks high among killers of children, alongside diarrhea, pneumonia, tuberculosis and malaria, and Hyder wants injury prevention mainstreamed into the public health agenda.

Hyder, MD, PhD ’98, MPH ’93, believes there is another essential element to injury prevention—increasing awareness of injury as a social justice issue. “The poorer you are, the more likely you are to get injured, and the care for your injury is worse,” he says. Children in Africa, for example, suffer unintentional injury at a rate of 53 per 100,000; in countries such as Australia, Sweden, United Kingdom and Canada, the rate is about five per 100,000.

WHO and UNICEF published the first World Report on Child Injury Prevention in December 2008. The report, which Hyder co-edited, outlines intervention strategies—well covers, window guards, motorcycle helmets and nontip lanterns—and policies such as speed limits, playground standards and urban design that mandates sidewalks. Already, the report has generated discussion about interventions. For example, in Vietnam, where many children ride motorcycles but few wear helmets, there is research under way to produce affordable child helmets that meet safety standards.

As director of the International Injury Research Unit (IIRU) in International Health, and a core faculty member of the Center for Injury Research and Policy (CIRP), Hyder touts the cost-effectiveness of interventions. A recent IIRU study of poisoning among South African children looked at kerosene stored in old soda or juice bottles. It found that distributing child-resistant containers for kerosene storage was effective at preventing poisoning. “People think you can’t do anything about injury, and that it’s too expensive,” says Hyder, “but that is a myth.”

Injury in the U.S.

Although they face different types of injuries than children in developing countries, American children remain at great risk. Injury is the leading cause of death for children in the U.S., and the millions of nonfatal injuries cost society an estimated $50 billion annually. For poor children, globally and nationally, the burden is worse. CIRP director Andrea Gielen and colleagues have done research showing that the injury rate for low-income children in Baltimore is twice the national rate. One explanation for the gap is that low-income families often do not have access to safe environments, products and information that can protect them from injuries.

Since 1987, U.S. deaths from unintentional injury have dropped dramatically—43 percent for children ages 0 to 14—as a result of education, safety product development, policy change, research and other measures. “The good news about this field,” says Gielen, ScD ‘89, ScM ’79, professor of Health, Behavior and Society, “is that we don’t have to hunt for a gene. We know a great deal about the causes of injury, and we have already identified many of the solutions. Our challenge is to get them implemented.

The Economics of Injury

Injury prevention products such as smoke detectors, bike helmets and cabinet latches are cheap and work well. But who should pay for their large-scale implementation? That question plagues David Bishai, PFRH associate professor and core faculty in IIRU and CIRP.

In countries with nationalized health care systems, the government pays for medical care and therefore has a financial interest in preventing injuries. In the U.S., though, managed care organizations (MCOs), not the government, bear the costs. So shouldn’t MCOs want to invest in injury prevention? Not necessarily, says Bishai, a health economist. “There’s too much turnover,” he says. On average, a person switches to a new MCO every five years. Some interventions, such as alcohol and drug rehabilitation programs, pay off in the short-run. But other interventions—smoke detectors, for example—need to be in place much longer before they pay off. “There’s no incentive for MCOs to invest in long-term prevention,” Bishai says.

Real progress in injury prevention may require a sea change, says Bishai. A single-payer universal health care system or portable lifelong private insurance contracts would solve the problem. “With the new [presidential] administration, these options are on the table this year,” he says.