REDUCING THE TOLL OF INJURIES
During my years at the CDC, few public health areas were more frustrating than violence. The area is often divided into intentional and unintentional violence, although both facets have many common factors. Intentional violence is often seen as homicide, suicide, war, domestic abuse, and bullying. Unintentional violence is often considered as highway injuries, drowning, natural disasters, and occupational injuries. Both share certain risk factors, such as alcohol consumption or aggressive tendencies, and both can be reduced by changing the physical or psychological environment.
During my years as head of the CDC, we would annually include injury control in our budget requests, only to have the proposal rejected, accompanied by explanations that this topic involved highway safety, law enforcement, or some other area, but it was not a public health concern. Part of the problem may have been that the Public Health Service had a Division of Accident Prevention in the 1960s, which had moved to the National Highway Traffic Safety Administration. So there was little enthusiasm for trying to resurrect injury control at the CDC.
Highway safety experts had indeed shown the potential for prevention. Injuries and deaths per million miles driven had steadily declined in this country. Part of the reason was a change in the environment, including limited-access highways, banking of curves, relocating tail lights, seat belt use, airbags, and better headlights. Other reasons were driver education, campaigns against drinking and driving, campaigns to encourage and finally mandate seat belt use, and child restraints. Sometimes these changes were federal requirements, based on experience; at other times, they were the result of grassroots efforts. Today, child restraints are used for 99 percent of infants, and parents don’t even question the requirement.
In the early 1970s, car injuries were the leading cause of death for young children in Tennessee when pediatrician Dr. Robert Sanders became chair of the state’s chapter of the Accident Prevention Committee of the American Academy of Pediatrics. In 1976, Sanders proposed a state mandatory child-restraint law, which was defeated in committee. It is hard in retrospect to understand these political representatives, but they felt government should not interfere with parenting and even accused Sanders of having a financial interest in safety-seat manufacturing. He was persistent, however, and in 1978 the Tennessee Child Passenger Safety Law passed by two votes. Seven years later, all fifty states had passed similar laws without the matter ever going through Congress or the federal government. (Actually, almost all public health advances, whether coming from the states, as with child restraints, or coming from the federal government, as in many of the childhood vaccine initiatives, are based on demonstrations at local levels that an approach is feasible.)
Despite the lack of appropriations for an injury-control program, the CDC established the Violence Epidemiology Branch in 1983. This small group of two physicians, a sociologist, an anthropologist, and a statistician was asked to look at violence as a public health issue and to determine what could be done to save lives and preserve health.
The director for the program was an inspired choice. Mark Rosenberg, a former EIS officer, was well versed in epidemiology. He had returned to Boston from the CDC in Atlanta for a residency in psychiatry. He quickly brought the two disciplines of psychiatry and public health to a fruitful coalition bearing on injury as a public health problem.
Rosenberg was familiar with controversy. In 1975, while investigating a polluted water supply at Crater Lake in Oregon, he and other CDC investigators came under attack as “out-of-state bureaucrats who did not vote for Senator Hatfield.” The investigators did not evoke a lot of sympathy from the folks in Oregon. He was to receive more such abuse in his new position.
It was not until after leaving the directorship of the CDC that I had an opportunity to be involved in a different approach to injury control. I was asked to chair an Institute of Medicine committee on the subject. Our goal was to make suggestions to improve the federal government’s response to injury control.
It was a wonderful committee of people from the federal government, state and local governments, NGOs, and academia. After documenting the extent of the problem of injuries and death from violence, the committee sought a way to channel the federal interest. The committee sent a questionnaire to federal agencies that asked how much money they spent on injury control or injury research; it revealed sizable expenditures, often because research funding was included that was actually quite generic and tangential to the injury problem. This is the expected and often observed reaction as agencies position themselves in the hope that they will acquire resources if a new program is instituted.
A second questionnaire was sent to agencies that had reported significant involvement in injury control, asking them a similar question, but in a different way. If the federal government consolidated injury-control efforts, what would be their contribution to the consolidated program? Now, apparently worried that they might be asked to give up resources, these same agencies indicated that they were doing very little in injury control. As the committee reviewed possible places to focus the government’s efforts, they reached the conclusion, after eliminating one place after another, to select the CDC—despite multiple arguments against that conclusion by myself and others. I was concerned that it would appear that I had engineered such a conclusion and, for that reason, argued against it, but the committee insisted on that result.
The IOM recommendation did not lead directly to a CDC program. HHS was still reluctant to make injury control or violence reduction a public health priority or responsibility. However, the committee was clear in its intent, choosing to title its report Injury in America: A Continuing Public Health Problem (1).
A declaration was not the same as funding, however. And, then, as happened so often during my time in public health, the unexpected happened. Congressman Bill Lehman from Florida had a deep interest in injury control and had come to know Mark Rosenberg. Lehman chaired the subcommittee that decided on appropriations for the Department of Transportation so he knew the impact of deliberate action on highway injuries and deaths. He included an item for $10 million in the budget of the Department of Transportation, on the condition that it would go to the CDC to establish a program on injury control. This is the kind of innovative government action that is so important and so rare. Many said they could not remember a similar maneuver. The money did go to the CDC to enhance the small injury research and control effort and brought renewed enthusiasm for a public health approach to injury control.
The year after receiving the $10 million from the Department of Transportation, there were high hopes that HHS would include injury in the CDC budget, but it did not. Congressman Lehman again placed it in the Department of Transportation budget. For three years, he had to take this approach until HHS conceded that this was a public health problem and should be funded by the Public Health Service. Bill Lehman should be added to the list of political heroes who changed the future of the health of the public.
The CDC set to work to carry out the objectives outlined by the Institute of Medicine of the National Academy of Sciences: to provide a scientific understanding of the causes of injuries and how they occur, to apply the findings from scientific studies to create programs to prevent injury, and to work in partnership with various groups dedicated to solving the injury problem in America. The program grew and provided better statistics, better analysis, and commonsense prevention ideas. As the program became stronger and covered larger areas of the injury landscape, the benefits became obvious. Thus, in 1992, it was officially made the Center for Injury Control.
Injury-control public health flourished. Academic centers worked on injury control, and research money became available. State health departments felt encouraged to support injury control. It was an optimistic time as the field became part of the great application of science to the improvement of human well-being.
The injury conversations led quite naturally to all areas of violence, which led to the question of what the possible role of a politically unbiased approach to gun safety could be. What if shooting incidents could be followed as one follows infectious diseases? Could a program collect and analyze the results as one would analyze a polio outbreak and discover ways of improving gun safety?
But it was too good to last. Public health absolutely needs the support of politicians. But it can also be totally undermined by the efforts of politicians and by forces more interested in turf or profit than health. Research on gun safety became a major political obsession.
After the 1994 election, there were many National Rifle Association–sponsored Internet postings, including one by a physician who wrote, “Goodbye CDC.” It stated that a favorable makeup of Congress made it possible to stop the CDC gun research. The physician urged readers to contact their congressional representatives and even suggested that Dr. Rosenberg be investigated for possible illegal political lobbying.
Meanwhile, the NRA was pushing the same anti-CDC message through its powerful friends on Capitol Hill. On October 19, 1995, ten US senators, including majority whip Trent Lott and presidential candidate Bob Dole, wrote a “Dear Arlen” letter to Senator Arlen Specter, chairman of the Appropriations Subcommittee that oversaw HHS. It urged the elimination of the CDC’s National Center for Injury Prevention and Control on the grounds that its work was wastefully “duplicative” and driven by “preordained political goals.”
On May 1, 1996, Rep. Jay Dickey (R-Arkansas) grilled Mark Rosenberg at an appropriations hearing.
“Dr. Rosenberg,” Dickey asked, “did you make the statement that you ‘envision a long-term campaign similar to tobacco use and auto safety to convince Americans that guns are first and foremost a public health menace’ ”?
Actually, he did not, Rosenberg explained. The words were those of a journalist writing about public health research into gun violence. They did not even make logical sense, Rosenberg said. Obviously, he said, cars are not “first and foremost” a health menace. What he had said, “was that we don’t even use the word ‘gun control’ and we don’t think that you have to ban guns to prevent these injuries, the same way that we never had to ban cars but we saved hundreds of thousands of lives on the highway.”
Rosenberg’s explanations were not enough. In June, the House Appropriations Committee approved a Dickey amendment cutting $2.6 million out of the National Center for Injury Prevention and Control budget—the precise amount it was spending on firearms research of all kinds. The Senate eventually restored the money but earmarked it for traumatic brain injury surveillance.
This was not only a setback for the work at the CDC but also for states attempting to reduce firearm injuries and for ten research centers in academic institutions. The public health emphasis on sophisticated data collection “has been a major contribution [to public health],” said Philip Cook, a Duke economist who had been working on gun violence for a quarter of a century. “That was a great casualty of this cutback.”
In 2013, Vice President Joe Biden headed an effort to find ways to improve gun safety after the horrendous tragedy of December 14, 2012, when twenty children and six adults were shot at the Sandy Hook Elementary School in Newtown, Connecticut. Some were outraged to find that the CDC had been prohibited from doing research on gun violence and wanted to know who was behind that action. It turned out to be Congress that was behind that action.
We are surrounded by enemies. Some are so small that they require microscopes to be seen. And some are in suits, occupying congressional offices or lobbying organizations, representing specific and special interests, rather than the interests of the public.