Death and Disability from Injury

(Figure 11)Figure 11. Anthony A. Meyer, MD, PhD President, American Association for the Surgery of Trauma Being President of the American Association for the Surgery of Trauma (AAST) has been both an incredible honor and a wonderful opportunity to serve an organization that has the true spirit of what a surgeon should stand for. The members of this organization represent not only dedication to treatment of those in need of the most emergent care, but commitment to prevent such injuries and improve the care of those who have been injured as well. I would like to thank all the members of the AAST for this honor, and especially several individuals who have helped me in my roles in the organization: Drs. Lew Flint, Jim Carrico, John Davis, Basil Pruitt. I would also like to acknowledge three past presidents and a past vice president: Bill Blaisdell, Don Trunkey, George Sheldon, and Bob Lim, who, along with other faculty from San Francisco General Hospital, including Bill Schecter, Art Thomas, and Frank Lewis, provided not only training and encouragement, but served as role models for dedication to the care of the injured. It was Don Trunkey who especially encouraged me in a career in trauma when I was a resident, gave me my first job, and made me realize, as a new faculty member, that injury is a much greater problem than what is seen in your own emergency department. I would also like to thank my colleagues, fellows, and staff at the University of North Carolina for their help and support in my clinical and research endeavors, and specifically Chip Baker for his leadership of an excellent trauma program. Most of all, I would like to acknowledge the support of my family: my wife, Marian, and my daughters, Jennifer and Christine, who have been so supportive of the work that imposes an irregular schedule with long hours and missed family events. Their encouragement and forbearance has made all the difference to me. With the development of merged economies, advanced communication, and expanding travel access, we are moving from local, regional, and even national, to global perspectives on many issues, including some regarding public health. Problems such as infectious diseases and pollution have been recognized as worldwide health issues for a relatively long time, and approaches to these problems have included this international perspective. Global attention to problems of malnutrition and infectious diseases has led to significant progress in health in so-called "third-world countries," and average life expectancy worldwide is now 65 years. 1 Injury, however, is still seen by most as a local issue, the result of random events, not amenable to an organized approach to prevention and treatment. Everyone recognizes the tragedy of disability and premature death from injury, but few equate this with a global health concern. I believe that it is this misconception that has contributed to the dramatic increase in injury as a world health problem, while it has received limited attention. This joint meeting of the American Association for the Surgery of Trauma and the Japanese Association for Acute Medicine provides a great opportunity to consider injury as a global problem. We are able to learn about clinical management of injury and related research from presentations and posters from eight different countries. Furthermore, participation by members and guests of both organizations from 17 different countries will enhance this international perspective. I will use this opportunity to review data regarding the worldwide incidence and impact of injury, to discuss a few specific issues common to all countries, and to propose some approaches we can use to meet the challenge of injury as a global health problem. To assess the global incidence, outcome, and impact of injury, I reviewed sources from 41 countries (Table 1) and 25 states in the United States. I also surveyed honorary and corresponding members of the AAST, receiving additional information on 15 countries. An especially notable source of information was the recently published Global Burden of Disease Study (GBDS), which was sponsored by the World Bank and the World Health Organization (WHO) and published by the Harvard School of Public Health. 1Table 1. Sources of information regarding injury as a global challengeThis study, published in two volumes, with a small companion overview, was recently summarized in four articles in consecutive issues of Lancet in May, 1997. 2-5 It represents the most complete contemporary international data on health statistics, permitting analysis of injury as it compares with other health problems. The GBDS separated countries into eight regions, based on economies, population, and geographic similarities. These are listed in Table 2 and displayed in Figure 1. These eight regions are the Established Market Economies, Formerly Socialist Economies of Europe, India, China, Other Asia and Islands, Sub-Saharan Africa, Latin America and the Caribbean, and the Middle Eastern Crescent. Briefly, this study used population-based data in countries where it was available, and estimates based on available data in other countries. In India and China, there were no usable population-based data, and estimates were based on samples. All of these data-collection methods have inherent inaccuracy, but significantly less with population-based data collection. However, this well conducted compilation of information represents the best available source of global statistics on disease, including injury.Table 2. Global Burden of Disease Study: World Bank and WHOFigure 1. This map demonstrates the eight different regional groupings of countries in the Global Burden of Disease Study. The regions are defined in Table 2.In the GBDS, the causes of death and disability were divided into three groups (Table 3): group I, communicable diseases, including infectious diseases, malnutrition, and perinatal disorders; group II, noncommunicable diseases, principally acquired diseases such as ischemic heart disease and cancer; and group III, injury, both intentional and unintentional.Table 3. Global Burden of Disease Study: causes of death and disabilityReview of data on mortality from the GBDS shows that injuries were responsible for 5.1 million deaths in 1990, 10.1% of the total deaths (Table 4). When total deaths are separated by age and by gender and analyzed for the eight different regions shown in Figure 2 A, Figure 2 B, and Figure 2 C, the proportional mortality from injury varies less than that from communicable and noncommunicable diseases. This demonstrates the consistency of injury as a health problem in all parts of the world. Subgroup analysis of individual causes of death demonstrates that vehicular injury is the most common cause of injury-related death, but ranks ninth in the overall frequency. A list of the top 30 causes of mortality worldwide in 1990 is shown in Table 5.Table 4. Global Burden of Disease Study: 1990 world mortality causesFigure 2. Proportional mortality by age category in the Global Burden of Disease Study. (A) Probability of death from three different groups of causes between ages 0 and 15 in both males and females. (B) Probability of death from three different groups of causes between ages 15 and 60. (C) Probability of death from different causes between ages 60 and 70. Regional definitions are given in Table 2.Table 5. Thirty leading causes of death worldwide in 1990The GBDS also examined not only mortality, but disability, and the impact of both depending on the age of the victim. The authors used the calculated outcome of Disability-Adjusted Life Years (DALYs), which permits consideration of years lost not only to deaths but also of degrees of different disability levels. Disability was assessed at the levels listed in Table 6, which gives examples of the conditions for each level. I believe that some of the assignments of disability for mental illness may be high when compared with injury. Some patients with mental illness can be effectively treated and returned to productive life, whereas patients with quadriplegia or amputation are less likely to return to productivity. In spite of this limitation, I believe that the use of DALYs provides a better measure of impact of disease than simple mortality. Other measures that attempt to include these variables in outcome measures are Years of Life Lost, Quality-Adjusted Life Years, and Years of Productive Life Lost. 6,7Table 6. Disability classes based on person-trade-off methodInjury most often affects younger people with more productive life years ahead of them and has a greater likelihood of causing long-term disability than other major causes of disease. 7,8Table 7 shows that worldwide, injury accounts for 15.2% of DALYs lost in 1990, whereas it was responsible for only 10.1% of deaths.Table 7. Global Burden of Disease Study: 1990 comparison of contribution of injury to death and DALYsThe 30 leading causes of DALYs, shown in Table 8, identify a greater number of injury-related causes compared with the leading causes of death shown in Table 5. There are more injury-related causes of DALYs in the top 30 than there are injury-related causes of mortality. These include motor vehicle crashes, falls, war injuries, self-inflicted injuries, violence, drowning, and burns.Table 8. Thirty leading causes of worldwide DALYs for both sexes in 1990Recent WHO have shown that the average life expectancy worldwide has to 65 of a in deaths to group I of life expectancy for the an increase in all eight regions for both and (Figure 3. of life from 1990 to in in the eight different regions of the Global Burden of Disease Study Regional definitions are given in Table to by the include in deaths from infectious diseases and perinatal and in deaths from motor vehicle crashes, violence, and The of this increase in life expectancy the outcome of diseases has led to dramatic in the cause of DALYs for the Table shows that DALYs from injury will that of group I, the communicable and perinatal diseases. in care for group II, the acquired diseases, and of group I DALYs will the impact of injury even greater in the Table shows the in of causes of DALYs by the All causes of injury in the top 30 in comparison with other Global Burden of Disease Study: DALYs by in for most causes of death from 1990 to in to about the to mortality and disability from injury, it is to the impact of injury compared with other causes as well as the for It is to the of an given to a in a much less the global impact of injury. in the difference in of care, and from the United published in in an excellent of in the United estimates the of injury that in the United as This is in Figure by of care and from premature mortality and disability 4. of the of injury in the United States. mortality represents of and represents of care for injured as well as of of the from the United to other Established Market Economies would be and there is no to use these with other The from a in injury compared with an acquired disease can be seen in the a in deaths be for injury, with an average age at mortality of or an acquired disease, with an average age of mortality of and is the overall average life the for injury prevention would a of years compared with years for the for acquired disease. There is also the consideration of at different years of this is shown in Figure A, Figure B, and Figure In data from the United for injury for only of the deaths but of the life years The even greater impact of injury is in Figure which demonstrates that the of deaths accounts for of the mortality When the impact of disability is included by years of productive life a number to DALYs, the impact of injury in the United was greater than that of and heart disease (Figure This demonstrates that of death and disability would have a major for the United but this to all countries. the United more of on health than other The are even more when health worldwide (Table where dramatic are seen in support of health care the world. The global impact of death and disability from injury will increase the limited to health in some countries, the most can in the is in prevention and care of the injured. estimates of Years of Life to injury will be in those countries with the to health care (Table 5. of the impact of the three leading causes of death in the United in (A) by number of deaths from leading causes in the United in (B) of years of life lost from leading causes of death in the United in (C) of mortality from leading causes of death in the United in 6. of years of life lost from heart disease, and injury in the United in the Global Burden of Disease 11. Regional total health in 1990 international Global Burden of Disease Study: years of life lost in of of the global of injury and we are often to the of the of injury. The death of and own individual that the of death and disability from injury on a is the of some to the of and We have all seen the in the of the death of a from an injury, especially a or and that of lost to that with for from many and of health care, we need to that to prevent or injury are not only but Figure 7 shows the to for each death from three major This a of prevention The of death and disability of would be an incredible 7. to for each death, separated into three major causes of of the GBDS and other sources has some in causes of death and disability from injury in different countries. However, there are several common global issues of injury that I would like to vehicular injury, injury, injury, and as a to injury. of these issues not only common major but demonstrates examples of and global for trauma is responsible for the mortality and DALYs lost of cause of injury in the This was true in all regions, and data on from war not vehicular injury in the of Furthermore, vehicular injury in greater death and disability in countries than in countries with more Table shows a compilation of vehicular deaths from study published in These represent some significant of vehicular deaths in countries, and not only deaths but deaths vehicle as well. It not identify the great in vehicular deaths based on of in some by of countries made in the to the high of vehicular deaths and approaches were to including vehicular and and care of the injured. of vehicular death between and by (Table has the of these in these and are likely to vehicular death and of mortality from to these vehicular injury is to be the number cause of DALYs by and the number 2 cause of DALYs in countries. 2-5 In most countries, injury the cause of death and disability in and health in countries, injury will a relatively much greater health problem in the of deaths in from injury the varies Some of these are summarized in Table The GBDS examined deaths in 15 and The incidence of death from injury is in less both in and death by have been significant in prevention of injury, including vehicular and and However, these are not available or even There is a need to measures to common causes of injury in individual and to prevention that are likely to be than to to an cause of injury, especially in some are often the of as seen in the and are all often the of An analysis of the number of treated at in for is shown in Figure 8. these include a few who in the represent injured or as 8. of of for to in from can have no greater on both the and impact of injury than we can the incidence of death and disability from injury in and death represents a and relatively limited cause of death in worldwide However, as a cause of disability, injury ranks much who in the care of I can that injury causes even greater impact on and family than can The incidence of death and injury from has significantly in countries This is the result of and other prevention However, these have to countries where there are no and many injuries are by used for and in the prevention of injury as well as the care of the injured a of all those in their treatment. A The role of in all of injury has been shown to be and it is still to the mortality, and disability of injury from all causes and in all countries where it has been The most complete data on the impact of on injury have been in vehicular injury. from the United that is with a greater of those injuries, and with a much of mortality. some common is with a incidence of death from with vehicular and a greater incidence of This of with injury is a global problem. A review of emergency in several countries levels demonstrates the incidence of in injured patients care compared with patients (Table many countries not for the role of in injury is an even greater problem in countries than in countries. In countries where has been to while a significant in vehicular injury and especially death has been and these worldwide is an an opportunity to injury. We to of the United or even the Established Market Economies as the source of vehicular injury. from the GBDS, shown in Figure as great a number of vehicular deaths in than in the Established Market Economies 1 in the United we have to vehicular deaths related to are now on the for more than of of the incidence of deaths from disease and injury in males between Established Market Economies and Sub-Saharan in 1990 Burden of Disease have reviewed data regarding injury and many problems and but this is of limited are to effectively at some of It is also much to with than to them I will to identify some and some that we be able to use to meet these Some of these are and the of individuals to work in different and on different problems. There are many in the who long this challenge and have made significant not only to the care of the but to that have injury or care the world. Some of these The AAST, by has made many to the care of the injured. Other organizations in the United and in other countries or regions are also significantly to all of death and disability from injury. This joint meeting with the Japanese Association for Acute and with the Trauma Association of identify two other such international organizations to trauma in which I believe and as can are information in care, development of trauma and are all and represent only a few of the of an injury is to the best and more Table 17 shows the of such It demonstrates the of prevention in vehicular of death and be by prevention but the incidence and can be significantly are most when for a specific and will need to be different depending on the and However, excellent prevention are in many countries. The AAST has made some of available on the AAST These are available to all to and use for their and of to injury and and usable information are to the global and regional problems of injury. With such about and commitment can be These may also as a source of data to the of the in to with injury. The on Trauma of the American of and several other organizations to trauma have to such data including the Trauma and will be but of a common data in a will a for to to improve care of the injured. We need to in these an of we will be at than We all to care to the but often on what that We need to the use of clinical to identify the best care for specific treatment is often or We need to use the methods of to for care of the injured. The AAST, the Eastern Association for the Surgery of the Trauma and the on Trauma of the American of have to work to for care of the injured. These will not serve as a for will a review of treatment for specific injuries that will the of individual trauma and help them better Furthermore, these will serve as excellent sources of and a for clinical for trauma I all members of the AAST and to in this It will but I believe it will be a to improve all of care of the injured. The of trauma have been examined in and by several including review to deaths and analysis of population-based injury death A of several such is shown in Table in the United and other countries have a of trauma the study of the at on in the United not that there was a However, the of many I believe that this of of was not of of many the of injury, and of the study from I of the of trauma and of of trauma on AAST has served as a for research at in care of the injured. to this organization have contributed to a better of injury and and led to in clinical Other organizations in the United and in other countries have the We need to regarding clinical problems of and along with problems such as These represent only some of the for the in injury. We need to to for for such which at is limited and on other When the of on research is compared with the impact on Figure as in Years of Life Lost, injury of such as in the AAST is for all of to support these I all of to help in this of research of life lost from three major causes of death in the United to meet these we need to effectively use available Some of these include trauma of and has been of the to global to improve trauma The of and by the AAST, has been of the most for of on injury and as a for the United and other countries to identify individuals with in care of the injured. The of Trauma has the leadership of Drs. John and Basil and now not only the AAST, but from the Eastern Association for the Surgery of the Trauma and the Trauma Association of The of Trauma has also an international it has received from countries in the and published from countries in that However, these international to The of Trauma only represent a small of the work on trauma the world. There are also several other published in the United and in other countries the world with a on injury. The and the have the of and to information on injury available on the helped me this The AAST has and to support a that has been more than in the The of of the AAST is additional of the to prevention about and even a for between trauma about This will be an not only for the I believe it can as a for global to improve care of the injured. There are of in injury in many countries. These have not only as of care of the but as of and where many of in trauma care are and many of in trauma are These need to for in care of the injured to to at these will that there will be a new to care of the injured. Trauma have been shown in different countries and regions to improve outcome from injury. I believe that the data to support development of trauma are study and more may be to trauma for individual countries. will in countries, with their limited and some is of the United not have a trauma a Trauma was in Furthermore, a of AAST past and members has only some and local trauma in the United States. The of and of the AAST that only of the countries trauma whereas more or the trauma a also represent an opportunity for There are a few organizations such as the AAST to care of the injured. These organizations a for communication, review of clinical and and development of new The and of these organizations are not issues that should these organizations with a of individuals with a commitment to a common We on this of care of the injured. we individual or will be less than the The to meet these is the people to in prevention and treatment of injury. problems in each and and these increase when a global perspective. global the of people to the problem of injury. It is and from to death and disability from injury, that represents We can use the available, and work effectively in many common I to with all of in meeting the The the of and in and the of in research and of the