Injuries and Public Health


Because of my focus on enabling individuals and families to maximize their health and get the best possible value from health care and health spending, I have often focused on those factors driving the use of the healthcare system that are not given sufficient focus by others. One such factor is the intensity of healthcare usage caused by injuries.

As a result, I was gratified to read a major story in The New York Times Magazine October 28, 2012, issue entitled “The Dead Don’t Lie” by Robert W. Stock. The story is a profile of an epidemiologist at Johns Hopkins named Susan Baker. The main message of the story is that Ms. Baker has spent most of her professional life focusing on healthcare encounters caused by injuries of various kinds. The good news is that she has made great progress in many areas in which she sought to make a difference. The bad news is that our society is seeing a significant increase in new sources of injury.

The Good News

Ms. Baker and many other people have been engaged in multi-decade campaigns to reduce the number of automobile and workplace injuries. In both cases, we are far better off today than we were 40 years ago. I am proud to be a member of the Board of Eaton Corporation, which, like a handful of great multinational companies like DuPont, Chevron, Alcoa (under the leadership of Paul O’Neill, who later became the Secretary of the Treasury) and Dow Chemical, has put into place a huge program to drive what is called a “zero incident culture” in the workplace.

We have improved significantly as a society in reducing fatal automobile accidents from 50,000 per year in the 1960’s to 35,000 per year in recent year. Three factors have contributed most to this success:

  • The requirement that every car be equipped with seat belts in all seats and that those sitting in the front and back seats fasten their belts at all times while in a moving vehicle;
  • The significant focus on cracking down on driving while intoxicated or while fatigued. Today, the combination of heavily enforced laws against driving while under the influence of alcohol, daily driving limits for truckers, and designated driver practices have reduced the incidence of fatalities caused by alcohol; and
  • The implementation of stricter standards for obtaining initial drivers’ licenses for teenagers, including staged license processes and the requirement that new drivers get a minimum amount of classroom and drivers’ school instruction before obtaining a license.

More remains to be done, and the best solution to reducing fatal auto accidents in the long run is the elimination of drivers. When most or all vehicles are automatically moved without the intervention of human error, we will see a significant drop in motor vehicle fatalities. We are at least 15-20 years away from this being a reality, but we must move in this direction, if for no other reason that we need to create mobility for our aging population, as people lose the reflexes that enable them to drive safely.

Aviation safety is another good news story. The frequency of fatalities through airline crashes has diminished significantly from even 10-20 years ago.

The Bad News

The source of injuries that simply was not as important 40 years ago as it is today is the extent of sports-related injuries. Football gets the most publicity because professional, college, and even high school players are bigger, stronger, and faster than ever, which makes football a more violent sport. The hard plastic equipment has actually made football even more violent when players collide. Tackle football is played more months of the year than ever, and players focus on football at a younger age. The day of the three-sport athlete who only plays football in the Fall is long gone.

Moreover, the seasons for all professional and college players are longer than ever. When I was growing up, professional football had a 12-game season, with a single championship game, and college football teams played 10 games, with a few teams getting selected for a single bowl game. Today, professional football has a 16-game regular season, and a three-game playoff process for the Super Bowl finalists. Moreover, there are playoff opportunities for 12 teams, instead of two. College football routinely has a 12-game season for Division I teams, and we are now entering a new phase in college sports in which the top four teams might play up to two bowl games. There are also 10 times as many bowl games as there were 40 years ago.

Not surprisingly, there are more sports-related injuries than ever, and a frightening number of head injuries, particularly concussions. Recently, I read the book Head Games and saw the documentary, also called Head Games by Chris Nowinski, a former Harvard football player and WWF wrestler, who retired from wrestling because of concussions. His portrait of professional, college, and scholastic sports was frightening in many respects:

  • Football is not the only sport giving rise to head injuries. We are seeing the same kinds of injuries in ice hockey, soccer (because of athletes using their heads to direct the flight of the ball), lacrosse, and, obviously, boxing. Any contact sport is producing head injuries.
  • The number of women experiencing head injuries has grown explosively because of the impact of Title IX. We are now seeing women with serious head injuries in growing numbers.
  • The incidence of head injuries among children under 12 is growing because more children, particularly in wealthier communities, are starting competitive sports younger and playing more months of the year.

Beyond head injuries, we are seeing more shoulder, arm, knee, hip and back injuries among adults who exercise without proper preparation, stretching and supervision, and children, who overexert themselves at a younger age. My son James refrained from throwing curve balls in Little League baseball because my nephew, an orthopedic surgeon, told me that it would risk long-term damage to his arm and shoulder. As a result, he did not get the opportunity to pitch, since many other boys were quite willing to risk their health to satisfy the coaches. Today, the Little League World Series is broadcast on ESPN and the sportscasters profile these 11 and 12-year-old boys who throw curve balls and put great strain on their arms.

If we are to bend the cost curve in healthcare, we must focus on reducing the incidence and the cost of injuries of various kinds, particularly sports injuries. We should have better supervised exercise for both young people and adults. With respect to adults, I am shocked when I walk into any major hospital today, particularly in wealthier communities like the one in which I live, to see the booming business hospitals do in joint replacement surgeries.

I have no worry that I will need a joint replacement in the foreseeable future because I walk, rather than jog, and train under the close supervision of an experienced, highly credentialed fitness trainer. When I am the gym, I watch many adults do foolish training, either in the form of excessive weight lifting, jogging, or cardio-vascular exercises, without knowing how to do the exercises right.

We should give more focus to exercise injury prevention, because it is relatively easy to do. The sports injury problem is more challenging, because so much money is made by various organizations from competitive sports programs, but we need to begin the same kind of effort that was begun a generation ago by people like Susan Baker to attack these societal problems.