Fatal injuries are the leading cause of death in the United States up to age 44 and “kill more Americans aged 1-34 than all diseases combined.” Injuries also constitute the nation's second most costly health problem—after heart disease—and because they disproportionately involve young people, they are the leading cause of productive years of life lost.

Until quite recently, most injuries were viewed as random, uncontrollable events. But this view is changing in the face of mounting evidence that many of the 140,000 injury-related deaths, as well as a large percentage of the estimated 70 million non-fatal injuries annually, were not inevitable.

As in the case of disease, prevention is becoming a major tool in reducing the injury toll. In the development of effective prevention strategies, the law can play a pivotal part. But to make proper use of this preventive approach, there must be considerably more planning, coordination and determination in its application.

Those who study, teach, and practice in the field of injury epidemiology and prevention often compare injuries to diseases; to do so enhances the understanding that injuries, like diseases, have etiologic agents that act within particular environments to affect predictable hosts. It is important to stress the scientific underpinnings of injury control, so that injuries will not continue to be seen as randomly occurring events that strike the unlucky, who have little or no preventive opportunity available to them. Those within the field argue that injury prevention, like disease prevention, when approached with the proper scientific method, holds the prospect of saving thousands of lives per year in the United States.

The comparison of injuries to diseases, however, can distract attention from some crucial aspects of injury prevention. Infectious disease control is the story of man's battle with living organisms that often do their damage to hosts at the cellular or sub-cellular level. The pathways of those diseases can be difficult to discern, and some mysteries are yet to be solved. Injuries, on the other hand, do their initial damage on a more visible level. Their etiologic events are often apparent, and do not require epidemiologic or biochemical detective work for an understanding of the causes of injury.

In 1970, when Congress was debating the Occupational Safety and Health Act, it was argued that:

Congress cited some grim statistics necessitating vigorous action:

The human tragedy associated with the loss of lives, adverse health impacts, and serious injuries were the focus of legislative hearings, but Congess also addressed the economic impact of industrial deaths and disability.

Injury control has gained gradual acceptance as both a public policy concern and the focus of scholarly research during the last decade. Observers have noted the costs to American society of both intentional and unintentional injuries and have sought to identify preventive intervention strategies that can reduce their incidence and impact. Although many of these intervention efforts have just begun, researchers have been far more successful at identifying potential strategies for the prevention of unintentional than for intentional injury. Indeed, many observers have asked whether the majority of intentional injuries can be prevented at all. In this paper I examine the various problems associated with the prevention of intentional injuries such as homicide, assaultive violence, and suicide. Homicide among blacks is used to illustrate the variety of theoretical, ideological and practical concerns that must be confronted in efforts to successfully prevent intentionally induced injury.

Proponents of efforts to designate injury, both intentional and unintentional, as a health concern have suggested that one result of such a designation will be the development of more effective strategies for the prevention of injuries.

Injury and its prevention, like other areas of public health regulation, pose a number of interesting challenges to the theory of democratic self government. To understand these challenges, a good starting point is the Great Society era, when in a brief ten year period, major new agencies were created to promote safety in the workplace, the marketplace, and on our nation's highways—agencies like the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), the Consumer Product Safety Commission (CPSC), and the National Highway Traffic Safety Administration (NHTSA).

The theory of injury that lay behind the new agencies was in sharp contrast to injury policy as pursued up to that time. The new public health and safety agencies were based on the idea that injury must be approached as an environment, not an individual, problem. The most articulate advocate of this view was William Haddon, Jr., the physician and injury researcher who became President Johnson's first head of NHTSA. Haddon argued for well over a decade for abandoning the view of injury as “accidents,” unpredictable and inevitable “acts of God.”

In December 1986 the New York State Commissioner of Health, David Axelrod, MD, designated an Injury Control Program within the Division of Epidemiology. This action was in recognition of the importance of injuries as a major public health problem in New York State. The public health importance of injuries is highlighted by the fact that injury particularly affects young and productive members of society as well as the poor and needy who make up the traditional clientele of public health departments. Injury is the leading cause of death in persons under age 35 in New York State and accounts for more years of potential life lost before age 65 than cancer, heart disease or AIDS (Figure 1). Injury is the fourth leading cause of death for all ages and a major cause of hospitalization and disability.

The New York State Health Department's authority to engage in injury control activities derives from four sources: the general powers and duties of the Health Commissioner as described in the New York Public Health Law; specific provisions of the law which direct the Department to engage in discrete injury-related activities, such as burn treatment and poison control; executive orders of the Governor, such as Executive Order #35 establishing the Governor’s Advisory Council on Highway Safety; and the authority of the Public Health Council to promulgate a State Sanitary Code which includes requirements for operation of swimming pools and bathing beaches, temporary residences (including children’s camps), regulations for emergency medical services, and so forth. The Injury Control Program’s major functions are based on the Department’s general authority.

Despite considerable declines in the early 1980’s, drunk driving remains a major public health problem in the US. In 1986, 46,050 people were killed on the nation's highways. Traffic crashes are the leading cause of death in the age group 1-34 years. Alcohol is unquestionably a major contributor to these crashes. In 1986, 23,987 traffic deaths, 52 percent of the total, involved a driver or pedestrian who had been drinking, and 16,728, 36 percent of the total, involved someone with a blood alcohol level above 10 percent. Many of the victims of drunk driving crashes were not drinking at the time of the event; more than one third of alcohol related vehicular deaths were persons other than drinking drivers: passengers, other drivers or pedestrians.

Legislation may influence drinking and driving behavior, and the consequences thereof, in a variety of ways: limiting access to alcohol; restricting access to vehicles; making vehicles and roadways safer; separating drinking and driving. Taxation, dram shop laws, minimum drinking ages, server liability, land use laws pertaining to the location of alcohol outlets, and prohibitions on advertising alcoholic beverages affect the driver's access to alcohol.

Motor vehicle injury in the United States constitutes the leading cause of death during more than half of the normal lifespan: from a few months after birth until 40 years of age. The number of deaths from motor vehicles in the U.S. annually during the 1980s has ranged from 5 1,000 to 43,000, approximately equal to the total deaths of U.S. combatants in the entire Vietnam War. In addition, millions of people each year are the victims of nonfatal motor vehicle injury and thousands become permanently disabled and dependent for the remainder of their lives as a result of brain, spinal cord and other damage incurred in motor vehicle crashes.

During the first half of this century, the manufacturers of motor vehicles successfully evaded responsibility for the damage done by their products. Although the increased risk of motor vehicle travel compared to horse-drawn vehicle and train travel was recognized by 1905, vehicle manufacturers and “safety experts” (often allied in symbiotic associations) managed to define the problem as mainly one of errant drivers.

America is burning at a faster rate than any other industrialized nation. Approximately 2.3 million fires costing $40 billion were reported in 1984. Over 5,400 American citizens are killed as a result of these fires and an estimated 130,000 are seriously injured. The leading cause of fire death and injury is cigarette initiated fires with the 1984 toll being 1,570 deaths and 7,000 serious injuries.’ Property damage alone totals over $390 million.

These numbers do not portray the human devastation caused by fires. No other injury causes more pain and suffering. Movies, television and radio have rarely documented the emotional and physical sequelae of a severe burn injury. One day's headline proclaims the devastation of a house fire, and then the story disappears at the point when the survivors begin the agonizing process of healing. The daily routine of burn treatment in America's burn centers is hidden from public view.

The chain saw emerged in the marketplace as a powerful and useful new consumer product in the 1960s. Once a massive and awkward professional logging tool, the device has been transformed into a hand held tool that a casual user can easily use to cut trees and branches. By 1970, 2.3 million saws had been sold; by 1979, 3.5 million. From 1973 to 1977 sales of gasoline chain saws grew at an average rate of 1 2 percent per year, and electric saws at 37 percent per year. The largest increase in sales occurred in the lower priced saws. By 1986 22 million chain saws could be found in American households, the result of an expansion in the market due to both the energy crisis of 1970 and aggressive marketing and price cutting by manufacturers. During the calendar year 1987 an estimated 1,350,ooo chain saws were shipped to dealers, the same level as 1986, and manufacturers anticipate that 1988 shipments may increase 2 percent. The market has softened considerably, but is still expanding.

In 1967 Osamu Takeuchi of Honda Research and Development Co., Ltd. took some spare motorcycle parts to an outdoor area in Japan. American Honda Motor Corporation, the United States distributor for Honda Motor Company, Limited of Japan had requested the development of a vehicle to compete with snowmobiles. The result of Mr. Takeuchi's work was the All Terrain Vehicle (ATV), first distributed in the United States in 1970.

By the end of 1987, an estimated 2.5 million ATVs had been sold by the major Japanese manufacturers and distributors: Honda, Yamaha, Kawasaki and Suzuki, and by Polaris, the sole American-owned manufacturer and distributor. According to U.S. Consumer Product Safety Commission (CPSC) estimates, over 340,000 hospital-emergency-room treated injuries have been associated with the use of ATVs. Almost 1000 deaths have been recorded by CPSC through their system for tracking state medical examiner's and coroner's offices. Almost half the deaths were children under 16 years of age and approximately 20 percent were children 12 and under. CPSC estimates that approximately 5 percent, or one of every 20 three-wheeled ATVs, is involved in a hospital emergency room treated injury each year.