Canadian Medical Association Journal 1996; 155: 1429-1431
[résumé]
Paper reprints may be obtained from: Dr. I. Barry Pless, Montreal Children's Hospital, 4292300 Tupper St., Montreal QC H3H 1P3; fax 514 934-4351
© 1996 Canadian Medical Association (text and abstract/résumé)
I was also asked to comment on the report by Ms. Jackie Petruk and associates on the tragic deaths of two children by strangulation (see pages 1417 to 1419 of this issue [full text / résumé]). Before I do so, however, I would like to broaden the focus somewhat to examine how injury prevention among children and adolescents is addressed in Canada at the federal level. Given that injuries are the leading cause of disability and death in these age groups, it seems fitting, in the context of National Child Day, to consider whether we are putting our money where our collective mouth is. My conviction is that we are not and that little will change until we create a national centre for injury prevention and control and provide it with strong teeth.
As I began to prepare this article, many news stories were being carried by the media containing expressions of concern about the possible nonrenewal of the National AIDS Strategy. My reaction to such stories is mixed. Without wishing to diminish the agony of those who suffer from this horrible disease -- or from any other -- I cannot help but be reminded of some other, equally grim facts. The number of children and adolescents who died in 1994 from various diseases that have become popular "causes" were as follows: 56 from leukemia, 37 from cerebral palsy, 26 from muscular dystrophy, 23 from cystic fibrosis, 20 from HIV infection and 6 from diabetes. In contrast, 1233 children died as a result of injury.[1]
My interest in such comparisons began in 1986, when I became chair of the board of directors of the Canadian Institute of Child Health. At that time the institute needed a clearer sense of direction, and it seemed logical that this direction should be based on current data on major problems in child health. We began by assembling vital statistics; this was not an easy task, because Statistics Canada does not combine age group with province or territory in its presentation of data. Later we added figures on admissions to hospital. The picture that emerged was illuminating. It forcefully brought home the immense importance of injuries and reminded us of the extent to which child health is related to poverty.
The first profile of these statistics, published in 1989,[2] provided impetus for the institute to promote the idea of forming a children's bureau within the Department of National Health and Welfare. Because there was no federal branch that specifically addressed children's issues, problems such as injuries usually fell through the cracks. They were everybody's business and nobody's business. The profile also supported the argument that a national child health policy was needed. Eventually, a children's bureau was formed, and an attempt was made to create a national policy on child health. Unfortunately, both fell short of expectations.
During its first incarnation the Children's Bureau focused on social welfare issues more than on childhood health problems and placed little emphasis on injury prevention. Not much has changed since its rebirth. The policy initiative produced a disappointing document[3] that has raised few banners under which child health advocates can rally.
All was not doom and gloom, however. When the Mulroney government abandoned its national day-care policy, a portion of the money saved was redirected toward a program called the "Brighter Futures Initiatives." Some of this money was applied to injury prevention by the Family and Child Health Unit of the Population Health Directorate and by what is now the Childhood Injury Section at the Laboratory Centre for Disease Control -- the home of our world-famous Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP).[4,5] Beyond this, however, remarkably little attention has been paid at the federal or (until recently) provincial level to injury prevention as an important public health issue.
The mortality figures listed earlier bring to light two paradoxes. First, despite the magnitude of the injury problem (whether measured as deaths, admissions to hospital or visits to emergency departments) there is no lobby or fund-raising group that promotes research or the delivery of needed preventive measures comparable to those that exist for "high-profile" (if comparatively rare) childhood diseases. The second paradox is that there is abundant and convincing evidence that most childhood injuries are preventable;[6] this is not the case with many childhood diseases that receive more attention. The problem lies in the gap between what is known and what is implemented. At least part of the reason for this mind-boggling discrepancy is the paucity of funding for prevention programs, which stems, in turn, largely from a lack of community-based pressure groups. Combined with the sporadic nature of the interest of professional bodies such as the CMA, the Canadian Paediatric Society and the Canadian Public Health Association, the result is a continued failure to create a national focal point remotely equivalent to those that have existed for so long in Sweden[7] and so successfully over a much shorter period in the United States.[8]
And so we come to the tragedy of the two cases reported in this issue. As with many other product-related injuries, there is a fundamental difference between officially acknowledging that a product is hazardous and taking the necessary steps to remove that hazard. As Canadians, our preference is for gentle persuasion rather than more forceful methods. We tend to opt for voluntary cooperation from manufacturers and retailers rather than tough regulations.
Typically, bulletins calling attention to dangers posed by certain products are issued by the Product Safety Branch of Health Canada. As far as I am aware, no one has ever studied the extent to which the vitally important messages in these bulletins reach their intended audience: parents. Nor is it clear to whom these bulletins are sent. My impression is that unless these warnings are picked up by the media it is hit or miss whether parents become aware of the danger in time to take action. Even if they do, relying on this cautionary and usually post-hoc educational strategy places a heavy responsibility on parents' shoulders. In a logical and fair world this responsibility would be shared by manufacturers and retailers.
The steps that Petruk and associates suggest be taken to prevent drawstring-related strangulations are typically Canadian: gentle, full of good intentions, but unrealistic. They state that "government agencies, health care professionals, clothing manufacturers, the media and consumers all have a role to play." But when everyone is nominated as advocate no one is likely to take up the role actively, least of all manufacturers and government agencies -- the customary targets of advocacy, not its sponsors.
The authors also place much more confidence in the ability of health care professionals to provide education and preventive counselling than seems warranted. Although some studies support the view that physician counselling in injury prevention is effective,[9] others sharply disagree.[10] In any event, such an approach can work only if physicians actually invest sufficient time in patient counselling. This does not seem feasible. It would require that physicians assiduously read Product Safety Branch bulletins and then somehow find the means to pass these messages on to all their patients, not just those who happen to visit in the next few weeks or months. Even if physicians were as good at counselling as Petruk and associates imply, how could such counselling be delivered in a practice to all parents whose children are at risk?
In contrast, the authors also note that physicians and professional organizations can influence the marketplace when they choose to do so. Although the examples they give (the elimination of baby walkers and the improvement of clothing flammability standards) were the work of a few family physicians or pediatricians, rather than of a collective, this point is well taken.
Petruk and associates suggest that the tragedy of drawstring-related strangulations involves "multiple factors" and demands a "multifaceted approach." Right on the first count, wrong on the second. Britain chose a "unifaceted" approach and banned such clothing by legislation years ago. No deaths from drawstring-related strangulations have been recorded there since. What is needed in Canada is a similar act of political will. A national centre for injury prevention and control would help to provoke change with the rapidity that is needed.
Finally, I wonder if the importance of active supervision really needs to be stressed to most parents. Despite the best efforts of parents and caregivers, providing constant, full supervision is an impossible mission. Would it not be better to ensure that all clothing, play equipment and playgrounds are truly safe? The authors urge that we "encourage, support and work with the appropriate organizations." What, exactly, does this mean? The Product Safety Bureau already has the authority to do what needs to be done. The Children's Apparel Manufacturers' Association, with all the good will in the world, cannot undo years of indifference. Petruk and associates also encourage the use of "resource publications." Until someone discovers who reads these and to what effect, I shall remain sceptical. This sort of material is, at best, supplementary.
The solution is to learn from others and create a national centre for injury prevention and control, to fund it adequately and to give it the powers needed to safeguard our children's lives. Then we could really celebrate National Child Day.
The deaths of these children and of many more could have been prevented. It is as simple as that. There is no T-cell mystery here. We know what needs to be done. Let's get on with it.