Childhood injury prevention
CMAJ 1997;156(4):479
In response to: R.S. Tonkin
Re: Childhood injury prevention: time for tougher measures, by I.
Barry Pless, CMAJ 1996;155:1429-31 [full text / résumé]
Although Dr. Tonkin and I agree on many points -- perhaps many more than he realizes -- his fundamental criticism is that government action is needed at the local (presumably, provincial) level, not at the national one. To buttress this argument he cites the landmark BC Child Health Profile that showed the importance of injuries, especially among adolescents in British Columbia, and the provincial government action that followed. He also notes that the injury statistics subsequently improved. Although I do not want to rain on his parade, so did the injury statistics for almost every other province, with or without provincial action. Having said this, I hasten to add that I firmly believe that what British Columbia has done in this field is exemplary and that all provinces should quickly follow its example.
The central issue, however, is not regional or provincial versus national, as Tonkin suggests. I am sure he would agree that it is both. Where we disagree, I suspect, is over which should come first. Perhaps Tonkin thinks that the provinces really can do it alone. If so, let us examine some of the examples he gives. The first is CHIRPP, which he believes is not "effectively used or adequately plugged in" locally. The system was not designed primarily with local needs in mind. However, many researchers have made excellent use of local CHIRPP data for several important projects. Nevertheless, I agree that this system, or any other like it, should be made more locally relevant, but not necessarily before a national centre is advocated. What Tonkin must acknowledge is that there is immense symbolic significance in having a national focus, especially when the issue is universal. If all provincial health ministries took on this issue with the same commitment as some have shown, it would be reasonable to argue that a federal role was less important. But most provincial governments do not view injuries as a health problem, and many of the most important powers to control and prevent injuries lie with national bodies such as the federal departments of transport and justice.
Concerning the drawstring-related strangulations highlighted in the article by Petruk and associates, it is true that the findings emerged from a commendably strong provincial program; regrettably, neither this program nor the provincial government has the power to regulate the industry responsible for the problem. That power remains in Ottawa with the Product Safety Bureau of Health Canada. Unless and until there is a national centre breathing down the neck of this branch, or similar pressure from many of the provinces, it will continue to pussy-foot around this problem and others like it.
Although Tonkin is correct in bringing me to task for not emphasizing the need for tougher measures at the provincial level, he is wrong in implying that I failed to do so because I think the federal government holds all the answers. The reality is that the power to take the tougher measures needed resides for the most part in Ottawa, not Victoria. If, and when, the provincial governments take this problem seriously and place it within the public health area, where it belongs, then there may be less need for a national centre of the kind I propose. However, in light of the US experience, there will always be a critical role, if only that of a standard-bearer, for the federal government.
I. Barry Pless, CM, MD
National Health Scientist
Professor of Pediatrics and of Epidemiology and Biostatistics
McGill University
Montreal, Que.
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