ROUND TABLE
Which pill should we take?
Shanthi Ameratunga
School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand (e-mail: s.ameratunga@auckland.ac.nz)
When Dr Pless presents his qualifications "to pontificate" on preventing child injuries, he forgets to mention that he has nurtured, cajoled, nagged and inspired a generation of researchers and practitioners in the field to strive for a better deal for children. I am among those so privileged. Perhaps for this reason more than any other, I find myself contemplating his convictions along with the likelihood that these might result in the goals to which we aspire.
Drawing on her study of Lewis Carroll's book Alice in wonderland, Alison Gopnik notes, "our unique ability to understand our world by creating theories is the same ability that lets us imagine possible worlds: science and fiction have a shared foundation".1 But do we have the courage to effect the changes required?
Injuries are a health problem but, even in settings where health departments are aware of their responsibilities, injuries could be viewed in an unhelpful light. For example, an algorithm designed to identify populations at increased risk of hospital admissions in England excluded injury admissions from the analysis.2 The reason provided was that "most major trauma is generally not preventable or avoidable". It could be argued that relative to chronic conditions (e.g. diabetes, coronary heart disease), more effort is required to evaluate injury prevention strategies in community settings. However, this disadvantage is magnified when injuries are considered discrete episodes that the health sector can do little to prevent. Perhaps we could gain some ground by reclassifying injuries as "long-term conditions". Thus the true potential for preventing many injuries may be recognized and acted upon. As noted by Pless, effective responses benefit from the engagement of many sectors outside health. We could invest considerably more effort influencing and working directly with these sectors, including transport, housing and urban planning.
I wholeheartedly agree with the second conviction noted: research alone is futile. Similarly, action without sound evidence is at best wasteful and potentially harmful. Respondents to a survey of trauma centres in the United States of America noted that most injury prevention activities undertaken were not evaluated.3 Distressingly, an issue that receives scant attention is the likelihood that some strategies may increase socioeconomic and ethnic disparities in injury outcomes, as suggested by a study from New Zealand.4 It is clear that the "inverse care law" is pertinent both in and outside the health sector.5
Finally, getting the attention of governments distracted by the "credit crunch" will require more than ordinary zeal. Impoverished communities are disproportionately affected by the adverse impact of the recession. The children in communities caught up in this financial vortex are inevitably at greater risk of injury. Blaming the victims may never be easier. It requires the courage of our convictions and much more to address the unjust inequalities in child injuries at global and local levels. Our capacity to act collaboratively, in and outside the health sector, has never been more important. 
Funding: This work was funded in part by an International Collaborative Grant awarded by The Wellcome Trust (UK) and the Health Research Council of New Zealand.
Competing interests: None declared.
References
1. Gopnik A. Life changing books: Alice in wonderland. New Scientist 2008. Available from: http://www.newscientist.com/article/dn13704-lifechanging-books-alice-in-wonderland.html [accessed on 20 March 2009] .
2. Billings J, Dixon J, Mijanovich T, Wennberg D. Case finding for patients at risk of readmission to hospital: development of algorithm to identify high risk patients. BMJ 2006;333:327. PMID:16815882 doi:10.1136/bmj.38870.657917.AE
3. McDonald EM, MacKenzie EJ, Teitelbaum SD, Carlini AR, Teter H Jr, Valenziano CP. Injury prevention activities in US trauma centres: are we doing enough? Injury 2007;38:538-47. PMID:17313948 doi:10.1016/j.injury.2006.11.020
4. Collins DC, Kearns RA. Geographies of inequality: child pedestrian injury and walking school buses in Auckland, New Zealand. Soc Sci Med 2005;60:61-9. PMID:15482867 doi:10.1016/j.socscimed.2004.04.015
5. Hart JT. The inverse care law. Lancet 1971;1:405-12. PMID:4100731