How do we contribute to the basic steps of problem solving? I'll use three steps: defining the problem, selecting the appropriate countermeasure, and evaluation. What's the problem? What are you going to do about it? And, finally, did you do it? We in public health have a great tradition of using data, although we are not the only people who do so. It is one of the things we bring to the party. Another thing we bring is epidemiology. In our program, epidemiology is a fundamental element of injury prevention. We produce a series of data reports called EPIC Proportions. (The name of our branch is EPIC, Emergency Preparedness and Injury Control.)
One of our reports showed the state's regional differences in injury rates. The urban areas have rates that are half those in some of the more rural areas. We don't know why, but injury mortality varies a lot by geography.
That's the way the experts define the problem. There's a whole other way to define the problem. That is to go to a PTA or a community meeting or a church and say, "I'm from the health department. I want to hear you tell me what your problems are." People know what their problems are. They don't need me to tell them what their problems are. I consider one of my greatest obligations is to listen and recognize how a community sees its own problems.
What happens then? With any luck, a planning process evolves in which the community's decisions about its problems and our expert decisions about the problems are brought together so that a plan evolves about what to do and who's going to do it. We engaged in such a planning process with support from the CDC and developed the California Strategic Plan for Injury Prevention Control. The plan elements about traffic safety were developed by a committee that included people from Emergency Medicine at Stanford, the California Office of Traffic Safety, the NHTSA regional office, the American Automobile Association, UC-Irvine, and the California Highway Patrol. Each made a tremendous contribution. Our plan is not owned and operated by the California Department of Health Services, which was the recipient of the CDC grant. It represents the expertise and the contribution of people who were working in this field long before we got here and who knew what needed to be done. People ask why California has a motorcycle helmet law, and a bicycle helmet law, and primary enforcement, and zero tolerance. Those things came about because people made them their highest priorities together through a collaborative effort.
What does public health contribute once the plan is done? One of the things we contribute is an ability to define the at-risk population. As Mark Rosenberg said on the videotape, the easy stuff's been done. You know the 80-20 rule: 20 percent of your effort goes into 80 percent of the solution. To get the last 20 percent of the solution takes 80 percent of the effort. You know that in injury the high-risk group is adolescent males. How do you reach the young high-risk driver? One of the things those folks do is take risks. One of risks they take is having sex. So we see them in STD clinics and we have an opportunity. We see young parents in baby clinics. We see young women in family planning and WIC programs. So we have opportunities with people who also happen to be at high risk for traffic and motor vehicle-related injury problems.
We have been fortunate to have a legislature and an administration that's sensitive to injury prevention and traffic safety. They have reinforced existing laws that punish folks who don't restrain their kids in car seats. Another way we came up with to help do that was to mandate that when someone is fined for not having their child restrained, a large percentage of the fine goes to a local health department to help establish a program to provide restraints to low-income families. We have introduced injury prevention and provided training for the staff of the other state maternal and child health programs so they can introduce injury prevention into their day-to-day activities. I could go on and on. These are some of the ways in which taking the traditional inclusive prevention orientation that we bring in public health can help extend people's horizons.
One of the fundamental principles of collaboration is to be sure you are not the obstacle. If the phone rings, answer it. If the phone doesn't ring, ask yourself who is it that's not calling, and call them. That is the way you demonstrate that you are open to collaboration. Don't sit in your office and wait for the phone to ring. Decide who is not calling you, and call them.
Another difference between public health and traffic safety concerns the time frame. There are some very sweeping visions in public health. In the 1790s, smallpox vaccine was invented; 250 years later, smallpox was eliminated. That is a tremendous public health accomplishment. We don't find traffic safety people thinking much about 200 years from now. In fact, with the constant need to defend the 402 program and carry out evaluations that measure the impact of short-term projects, we usually take a short-term focus. Public health takes a long-term focus. Public health talks about changing society: if we just reach people in kindergarten, when they grow up they'll really be impressive. We can't do that in traffic safety.
Many of the ways in which public health approaches injury prevention have roots in maternal and child health. That created a tremendous public health focus on children and youth. It seems that injury prevention often leaves out those most likely to be killed and injured in motor vehicle crashes--young adults and older teenagers. Motor vehicle injury is certainly a major killer of children. But if you look at the numbers and the rates, you realize that we need to focus more on youth. I think that the solution is to talk about the idea of delegating responsibility. Maybe we shouldn't cooperate closely on every single area.
Another difference is breadth of focus. Public health often has a very broad focus, while traffic safety often uses a very narrow focus. The best way to think about this is using the example of alcohol abuse. Public health people talk a lot about domestic violence, about intentional injury, about drunkenness leading to other health problems. In traffic safety we don't care about whether or not people drink as long as they don't drive while they're impaired. Some say that designated driver programs may encourage people to drink more. That's something that public health people want to think about and should think about. Another area is alcohol taxes. The Surgeon General's Workshop on Drunk Driving said one of the most effective things you can do to reduce DWI death and injury is to raise taxes on alcohol. Traffic safety has been slow to embrace this. Public health hasn't been quite so slow.
There are also differences in scales of vision. Public health often has a very sweeping vision while traffic safety has a very focused one. I've teased one of my colleagues in public health about a project in which she was involved. There is a little town in northern New Mexico where the teenagers have nothing to do. So, the state health department gave a tiny little grant to this organization to provide ice skating at a lake that freezes over all the time up there. Perhaps it made a difference. But I'd have a hard time putting this project into a highway safety plan.
Public health and traffic safety also focus on different types of interventions. It seems to me that most everything that's ever worked in motor vehicle injury prevention has been environmental. Remember when driver's education was pushed in the 1950s and 1960s? Again, this was based on the idea that people are vessels and if you pour in knowledge, they go out and act on that knowledge. The focus now seems to be that people know what they should do, they're just not doing it. And it's the job of environmental conditions to reshape those bad decisions, so we ought to refocus our emphasis on environmental change: raise alcohol taxes, increase perception of enforcement.
Another difference is that of approaches to community organizing. I've been learning a great deal about community organizing from the public health folks in New Mexico. We've got community DWI prevention programs in 30 of our 33 counties. And this was done with microscopic funding. The reason we got involved was that we had something that we wanted communities to do. I met with some folks in the health department that had a very different focus. They almost don't care what communities do as long as the communities feel powerful enough to do it. Give them the authority and they will use it wisely. Well, I'm a control freak. I have very definite ideas about what I think communities ought to do and I have designed a planning process that will try to push them in the direction I think will make a difference for motor vehicle injury prevention.
Other differences between traffic safety and public health include funding sources, data sources, the basis on which priorities are determined, and evaluation designs. But I'm not going to talk about them here. Ultimately, what matters is bringing these diverse resources together and focusing on common ground. The opportunities are there. It's up to you to put them to work.
What can EMS bring to the table in a collaboration? Most state EMS agencies are regulatory. They license all the service providers. In North Carolina alone, we've got 615 providers who utilize 22,000 technicians. You add fire services to that, that kicks it up to about 60,000 people. That does not include organizations such as paramedic associations, emergency nursing care, and others. The EMS state agency brings contacts with a multitude of local EMS-related organizations. The state agency can call the local EMS provider and say, "They're doing something down here about training local people in the proper way to use a child seat. You really should get involved with that." It's amazing how many of them agree. The fact that we issue their permits may or may not be part of the equation, but they get involved. That's something the state agency can bring to the table. What can the local agencies bring to the table? Local agencies understand what's going on. They know all the local resources. In the rural parts of North Carolina the local EMS and fire departments are cornerstones of the community. If you get those people involved, you bring about change. And they're willing to get involved. But they need resources and somebody to educate them and point them in the right direction.
Some of the other collaborative activities taking place in North Carolina include the Click It or Ticket program, the Booze It and Lose It program, as well as children's safety seat projects. In the last two or three years, we have been working with the Federal Highway Administration. Before then, I didn't know what the Federal Highway Administration was. I'm on the Safety Management System team. I didn't know what that was two years ago. This helps. For example, DOT engineers say, "We need to put up this barrier" on a highway. But they forgot to ask EMS. And now EMS can't get to patients because of the barriers. They have to go four miles down the road before they can turn around and come back.
Are we collaborating? Much more than we used to. Is there still a lot of room for improvement? Yes. Where's the rub? Personalities. Turf. Does it happen overnight? No. When you sit down across the same table and start talking, you find out that there are areas in which agencies really don't overlap. But there are a lot of areas in which we do. And those are the areas that we need to work on. Thank you very much.
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