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December 28, 2016

The Toll of Death and Disability From Traumatic Injury in the United States—The “Neglected Disease” of Modern Society, Still Neglected After 50 Years

Author Affiliations
  • 1Department of Surgery, Yale School of Medicine, New Haven, Connecticut
  • 2Department of Surgery, University of Tennessee, Memphis, Memphis
  • 3Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
JAMA Surg. Published online December 28, 2016. doi:10.1001/jamasurg.2016.4625

In a seminal 1966 report, the National Research Council (NRC) declared1(p5) that unintentional injury is the “neglected epidemic of modern society [and] the nation’s most important environmental health problem.” The report noted that traumatic injuries were the leading cause of death for Americans younger than 40 years. At that time, 52 million unintentional injuries (excluding suicides) killed 107 000 people, temporarily disabled more than 10 million, and permanently impaired 400 000 American citizens at a cost of approximately $18 billion each year.1,2

Several but not all of the authors’ suggestions were acted upon over the ensuing half century. Improved training in basic life support, the use of aeromedical transport in rural areas, improvements in Emergency Medical Services, and the development of trauma centers and trauma registries have all occurred. Additionally, US emergency medicine and trauma systems have also vastly improved, thanks to advances gleaned from military experience and implementation of many of the recommendations initially made in 1966.

Yet the public health problem of traumatic injury has continued to worsen, reaching epidemic proportions. According to the Centers for Disease Control and Prevention,3 12.6% of the population will have traumatic injury (126.3 episodes per 1000 population), resulting in 43 million emergency department visits, and 80 million ambulatory care visits. Mortality related to traumatic injury is increasing, reaching 144 409 in 2013 (456.2/100 000 persons) and 147 790 deaths in 2014 (463.2/100 000 persons, an increase of 1.5% over 2013); since 1966 the mortality rate has increased 0.66% per year, which is half the population growth rate of 1.11% per year over the same time frame.4 Trauma remains the third most common cause of death overall, and the leading cause of death in persons younger than 46 years.3,4 The costs of fatal traumatic injury reached $214 billion in 2015.

The costs of nonfatal injury are even more overwhelming. Because trauma affects a younger population than most other public health epidemics, there is an additive cost burden of life-years lost, including work productivity. In fact, only one-third of the costs associated with nonfatal injury are related to medical care; the remainder reflect work loss (productivity) costs. The costs associated with nonfatal injuries accounted for a total of $457 billion ($1.44 billion/100 000 persons). Eighteen percent of new and existing disability claims in 2013 were related to injury, representing a population of 6.7 million Americans. More than 50% of disabled Americans are in their working years (ages 18-64 years).5

How is this possible? Why is traumatic injury an unrelenting and growing burden on the American health care system? It may well be that research funding is key. Without a centralized, national home and stable funding for trauma research, injury research has steadily lost ground even as other public health problems like AIDS, Ebola, Zika viruses, and cancer have seen research investments keep pace with or exceed their toll (Figure). The health and economics tolls of many diseases have been reduced through research funding, as evidenced by the decreased age-adjusted death rates per 100 000 persons for both heart disease (56% reduction) and stroke (73% reduction) since 1950.8

Estimates of Funding for Various Research, Condition, and Disease Categories
Estimates of Funding for Various Research, Condition, and Disease Categories

A graphic demonstrating that trauma research is significantly underfunded relative to other disease processes. Reprinted with permission from Catherine A. Richards, PhD, MPH6; data are from Moses et al.7

Despite the fact that a lack of long-term funding to support trauma research was identified in 1966 as “the most significant obstacle at present,”1(p33) the most fundamental recommendation of the NRC, to create a National Institute of Trauma (NIT), was never implemented. The NRC recommended that “appropriated funds should be earmarked in support of the program of research in the therapy of trauma recently announced by the National Institute of General Medical Sciences. This would include processing of grant requests for research related to shock and trauma which are now considered by numerous Institutes. A NIT should be established under the US Public Health Service.”1(p7)

In 1965, only $5 million in National Institutes of Health (NIH) grants went to support research related to trauma—out of a total expenditure of $1.68 billion (0.03% of dollars allocated). Today, 50 years after the initial NRC report, the percentage of NIH funding dedicated to injury remains paltry: trauma ranks last in a comparison of its funding to the disease burden (Figure), receiving $399 million of the total NIH budget of $156 billion (0.02%) in 2015.9 Imagine the advances that might have been possible had traumatic injury received research resources commensurate with its toll on society and the number of lives that might have been saved.

Fifty years is a long time to delay dealing with a deadly serious public health problem. Consider that in the United States, 1 person died of Ebola and the administration sought $6.2 billion to prevent, detect, and respond to the public health crisis—including $238 million to fund advanced clinical trials at the NIH. A Zika virus exposure in the Dominican Republic has caused 1 birth defect in the United States, and the President asked Congress for $1.9 billion to help state and local officials prepare for a summer outbreak (Congress countered with a $1.1 billion proposal). These public health problems are serious ones, and deserve both funding and attention, but so does traumatic injury. It is shocking that nearly 150 000 deaths every year do not warrant a similar response.

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Article Information

Corresponding Author: Kimberly A. Davis, MD, MBA, Department of Surgery, Yale School of Medicine, 330 Cedar St, Boardman Building, Ste 310, New Haven, CT 06520 (kimberly.davis@yale.edu).

Published Online: December 28, 2016. doi:10.1001/jamasurg.2016.4625

Conflict of Interest Disclosures: None reported.

Additional Contributions: We acknowledge the contributions of the Executive Committee of the Coalition for National Trauma Research: Thomas Scalea, MD (American Association for the Surgery of Trauma [AAST]), Grace Rozycki, MD (AAST), Donald Jenkins, MD (National Trauma Institute [NTI]), Gregory J. Jurkovich, MD (NTI), Ronald Stewart, MD (American College of Surgeons Committee on Trauma), Nicole Stassen, MD (Eastern Association for the Surgery of Trauma), Christine Cocanour, MD (Western Trauma Association).

National Academy of Sciences and National Research Council Committee on Trauma and Committee on Shock. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academies Press; 1966. https://www.ncbi.nlm.nih.gov/books/NBK222962/. Accessed November 29, 2016.
US Department of Health, Education, and Welfare. Vital Statistics of the United States1960: Volume II—Mortality (Part A). http://www.cdc.gov/nchs/data/vsus/VSUS_1960_2A.pdf. Accessed May 16, 2016.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) http://www.cdc.gov/injury/wisqars. Accessed May 17, 2016.
US Population Growth Rate. http://www.multpl.com/us-population-growth-rate. Accessed May 11, 2016.
Rhee  P, Joseph  B, Pandit  V,  et al.  Increasing trauma deaths in the United States. Ann Surg. 2014;260(1):13-21.
Richards  C. Is the amount of disease-specific NIH funding related to burden of disease? http://dotdata.cc/is-the-amount-of-disease-specific-nih-funding-related-to-burden-of-disease/. January 13, 2015. Accessed February 11, 2016.
Moses  H  III, Matheson  DH, Cairns-Smith  S, George  BP, Palisch  C, Dorsey  ER.  The anatomy of medical research: US and international comparisons. JAMA. 2015;313(2):174-189.
Centers for Disease Control and Prevention (CDC).  Decline in deaths from heart disease and stroke--United States, 1900-1999. MMWR Morb Mortal Wkly Rep. 1999;48(30):649-656. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm. Accessed September 22, 2016.
US Census Bureau. American Community Survey, 2015. http://www.census.gov/programs-surveys/acs/. Accessed April 21, 2016.