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Worldwide, some 300 000 children die each year in road traffic crashes, a further 300 000 children drown, and some 100 000 die in fires.1 Many millions of children are seriously injured and hundreds of thousands sustain permanent disabilities. The public health response to this human tragedy is pitiable and raises important questions for child health professionals. Why, for example, is the death of a child following abuse taken as clear evidence of the failure of our collective efforts to protect children, whereas a child pedestrian death represents only the failure of an individual child to stop, look, and listen when crossing the road? And why did medical research “declare war” on cancer and ignore injury, when as many children die from injury as from all forms of cancer combined?
Most of the road deaths, particularly those in the developing world, involve children as pedestrians.2 In Britain, the pedestrian injury epidemic peaked in the 1930s with an average of nine deaths each day.3 Since then death rates have fallen, but not necessarily because our roads have become safer. On the contrary, the two most likely explanations for the decline in child pedestrian deaths are the massive reduction in walking that has accompanied increasing traffic volume,4 and the increased survival chances of seriously injured children from improvements in hospital care.5 There can be little doubt that in the struggle for the streets, the pedestrian lost, with tens of thousands of children killed in the process. But for most of the world the battles are just beginning. Like so many Western epidemics, the pedestrian injury epidemic is now being exported to the developing world. European and North American car markets are reaching saturation point and motor manufacturers are looking east. The road death epidemic in China is only just beginning, but already an estimated 29 000 children are killed on the roads each year,1 and the epidemic will generate a mountain of disability. It is estimated that by 2020 road traffic accidents will be the third leading cause of disability adjusted life years (DALY) worldwide, and the second leading cause of DALYs in the demographically developing countries.6
An epidemic of this scale demands an appropriate and timely public health response. It is a matter of urgency that effective strategies are identified for the prevention of road traffic accidents, drowning, fire deaths, and other leading causes of injury, and for the treatment and rehabilitation of injured victims, particularly in low income countries. A logical first step would be to find out what we already know about the effectiveness of injury prevention and injury management by conducting systematic reviews of controlled intervention studies, and of case–control and cohort studies where no intervention studies are available. The Cochrane Injuries Group, an international network that prepares, maintains, and promotes the accessibility of systematic reviews of the effectiveness of interventions in the prevention, treatment, and rehabilitation of injury has been established to facilitate this process.7 To date, findings from systematic reviews include the demonstration that random breath testing reduces road deaths,8 that pool fencing reduces the risk of drowning,9 and that albumin infusion for hypovolaemia following trauma is of no proved benefit and may even increase the risk of death.10
The effectiveness of some prevention strategies is not in doubt, but for many mechanisms of injury the value of preventive measures remain uncertain, and large scale randomised controlled trials are required to determine their effectiveness. For a problem as common as injury, even moderate intervention effects would be important. However, to detect reliably moderate effects, both moderate biases and moderate random errors must be avoided.11 Injury prevention trials must therefore be large enough to avoid moderate random errors and should be designed in such a way that moderate biases are avoided. Some injury prevention interventions cannot be implemented separately for each individual and individual level randomised controlled trials will not be possible. Evaluation of these strategies requires community intervention trials, and recent developments in the methodology of cluster randomised controlled trials will facilitate these.12 Probably the main obstacles to the conduct of such studies are political rather than methodological: first the importance of random allocation in the unbiased assessment of effectiveness is not widely appreciated in areas such as transport, housing, and education; second, injury research is grossly underfunded compared with other health problems.13
The identification of effective injury prevention interventions is necessary but not sufficient to prevent childhood injuries. Many injury prevention strategies require structural change and will encounter strong opposition from vested interests. The strategy for overcoming structural barriers to child health is advocacy. Advocacy is structural therapeutics, which, to date British paediatricians have shown a notable reluctance to prescribe.14 But there are encouraging signs that things are now changing, as evidenced by the support by the Royal College of Paediatrics and Child Health for the Road Traffic Reduction (UK Targets) Bill.15 Striving to make a better world for children does not require a choice between science and activism. It requires both.
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