AMERICAN JOURNAL OF
PUBLIC HEALTH
EDITOR’S CHOICE
Swimming Upstream
Injuries are not accidents, so in public health we search
for their causes to improve prevention. The best of
these efforts seek to identify root causes, avoiding the
more limited approach that stops at the level of “the
human” responsible for “the error.” Attention is directed
to the variety of systems-related determinants that
permit or promote human error—a root cause analysis
resulting in a robust understanding of injury causality.
As these root cause analyses move further upstream
past a focus on individuals into systems, cultures, and
societies, we have learned that the prevention of the
majority of injuries depends much more on under-
standing organizational rather than individual factors.
The importance of the interaction between the
environment and the individual at risk in injury pre-
vention is clear, particularly in the work environment.
Advances in understanding and prevention of occu-
pational injuries have resulted in a reduction in re-
ported workplace injuries over the last 20 years in the
United States. This suggests that intervention efforts
have made a difference, although uncertainties in
injury counting, underreporting, transformation
to a service-based economy, and increased forms of
poorly monitored contract and contingent work
affect confidence in true progress.
Although much has been gained by classifying and
studying injuries according to the proximate location or
event associated with the injury (motor vehicle, home,
leisure time, workplace), this focus may limit inquiries
too narrowly. Rigid classification forces a possibly mis-
guided effort to identify only driver or road causes for
motor vehicle accidents, or only home environment or
family stressor causes for home-based injuries. This
narrow view may inappropriately focus attention on
work injury causes exclusively to workplace factors.
Workers, healthy or injured, live and function in
a broader environment than the workplace. Exposures
and conditions at work can have a profound effect on
out-of-work injury; similarly, home and community
factors may increase or reduce the risk of injury at work.
One example is provided by attention to prevention
of road traffic injuries (RTIs). Hyder et al. (p. 1061) report
that “RTIs will be 1 of the 3 leading contributors to the
global burden of disease . . . over the next 2 decades.”
Efforts to address this problem are commendable.
However, in the United States, RTIs are rarely consid-
ered occupational in origin, yet commuting time should
be tied to work, and RTIs associated with commuting
should be seen in light of increasing commuting time.
Patterns of affordable housing distant from employment
opportunities in many urban areas directly influence
commute time (Lipman BJ. A Heavy Load: The Com-
bined Housing and Transportation Burdens of Working
Families. Washington, DC: Center for Housing Policy;
2006), increasing exposure to RTI risk. In addition, long
June 2012, Vol 102, No. 6 | American Journal of Public Health
EDITOR-IN-CHIEF Mary E. Northridge, PhD, MPH
DEPUTY EDITOR Farzana Kapadia, PhD
FEATURE EDITOR Gabriel N. Stover, MPA
IMAGE EDITOR Aleisha Kropf
ASSOCIATE EDITORS Mary T. Bassett, MD, MPH
Felipe González Castro, PhD, MSW
Michael R. Greenberg, PhD
Sofia Gruskin, JD, MIA
Said Ibrahim, MD, MPH
Robert J. Kim-Farley, MD, MPH
Stewart J. Landers, JD, MCP
work hours, double-shifts and two jobs are associated
Stella M. Yu, ScD, MPH
with a higher level of fatigue that results in less attentive
ASSOCIATE EDITOR FOR STATISTICS AND EVALUATION
driving under any circumstances (Akerstedt T, Philip P,
Capelli A, Kecklund G. Sleep loss and accidents: work Roger Vaughan, DrPH, MS
hours, life style, and sleep pathology. Prog Brain Res. INTERNATIONAL ASSOCIATE EDITORS
2011;190:169-188). Furthermore, some work-related Kenneth Rochel de Camargo Jr, MD, PhD
stress could be leading to increased alcohol consump- (Rio de Janeiro, Brazil)
tion (Frone MR. Work stress and alcohol use. Alcohol Daniel Tarantola, MD (Sydney, Australia)
Res Health. 1999;23[4]:284-291; Dawson DA, Grant DEPARTMENT EDITORS Leslie Beitsch, MD, JD
BF, Ruan J. The association between stress and drink- Government, Politics, and Law
ing: modifying effects of gender and vulnerability. Elizabeth Fee, PhD, and Theodore M. Brown, PhD
Alcohol Alcohol. 2005;40[5]:453-460) to “relieve” Images of Health
stress that, in turn, is associated with RTI risk. Elements Public Health Then and Now
of work-related fatigue, stress-relieving alcohol con- Voices From the Past
sumption, and poor public transportation alternatives all Mark A. Rothstein, JD
need to be incorporated in any systems view of RTI Health Policy and Ethics Forum
prevention. But if we don’t begin by considering Kenneth R. McLeroy, PhD, and
commuting a part of “work” then attention to work- Deborah Holtzman, PhD, MSW
associated mutable elements of the risk equation will Framing Health Matters
continue to be ignored. EDITORIAL BOARD Jeffrey R. Wilson, PhD, MS (2012), Chair
Beyond RTIs we should consider what, if anything, Jermane Bond, PhD (2013)
is gained by drawing a line between work and nonwork Linda Chan, PhD (2013)
injuries. Is an injury associated with an accident at Roy Grant, MA (2013)
home a home injury or a work injury, if analysis of the Thomas Greenfield, PhD (2012)
injury circumstances identifies work stress or work- Jeffrey Hallam, PhD (2014)
related fatigue as the cause? Is an injury at work a work Alice M. Horowitz, PhD, MA (2012)
injury or a home injury if analysis of the injury cir- Cassandra L. Joubert, ScD (2012)
cumstances identifies distraction due to a sick child as Dio Kavalieratos, BPhil (2012), Student
a contributing cause of the injury? Although in the Louise-Anne McNutt, PhD (2013)
United States workers’ compensation systems force Joan Reede, MD, MPH (2014)
a determination as to whether an injury is occupational, Brian Saylor, PhD, MPH (2013)
this artificial creation of a bright line between work
Helena Temkin-Greener, PhD, MPH (2014)
and out-of-work should not be allowed to interfere
David H. Wegman, MD, MSc (2014)
with good research and effective preventive interven-
Lynne S. Wilcox, MD, MPH (2012)
tions. Ultimately, a comprehensive, integrated approach
STAFF Georges C. Benjamin, MD
to investigation of injury causation will result in more
Executive Director/Publisher
complete knowledge, the identification of promising
Nina Tristani, Publications Director
areas for intervention, and more effective prevention. j
Brian Selzer, Publications Editor
David H. Wegman, MD, MSc Ashell Alston, Director of Advertising
Department of Work Environment Frances Steinlage, Journal Production Coordinator
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University of Massachusetts Lowell
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National Institute for Occupational Safety FREELANCE STAFF Greg Edmondson,
and Health Atlanta, GA Michelle Quirk, Gretchen Becker,
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doi:10.2105/AJPH.2012.300826
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Editor's Choice | 1053