Mark L. Rosenberg

Operational criteria for the determination of suicide

Suicide is an important public health problem for which we have an inadequate public health database. In the United States, decisions about whether deaths are listed as suicides on death certificates are usually made by a coroner or medical examiner. These certification decisions are frequently marked by a lack of consistency and clarity, and laws and procedures for guiding these decisions vary from state to state and even from county to county. Without explicit criteria to aid in this decision making, coroners or medical examiners may be more susceptible to pressures from families or communities not to certify specific deaths as suicide. In addition, coroners or medical examiners may certify similar deaths differently at different times. The degree to which suicides may be underreported or misclassified is unknown. This makes it impossible to estimate accurately the number of deaths by suicide, to identify risk factors, or to plan and evaluate preventive interventions. To remedy these problems, a working group representing coroners, medical examiners, statisticians, and public health agencies developed operational criteria to assist in the determination of suicide. These criteria are based on a definition of suicide as death arising from an act inflicted upon oneself with the intent to kill oneself. The purpose of these criteria is to improve the validity and reliability of suicide statistics by: (1) promoting consistent and uniform classifications; (2) making the criteria for decision making in death certification explicit; (3) increasing the amount of information used in decision making; (4) aiding certifiers in exercising their professional judgment; and (5) establishing common standards of practice for the determination of suicide.

Alcohol use and interpersonal violence: Alcohol detected in homicide victims

To characterize the relationship between alcohol use and homicide victimization, we used data from the Los Angeles City Police Department and the Los Angeles Medical Examiners Office to study 4,950 victims of criminal homicides in Los Angeles in the period 1970-79. Alcohol was detected in the blood of 1,883 (46 per cent) of the 4,092 victims who were tested. In 30 per cent of those tested, the blood alcohol level was greater than or equal to 100 mg/100 ml, the level of legal intoxication in most states. Blood alcohol was present most commonly in victims who were male, young, and Latino, categories where rates have been increasing at an alarming pace. Alcohol was also detected most commonly in victims killed during weekends, when homicides occurred in bars or restaurants, when homicides resulted from physical fights or verbal arguments, when victims were friends or acquaintances of offenders, and when homicides resulted from stabbings. The evidence for alcohol use by homicide victims focuses attention on the need for controlled epidemiologic studies of the role played by alcohol as a risk factor in homicide and on the importance of considering situational variables in developing approaches to homicide prevention.

Shelters for battered women and their children: an under-recognized source of communicable disease transmission.

A survey of 73 full-time government-funded shelters for battered women and their children from five geographic regions in 15 states provided information on communicable disease problems and control measures (focusing on diarrheal illness). Outbreaks of diarrheal illness involving more than 10 persons were reported by 12 per cent (9/73) of shelter directors. Less than half reported screening potential residents for communicable diseases before admitting them, and the majority reported that most of their staff are trained in basics of first aid, principles of hygiene, and experienced in day care work. More than half of the staff in the majority of shelters are counselors, but only 5 per cent (4/73) of shelters have health care workers. Less than one-fourth of the shelters have areas designated for diapering infants and less than half of the shelter directors knew of specified health regulations applying to their shelter. For most shelters, limitations on staff size, training, and funding may restrict the types of disease control measures they can apply. However, basic hygienic practices, such as strict handwashing and identification and cohorting of sick clients, may be effective in disease prevention.

The federal role in injury control

Early federal injury control programs in the 1960s and 1970s were centered first in the Division of Accident Prevention (Public Health Service) and subsequently in the National Highway Traffic Safety Administration (Department of Transportation) and the Consumer Product Safety Commission. The Centers for Disease Control (CDC) in the early 1970s also began to investigate injuries, particularly in the home and recreational environment. The field expanded in the 1970s and 1980s to include injuries that occur in many settings and both intentional injuries (violence) and unintentional injuries. After a 1985 report, Injury in America, CDC was chosen to be the national coordinating agency because of its mission of prevention. The current program also includes acute care, rehabilitation, and biomechanics.

Building a foundation for suicide prevention: the contributions of Jack C. Smith

Among his many other accomplishments, Jack C. Smith nurtured the early development of efforts by the Centers for Disease Control and Prevention (CDC) to address suicide as a public health problem. Smiths vision was to achieve suicide prevention through epidemiology, and his vision shaped the emergence of suicide as a public health issue. With his typical enthusiasm and inherent ability to insinuate himself into critical social networks, Smith spearheaded CDCs initial suicide surveillance activities and established strong partnerships between CDC and the National Institute of Mental Health (NIMH) and the American Association of Suicidology (AAS). These surveillance activities and relationships were the foundation on which subsequent research and programmatic activities addressing suicide as a public health problem were built at CDC. In this paper we document Smiths role in the development of the public health approach to suicide prevention. We also articulate the conceptual basis for a public health approach to suicide and discuss future directions for public health in the prevention of suicide and suicidal behavior. While Smith also made important contributions to development of CDC efforts to address homicide, his special interest was suicide; therefore, this article will emphasize his contributions to this area.

There's Safety in Numbers

The articles in this series and the unique report, Injuries in the Military: A Hidden Epidemic1 that generated them, not only make the problem of injuries visible but give it dimension for an entire population, the U.S. military. Part I of this series of articles illustrates the value of data in determining the existence of a public health problem and defining its magnitude, the first step of the public health approach to prevention.2,3 Part II shows how research can further identify populations at risk and modifiable causes and risk factors for the problem, which are necessary for prevention, the second step of the approach. The articles demonstrate some of the great successes of the military services in preventing injuries, the third and fourth steps of the public health approach. The series also provides clear direction for improving surveillance, research, and prevention activities that should be of interest not just to military commanders, policymakers, and service members, but to all of us who are interested in preventing injuries. Various articles in this series highlight not only some of the differences between military and civilian populations but also commonalities. Off-duty military personnel do the same things that lead to injuries as other young Americans. They drive cars, ride motorcycles, play football and basketball, and do household chores and maintenance. On duty, many have jobs similar to civilian workers—jobs such as truck drivers, clerks, physicians, nurses, and wheeled-vehicle mechanics. The underlying causes and risk factors for most injuries must be the same for military personnel and civilians; so as this series of articles illustrates, much can be learned from the rich data sources and research of the military services. What the first sequence of articles does that is unusual is to provide a context for seeing how truly large the problem of injuries is for the military services measured against other causes of morbidity and mortality. It has been recognized for some time that injuries occur frequently among military personnel, but most commonly past reports have looked at a single data source to define the problem (e.g., fatalities, hospitalizations, or outpatient visits). Frequently, such reports examine only injuries, and therefore do not convey an appreciation of the relative size of the injury problem compared to diseases or health conditions. Part I of the series systematically examines the importance of injuries across the spectrum of health starting with the most serious injuries, those resulting in deaths.4 Then it successively looks at the less serious but more common injuries resulting in disabilities,5 hospitalization,6 and outpatient treatment.7 Each sequential piece of the puzzle shows that for this young military population, injuries are the most important health problem relative to others.3 What emerges when all the pieces are fit together at the end of the first sequence of articles is a picture of an injury problem that is much bigger than previously realized from examination of single data sources, such as deaths. In addition to revealing the true size of the problem of injuries for the military, Part I of this series also shows that, as with other young populations, much of the injury problem for the military stems from motor vehicle crashes, falls, and sports. Interestingly, these were the leading causes of morbidity and mortality for the Army in the Persian Gulf War (Operation Desert Shield/Desert Storm) and other deployments in the 1990s.3,8 The civilian experts who made up the work group that produced the first series of articles evaluated each database not only to determine the important causes of injuries in the military, but more importantly, to determine how the available information sources could best be utilized for injury prevention in the future. The major recommendations from the panel of experts were (1) that a comprehensive military medical surveillance system be established, and (2) that the data from that system be used to prioritize prevention and research activities.1 The research articles in Part II of this series should be of equal interest to those concerned with preventing injuries in military and civilian populations. Papers in the second series investigate causes, risk factors, and populations at risk with general relevance to public health and safety. Some of the topics explored include: ● The association of seat belt use, alcohol use, and age on the likelihood of hospitalization.9 ● The association of smoking cigarettes with higher risks of training-related injuries in Army trainees.10 ● The risks of disabling occupational knee injuries among different demographic groups11 and the early impact of prior knee injuries on disability and discharge from the military.12 From the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia Address correspondence to: Mark L. Rosenberg, MD, MPP, Director, Collaborative Center for Child Well-Being, Task Force for Child Survival and Development, Suite 400, 750 Commerce Drive, Decatur, GA 30030. E-mail: mrosenberg@taskforce.org. Dr. Rosenberg is currently affiliated with The Task Force for Child Survival and Development, Decatur, Georgia.