Every day I'm in the emergency room, I see patients and problems vying for critical resources, from acute asthma patients to traumatic injuries. Injury is the leading cause of death for those under the age of 45. And it is the fourth leading cause of death overall in the United States. About 150,000 deaths every year.
According to 1990 statistics from the Centers for Disease Control and Prevention, traumatic injury was responsible for approximately 3.7 million years of potential life lost. In contrast, cancer was responsible for 1.8 million years of potential life lost. Heart disease was responsible for 1.3 million years of potential life lost.
How is this relevant to the debate over the ozone and particulate matter standards? It can be simply put in three words, "public health priorities." The fact is that society has limited resources that it can spend on public health. The International Trauma Anesthesiology and Critical Care Society is not convinced, and neither should the public be, that the proposed ozone and partic ulate matter standards are a smart way to spend our limited resources, The proposed standards are merely the latest example in what we see as a disturbing trend of the past two decades in which scarce public health resources are diverted from more clearly demonstrated beneficial uses.
First, the proposed rules do not provide a ranking or comparison between the estimated health effects attributed to ozone and particulate matter and those of other public health needs. One of the health endpoints associated with the proposed rules is asthma. No doubt asthma is a serious issue and public health resources should be directed at asthma. But a recent study published in the February 1997 American Journal of Respiratory and Critical Care Medicine helps place air pollution-induced asthma in perspective.
In a type of study that has been characterized as the most reliable study of the potential health effects of ambient ozone —. i.e.., a study of children attending asthma camp — air pollution was associated with a 40 percent increase in asthma exacerbation in children. It sounds bad, but what does this really mean? According to the study's authors, this increase in asthma exacerbation equates to one extra use of an inhaler among one in seven severe asthmatics on the worst pollution day.
Second the proposed rules do not provide an accurate estimate of what their associated opportunity costs are. For example, if a community is forced to spend its resources ozone and particulate air quality standards, what other public health needs will the community sacrifice? A new trauma center? Training for its paramedics? A new ambulance? Filling these other public health needs can produce results that cut across many public health problems. For example, ambulances and trauma centers benefit everyone from asthmatics to heart attack and trauma victims.
Third, the true uncertainties associated the proposed ozone and particulate matter air quality standards have not been fully presented. For example, it has been estimated that chronic exposure to particulate matter causes 20,000 deaths per year. In fact this estimate is based on very uncertain epidemiology. It was acknowledged recently by EPA and reported in major newspapers such as The Washington Post that the error of using an arithmetic "mean" instead of an arithmetic "median" reduced the estimated mortality from fine particulate matter by 5,000 deaths. It could very well be that chronic exposure to fine particulate matter, in fact, causes no deaths.
On this point, it is greatly troubling that the data underlying this estimate has yet to be made publicly available. Given that major confounding factors for mortality appear to be omitted from the analyses factors like lack of exercise, poor diet, and prior health history — weak epidemiologic associations could easily vanish with more thorough analysis.
In stark contrast to what has been hypothesized about particulate matter and mortality, we know that about 150,000 people die every year from injury. These are real deaths, not those calculated through debatable assumptions and statistics.
One year ago the television show "Dateline NBC" featured the story of Robert Meier. In April: 1995, Mr. Meier was driving through rural, Oklahoma heading home for Easter. Just before 4 p.m. that Saturday Mr. Meier's van careened off the highway, slamming through a guardrail. His van rolled over five times before plummeting into a ravine.
Within a few minutes rescue personnel were at the scene. The ambulance took Mr. Meier to Shawnee Regional Hospital. But the doctor on duty determined that Mr. Meier had serious internal injuries and needed to be transferred to another hospital better equipped to treat them. As Mr. Meier bled profusely from a ruptured aorta, no hospital in the area would accept him because critical resources were not available.
It was not until half past midnight, eight hours after his accident, that a surgeon was found to operate on Mr. Meier. But this delay cost Mr. Meier his life. Mr. Meier was fully covered by health insurance. He had done his part, but because of a lack of crucial resources, the system failed.
Stories like this one are common. But they should not be, nor do they have to be. Proven solutions are possible now, but must compete for attention and funding. More than 25 studies indicate that between 20,000 Americans who die each year could be saved if regional trauma systems were in place across the nation ensuring prompt access to a qualified trauma center.
In 1973, Congress enacted the Emergency Medical Services System Act to help improve their trauma systems. But federal support made this an unfunded mandate that states could not afford to implement on their own. And as a result, significant deficiencies exist in trauma systems across the country like the one that resulted in Mr. Meier's death.
Those who wish to commit the public's limited resources should be required to justify such proposed commitments against other competing needs. And, as a major allocator of public health resources, Congress must ensure that the public health is not short-changed by unproductive expenditures.
Christopher Grande, M.D., a Baltimore physician, is executive director of the International Trauma Anesthesiology and Critical Care Society, an association of trauma specialists, nurses and related professionals. This column is an edited version of congressional testimony he gave last month. A related editorial appears today.
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