July 22nd, 2021
“Throughout history, the two major causes of early death have been infectious disease and injury. For most of the world, they continue to be the major determinants of longevity. In the developed countries, inroads have been made in the battle against infectious disease, but injury continues to take its toll — relentless, unexpected by those involved, and yet often avoidable and unnecessary.” – from “Injury in America: A Continuing Public Health Problem” (1985)
Less than one year after the COVID-19 pandemic began, researchers created the first vaccine that could be used to treat it. Now, not only are there multiple vaccine options, but improved testing, treatments, and protocols for managing the unpredictable disease known as COVID-19. We achieved all this in just 18 months, and while we still have a long way to go, the sunlight is starting to peak above the horizon.
The same cannot be said for all public health problems. For years, researchers and practitioners have worked to address injury and violence in the home, at the workplace, and on the road. While more than 38,000 people are killed in crashes on U.S. roadways each year, nearly twice as many die from drug-related overdose. One in four women (and one in nine men) experience intimate partner violence and more than 4 million child abuse reports are filed annually.
No matter who you are or where you’re from, it is likely you have personally experienced one of these traumas or know someone who has.
“Trauma is common — and many of us have been touched by it one way or another,” says Steve Marshall. “If not directly, then through friends and family members. So this is a gift to be able to do this work. Because this is the real work of people’s lives.”
Marshall began studying trauma and violence in the early 1990s, just a few years before he enrolled in the epidemiology PhD program at UNC. At the time, he worked for the Injury Prevention Research Unit at the University of Otago in New Zealand on a project assessing the injuries of rugby players — the first of its kind in the country.
“They were great partners, and we are still working with New Zealand Rugby,” he shares.
Marshall loved this type of community-based research so much he decided to pursue his PhD to continue studying injury. At the time, UNC was home to one of just five Centers for Disease Control-funded injury research centers in America that opened their doors in 1987.
Today, the UNC Injury Prevention Research Center, now overseen by Marshall and his colleague Beth Moracco, specializes in research on gender-based violence, child abuse and neglect, traumatic brain injury, opioid use and overdose, and road traffic injury. In the last three decades, center researchers have overseen hundreds of injury and violence research projects, elevating and addressing some of the most important public health problems of our time.
Danger on the road
The injury prevention movement birthed from the desire to make cars and roadways safer as large transportation projects like New York City’s Lincoln Tunnel, the Florida Keys’ Overseas Highway, San Francisco’s Golden Gate Bridge, and the Los Angeles freeway — the first of its kind — completed construction in the 1930s. Roads continued to expand after World War II with the creation of the Interstate Highway System, arguably the largest engineering project in U.S. history.
By the middle of the century, tens of thousands of Americans were dying in car crashes each year. And that was just one of many problems created by modernization. We were also dealing with poisonous preservatives and dyes in foods, refrigerators with auto-latching doors that could trap small children inside, and a pharmaceutical industry that wasn’t held accountable for the long-term effects of its products.
In the 1950s, the Kellogg Foundation gave funding to five states to set up accident prevention programs as public health services. North Carolina was one of them. The goal was to hire public health practitioners — like nurses, health educators, and sanitarians — to encourage behavioral changes that would reduce injury among risk-prone populations.
By the 1960s, automobile production was at an all-time high. So were car crashes. Airbags and seatbelts were not yet available to consumers or required in vehicles. In 1966, the same year the U.S. Department of Transportation was founded, UNC created the Highway Safety Research Center (HSRC) to address such problems. Its research led to safer roadway design and traffic operations — including the “Click It or Ticket” program — better vehicle inspections, and advances in pedestrian and bicyclist safety. HSRC is also credited with developing Graduated Drivers Licensing (GDL), a three-stage approach for granting young drivers full license privilege.
Women lead the way
Patricia Waller was instrumental in leading Graduated Drivers Licensing research at HSRC, which she joined just one year after its founding in 1967. She spent two decades with the center, serving as the associate director for driver studies and working to incorporate injury control into the national transportation agenda.
In the early 1980s, Waller began working with Carol Runyan, a PhD student at the Gillings School of Global Public Health. During her graduate work in health education, Runyan had a fascination with injury prevention and researched a variety of topics including childhood injuries, abuse among adolescents, and traffic safety policies. The last became the subject of her dissertation, and she asked Waller to be a member of her committee.
After graduating, Runyan was hired by Dale Williams, a UNC biostatistician and director of the newly formed UNC Center for Health Promotion and Disease Prevention (HPDP). When Williams asked Runyan to create a task force on injury prevention, she knew Waller should be involved.
“A psychologist by training, Pat was one of the first women working in this field and brought tremendous energy to her work,” Runyan shares.
Together, Runyan and Waller received a grant to develop a case study focused on raising the drinking age and the potential implications for teen drivers. It was one of the first grants awarded for injury work from the CDC — and the first grant awarded to HPDP. A second project focused on working with local leaders to pass city or country policies to increase safety, such as requiring smoke alarms in households.
One year after the National Research Council issued a report calling for more injury research, the CDC released a request for proposals to form injury centers. Waller and Runyan were awarded one of the grants, and the UNC Injury Prevention Research Center was born in 1987.
“It was a little awkward,” Runyan admits. “At the time we were actually working on the proposal, I was doing a postdoc at Johns Hopkins, and so Pat and I were communicating back and forth about putting the center grant together while, literally in the next room, my colleagues at Johns Hopkins were writing a competing application. But we both — Johns Hopkins and Carolina — got funded.”
Waller and Runyan led the new center until 1989, when Waller was became director at the University of Michigan Transportation Research Institute. Less than five years out of her PhD program, Runyan was pleased to take over IPRC, but recognized she needed support from senior leaders. She credits Williams for helping her navigate the process of building the center.
One of his biggest pieces of advice, according to Runyan, was to avoid telling faculty what to study. Instead, he said, bring them in based on their interests.
And that’s what she did.
“We went about finding people who were doing interesting and important work that already related to injury or could relate to injury,” she says. “But we also wanted to be really careful that we weren’t just a collection of projects. The whole needed to be greater than the sum of the parts.”
Injury and violence: a public health problem
In 1982, the U.S. Department of Health and Human Services (HHS) received nearly 1 million reports of child maltreatment and news reports featuring allegations of child sexual abuse in day-care centers began circulating throughout the nation.
“The prevention — not correction, but prevention — of child abuse has become critical. Our society is suffering and will continue to suffer if we do nothing to stop this plague,” wrote then HHS Secretary Margaret Heckler.
Today, we know that abuse and neglect is an underlying cause of various individual and societal problems, including delayed development, poor performance in school, delinquency, depression, alcohol and substance abuse, and domestic and criminal violence. We know this, in large part, thanks to one of the Injury Prevention Research Center’s first projects: the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN).
The project began in 1990 and was led by UNC pediatrician Desmond Runyan, who conducted assessments with families in five different locations across the U.S. He followed up with them every two years for two decades and worked with state medical examiners, child protective services, and local police departments to develop policies that protect children from harm. LONGSCAN led to studies on harsh discipline and shaken baby syndrome and gave UNC recognition as a leader in child abuse research, with more publications on the topic than almost any other university in the world.
While child abuse and neglect continues to be a major research focus of the center today, a slew of events in the 1990s also shaped IPRC’s trajectory. At the time, homicides were the second leading cause of workplace injury deaths (motor vehicle crashes were the first) — a statistic that led to a series of studies organized by Runyan and epidemiologist Dana Loomis. They also researched occupational suicides, child labor, and safety measures to improve these environments.
For Beth Moracco, one of the most startling events of the ’90s was the murder of Nicole Simpson, the ex-wife of NFL player O.J. Simpson, and her partner Ron Goldman. What followed was one of the most widely publicized events in American history: an 11-month trial in which O.J. was the prime suspect but was ultimately acquitted of all charges.
“I think the O.J. Simpson case opened people’s eyes to the fact that, contrary to stereotypes, domestic violence occurs among wealthy, successful people,” Moracco says. “It was one of those events that pulled back the curtain.”
The early 1990s, overall, was a time when violence underwent a paradigm shift, becoming recognized as a public health problem.
Back then, Moracco was a PhD student in the Gillings School of Global Public Health and a research assistant at IPRC who was actively engaged in the North Carolina Partner Homicide Study, which examined homicide-suicide case files from the state medical examiner to identify event characteristics and precursors. In 86 percent of cases, the perpetrator was the current or former partner of the victim, and 41 percent of victims had left their partner prior to their death.
As the current associate director of IPRC, Moracco is still engaged in this work and is currently researching domestic violence protective orders (DVPOs). A type of restraining order, DVPOs can effectively protect survivors from continued abuse and prevent intimate partner homicide, particularly when orders include provisions that restrict access to guns for those who have orders against them. Moracco is researching how this mechanism is implemented and enforced in North Carolina and whether electronic filing of DVPOs can increase access to this vital resource for survivors of intimate partner violence and their families.
While America awaited the verdict of the O.J. Simpson trial, The New York Times was writing about another NFL-related topic: concussions. Earlier that year, in the NFC championship game, Dallas Cowboys quarterback Troy Aikman was hospitalized after taking a knee to the head, causing such a severe concussion he couldn’t remember the game at all — a moment in sports history that “focused attention on a dangerous and recurring injury in the National Football League,” reported the Times.
UNC already had a strong presence in sports-related injury thanks to the work of exercise and sport scientist Fred Mueller, founder of the National Center for Catastrophic Sports Injury Research, and it only made sense that such work became an arm of IPRC’s research agenda. In fact, the center’s first NIH-funded project was on sports-related concussion and led by Mueller. Research team members included sociologist Mike Bowling and then graduate student Steve Marshall, now center director.
Sports-related injury drew future university leaders to IPRC, as Mueller hired young scholars like Darin Padua, now chair of the Department of Exercise and Sport Science, and Kevin Guskiewicz, a renowned concussion researcher and current chancellor of the university.
“When I started working with Kevin in the late 1990s, I was in the Gillings School of Global Public Health and he was in the Department of Exercise and Sport Science in the College of Arts & Sciences — and there weren’t a lot of people between those two realms talking together and collaborating,” Marshall explains. “IPRC was a place where we could step outside of our disciplinary perspective and work together in an interdisciplinary way on the problems that Kevin saw clinically in concussion.”
As an epidemiologist, Marshall was interested in uncovering the risk factors that lead to concussion to prevent their occurrence. He has also studied ACL injuries, osteo-arthritis, and heat injury during play and evaluated the effectiveness of face guards, shoulder pads, helmets, and other types of safety equipment used in contact sports.
A new epidemic
As the center grew its projects in the fields of sports-related injury, gender-based violence, workplace injury and violence, and child maltreatment, doctors across the nation began prescribing more and more opioids for pain relief in response to pharmaceutical companies’ claims that patients would not become addicted to them — “and the mistaken belief that patient pain could be eradicated by drugs,” according to Marshall. By 2003, nearly 3 million people were using OxyContin for non-medical purposes and, by 2009, 1.2 million emergency department visits were related to the misuse or abuse of such drugs.
What’s more, deaths from opioid overuse were beginning to equal, and even surpass, those from vehicle crashes in some states — a particularly startling statistic for those who experienced the field’s beginnings, when crashes and violence killed more people under the age of 55 than any other public health problem.
It was during this time, in the mid-2000s, that UNC epidemiology PhD student Nabarun Dasgupta began working with local leaders in Western North Carolina to promote the distribution of naloxone — more commonly known as NARCAN — a medicine that, if administered immediately, can reverse opioid overdose. That program, called Project Lazarus, became the first in the world to use naloxone to save pain patients and drug-users who overdose.
Now a senior scientist at the Injury Prevention Research Center, Dasgupta works within the Opioid Data Lab, helping to create tools that promote drug safety. His most recent project focuses on creating new methods to test street drugs for dangerous fillers that cause injection-related health harm.
While Dasgupta was co-founding Project Lazarus, long-time UNC public health researcher Christopher Ringwalt was working with staff at the N.C. Department of Health and Human Services to develop strategies for identifying the over-prescription of opioids. More specifically, he collaborated with the Injury and Violence Prevention Branch to use data from the NC Controlled Substances Reporting System, which monitors the prescription of controlled substances to improve patient care and safety.
Ringwalt has also overseen several evaluations of the Drug Abuse Resistance Education (DARE) Program and studies on alcohol, tobacco, and other drug use.
“We’ve been fortunate in North Carolina and at UNC to have some people recognize what was happening with opioids and start to develop interventions very early on,” Marshall says. “It’s such a fast-moving problem. We knew what was happening on the ground through our collaboration with the state health department, and they could bring us their research needs.”
In the last two decades, IPRC researchers have developed new tools to evaluate drug abuse; assessed existing services, treatments, and prescribing guidelines; studied overdose in people who have been incarcerated; and examined trans- and poly-substance deaths, when someone overdoses on multiple classes of drugs at once.
Most recently, IPRC and the Injury and Violence Prevention Branch have partnered to develop the SHARP Network, establishing peer support networks to share best practices for harm reduction strategies — an evidence-based approach to prevent opioid and poly-substance overdose, secondary illness, and death.
The power of partnership
Collaboration with the N.C. Department of Health and Human Services has continued to expand under the leadership of Marshall and Moracco, building on a 30-year partnership that began when Runyan joined the Governor’s Task Force on Injury Prevention in the late 1980s.
In the following decade, the center birthed the first online training program for injury and violence professionals, which eventually evolved into Preventing Violence and Injury through Education, Networking, and Training (PREVENT). Together, these programs reached more than 2,000 practitioners nationwide. With continued support from the state partners, PREVENT has transformed into Injury-Free NC, an ongoing program that focuses on a different topic from the field each year.
Work with the state has also led to the creation of a comprehensive suicide prevention program, improvements in child maltreatment statistics, and initiatives to prevent overdose in people recently released from prison.
“IPRC is an invaluable source of expertise for us, and a group that has committed to working with us in a long-term relationship,” says Alan Dellapenna, head of the Injury and Violence Prevention Branch within the N.C. Department of Health and Human Services.
While IPRC has succeeded locally through partnerships with practitioners and conducting research that directly benefits the people of North Carolina, its leaders are continuously working to expand its reach nationally. They do this by responding to new problems as they emerge, growing their training programs, and engaging often with policymakers.
“These are really hard problems to interact with,” Marshall says. “People who struggle with drug use. People who have been mistreated as children. People who have been sexually assaulted. People who have been badly hurt, badly burned, injured in car crashes. And we want to use our research and other data-informed tools to heal our society and make better systems going forward, so that we prevent the carnage before it happens.”