Harborview-based center wants to stop injuries before they happen


prevention revisited

Last September, one of the five victims of the Cascade Mall shooting in Burlington lived long enough to be rushed to Harborview Medical Center, where trauma surgeons struggled in vain to save his life.

Earlier last summer, three young people were killed by a gunman at a house party in Mukilteo and a fourth, a UW student, arrived at Harborview with a bullet in his chest.

And last December, a Mount Vernon policeman was wheeled through the ER doors after being shot in the head during a standoff.

High-profile gun violence cases here in Washington—and there are many—make up just part of the story. State counts show that still hundreds more people are injured or killed by firearms each year. Yet we know so little about the causes of gun violence or how to prevent it. Hardly anyone is studying the phenomenon from a public health perspective because there’s next to no public funding to do so.

But Harborview’s Injury Prevention & Research Center (HIPRC) is doing it anyway. The center works with Seattle Children’s Hospital and a number of UW schools and departments to explore everything from infant vaccination to the role alcohol plays in traumatic injuries. And when it comes to firearms, the center has a long history of exploring such subjects as the likelihood of gun injury for gun owners and if the use of trigger locks could reduce firearm deaths. Now, with support from the state and funding from the City of Seattle, the center is expanding that work.

“There’s no doubt that gun violence is a public health concern,” says Fred Rivara, ’80 a professor of pediatrics and founding director of the HIPRC. More than 30,000 Americans die from firearms each year and in Washington, firearm deaths (suicide, homicide and accidental) outnumber motor vehicle deaths.

But researching firearms is not a priority for federal policy makers. In the 1990s, Congress reduced funding for gun violence research, cutting $2.6 million from the Centers for Disease Control and Prevention’s budget. It also passed a measure banning funding for research that would “advocate or promote gun control.” This move came in response to Rivara’s work, a landmark 1993 study that explored whether the risks of keeping a firearm in the home outweigh the potential benefit of personal safety. The study, which focused on homes where homicides had occurred, found that having a gun in the home is associated with a threefold increase in the risk of homicide. Victims were more likely to die “at the hands of a family member or intimate acquaintance” than a total stranger.

The study caught the attention of the NRA, which complained to Congress that the research was tantamount to advocating for gun control. With no federal funding for further research around gun violence, politicians and policy makers have had to debate the issues of gun ownership and control with very few facts.

As a legitimate topic for public health research, says Rivara, gun violence falls right in the wheelhouse of the HIPRC where epidemiologists, pathologists, social workers and surgeons study every manner of injury and death with the mission of reducing the impact of injury and violence on people’s lives. On any given weekend, the Harborview emergency center treats motor vehicle crash victims, burn patients, broken bones, and those harmed through purposeful acts like suicide and murder.

Finding ways to prevent these and other kinds of injury and death prompted pediatrician Abe Bergman to help establish the HIPRC in 1985. He had had been working with surgeon Clifford Herman to track and research the injuries and deaths that came through the hospital. Their goal was to understand the circumstances around preventable injuries and inform the public and public policy makers about them. When they launched the center, it was one of the first CDC-funded injury research centers in the country. The doctors hired Rivara, already a known figure in prevention research. “He brought, more than anyone else, rigor to our research in injury prevention,” says Bergman.

One of the center’s early projects focused on bicycle helmets. In the mid 1980s, only about 1 in 100 Washington children wore helmets and Harborview pediatricians were seeing nearly 200 children a year with bike-related head injuries. The HIPRC study into why parents didn’t buy their children helmets revealed that cost was an issue, as was general awareness. Seven years later, after an outreach campaign involving TV, radio, pediatricians and giveaways, helmet use in Seattle had increased to 57 children out of a hundred. In adults that number had increased to 70 percent. And Seattle hospitals were seeing significantly fewer bicycle-related head traumas.

Today, the HIPRC collaborates with several UW schools including medicine, public health, social work, nursing. The center also conducts research in five countries to study the injuries suffered by everyone from infants to the elderly, says director Monica Vavilala, ’97, professor of anesthesiology and pediatrics. In a suite of offices just a block from Harborview’s ER, more than 60 faculty and 30 trainees explore a spectrum of topics including improving the care of adults and children with traumatic brain injury; drowning; the effects of marijuana on driving; inequity in rehabilitation support; cell phone blocking for teen drivers; lower speed limits; preventing falls in older adults; and children walking safely to school.

After finding that alcohol is a major factor in many trauma injuries and one that can adversely recovery, the center recommended—and Harborview implemented—alcohol counseling for ER patients. The practice is now widely used around the country.

Epidemiologist Ali Rowhani-Rahbar, ’09, started his career exploring infections and vaccines. But after the shootings in Sandy Hook in 2012 where 20 children were killed, he expanded his research at the UW to include gun violence. In one recent study, he and Rivara tracked gunshot victims at Washington state hospitals for five years and discovered that they were 21 times more likely to get shot again, four times more likely to die of a gunshot wound and twice as likely to get arrested.

Those numbers justified an intervention with the high-risk group, says Rowhani-Rahbar, “We can do something to make their lives better.” So he started a randomized trial, pairing gunshot victims with a support specialist who meets them in the ER and then works with them for six months to find resources like mental health support, vocational training, drug and alcohol treatment, housing and even financial counseling. “We hope to provide evidence to policy makers that this support can significantly reduce the risk of subsequent injury,” he says.

According to a 2013 Washington State Department of Health report, 25 percent more residents die from firearms than from vehicles. Nonetheless, “when you think about the scale of the problem, it pales when compared to funding for research into other injuries,” says Rowhani-Rahbar. In January, the Journal of the American Medical Association published an exploration of research funding for 30 different causes of death and found that, based on mortality rates, gun violence was the least researched. It had 1.6 percent of the funding by comparison and 4.5 percent of the volume of publications. Gun violence killed about as many people as sepsis, but funding for gun violence research was just .7 percent of that for the infection-related syndrome.

Now Seattle’s city leaders are asking for more research and interventions to reduce gun violence. In 2015, the city council passed a gun violence tax on the sale of firearms and ammunition in the city. That means $25 for every firearm sold—and up to 5 cents for every bullet—is slated to fund research into gun violence and injury. Seattle is a great place to do this work, says Rowhani-Rahbar. “You don’t see this in other cities around the country.”