Deirdre Anglin believes that the road to ending violence and injuries begins with examining the causes behind them.
Prevention is all the rage in health and medicine these days, as doctors promote exercise and healthy eating to lower the risk of disease, and researchers study the root causes of illness.
That works for diseases, but what about preventing injuries? Should healthcare professionals try to prevent patients from getting injuried intentionally or unintentionally, just as they do with disease?
Ask Deirdre Anglin, M.D., M.P.H., associate professor of emergency medicine at USC, and the answer is an emphatic yes.
Anglin has anchored her career on that very idea: that many injuries ending up in the emergency room have causes that can be researched, identified and potentially avoided. Statistics back up her convictions: Injuries, homicide and suicide make up the three leading causes of death for those between ages 15 and 34.
The trends she has studied and brought to light vary as widely as the victims who swell the LAC+USC Medical Center emergency room on a Saturday night-hate crimes, suicide-by-cop, police dog bites, date rape.
It all started with Anglin's research on street gangs, a topic of much discussion-but not well understood when the victims of gang violence were being wheeled into emergency rooms in the early 1990s.
"There were so many deaths," Anglin says. "I thought, `Isn't there something that can be done about these deaths to make them not be in vain?'"
She has done just that.
A Balancing Act
Anglin started her medical career in a place not renown for drive-by shootings or high-speed car crashes.
A native of Canada, Anglin graduated from medical school at Ottawa University and participated in an internship staffing a series of clinics at outposts in quiet fishing villages along the rugged coast of Labrador.
When it came time to choose a specialty for her residency, she decided on emergency medicine, spurred by an interest in acute care. Just one small problem: only six emergency medicine residency spots were open throughout Canada. They were all at McGill University in Montreal.
Despite discouragement from some, she took the risk, applied for a prized slot-and got it.
In Montreal, Anglin not only found her career path, but her eventual husband: Thomas Kovacs, a gastroenterologist. Not that everything went smoothly, though. Shortly after they met, a research opportunity swept Kovacs away to UCLA.
Three years later, Anglin finally joined Kovacs in Southern California, and she joined the USC faculty in 1988.
It has been a careful balancing act ever since, as she keeps family, friendships, research and clinical duties a part of her daily schedule.
The couple have a 10-year-old son as well as 7-year old twins, a boy and a girl, and Anglin often can be found toting them back and forth to soccer, basketball and baseball practices.
"She's a very devoted mother," says Erin Quinn, Ph.D., associate dean of admissions and Anglin's friend. "We often talk about how hard it is to be a good mom, a good doctor and a professional woman, and how you balance them. She pulls it off."
And, like other academic physicians, Anglin handles lots of administrative and teaching duties. She directs emergency medicine's student and intern electives and clerkships. She mentors residents and advises medical students, and serves on committees for curriculum, selecting residents, appointing faculty and so on.
Anglin has been invaluable as a vice-chair of the Institutional Review Board, a university committee that reviews all research involving humans, says Darcy Spicer, M.D., associate professor of medicine and chair of the review board. "She has been dedicated and vital to the board," Spicer says. "Despite her demands as an emergency physician, she often puts in time between shifts to keep the IRB running smoothly."
Of course, as a faculty physician, Anglin also regularly treats patients who show up seeking help at the emergency room. And that is where her passion for research began.
Driving Policy Change
According to Webster's Dictionary, an accident is an unpleasant and unintended happening, sometimes arising from negligence that results in injury, loss or damage.
"Most people believe that an injury is an accident that cannot be predicted, that there is no pattern to it," Anglin says. "When you look through injuries, though, and understand why they happened, there's nothing that isn't really predictable in some way."
In her first few years at LAC+USC, Anglin saw hundreds of patients week after week suffering from injuries. And she did the expected: She patched up the injuries and discharged patients.
"Emergency medicine is a `fix-them-then-send-them-on-their-way' sort of field," she says.
The drive-by shootings of tattooed young men, and occasionally, the men's neighbors, girlfriends and children, became part of every emergency doctor's shift. But each gang-related patient had a story.
The deaths gnawed at Anglin, just as they did at her then-LAC+USC colleague, H. Range Hutson, M.D.
"We started thinking about it," Anglin remembers. "Every day you'd be pronouncing some young person dead. It was terrible. It still is."
She and Hutson shared frustrations. "Gang violence was something we felt we were seeing a lot of, and no one was addressing," remembers Hutson, now an assistant professor in the Department of Medicine, Harvard Medical School, Brigham and Women's Hospital in Boston.
The shootings posed a criminal justice problem. A social problem. But surely not a medical problem, right?
That is where Anglin and Hutson decided to change some minds. "A little green light came on in my head," Anglin remembers. "I said, `This is it. This is where I can make a difference."
The physicians interviewed Los Angeles police officers, sheriffs, priests and criminologists who worked with gang members. They analyzed hospital data, but found no information in the medical literature. "People had no understanding of turf, loyalty or ethnic gangs," Anglin remembers.
In the New England Journal of Medicine, Anglin and Hutson pointed out the appalling number of teens and children killed in gang violence, and noted patterns. They found most shootings were on public streets and at night, most (but not all) victims were gang members, and most shootings occurred in the summer, for example.
Anglin takes pride in the work, noting that the paper and subsequent research published in the Journal of the American Medical Association helped bring gang violence to the fore as an important public health issue.
"Just as people say car crashes are not accidents-you can predict intersections and times of poor visibility when they are likely to happen-with gangs, once you define the problem, then you can try to figure out what to do about it," Anglin says.
The researchers believe that anti-gang money is best spent on root causes of gang formation, such as stressed families and unemployment.
"My goal is to put out information, and give people the facts needed to change policy and save lives," she says. "As physicians, we have so much power to influence change."
On the Front Lines
Anglin had no background in how to conduct research, so she taught herself the basics. She also earned a master's in public health from UCLA to learn epidemiology while working full-time.
Research that lands in important journals, is heavily cited and enters public debate cannot help but launch and motivate a researcher to do more.
"The first articles encouraged us to keep writing," says Hutson, who describes Anglin as "a doer, who is aggressive at getting things done in a timely fashion and getting it right the first time."
Their research comes from being on the front lines of emergency medicine:
When hate crimes increased in the 1990s, Anglin and colleagues proposed guidelines for best treating these victims of prejudice. Such victims are more likely than others to sustain severe physical and psychological injury, and need appropriate support and treatment, she notes. (Annals of Emergency Medicine, June 1997)
When serious bites from law enforcement (K-9) dogs brought crime suspects into the emergency room with injuries, Anglin analyzed the effects of police K-9 policies on numbers of injuries. (Annals of Emergency Medicine, May 1997)
When women began coming into emergency rooms after they had been raped-but with vague memories of the crime-Anglin and colleagues illuminated the issue of date rape. They wrote that emergency physicians should test the women for Rohypnol, the so-called date rape drug. (Academic Emergency Medicine, April 1997)
And the researchers first identified the trend now known as "suicide-by-cop," in which suicidal crime suspects butt heads with police through standoffs or car chases, trying to provoke police to shoot and kill them. (Annals of Emergency Medicine, December 1998)
One issue that has deeply touched her, though, is domestic violence, now often called intimate partner violence.
"There are women dying all the time," she says. "It is so unnecessary."
Experts estimate that intimate partner violence poses risk of injury or death to one of every five women in her lifetime.
In the last few years, Anglin has honed her focus on the issue. She is very involved in the domestic violence program at the LAC+USC's Violence Intervention Program, where she is a vital link between the women who present to the clinical areas and the counseling and supportive services available. In addition, in December 1999, the New England Journal of Medicine published her study on the characteristics of abusive men.
Women most likely to be intentionally injured through domestic violence appear to be those with male partners who abuse alcohol or drugs, are unemployed or intermittently employed, did not graduate from high school or who are estranged, she and her colleagues found.
Psychologists and sociologists believe that for an intimate relationship to involve physical, sexual or emotional abuse, one partner must be more coercive, controlling and powerful than the other. Alcohol use by men in relationships with an imbalance of power might increase the chance that they will assault their partners.
The findings indicate possible areas of treatment for batterers: They not only need to seek treatment for alcohol and drug abuse, Anglin says, but they also require counseling for intimate partner violence.
In the coming months, Anglin will gather more data about intimate partner violence, with an eye toward learning more about affective interventions for the victims. She also is following other trends-such as the relationship between suicide-by-cop and domestic violence, and the effectiveness of restraining orders in domestic violence-and is furthering the studies despite the paucity of funds available for emergency medicine research. "It's tough to get grant money in this field," she says.
Still, the research continues because Anglin is confident that causes can be found for the societal problems that end up in the emergency room.
"Injuries are not like a lump you can cut out and biopsy, then treat," Anglin says. "But they have causes behind them, and once you understand them, that's the road to finding a solution."