The White Paper and the Future: Where to Now?

This year marks the 50th anniversary of the release of Accidental Death and Disability: The Neglected Disease of Modern Society, the seminal "white paper" that birthed American EMS. We celebrate in the September EMS World with a look back at the paper's impact, and asked some top EMS leaders about its relevance today and how it can be modified to guide us into the future. Here are their responses. 

What is the relevance of the 1966 “white paper” to the future of EMS in 2016? Is it still relevant? How should it be modified?

The 1966 white paper remains relevant—part of what is post-modern EMS remains the care of victims of traumatic injury. However, EMS has expanded well beyond the thoughts of the early writers. We are now focused more on illness and the unmet health needs of the community than on injury. While injury will remain an important part of what we do, we will need to look more broadly to the environment of the 21st century. The focus is not on “America’s highways”—it is on the entire country. Our educational efforts need to greatly widened in the years to come.

—Skip Kirkwood, MS, JD, EMT-P, Director, Durham Co. (NC) EMS

The 1966 white paper was a landmark paper that revolutionized our view of the possible and stimulated the birth of prehospital care. The EMS Agenda for the Future built upon that framework. While many parts of the white paper and the EMS Agenda for the Future remain relevant, it is time to advance prehospital care to another level of excellence. It is time to revise these documents to provide a path and agenda for the growth of our specialty.

—Jane Brice, MD, MPH, President, National Association of EMS Physicians

It is remarkable how much has changed, and how much has remained the same, since publication of Accidental Death and Disability: The Neglected Disease of Modern Society. The focus of the white paper was trauma care, but in 50 years EMS has evolved into so much more. We now have sophisticated EMS response systems in virtually every community in the nation and hundreds of thousands of well-trained and dedicated professionals responding to millions of calls a year. EMS is now an essential part of the healthcare system providing access to care to a broad spectrum of patients, and the conversations about the continued evolution on EMS into a broader mobile healthcare system are very exciting.

In the year the white paper was written, 107,000 Americans died from injuries; about 44% from motor vehicle crashes. Since 1975 there has been a steady decline in motor vehicle crash rates to historic lows in 2014. That is good news, but trauma remains a major public health concern. Trauma is still the No. 1 cause of death from ages 1–44, claiming almost twice as many lives a year as when the white paper was written. Injuries result in almost 27 million ED visits and 2.5 million hospitalizations a year, with an annual cost to society of $671 billion. 

Lessons from recent military conflicts and the successful efforts to reduce motor vehicle crash deaths have demonstrated that we can get better, and EMS has a role. EMS can play major roles in achieving a goal of zero preventable trauma deaths. If we apply these lessons, the lives saved would be enormous.

So, as EMS enters its sixth decade, let us redouble our efforts. EMS must continue to evolve as an integral part of the healthcare system. At the same time, we must remain focused on our response to acute life- and limb-threatening illness and injury. In that way we can create systems of care that provide the best possible outcomes for the entire spectrum of patients who rely on us in there moment of need, pain, confusion or worry.

—Gregg Margolis, PhD, NRP, Director, Division of Health System Policy, U.S. Department of Health and Human Services

Accidental Death and Disability remains relevant because it demonstrates the need for the inclusion of EMS in the broader healthcare system to quantitatively decrease morbidity and mortality. The dynamism of EMS allows this relevance to exceed the scope of trauma and apply to recognized (STEMI, stoke, sepsis) and unrecognized clinical conditions. The document should not be limited to trauma. 

—Michael Szczygiel, Chair, NAEMT EMS Safety Committee; Senior Loss Control Specialist, Markel Specialty Programs Medical Transportation

The 1966 white paper was instrumental in shining a light on the weaknesses in the nation’s “EMS” system. It illustrated the significant gaps in prehospital trauma care and laid a road map to helping communities strengthen their local EMS systems.

The primary focus of the paper in 1966 was preventing death and disability due to traffic crashes. Today the focus of the nation’s EMS systems is transforming from simply responding to emergencies to preventing them—from transporting every patient to the emergency department to making patient-centric clinical decisions based on the patient’s needs. 

The 1966 paper transformed EMS to meet the needs of the then-“modern society”—and EMS needs to keep transforming to meet the needs of our current and future “modern society.”

—Matt Zavadsky, MS-HSA, EMT, Director of Public Affairs, MedStar Mobile Healthcare, Ft. Worth, TX

It is important to understand our history and how we have progressed as a profession since 1966. It is equally as important to see where we are currently and should be moving in the future.

We have made great strides in professional education and licensure, data collection and system design, and we need to continue to improve our progress in these areas.

To ensure our profession progresses and that our primary goal of providing quality patient care in the prehospital setting continues in the future, we need to support and perform research to assure we provide evidence-based medicine in the most effective and efficient EMS systems possible.

—John Todaro, BA, NRP, RN, President, National Association of EMS Educators

This paper provided a remarkably enduring vision of EMS and its contribution to the nation’s health and safety. It served for 30 years as the road map for system development, and then as the outline for the 1997 EMS Agenda for the Future. The Table of Contents continues to serve as a blueprint of needed relationships in the modern trauma and emergency system. 

Perhaps someday we will be able to fulfill the vision of a seamless communication system and mission of trauma prevention that are specified in the document.

—James Augustine, MD, FACEP, Medical Advisor, Washington Township (OH) Fire Department

The National Academy of Sciences’ groundbreaking work in the white paper offered evolving EMS systems a compelling vision, most notably in the treatment of the full spectrum from prevention through rehabilitation and research. Despite the remarkable advancement of EMS in the last half century, several of the recommendations remain elusive, so we must work collaboratively to continue to pursue those goals.

—Paul Patrick, President, National Association of State EMS Officials

The 1966 white paper Accidental Death and Disability: The Neglected Disease of Modern Society said accidental injuries and deaths cost America approximately $18 billion. In 2013 the CDC reported that cost to society to be $671 billion. If we adjust 1966 dollars to 2013 dollars, the $18 billion would equal about $129.4 billion. This is a very simple calculation, and the issue of the cost of accidental death and disability is much more complex. However, based on this calculation, the cost has gone up more than five times. We need to examine this more closely and really think about the impact EMS has actually had.

EMS responds to a long list of medical complaints, not simply to trauma. We need to recognize that the white paper provides historical insight into one dimension of our practice at one point in time, and that we need to research the actual dollar impacts of all the aspects of the services we provide. This is a daunting task but one that is essential to understanding the real value of our services.

—Michael Touchstone, BS, EMT-P, President, National EMS Management Association

Accidental Death and Disability: The Neglected Disease of Modern Society was published by the National Academy of Sciences in 1966. Much of the inspiration behind this paper stemmed from the battlefield experience of its authors, who deliberated on the report for four years before its release in 1966. One of the primary authors, Dr. John Howard, an Army surgeon who served in Korea, cited the paper as a turning point that marked the beginning of a comprehensive, organized system of prehospital care—a concept still relevant today.

The National Academies of Sciences, Engineering and Medicine recently published A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. This report evaluated trauma care in the military and civilian settings and has called for improvements to trauma care in the United States. 

The Federal Interagency Committee on EMS (FICEMS) is leading efforts to revise the 1996 EMS Agenda for the Future, presenting opportunities to improve trauma care in the coming years.

 —National Highway Traffic Safety Administration Office of Emergency Medical Services