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Executive Summary Injuries are the leading cause of death and disability in children and young adults. They destroy the health, 1 Ives, and 1 ive}ihoods of millions of people, yet they receive scant attention, compared with diseases and other hazards. injury. Injury is the last major plague of the young. Injuries kill more Americans aged 1-34 than all diseases combined, and they are the leading cause of death up to the age of 44. In jut ies cause the loss of more work ing years of life than all forms of cancer and beer t disease combined. One of every eight hospital beds is occupied by an injured patient. Each year, more than 140,000 Americans die from injuries, and one person in three suffers a nonfatal . Every year, more than 80~000 people in the United States join the ranks of those with unnecessary, but permanently disabling, injury of the brain or spinal cord. . Injuries constitute one of our most expensive health problems, costing S75-S100 billion a year directly and indirectly, but research on injury receives less than 2 cents out of every federal dollar for research on health problems. In jury is not an insoluble problem. Exciting oppor- tunities to understand and prevent injuries and reduce their effects are available. By taking advantage of such opportunities, we can save or improve the lives of countless Americans who otherwise will die or become disabled because of injury. 1

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: 2 The committee found serious, but remediable, inadequa- cies in the understanding of and approach to injury as a health problem. Injury has traditionally been regarded primarily as an unavoidable accident or a behavioral problem, rather than a health problem. No central agency has responsibility for reducing the incidence of injuries. Injury control, including research, has not been given high priority. Reducing injuries requires coordinated effort among specialists in epidemiology, prevention, bio- mechanics, treatment, and rehabilitation; trained manpower is inadequate. Funding for injury control is disproportionately low and discontinuous, in comparison with that for cancer, heart disease, and other major health problems Without funding continuity, centers of excellence in iniurv research and care cannot curers ve and prow. _ ~ _ _ .. _ _ ~ Funding Is not only inadequate, but widely and unevenly distributed; some crucial subjects, such as biomechanics, receive scant attention. . The result of those inadequacies is that research efforts in injury are unfocused, lack continuity , and ar e undersupported. Many gaps exist in efforts to prevent and treat injury and deal with its aftermath. Almost no current research deals with the mechanisms and prevention of injury from falls (the leading cause of nonfatal injury) and many other important injury-related causes of death, such as injuries associated with farm machinery and light aircraft. m e causes and circumstances--and even the numbers--of assaultive injuries are not known. Injury-prevention measures have been poorly implemented, and the effectiveness of many such measures has not been evaluated. Knowledge of the tissue-injury thresholds of children, women, and middle-aged and elderly men is sparse. Little is known of the mechanism of functional damage to the brain and spinal cord.

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3 The committee found one recurrent theme in i ts exami- nation of the current research effort on injury--the lack of a single coordinated focus of activity that would give visibility to this important public health issue and permit an organized program of effective action to address the problems. The committee recommends the establishment of a center for injury control within the federal government. The Centers for Disease Control of the Department of Health and Human Services is recommended as the location for that center. The second overriding problem the committee has identified is the lack of f inancial support for research on injury. The committee recognizes that competition for available dollars is already severe in this time of financial constraint, but contends that research on injury has been undersupported historically and that vast sums could be saved by a relatively small investment in this f ield. The committee recommends that funding for research on injury be commensurate with the importance of injury as the largest cause of death and disability of children and young adults in the United States. Chapter 1 of this report introduces the subject by defining and describing injury and the magnitude of the injury problem. Chapters 2 through 6 describe the state of knowledge of various facets of the injury problem and identify the kinds of research that are required. Chap- ters 7 and 8 deal with the research funding and organi- zational arrangements for research and training related to injury. Appendix A contains some examples of the general research problems associated with injury control and the committee's recommendations for address ing them, and Appendix B contains brief biographies on the committee members. INJURY: MAGNITUDE AND C~ARAC-~RISTICS OF The PROBLEM Injury is caused by acute exposure to energy, such as heat, electricity, or the kinetic energy of a crash, fall, or bullet. It may also be caused by the sudden absence of essentials, such as heat or oxygen, as in the

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4 INJURY (X) ~ "% ~ ~ 31% ~ - ~-~ - ~4 46 64 : i NONI NJURY |{X} _ 55% 15-24 - ~79% / 2% 66+ 25-34 / _ / ~ 62% _~ , . . .. Congenital Pneumonia/ Heart Liver Age Injuries Anomalies Cancer Influenza Disease Disease Stroke Other . . 14 46% 5-14 55% 15 24 79% 25-34 62% 35 44 31% 45~64 7% 2% V 13% 5% 3% 4% 3% 3% 6% 20% 36% 3% 4B% 4% 5% 10% 27% 23% 13% 19% t8% 16% 18% FIGURE 1 Percentages of deaths from in jury and other causes in the United States in 1980, by age . Modif fed from Baker, S. P., B. O'Neill, and R. Rarpf. The Injury Fact Book (Lexington, Mass .: Lexington Books , 1984 ) . case of drowning. Injury may be either unintentional (accidental) or deliberate (assaultive or suicidal). Each year, more than 140 , 000 Americans die from injuries and 70 million sustain nonfatal injuries. Injury causes almost half the deaths of children aged 1-4, more than half the deaths; of children aged 5-14, and nearly four-fifths of the deaths of persons aged 15-24 (Figure 1). Thus, injury is the leading cause of death among children. As infectious diseases have come under control during the last century, the relative importance of injury teas increased to the point where it is now the most prominent cause of death for more than half the human lifespan (ages 1-44). For more than three decades of life (ages 1-34), motor-vehicle crash injuries alone are the leading cause of death. For all ages combined, the injury death rate is surpassed only by the rates for heart disease, cancer, and stroke.

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s / Al I Other / Diseases 24.8% Heart Disease 1 6.4% _t 1\1 n)ury 40.8% / Ca ncers\\ 18.0% \ FIGURE 2 Percentages of years of potential life lost to injury, cancer, heart disease, and other diseases before age 65. Modified from Centers for Disease Control. Table V. Morb. Mart. Weekly~p. 31:599, 1982. Injury greatly surpasses all ma jor disease groups as a cause of prematurely lost years of life, because it is the preeminent cause of death among children and young adults.- More years of future worklife are lost to injury than to heart disease and cancer combined. Each year, over 4 million years of future worklife are lost to injury, compared with 2.1 million to heart disease and 1 .7 million to cancer (Figure 2 ) . The impact of nonfatal injury is of similar proportions. Injury is the leading cause of physician contacts. It is the most common cause of hospitalization among people less than 45 years old. The personal, family, and societal costs of mental and physical disability and disfigurement are huge. Although injury is the most costly of all major health problems (about S75-S100 billion per year), support for injury research has been minimal. The total annual expenditure for injury-related research by the Hational Institutes of Health (NIB), about S34 million, is less than 2 percent of the NIB researab budget. The total expenditure by all nonmilitary federal agencies is about S112 million--less than $2 for every Sl,OOO of the cost of in jur ies themselves.

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~6 EPIDEMIOLOGY OF INJURY: THE NEED FOR MORE ADEQUATE DATA A prerequisite for the scientific study of injury is the acquisition of data on which to base pr for ities and research. Despite the obvious importance of injury as a public health problem, information to permit the study of the epidemiology of most in jur ies is not available. Although there are basic data on time, place, and person for some injuries and deaths, even basic information is often lacking as to the numbers and characteristics of people injured and the factors that influence injury causation, especially in nonfatal events. Detailed information on the groups that are particularly sus- ceptible to injuries and their effects is not adequate. Injuries from motor-vehicle crashes constitute the only exception to this limitation. The incidence, prevalence, and effects of motor-vehicle injuries, as well as measures to counter them, are moderately well understood, compared with the epidemiology of other injuries, although even here information about long-term effects is sparse. The acquisition of knowledge about motor-vehicle injuries is a direct result of the funding of research on injury epidemiology from two sources whose primary mandate is the study of automobile injuries--the National Highway Traff ic Safety Administration and the Insurance Institute for Highway Safety. Little funding has been available for researab into the epidemiology of other injuries; consequently, our knowledge of these other injuries is slight. Continuous, systematic data collection is essential for planning and evaluating preventive programs. The lack of appropr late data systems has led to the institu- tion of some expensive but ineffective preventive programs. Recommendations The United States requires effective in jur y surveillance systems for gathering and integrating information from a variety of sources on which to base the planning and evaluation of control efforts. This would include long-term longitudinal 'studies of injuries and the collection of more ref ined data on specif lo types and causes of injuries and exposures to injurious environments .

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7 A national capacity should be developed for the quick identification and control of outbreaks of specific injuries. A consistent and accurate system for coding the causes of injuries needs to be used by hospitals. More refined data on the specific types and causes of injuries are needed to develop effective interventions. Research is needed to determine the short- and ong-term costs of injuries. PREVENTION OF INJURY Injuries can be prevented with a variety of strategies. The effectiveness of these strategies varies inversely with the extra effort required to keep people from being harmed and the degree to which people must change their usual behavior patterns. Three general strategies are available to prevent injuries: Persuade persons at risk of injury to alter their behavior for increased self-protection--for example, to use seatbelts or install smoke detectors. . Require individual behavior change by law or administrative rule--for example , by laws requiring seatbelt use or requiring the installation of smoke detectors in all new buildings. Provide automatic protection by product and environmental design--for example, by the installation of seatbelts that automatically encompass occupants of motor vehicles or built-in sprinkler systems that automatically extinguish fires. Each of these general strategies has a role in any comprehensive injury-control program; however, a basic finding from research is that the second strategy-- requiring behavior change will generally be more effective than the first, and that the third--providing automatic protection--will be the most effective. A fundamental reason for this is that members of high-risk groups tend to be the hardest to influence with approaches that involve either voluntary or mandated changes in individual behavior . Teenagers, for example, are much less likely than adults to wear seatbelts, whether or not a law requires them to do so. Programs

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Q : V intended to change alcohol-related behavior value tar fly have not produced sustained reductions in death rates. Elderly pedestr fans admonished by police for jaywalk ing were no less likely to do it sea i a- Scofflaw drivers snore Licenses nea seen revoked were more likely than the average licensed dr iver to be involved in fatal crashes . And not only are young children hard to influence, but intensive ef forts at a well-baby clinic, for example, had no effect on dangerous maternal behavior, such as leaving knives and matches within the reach of small children. The shortage of health professionals and scientists with relevant training is ~ major impediment to injury control. Without knowledgeable and interested persons trained in the relevant sciences, the injury toll will continue e ~ ~ _ ~ ~ ~ ~ ~ ~ e _ _~ _ _ _ ~ ~ Recommendations Education, training, and information programs intended to control injuries should be evaluated exper imentally . Laws and regulations aimed at controlling injuries should be scientifically evaluated. The separate influences of degree of enforcement, severity of punishment, and speed of administration of punishment should also be researched. . Continuing research is needed on ef f icacy of product des igns and environmental modifications in protecting people effectively and automatically. Research is needed to understand the barriers to implementing existing effective injury-control measures that are not widely applied. Research is needed in the prevention of injuries in the recreational, occupational, and home environments. Training health professionals and other scientists in injury research and the basic concepts of injury control is crucial, if we are to develop and apply new knowledge about the prevention of injury. . . INJURY BIOME:CHANICS RESEARCH AND THE: PREVENTION OF IMPACT INJURY Impact injury of the human body occurs by deformation of tissues beyond their failure limits, which results in damage of anatomic structures or alteration in normal

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9 function. Injury biomechanics research uses the prin- ciples of mechanics to explore the mechanisms of physical and physiologic responses to impact, including both penetrating and nonpenetrating blows to the body. Although in jury can occur by slow deformation, in crushing, the predominant feature of impact in jury is ache fast, violent nature of the event, whether it is the rapid impact of a person's chest on the instrument panel of an automobile or a bullet 's penetration of the chest cavity. Improved protection could be realized with a better understanding of the biomechanics of in jury and disabil- ity. Design of less injurious environments depends partly on knowledge of the effects of specific k inds and amounts of energy on specif ic human tissues . Although we know the approximate limits of forces that can be tolerated by young healthy males in rapid deceleration, we do not have ref ined data on other elements of the population, on the extent of reversibility of damage, or on effects on nervous tissues or tissues outside particular size and structural ranges. Recononenda t ions High pr for i ty should be ~ iven to research that can provide a clearer understanding of injury mechanisms. Crucial sub jects are the relative con tr ibutions of linear and angular acceleration of the head to deformation and injury of the brain and the body deformations that cause injury of the spinal cord, thoracic and abdominal viscera, and the joints. Quantification of the injury-related responses of or itical body areas--nervous system, thoracic and abdominal viscera, joints, and muscles- to mechanical forces is needed. High priority should be given to obtaining and defining limits of human tolerance to injury, particularly with regard to segments of the population on which data are extremely limited, including children, women, and the aged; both whole-body and regional tolerances; the effect of human and environmental variables on tolerance; long-term effects of impact deceleration on the body; and survival of extreme impact. Improvement in injury assessment technology is needed, including development of means for assessing the important debilitating in juries and causes of fatality, .

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i: ~ 10 improvemen t of anthropomorphic dummies, and developmen t of computer models to predict in jury in complex crash conditions . There is a need for an organization to administer r esearch on in jury mechan isms and in j ury b iomechan ics and ensure a supply of 'scientists trained in injury b iomechanics . TREATMENT Except when death occurs immediately, the outcome of an injury depends not only on its severity, but also on the speed and appropriateness of treatment. Communication systems are needed to facilitate decision making, injury management at the site, and the rapid delivery of the patient to a hospital that can provide the needed care. Once a severely in jured person arrives at a hospital, treatment requires the effort of a team that includes specialists in various aspects of injury management. Designated trauma centers with experienced teams avail- able and necessary backup facilities, such as well-stocked blood banks, are essential. In addition to the develop- ment and evaluation of such systems, there is a need to ensure that patients treated in hospitals other than trauma centers receive the most up-to-date care, so the t unnecessary morbidity, mortality, and residual disability are avoided. The most important topic to be addressed with regard to treatment is control of swelling of the brain ; improve- ments could substantially reduce injury mortality. Under- standing of Ache immune system and prevention and control of infection also warrant high priority as does control of spinal coed swelling and research in spinal cord regeneration. Recommendations Long-term collaborative studies should be insti- tuted by epidemiologists, statisticians, biomedical engineers, trauma physicians, rehabilitation physicians, behavioral scientists, and health economists, to identify and evaluate factors that produce optimal results, to identify factory that result in less than optimal results, and to institute programs for promulgating optimal management techniques.

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11 Programs in basic research should be instituted and supported, in collaboration with morphologists, biochemists, membrane physiologists, pharmacologists, neurobiologists, bacter iologists, virologists, and others, to study shock, infection, tissue responses and healing, and brain and spinal cord swelling. Biomedical and biomechanical programs should be instituted and supported in relation to injury mechanism and prevention and the development and evaluation of biomedical materials, including prostheses and artificial organs. . Clinical studies should be instituted and supported in development and evaluation of pharmacologic options, of surgical techniques, and of management options. Programs designed to train professionals in the research and care of injury should be instituted and supported. REHABILITATION Rehabilitation is the process by which physical, sensory, and mental functional capacities are restored or developed af ter damage . In the context of ire jury control, rehabilitation is the process by which biologic, psychos logic, and social functions are restored or developed to permit an injured person to achieve maximal personal autonomy and an independent noninstitutional lifestyle. Rehabilitation is achieved not only through functional change in the person (e.g., development of compensatory muscular strength, use of prosthetic limbs, and treatment of postinjury behavioral disturbances), but also through changes in the physical and social environment, such as reductions in architectural and attitudinal barriers that h ~ er those requiring use of a wheelchair. In the last decade, improvements in emergency medical systems, in immediate management by trauma centers, and in care of the injured en route to hospitals have increased the survival of persons with nervous system injuries, multiple injuries of the mu-=culoskeletal system and viscera, or extensive burns. Trauma units have increased the need for def ined referral to special rehabilitation programs and follc~w-up services. More persons survive major injuries, and survivors often have severely disabling effects from the injuries; themselves and from untreated complications. Many need functional

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12 restoration of cognition, sensation, movement control, and mobility after brain, spinal cord, and musculoskeletal injury. Further negative effects on health and perfor- mance in daily life that result from the loss of body per to and from inactivity and immobility must be prevented. Preventable disability is not an uncommon consequence of inadeguate management of the injury patient--for example, limitation of motion due to contracture in burned patients or paralysis in patients with unrecog- nized injury of cervical vertebrae. Pressure sores, or ~bedsores, ~ are an entirely preventable complication that occurs in 35-40 percent of persons with spinal cord injury, at an average cost of $25,000-$28,000 per pressure sore, inestimable misery, and increased debilitation. With comprehend ive care, the profound biologic, psycho- logic, and social responses to paralysis and movement disorders, disfigurement, and loss of body parts are controllable to a remarkable extent. Although limited resources for clinical programs have been provided through private and publicly supported efforts, parallel research and educational resources for the development and dissemination of knowledge and technology have been seriously inadequate. The development of expanded special regional centers and programs has been lacking for the large number of unserved persons who could benefit. Recommendations Major research centers should be de~reloped for clinical neurophysiology programs on evaluation and management of neural injury residue, neural 'system function, and ethnologic replacement of lost function. Funding priority should be given to research on Me identification and preservation of residual functions, de~relop~ent of substitute functions, psychosocial manage- ment of the patient and family, and deinstitutionaliza- tion. Research programs aimed at minimizing the effects of injury to the musculoakeleta1 system, including both bone and soft tissue, that result from physical, chemical, and tberaul causes should be promoted. Research program; should be established in the behavior al and social sciences for cross-disciplinary

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13 studies of adaptive behavior and its relationship to brain function in environmental adjustment and learning. Wider application of existing knowledge related to rehabilitation and prevention of second injury is needed. Development and evaluation of model systems of rehabilitation should be promoted. Research should be greatly expanded on behavioral and social factors related to stigmatization of and discrimination against the disabled. . . A system is needed that can identify disabled persons and persons with injuries that are likely to produce severe disability, so that services for those who might benefit can be planned. Linked local, regional, and national reporting systems for the disabled are necessary to go beyond social security studies limited to work disability; these systems could be built into the surveillance systems recommended in Chapter 2. CURRENT FEDERAL EXPENDITURES FOR INJURY-RELATED RESEARCH To assess federal support for in jury-related research, the committee reviewed federal research expenditures for fincal 1983. The total federal expenditures for nonmilitary research on injury were approximately S112 million in fiscal 1983. Expenditures in 1 year are more relevant when compared with over expenditures in the same year. For example, although injury research in fiscal 1983 accounted for approximately ~t34.4 million of expenditures at the National Institutes of Bealth (NISI), that was less than 2 percent of the total NJ}! research budget. Although injuries are responsible for the loss of more economically productive years of life than heart disease and cancer combined, the federal expenditure for research in injury control is relatively small approximately one-tenth of that for cancer and less than one-fifth of that for heart disease and stroke (Figure 3). Thus, when one compares the relative research expenditures and the years of life lost to these causes of death before age 65, it is apparent that the smallest portion of the funds is being allocated to the largest problem injury. The committee believes that substantial decreases in current injury rates would result from research requiring substantially less support than iE; now expended on cancer

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: ~ 14 S1 12 Million Resear ch E xpend~tures _ :::::: :::::: :,:,: ::: ... i: ;; ;-,, . ;-. ~ 4.1 Million Years of Life Los' . ::::::::::::::::::::::::::::::::: :.:2:~:::::::::::2:,:.,:::,:~:,:.: :~:.:.:~:2:2: :~:.'. .. ......... ~ 2 ~: ~ ::,:::,:,:,:.:.:~:,:::::::::::::::: :::::::::::::::::::,:~:~:.: :.: :.::.:,:.:.:.:.:.: :, :,:.:~: :::.::.:::: :::::::::::::::::::::::::::: :;::: : .2 . 2:: :2:.::::: :~:: :~: ,:2:,:,:: :.::::::::::::: arm:::: . , ~. ~ . ~ .. .. :.:.:.::::::: :.:::::::,. :~:.:.:.:~:~:~:~:,:.:,:. :::.: ::: :.::::.::::::~:.:.:~:,:~:.:,:~:.:.:,:~:: ::: :::,: :::::~:.:.::::::::::: :::::::::::::::. S998 Million ',Remarch Expenditures ........................... :::::::::::::::::::::::: ::::::::::::::::: . ::::: ::: :.: :,:~:~:~:.:~:.:~:,:,:.:.:.:.:~:.: :::::::::::::::::: :::::::::::::::::: : :-:::::::::::::::: :::::::::::::::::: 2:,: :~:~:2:.:,: :::.:.::.: :.:.:~:~:~:~:.:.:::::.: :::::::::::::::::::::::::::::::::::: :~:.:~: : ::,:.:::::2:2::::. .:.:. ::.:::: . :::::::::::::: : ~ .: . :::::::::::::::::-:::::::::: :.:~.:,: :.:~:.:.:.:.:.:.:,:.:.:.:.:.:.::::: :.2::::::: . ::::::::::::::::::::::::::::::: ::,:: :.:.::: :.:~:,::~:2:::~::::.: . .:::::::::.: ::::::::::::::::::~::::~:~::~:.:. :.:,:,:':.:.: :.:.:,:,:.: :.:.:.:2:.:~:.:.:.:~: :,:: . ::.:.:,:.:: :~:: :.:.:2 ' .: ~ ~ . .:: : ::::::::::::::::::.:::::::,:.:, .:~:2:,:.:~:,: :.:.: :,:~:~:.:~:.:~:~.:,:.:2:~:.:::::.: . ::::::::::::::::::::::::::::::::::: :2:.: : :~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:. .:: ~ .:.:::: . ~. ~. :~:~:~:~:~:~:~:~:~: : :~:~:~:~:~:~:~: :~:~:~.~: :~:~: ::::::::::::::::::: :::::::-:::::::: ::::::::::::::-.:::::::::::::::::: :.:~:.:~:::,:,:~:~:,:: :.: :.,: :~:.:2:.:~:.:.:2:,:~: . I ............ :::::::::::::::::::::::::::: :::::::::::::::::::::::::::: :::::: .. .e ... . . :: 2 2 :::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::: : :S624 Million : . Research E xpenditures - : :.:::::::::::::::::::::::::2 . :::::~:::::~:::~:::,:.:.:.:~:~:~: :~:,:.:.:.:.:.:~:~:~: ::::,:.::.::,::::::::::::::::::: ,:::~:.:2:~: :~:.:~:~:~:.:,:.:~:.:~:~:,:~:2:~:~:.:.:~:. . : .:: :,:.:.:.:.: :~:2:~:~:: :,:,:,:.:~:2:,:~:~:e2: : :::::::::::::::::::::::::::: :: .2 :.:::::::: :.:.:2:,:.:.:.. .:::::::::::: :::::::::::::::::::::::::::::::: . :: :::::::::::::::::::::::::::::::::::::::::::::::::::: :.: :.:,:::~:~:.:.:,..:~.:.:.:.:~: :.:.:,::: .:,:::.2:~: :::::.::::::::::::::::.::::-::: ...... .................... .. . ~ l-2 :,:. 2.1 Million I:,::: , Late Lost ~ Injury Cancer l~lears D~/Stroke FIGURE 3 Preretirement years of life lost annually and federal research expenditures for ma jor causes of death in the United States. Years of life lost derived from age-at-death distributions in the National Center for Bealth Statistics Vital Statistics of the United States, 1978, Volume II. Mortality (Ryattsville, Md.: U.S. Department of Bealth and Human Services, 1981). The total federal expenditure for injury research is the sum of the amounts discussed in Chapter 7 plus a ~ percent increment for administration, the latter in line with NIB adminis tration costs. Expenditures for research on neoplasms and cardiovascular diseases are the 1983 fiscal year budgets of the National Cancer Institute and the National Heart, Lung, and Blood Institute from the Institute of Medicine's Response to Health Needs and Scientific Opportunity The Organizational Structure of the National Institutes of Health (Washington, D.C. : National ~- Academy Press, 1984 ) .

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15 and cardiovascular disease. An increment in current funding with close monitoring of the application of the research results could illustrate the investment value of such expenditures for the entire population. The committee does not advocate a reduction in federal expenditures for health researob in cancer or heart disease and stroke. It does feel, however, that federal expenditures for injury research and injury control are seriously inadequate. The committee believes that substantial progress could be made in the reduction of the incidence of in jury and its associated morbidity and mortality if adequate funding, direction, and support were given to a coordinated federal program of injury r esearch . ADMINISTRATION OF INJURY RESEARCH The committee discussed the advantages and dis- advantages of various model'; for managing injury research in the federal government. Criteria were established for a unit that could effectively manage a large-scale federal program in injury research, and the selected models were compared for suitability. After consideration of the various alternatives, the committee recommended the establishment of a new Center for Injury Control. (CIC) in the Centers for Disease Control (CDC). The function of the Center for Injury Control would be to carry out a national injury research program in the following manner: . Support research in biomechanics, injury epidemi- ology and prevention, acute care, and rehabilitation. Establish injury surveillance systems and conduct injury prevention projects. ~ Improve and expand professional education and training . Establish centers of excellence in injury bionic mechanics, prevention, and care. Collect and analyze data on injury. Serve as a clearinghouse and lead agency among federal agencies and private organizations interested in injury research and prevention. The structure of CIC it; visualized along Me lines of the diagram in Figure 4. Divisions dedicated to the major sectors of needed research--epidemiology, preven- tion, biomechanics, acute care, and rehabilitation- would

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16 Assistant Secretary for Health Public Health Service | Director | Director | Advisory CIC ~ ~ Council ~ ~ Prevention | | Eliomechanics | ~ Acute Care ~ ~ Rehabilitation FIGURE 4 Suggested location and organizational structure of proposed center for injury control. be coordinated by a director. The CIC director would report administratively to CDC and would convene an advisory council consisting of representatives of federal agencies and other organizations engaged in injury research. The CIC director and staff would review priorities, establish specific research goals, identify scientists capable of implementing the research, and coordinate peer review. It is imperative that all appropriate disciplines be represented and that the CIC director be a scientist with recognized research accomplishments and successful experience in interdisciplinary investigations of injury. No single discipline or disciplinary orientation can produce the broad spectrum of researab needed for injury control. Clearinghouse and coordinating functions in CIC are essential, although the in jury research problem is much more than a matter of insufficient coordination. CIC should foster and support research directed to filling the knowledge gaps that inhibit the control of injury. To do this, it should contain special study sections and a granting mechanism in each that would provide for continued, rather than year-by-year, funding of research projects. Funding should cover demonstration programs, multiple centers of excellence, and training of researchers in appropriate fields. CIC funds should supplement, rather than replace, funds currently allocated to other agencies, such BB the Department of Transporta

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17 tion (DOT), the Department of Defense tDOD), and NIH; and their funding related to injury research should not be channeled through CIC. The director and the advisory council should be charged with the development of an annual plan and report to Congress--an approach similar to that followed by the National Toxicology Program. This administrative mechan- ism would encourage the CIC director and representatives of other agencies to consider the scope of what is being done, in view of the various agency mandates, and to avoid inappropriate duplication of effort. An independent review of CIC should be conducted within 5 years of its establishment to assess its progress in accomplishing the objectives recommended in this report. At that time, consideration should also be given to the elevation of th is center to independent agency status. Injury is the major health problem facing young Amer icans today . The oppor tunity exists to create a focused, coordinated research effort with the potential to save lives, improve productivity, and reduce costs and long-term losses to the injured, their families, and society. The alternative is the continued loss of health and life to predictable, preventable, or modifiable injuries. The committee firmly believes that it is time to plan and undertake a national program to address this problem.