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8 Administration of Injury Research As part of its charge, the committee was asked to examine whether and how the federal government could efficiently manage an injury research program and to consider among the alternatives the possible benef its of an interdisciplinary, comprehensive approach to injury research. Research on the various aspects of injury outlined in this report has been fragmented and poorly financed. Although the field has been 'substantially defined in terms of the scope of the problem and ache enormous costs to society, important parts of the field beve lacked the recognition of the scientific community and the support of the go~rernment--recognition and 'support that have contributed to the amelioration of other health problems. Effective research on injury control and prevention requires strategies and program that differ from those used for other leading public health problems. An integrated multidisciplinary approach involving physi- cians, epidemiologists, engineers, physicists, behavioral scientists, and others is needed. The present fragmented approach, winch various agencies handling some of the piece" of the problem, virtually guarantees that injuries will continue to constitute a major public health problem and that progress in combating the problem will continue to be slow and inefficient. With injury research spread among a variety of institutes, departments, and regulatory agencies, there is no means of considering the implica- tions of research on one aspect of the problem for the others, and unnecessary duplication of effort is a strong possibility. Although reasonably large current expenditures for injury-related research can be identified in the budgets of a number of federal agencies, the amounts are mis 109

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110 leading. Much of that research is only peripherally related to injury, and its principal focus is other health problems. In addition, because of the narrowly defined missions of the individual agencies that do the research, it is not nearly as comprehensive as is needed. Much important research is never funded at all, because it does not fit the programs of any of the agencies that support injury research. Nothing short of a program with principal responsibil- i~cy for injury research will suffice. Leaving the effort fragmented will mean that yet another opportunity to reduce a continuing public health problem will have been lost. The foregoing chapters of this report have defined the dimensions of the field and identified numerous research needs and opportunities that merit the attention of the scientific community. (It should be noted that important factors that have been less neglected, such as alcohol and drug research, have not been discussed at length.) The various agencies of the federal government use several approaches to administering research. Some agencies are engaged in both research and regulation (for example, the Food and Drug Administration and the Environ- mental Protection Agency); others are limited to research (the National Institutes of Bealth, NIB) or regulation (the Occupational Safety and Health Administration, OSAKA). In occupational health, the research function is performed by the National Institute for Occupational Safety and Health, a part of the Department of Health and Human Services, and the regulatory function is carried out by OSEA, a part of the Department of Labor. In addition, research programs like the National Toxicology Program tNTP) comprise research components from more than one agency. This chapter examines a number of those approaches and recommends ~ means by which research on injury could be efficiently and effectively administered. CRITERIA FOR ORGANIZTNG INJURY RESEARCH The committee first sought to identify criteria by which to find the organizational structure that would best meet the need to make research on injury efficient and effective. The criteria established by the committee reflect its recognition, gained in its examination of

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111 current efforts on injury research, that these efforts are too narrowly focused and underfunded. To correct the present situation, the committee considered the following criteria for determining the organizational setting and structure for the study of ~ Injury: . Research efforts should be organized in such a manner that all aspects of injury can be addressed by one unit-- .e., research on epidemiology, prevention, bio- mechanics, treatment, and rehabilitation; information gathering and dissemination; and training. . The unit should be so placed in the federal organizational structure that it fits the mission of the department that houses it, can receive continuing attention, and has a degree of visibility commensurate with the importance of injury to the nation 's public health. . The unit should be so placed that it will be recognized as the leader in in jury research and will be able to initiate cooperative efforts among appropriate federal agencies and serve as a contact point for private organizations and individuals. . It should be so placed that it will be able to improve communication, management, pr for ity-setting, and accountability . It should be part of a research organization, rather than part of a regulatory organization, and should itself be organized accordingly. FUNCTION OF A FEDERAL CENTER TO ADMINISTER INJURY RESEARCH Agencies are not uniform in their definitions of injury, and many agencies consider some of their activities in this field to be oriented toward ~service. or ~operations,. rather than ~research.. The solutions to problems addressed by injury research program-c often involve many disciplines. The objectives of a research program must consider the diverse elements of present research efforts, fully assess the resources available, establish priorities, and address the solutions that have the best cost-effectiveness relationship. But the objectives should not focus solely on cost. They should recognize the necessity of a balanced national program, consider all projects that might prove fruitful, and

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112 support projects that have the potential to reduce injury morbidity, even if the benef icial ef feats will be evident only in the longer term. The program objectives of the unit must be related to specific injury problems and focus on timely solutions. The program must include data collection, as well as research on and implementation of injury prevention, treatment, and rehabilitation. analysis are critical factors Data collection and in enabling the new unit to focus its research efforts on specific problems. On the basis of evaluation of the needs for research on injury, examination of the existing models for the organization of research, and the criteria for a unit that could effectively manage research on injury, the committee believes that it is essential to establish an injury research unit that would be administered by an agency of the federal government and whose sole interest is reduction of injury morbidity and mortality. The function of the unit would be to carry out a national injury research program in the following manner: Conduct and support research in biomechanics, injury epidemiology and prevention, and treatment and rehabilitation of the injured. Establish injury surveillance syste s , collect and analyze data on injury, and conduct injury prevention projects. Promote professional education and training in injury control. . Establish centers of excellence in in jury bio- mechanics, epidemiology, prevention, treatment, and rehabilitation. . Serve as a clearinghouse, coordinator, and lead agency among federal agencies and private organizations interested in injury research and control. I,OCATION OF A FEDERAL CENTER TO AI~STNISTER INJURY RESEARCH The committee considered the placement of a new entity in the private sector, but believed that no single private industry, foundation, or university could be expected to undertake a research program of the scope and magnitude necessary to pursue the wide-ranging needs outlined in this report. Although individual citizens would be the

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113 ultimate consumers of the product of injury research, the committee thought that location of the new unit within the federal government would be in keeping with its responsibility to promote public health. For that reason and because the government would be a major beneficiary if the costs associated with federally funded health-care programs were reduced, the committee concluded that the new unit should be estate, ished in the federal government structure. Having the federal government administer and coordinate the research would also facilitate communica- tion with executive and legislative agencies of the government . Many federal agencies already have in jury research programs, and development of a new organizational struc- ture must consider the consequences of leaving those programs in place or incorporating them into the new unit. The committee felt that existing agency programs should not be moved, but rather coordinated with the new unit to support the overall objectives. Part of the new unit 's mission, therefore, would be to serve in a coordi- nating role for the vat ious agencies that have research programs. The location of the unit is of the utmost importance, if it is to be successful in carrying out the functions enumerated above. If it is placed in an existing agency, the primary concerns are compatibility of mission, recep- tivity to the research approach, and possibilities for application of research f inding';. The committee discussed many possible locations for the unit and concluded that five existing federal agencies could reasonably be con- sidered: the National Institutes of Health (NIB), the Department of Defense (DOD), the Department of Transpor- tation (DOT), the National Bureau of Standards (NBS), and the Centers for Disease Control (CDC). The committee offers the following opinions on how well the placement of the unit to administer injury research in each of these agencies would meet research program needs. National Institutes of Health Persons concerned about the neglect of injury research have recently advocated the establishment of a national institute of trauma research in NIB. Although NIH is an attractive model to follow, the committee re jounced this approach for two main reasons:

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114 . NIH is or tented more toward basic research than toward the problem-or tented research essential for in jury control. The traditional focus of NIB on basic bio- medical research does not match the interdisciplinary needs of injury research, e.g ., the need for research in biomechanics and rehabilitation. The establishment of additional institutes does not have priority. A recent reported by the Institute of Medicine on the organizational structure of NIB stated that KNIN is now at a stage where there should be a presumption against additions at the institute levels Department of Defense DOD is the only agency that might currently have extensive programs in all the fields of research needed. However, its efforts concentrate on defense-related applications of injury research. The committee rejected DOD as a home for the new unit, because the department's mission does not match the needs of injury research. Department of Transportation Although NOT has the largest and most comprehensive injury-related program, the committee rejected placement of the new unit in DOT, because of its regulatory responsibilities and because its transportation-related mission was too narrow to fit the needs of the new unit. The committee acknowledges, however, that separation from the regulatory setting might reduce the unit's ability to influence regulatory decisions with relevant data. National Bureau of Standards NBS is highly respected for its research activities and could be considered to administer many technical aspects of an in jury research program. However, much as NIR focuses on basic biomedical sciences, the NBS research programs are too narrowly focused on engineering appli- cations.

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115 Centers for Disease Control The mission of CDC is the prevention of disease, disability, and premature death through interdisciplinary r esearch and dissemination of information. That is the type of approach needed in injury control and injury r esearch . Tn CDC, both laboratory and f ield research are integrated into a comprehensive public health program. CDC has authority to give grants, but most of the research funds are allocated by contract or cooperative agreement. Specific instructions for a proportion of funds to be used for investigator-initiated, peer-reviewed grants would be necessary, to guarantee a more complete range of research ideas. Although CDC has modest regulatory responsibility, it maintains a strong liaison with state health departments and can quickly disseminate information and technology nationwide. The committee acknowledges that location outside the Washington, D.C., area could be a disadvantage with respect to coordinating with other research efforts or maintaining informed support in Congress. However, the committee points to CDC and the National Toxicology Program (NTP) as examples of successful research programs which are administered outside Washington, D.C. CONCLUS TONS AND RECOMMENDATIONS The committee believes that improvements are needed in the current approach to administering injury research in the federal government. The nation needs a coordinated injury research program with clear objectives and more focus on critical needs, with adequate funding, and with the support of Congress and the executive branch. The substance of a national injury research program is important, but the organizational structure established to administer Me program is also importance Adequate communication among the agencies involved in injury research and the ability to focus research efforts on problems are essential. The structure of the organization should be such that it would facilitate the achievement o f those ob jectives . in keeping with the federal government ~ ~ interest in promoting the public welfare, the committee concludes that the new entity should be in the federal government structure. Such placement would facilitate communication

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116 with the executive and legislative agencies of the federal government. The committee believes that a new independent agency modeled after components of the Centers for Disease Control could best provide the needed national focus for injury research--focus that is difficult to obtain in any other way. The committee concludes that a Center for Injury Control (CIC) should be established as part of CDC. This would take advantage of the existing mission-oriented epidemiologic interests and data-collecting abilities of CDC. Although CDC does not now have programs in bio- mechanics, emergency care, acute care, and rehabilitation. it does have authority to give grants and a mechanism to establish study sections. It can also conduct demonstra- tion projects. The general miss ion of CIC would be to direct a coordinated research program to reduce morbidity, mortal- ity, and disability from injury. To accomplish these ob jectives, CIC must be a visible organizational entity in the government. Clear inghouse and coordinating functions in CIC are essential, although the in jury research problem is much greater than a problem simply of coordination. CIC should coordinate information on the efforts of various agencies now supporting injury research to avoid inappro- priate duplication of effort and to identify gaps in knowledge. It should also develop and maintain liaison with public and pr ivate agencies involved in in jury control, to disseminate the knowledge and technology developed in their efforts, to redirect efforts known to be ineffective, and to provide expertise in the study of efforts of unknown effectiveness. Because of the complex and broadly based scientific tasks that would be within the mission of CIC and the need to integrate the programmatic activities of several agencies, CIC should have an advisory council that includes representatives of federal agencies and other organizations engaged in injury research, as well as those which implement injury control programs. The council would provide guidance in identifying research subjects that need additional work and help to avoid inappropriate duplication of effort. CIC research priorities, however, should be established from within CIC. CIC must have a clearly identified budget authorization within that for CDC. It would be justified by identi

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117 f table research and training needs and by the availability of competent researchers required to meet those needs. The mission for CIC should be established by statute ithin CDC. The director and staff of CIC would be appointed to 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 director be a scientist with recognized research accom- plishments and successful experience in interdisciplinary investigation of injury. No single discipline or dis- ciplinary orientation will produce the broad spectrum of research needed for injury control. An appropriate structure of CIC is shown in Figure 8-1. Divisions dedicated to the major fields of needed research--epidemiology, prevention, biomechanics, acute care, and rehabilitation--would be coordinated by the CIC director. The center would report administratively to CDC, and the director of the center would have authority to appoint and convene the advisory council. CIC should foster and suppor t 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 Assistant Secretary for Health Public Health Service Director l CDC in! Advisory CIC | | Council | Epidemiology | | Prevention | | Biomechanics 1 | Acute Care 1 | Rehabilitation FIGURE 8-1 Suggested location and organizational structure of proposed center for injury control.

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118 supplement, rather than replace, funds currently allocated to other agencies, such as DOT, DOD, and NIB; 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 mech- anism 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 this center to independent agency status.