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7 Current Federal Expenclitures for Injury-Related Research The committee was charged to determine, to the extent possible, the adequacy of total federal funding of the major kinds of trauma research and to explore the impor- tance of pr ivate research and funding contributions from pr ivate , nongovernment sources . Th is chapter describes the extent of support from the various federal agencies and categorizes them according to the types of research that the committee has identified as necessary if the nation is to move toward reducing injuries and injury- related deaths. The motor-vehicle and insurance industries support some research, mainly on motor-vehicle injuries, but the support is modest relative to the need. We know of no major source of private funds for research on injury. In contrast, large amounts of money are raised by private groups interested in cancer, heart disease, and respira- tory diseases. Although no private organization, even one as large as the American Cancer Society, can alone support a large portion of the research in the subject of its interest, private organizations do play a critical role. They can provide seed money for the initiation of research centers. They can support innovative research that has not received attention from the federal agencies. As important, but not as tangible, private organizations focus interest on various subjects and keep the public, the federal agencies, and the Congre';s aware of the importance of those 'subjects. Whether a major fund- raising effort for injury research comparable with that devoted to the noted diseases is feasible in a society where mailboxes are clogged with computerized appeals to support all sorts of causes is problematic. To assess current federal support for injury-related r esearch , the committee reviewed research expenditures in 99

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100 relevant federal agencies dur ing the 1983 f iscal year . The agencies were asked to respond with lists of projects and budgets; these were supplemented by a search of records in a few instances where it appeared that the work of some agencies was not listed. This survey was not exhaustive, but it is unlikely that major expendz- tures were overlooked. The survey was based on reports of projects from the agencies and computerized indexes of research expenditures. This summary deals only with expenditures by civilian agencies. Much of the informa- tion from the military services was too sketchy for refined categorization. Some of the military research might be relevant to the prevention and treatment of civilian injuries, but most of the military research is oriented to military operational activities, such as the Air Force's development and testing of pilot e Section seats. Each listed project was coded according to the inter- ests outlined by the committee, which are substantively reviewed in the individual chapters of this report: epidemiology, prevention, biomechanics, treatment, and rehabilitation. Many projects deal with more than one category; in such cases, the committee determined the major emphasis of the research and assigned a code accordingly. These data are mostly from fiscal 1983 budgets, but that is ambiguous in some cases. Expenditures for research in the various aspects of injury epidemiology are presented in Table 7-1. Most of the funds allocated to epidemiology were expended on surveillance programs both for research purposes and for identifying problems to be addressed by regulatory agencies. The major expenditures were related to motor- vehicle injuries and those associated with some other consumer products. The Fatal Accident Reporting System (FANS) and the National Accident Sampling System (NASS) developed by the National Bighway Traffic Safety Adminis- tration (AETNA) are designed to monitor trends in mator- vehicle fatalities (FARS) and nonfatal crashes (MASS). Both are used extensively by extramural researchers. The National Electronic Injury Surveillance System (NEISS) is the major research activity of the Consumer Product Safety Commission. Through NEISS, a sampling of hospital emergency rooms provides information on consumer products (with exceptions, such as motor vehicles and firearms) that are involved in injuries treated in hospitals. Relatively small amounts were expended in fiscal 1983 to document psychologic consequences and calculable dollar

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101 TABLE 7-1 Federal Support for Research on Injury Epidemiology in Fiscal 1983 Subject and Source of Support Thousands of Dollars A. Incidence and severity Federal Aviation Administration National Highway Traffic Safety Administration National Institutes of Health Centers for Disease Control Consumer Product Safety Commission B. Costs National Institutes of Bealth C . Psycholog ic consequences National Institute of Mental Health D. Methodology National Highway Traffic Safety Administration National Institutes of Health E. Behavioral factors National Instituter of Health Alcohol, Drug Abuse, and Mental Health Administration National Institute of Occupational Safety and Bealth F. Product-related factors (e.g., guns, cars, industrial machines) National Bighway Traffic Safety Administration National Institutes of Health National Institute for Occupatione1 Safety and Bealth G. Social environmental factors National Institutes of Health B. Physical environmental factors other than products TOTAL 193 7,526 988 160 2,999 104 245 9,104 810 27 975 115 1,241 79 99 432 o 25,097

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102 costs of injuries. The relatively large amount listed under Methodology includes capital funds for computers and computer time that are no doubt used for a variety of tasks in addition to processing and maintaining in jury surve illance data . In addition to surveillance, epidemiology includes studies of factors involved in initiation and severity of in jury. Categor ies E through H in Table 7-1 refer mainly to f ield research. Behavioral re';ez~rch was directed primarily at the effects of alcohol and drugs on injury incidence. Relatively small amounts were expended to study the effects of vehicle and environmental factors as causes. The major expenditures for prevention research (Table 7-2) were provided by the Federal Highway Administration (FHA) and NHTSA. They were directed at the behavior of motor-vehicle operators and pedestrians and at modifica- tions of motor vehicles and road environments that would prevent collisions or ameliorate their severity. Almost two-thirds of the National Institutes of Health (NIB) expenditures for research on preventing injurious behavior was for evaluations of measures to counter dr iving by alcohol-impaired persons--the type of research that would normally be supported by NHTSP.. Despite the remarkable success of vehicle and environments modifications in reducing fatalities and severe in juries, 'such as the reduction in deaths of children caused by falls from tall buildings in New York, very little investigation of that type of prevention of other than motor-vehicle injuries was supported in fiscal 1983. The major efforts were N~TSA's crash-testing programs listed under ~Product- related factors. and programs in FBA on roadside hazards, listed under Environmental factors.. The FRA effort on implementation of safety research and development, listed under Organization and delivery,- is also a noteworthy exception to the general lack of Of for t in that sub ject . The funds devoted to injury mechanisms and bionic mechanics are shown in Table 7-3. A substantial proportion of the NIB allocations in directed at basic science in pursuit of spinal cord regeneration and understanding of the consequences of injury at the cellular level. The categor ies and dollar amounts in some instances suggest more activity in the research discussed than was seen to be the case when the project descriptions were examined in detail. For example, virtually none of the NIB funding under ~Mechanisms. was directed at research in biomechanic';. Support of research

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103 TABLE 7-2 Federal Support for Research on Injury Prevention in Fiscal 1983 Sub ject and Source of Suppor Thousands of Dollars A. Behavioral factors Coast Guard Federal Highway Administration National Highway Traffic Safety Administration National Institutes of Health National Institute for Occupational Safety and Health B. Product-related factors Federal Aviation Administration Federal Highway Administration National Highway Traffic Safety Administration Consumer Product Safety Commission C. Environmental factors Coast Guard Federal Aviation Administration Federal Highway Administration National Institutes of Health National Institute for Occupational Safety and Bealth D. Organization and delivery Federal Highway Administration National Institute for Occupational Safety and Bealt}1 E. Host physical susceptibility (e.g., osteoporosis ) National Institutes of Health TOTAL 150 3,220 2,3g4 910 63 637 450 7,293 320 318 181 7, 305 48 141 1,507 33 480 25,450

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104 TABLE 7-3 Federal Support for Research on Injury Mechanisms and Biomechanics in Fiscal 1983 Subject and Source of Support Thousands of Dollars A. Mechanisms National Highway Traffic Safety Administration National Institutes of Health National Institute for Occupational Safety and Health B. Biolog ic response and adaptation National Institutes of Health National Institute for Occupational Safety and Health Veterans ' Administration C. Secondary consequences (infections, etc.) National Institutes of Health TOTAL 1,676 5,891 570 13,142 21 3,039 6,002 30,341 in biomechanics is included in the S1.7 million listed for NRTSA, and the military services contributed an unknown amount. Many projects listed by the NIH computer as injury-related were excluded from our accounting, on the grounds that the connection was not evident in the project abstracts. These included projects investigating psychic ~trauma. not related to physical injury, labora- tory ~accidents. involving biologics, birth injury, and the like. Had the HIM computer totals for Trauma and injury. been used without project-by-project examination, grants for cancer center core support, aplastic anemia centers, etc., would have been included. Some of the included projects are of questionable relevance, but they do deal with infection, which often complicates the outcome of injury. Research expenditures relevant to treatment of the injured are indicated in Table 7-4. All ';uch funds in fiscal 1983 were allocated for technology, such as surgical techniques and devices. No funds were allocated

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105 directly for training or for organization and delivery of services, although some of the funds for multidisciplinary centers include such research. All the funds allocated for treatment research were directed at treatment in hos- pitals. No research on emergency response and treatment at the site of the injury event was included in the data submitted to or found by the committee. The funding for long-term care and rehabilitation, summarized in Table 7-5, was more balanced among medicine and technology, training, and organization and delivery of services than was funding for research on acute care, but the total was low, in the light of the enormous costs of tak ing care of persons who survive in jur ies with ma jor loss of function. In addition to the supper t shown in the tables, the National Transportation Safety Board (NTSB) expended S14 million for investigations, technology and safety programs in f iscal 1983 that could not be categor ized because of the interdisciplinary nature of the work. Although the interdisciplinary approach of the NTSB-supported work is commendable, the lack of a sampling plan results in questionable generalizability of the f indings. The investigation of fatal motor-vehicle crashes by NTSB duplicates much of the effort of N=SA's FARS program, albeit in greater detail, but without a sampling scheme. Table 7-4 Federal Support for Research on Acute Care of the In jured in Fiscal 1983 Sub ject and Source of Suppor t Thousands of Dollars A. Technology National Institutes of Health Health Resources and Services Administration B. Training C. Organization and delivery TOTAL 4,125 451 o o 4,576

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106 TABLE 7~o Federal Support for Research on Long-Term Care and Rehabilitation of the Injured in Fiscal 1983 Sub Sect and Source of Support Thousands of Dollars A. Medicine and Technology National Institutes of Health Veterans' Administration National Institute of Handicapped Research B. Training Veterans' Administration National Institute of Handicapped Research C. Organization and delivery Veterans' Administration National Institute of Handicapped Research Health Resources and Services Admin is tr ation TOTAL 1, 382 6,020 2,117 800 733 800 612 128 12,592 The specification of research allocations in a given year might not reflect the extent of involvement of agencies in relevant fields in other years or unsuccessful attempts by the agencies to find investigators to study problems that are recognized as needing attention. Never- theless, in some cases where one would expect some expen- ditures under current agency missions, there were none. Expenditures in a given year are perhaps more relevant when compared with allocations to other health-related research in the same year. The total expenditure for injury research by NIE, about S34.4 million, is less than 2 percent of the total NIB research budget.86 In 1980, motor-vehicle injuries alone cost the federal government S1. s billion in public assistance programs, S86 million in federal employees ' worker compensation and sick leave, and 35~6 billion in revenue losses. 3 0 Although the costs of all injuries have not been re- searched adequately, they were undoubtedly two to three times those amounts. Even a modest reduction in current death and injury rater would save hundreds of millions,

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107 if not billions, of dollars in government expenditures and in loss of revenues, not to mention the costs to individuals and organizations not associated with government. The total federal expenditures for nonmilitary research on injuries were approximately S112 million in fiscal 1983. Although injury results in the loss of more eco- nomically productive years of life than cardiovascular disease and cancer combined, the support for research on injury control is relatively small (Figure 7-1, on page 108), about 11 percent of that for research on cancer and 18 percent of that on cardiovascular disease. This is not intended to imply that the retirement years are inherently any less valuable than the preretirement years. But the welfare of the retired depends sub- stantially on the productivity of the working population. The committee believes that substantial inroads in current injury rates would result from research requiring substantially less support than is now expended on cancer 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.

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108 4 1 Million Years of Lite Lost S1 12 Million Research Expenditures Aim... ::: ::: :-:: _ :::< . . - _~ , . ... . ; ; :::::::::..:::::,:::::;:::::: 2: :,:.:.:~:.:~: :.:,:.:.:..:2:.:,:.:.:2:.:.2:,: :2:. :~:~:,:~:~:.:.:,:~:~:~:~:.:,:~:~:,.,: :.::.:,:.::: .: :.:,:.:.:.:,:2:,:.:::::::::::2::: :.: :.: :.:.:.:. :.:.:,: :.:.::: :::.,: :..:: .::: ::,:.::::::: :::::::::..:::.:,:::.::.:::: ,:.:.: .:2:.:,:.: :,:~:: :.:.: . ~ ~ . :: ::::::::::::::::::::::::::::.::::::::: :2:. :~:~:,:~: :,:.:,:.:.:~:::~:.:~:::. .:.:::,::,:.:...: ::::::::::::.::::::::.::::::: .:~..:~:.:.:~: :~.:~:.:.:~:.:~:~.:.:~..:.:~: :.2:.:, ,: ::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::: :S9961 Million Re#arch Expenditures :~:~:~:~:~::::::: ::::...:::~:::: ::::::::::::::::::::::::::. ::::::::::: ::::::::::::::::::::::::::::: :::::::: ::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::: :::::::::::::::::: : :,:.: :2:2: :. 2 . . . ~ .: .::: . : :::::::::::::::::::~:::.::~::: .: ::.:.: :.:,:.:: ::: :::.: ::::::::::::::::::::: ::::::::::::::::::::::::::::~::: :::: :.:~:::~::: ::.:.: :~:2:~:~:~:2:.:.:.:2..2.::::: :,::: ..................................................... ., ...2.' ~2','2.''.2 ' ' .' 2 :::::::::::::::::::::::::::::: :~: ::: :.:: ::::: .> ::2:~::~::~:::2:::.:2... ::::::::,: .... :::::::::::::: .. : :.: ... .:.:.:2:.:: :2:~: :2:2: :2. :' .::: :.: :.: :. .. ::::::::::::::::::::::::::::::::: :::::::::: <. :::::::e ::::::::::::::::::::::: :.::::: :~:, :, :::::::::::::::::::::::::::::::::::::::::: . . : :.:.:,:.:~:.:~:~:~:.:.:.:.:.:~:~:~:~:.:~: :,: :.:.:. .. ,:,: . ::::: . 2:~:.: . :::::: . . . ...~2 :::: :::: ::-: :: .~ ; ; ; . . . :-: ~ . 1.7 Million Years of Life Lost :::::::::::::::::::::::::::: ............................... ,. . ::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::: :$624 Million : Research Expenditures . ~. ~.~.~ ..~.~. ~.~.~.~. ~ ~.~.~ -;; ;~;; ;;;.;;; a; .~;~;~;~;~;~:~:~;~: a; , .:,:,:.:~:,:2:.:.:.:.: :,: :~:.:.:~:.: :::,: ::.:. ::::::::::::::::::::::::::::::::::::::::::::::::::::::: . ~ ~.~.~ :~:~:::::~::::::::~:::::::. :::: ....................................................... ................................................ :2:.:~:~: :::: :::::::: . . ::: :::::::::::::::::::::::: - -: :: :,:,:.:: :,:: ::: :. .: . . . : :. .............................. ,,..,.2 ~ ,! i..'2 ~Years of 1i ~ 2.1 Million Years at Life Lost Injury Caneer Heart Dnea - /Stroke FIGURE 7-1 Preretirement years of life lost annually and federal research expenditures for ma jar causes of death in the United States. Years of life lost derived from National Center for Health Statistics. ~ 2 6 The total federal expenditure for injury research is the sum of the amounts discussed in this chapter plus a 5 percent increment for administration, the latter in line with NIH administration costs. Expenditures for research on neoplasm and cardiovascular diseases are the 1983 f iscal year budgets of the National Cancer Institute and the National Heart, Lung, and Blood Institute . ~ 6