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Reducing the Burden of Injury: Advancing Prevention and Treatment 8 Federal Response The purpose of this chapter is to evaluate the current federal response to the problem of injury and to make recommendations to strengthen that response for the future. The federal government's collective response spans the work of numerous agencies in nearly all cabinet-level departments (Table 8.1). These agencies have far-ranging missions, varying approaches, and differing levels of commitment to preventing injuries. Since the federal effort is so multifaceted and diverse, the committee chose to focus on eight agencies for which it felt that its recommendations would significantly advance the injury field. For each agency, this chapter contains a description of the agency's mission, resources, and injury-related programs, followed by the committee's assessment and recommendations. However, the committee did not restrict itself to an agency-by-agency assessment. An effective federal response relates to more than just the sum of its parts, especially when the "parts" are dispersed across dozens of agencies. Consequently, the final portion of this chapter emphasizes the need to avert fragmentation through cooperation, coordination, and leadership, so as to reduce the toll of injuries. The eight federal agencies covered in this chapter are (1) the National Highway Traffic Safety Administration (NHTSA) of the Department of Transportation; (2) the Consumer Product Safety Commission (CPSC); (3) the Occupational Safety and Health Administration (OSHA) of the Department of Labor; (4) the National Institute for Occupational Safety and Health (NIOSH); (5) the National Institutes of Health (NIH); (6) the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA);
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Reducing the Burden of Injury: Advancing Prevention and Treatment (7) the Office of Justice Programs (OJP) of the Department of Justice; and (8) the National Center for Injury Prevention and Control (NCIPC). 1 The committee's evaluations and recommendations are based on insights gained from an array of activities it sponsored over the course of 18 months. The activities included workshops, public meetings, site visits, surveys, written testimony, and extensive interviews of, and discussions with, federal and state leaders in injury prevention and treatment. The committee identified the following overarching themes: the need to strengthen research at some agencies; the need to encourage more emphasis on research planning and priority setting; and the need to enhance funding for research, training, and programs in select areas. NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION The National Highway Traffic Safety Administration was created by the Highway Safety Act of 1970 as the successor to the National Highway Safety Bureau, itself the product of highway safety legislation passed in 1966. NHTSA's mission is "to save lives, prevent injuries and reduce traffic-related health care and other economic costs. The agency develops, promotes, and implements effective educational, engineering, and enforcement programs toward ending preventable tragedies and reducing economic costs associated with vehicle use and highway travel" (NHTSA, 1994). NHTSA's traffic safety activities span research, surveillance, programs, public education, and regulation. The focus is primarily on prevention and acute care, rather than on rehabilitation. Regulation NHTSA's regulatory activities are authorized separately under the National Traffic and Motor Vehicle Safety Act of 1966. This legislation mandates the establishment and enforcement of safety standards for new motor vehicles and motor vehicle equipment. These standards relate to windshields, headlights, occupant protection systems, brakes, and side impact protection, among other items. NHTSA's safety standards are developed through a formal rule-making process, after which NHTSA enforces the standards through compliance investigations. Compliance investigations are often triggered by the approximately 1,500 reports received from the public per month about alleged safety problems. NHTSA also develops standards for collision bumpers, odometers, fuel economy, and theft prevention under the Motor Vehicle Information and Cost Savings Act. Since the 1970s, NHTSA has shifted its regulatory strategy away from 1 NCIPC and NIOSH are part of the Centers for Disease Control and Prevention (CDC), which is within the Department of Health and Human Services, as are the NIH and HRSA.
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Reducing the Burden of Injury: Advancing Prevention and Treatment TABLE 8.1 Federal Agencies Involved in Injury Prevention and Treatment Agency Injury Focus Consumer Product Safety Commission Consumer products Department of Agriculture Farm safety Department of Commerce National Institute of Standards and Technology Safety materials Department of Defense Safety of military personnel Department of Education National Institute on Disability and Rehabilitation Research Rehabilitation Department of Energy Worker safety Department of Health and Human Services Administration for Children and Families Children's Bureau Child abuse Administration on Aging Safety of older Americans Agency for Health Care Policy and Research Injury outcomes, managed care Centers for Disease Control and Prevention National Institute for Occupational Safety and Health Occupational safety National Center for Injury Prevention and Control Intentional and unintentional injuries National Center for Chronic Disease Prevention and Health Promotion Injury prevention National Center for Environmental Health Disabilities Health Resources and Services Administration Maternal and Child Health Bureau Children's safety Indian Health Service Native American populations National Institutes of Health National Institute on Aging Elderly populations National Institute on Alcohol Abuse and Alcoholism Alcohol National Institute of Arthritis and Musculoskeletal and Skin Diseases Fractures, musculoskeletal injury National Institute of Child Health and Human Development National Center for Medical Rehabilitation Research Rehabilitation National Institute on Drug Abuse Drugs, violence National Institute of General Medical Sciences Wounds, shock, burns National Institute of Mental Health Suicide, abuse National Institute of Neurological Disorders and Stroke Spinal cord injury, CNS injury Substance Abuse and Mental Health Services Administration Violence and suicide prevention
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Reducing the Burden of Injury: Advancing Prevention and Treatment Agency Injury Focus Department of Housing and Urban Development Youth violence Department of Justice Office of Justice Programs Crime, violence, and justice Bureau of Justice Statistics Statistics National Institute of Justice Violence Office of Juvenile Justice and Delinquency Prevention Juvenile crime and justice Department of Labor Bureau of Labor Statistics Occupational safety statistics Occupational Safety and Health Administration Occupational safety Department of Transportation Federal Aviation Administration Aviation safety Federal Highway Administration Highway safety Federal Railroad Administration Railroad safety Federal Transit Administration Public transportation safety National Highway Traffic Safety Administration U.S. Coast Guard Highway and traffic safety Boating safety Department of the Treasury Bureau of Alcohol, Tobacco, and Firearms Alcohol and firearms Department of Veterans Affairs Rehabilitation, treatment of injury Federal Emergency Management Agency U.S. Fire Administration Fire safety National Science Foundation Biomechanics, violence, biomedical engineering National Transportation Safety Board Investigation standard setting to greater reliance on mandatory recalls, a shift paralleled by the Consumer Product Safety Commission (CPSC). The impetus for this transformation has been judicial review, among other factors (Mashaw and Harfst, 1990; Dewees et al., 1996). Resources and Structure In FY 1997, NHTSA was appropriated $300 million. Its 632 FTEs (full-time equivalents) were divided among seven branches and five offices serving the administrator. A significant portion of NHTSA's budget, about 55 percent in
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Reducing the Burden of Injury: Advancing Prevention and Treatment FY 1997, was devoted to financing state programs authorized under Section 402 of the Highway Safety Act. The largest single program is the "Section 402 State and Community Formula Grants," which support performance-based highway safety programs planned and managed by states in order to reduce highway crashes, deaths, and injuries. Formula grants for state programs under Section 402 are similar to block grants in that they are awarded on the basis of a state's population and public road mileage in relation to national figures. In FY 1997, the Federal Highway Administration (FHWA) merged its Section 402 highway-related safety grant program with NHTSA's Section 402 traffic safety grant program and the resulting State and Community Formula Grants Program is now administered by NHTSA. From 1992 to 1998, a total of $887 million was allocated to the states. NHTSA also funds incentive grants to states, including Alcohol Incentive Grants, which enable states to reduce safety problems related to driving while impaired by alcohol.2 In comparison to formula grants, states are eligible for alcohol grants only if they have met specific criteria, such as administrative driver license actions, graduated licensing systems, and sanctions for repeat offenders. These funds are used to encourage states to enact strong, effective anti-drunk driving legislation; improve enforcement of drunk driving laws; and promote the development and implementation of innovative programs to combat impaired driving. In 1997, 38 states received a total of $25.5 million for this program. Research NHTSA conducts a research program on vehicle and traffic safety. Its traffic safety research—funded at approximately $6 million annually—focuses on behavioral research and emphasizes alcohol and drugs, occupant protection, and driver fatigue and inattention. Vehicle safety research, the larger of the two research programs—funded at about $30 million annually—stresses crashworthiness (biomechanics, air-bag and occupant safety); crash avoidance (directional control, braking, rollover stability, and intelligent transportation systems); high fuel efficiency vehicles; and crash testing in an in-house facility. NHTSA supports its research largely through contracts, although some research is performed internally (TRB, 1990). Contracts are awarded competitively after publication of a request for proposals (RFP) and a structured internal review process according to published criteria (unless contracts are sole source). Contract recipients are typically either private firms or universities. NHTSA does not sponsor investigator-initiated research through an extramural grant program, with the exception of one program on intelligent transportation systems. NHTSA also does not sponsor a formal research training program. 2 In FY 1998, alcohol grants were consolidated under the Section 402 program.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Surveillance NHTSA conducts surveillance activities through its National Center for Statistics and Analysis, which received about $20 million in FY 1997. This center houses two major data systems, the Fatality Analysis Reporting System (FARS) and the National Automotive Sampling System (NASS). FARS tracks all motor vehicle crashes on public roads that result in a fatality. Begun in 1975, it is used to monitor trends in traffic safety and evaluate the impact of motor vehicle safety standards. FARS relies on a designated person within each state who, under contract to NHTSA, extracts and codes 100 data elements on the crash, the vehicles, and the people involved. These elements are obtained from the analysis of multiple state information systems, including police accident reports, vital and death certificates, coroner or medical examiner reports, hospital records, and emergency medical service reports. Surveillance of all types of traffic crashes, which involve both deaths and injuries, is the focus of the NASS. This system is made up of two separate surveillance systems, both of which are representative samples of traffic crashes. The oldest, the Crashworthiness Data System, formed in 1979, depends on thorough crash investigations conducted by 24 field research teams studying about 5,000 crashes annually. The research teams measure crash damage, interview crash victims, and review medical records to ascertain the nature and severity of injuries. Among the uses of this system are detailed data on the crash performance of passenger cars, the evaluation of safety systems and designs, and improved understanding of the relationship between the injuries and severity of the crash. The second system, created in 1988, is the General Estimates System (GES). This system is a nationally representative probability sample of police-reported crashes. Eligibility for sampling depends on a police accident report having been filed; the crash having involved at least one motor vehicle; and the result being either property damage, injury, or death. GES samples about 50,000 police reports each year covering 400 police jurisdictions in 60 selected areas in the United States. NHTSA publishes an annual compilation of data on traffic-related injuries and deaths, including trend data, from FARS and GES (NHTSA, 1996). Assessment and Recommendation Substantial improvements in motor vehicle safety have been achieved over the past 25 years (see Chapter 5). Although many factors have contributed to this success, including increased urbanization and improved highway design, NHTSA's activities have undoubtedly played a major contributing role (Graham, 1993). NHTSA has effectively led the motor vehicle safety field by promulgating science-based vehicle safety standards; supporting, evaluating and disseminating safety programs at the state and local levels; and forging research partnerships with universities.
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Reducing the Burden of Injury: Advancing Prevention and Treatment State and Local Programs NHTSA has developed an outstanding program of assisting state and local governments to combat motor vehicle injuries. NHTSA's grant programs authorized under Section 402 of the Highway Safety Act have been instrumental in the development of a national infrastructure. NHTSA studies have found some state programs to be not only highly effective but also cost-effective in terms of lives saved relative to costs incurred (NHTSA, 1991, 1995). In addition to its grant programs, NHTSA plays a leadership role through the conduct of national evaluations that guide states and communities in moving interventions into practice. For example, its research has examined the impact of state laws relating to blood alcohol levels, seat belt use, and motorcycle helmets. Research results, in turn, are widely distributed to states. They have been pivotal in the passage of state laws to curtail drunk driving and promote helmet usage, among other areas. NHTSA also is to be applauded for recruiting new types of stakeholders who are concerned about injury prevention at the local level. NHTSA wisely recognized that the traditional stakeholders (e.g., health care professionals, emergency medical technicians, safety advocates) must be expanded to include law enforcement, business, local government, and schools. NHTSA has fostered the development of the Network of Employers for Traffic Safety, a public and private partnership that encourages employers to integrate traffic into their safety management systems. With coordinators in approximately 30 states, the network's major activities include training in traffic safety management practices and an emphasis on safety awareness programs such as BeltAmerica 2000, the employer component of Buckle Up America! and National Drive Safely@Work Week. At the community level, NHTSA has forged the Safe Communities program designed to integrate injury control at the community level (NHTSA, 1997). Guided by the philosophy that communities are in the best position to design innovative solutions to all of their injury problems, NHTSA launched Safe Communities in 1995 with assistance from federal, state, and local partners. NHTSA provides leadership, resources (through Section 402 grants), and technical assistance. To qualify as a Safe Community, a community must meet four criteria: (1) it uses injury data analysis and linkage to define its injury problem; (2) it expands partnerships, especially with health care providers and businesses; (3) it involves citizens and seeks their input in program design and implementation; and (4) it creates an integrated and comprehensive injury control system. Research and Training In order to fulfill its regulatory role, NHTSA has a strong applied research portfolio that is conducted through contract and internal research. Contract research is most appropriate when the purpose is not to answer fundamental questions but to identify and evaluate different methods of achieving agreed-upon
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Reducing the Burden of Injury: Advancing Prevention and Treatment goals. However, it is less likely than grant research to produce innovation because it is driven by agency need and is not subject to independent peer review. The committee urges NHTSA to expand its investigator-initiated research program and to implement greater reliance on external peer review for both its contract and grant programs. It is crucial to encourage the publication of results from all types of NHTSA funded research in peer-reviewed scientific journals, and NHTSA may consider accepting publication of journal articles in the peer-reviewed literature in lieu of final reports. NHTSA currently cosponsors one small investigator-initiated research program, the IDEA program (Ideas Deserving of Exploratory Analysis) which funds innovative research in intelligent transportation systems. The program is jointly sponsored by NHTSA, FHWA, and the Federal Railroad Administration with the peer-review process administrated by the NRC's Transportation Research Board (TRB). To promote greater scientific innovation and quality the committee believes that NHTSA needs to establish formal procedures for independent review of its research plans. One NHTSA research office recently published a five-year draft strategic plan for its research program in the Federal Register.3 In addition to seeking comments, the office plans to follow up with meetings involving outside experts. This is an important step, especially because NHTSA controls much of the country's agenda on highway safety research. The approach taken by the Federal Highway Administration (FHWA) may serve as a model for NHTSA. FHWA asked the National Research Council's Transportation Research Board (TRB) to review its research plans covering a large amount of research through many different programs.4 Since 1991, a TRB committee,5 consisting of a wide-ranging group of experts in transportation and related fields, has reviewed research plans and made recommendations to the FHWA. A similar strategy could be adopted by NHTSA to improve the quality of its contract research portfolio. Following the creation of the federal highway safety program in 1966, there was an expansion of extramural research capacity that endured through the early 1970s. When funding leveled off and actually decreased somewhat in constant dollars, many researchers left the field. More recently, funding has expanded somewhat, primarily in engineering disciplines, but there is a ''missing generation" in between. Over the next decade, most of the leadership developed during the early years is destined to retire, without seasoned replacements. If a field of study is to remain vibrant, there must be a commitment to continuity of training and research support, both to attract and train new researchers and to sustain and nourish the growth of those already in the field. Unlike programs for other major health problems and other programs in DOT, funding in highway safety does not include support for graduate study. In order to attract young investigators to the field, support could be provided for graduate education in biomechanics, biosta- 3 The Office of Research and Traffic Records, Research and Evaluation Division. 4 Research spending amounted to $201 million in FY 1993 (TRB, 1994). 5 The Research and Technology Coordinating Committee.
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Reducing the Burden of Injury: Advancing Prevention and Treatment tistics, engineering, epidemiology, health education, psychology, or any of a number of other disciplines that are relevant to highway safety research. Longer-term research support also is needed if serious researchers are to commit to careers in the field. The committee recommends that NHTSA expand its investigator-initiated research program, conduct periodic and independent peer review of its research and surveillance programs, and provide training and research support to sustain careers in the highway traffic safety field. CONSUMER PRODUCT SAFETY COMMISSION The Consumer Product Safety Commission is an independent regulatory, research, and educational agency established in 1972 by the Consumer Product Safety Act. This legislation mandated CPSC to "protect the public against unreasonable risks of injuries and deaths associated with consumer products." CPSC has jurisdiction over approximately 15,000 types of consumer products that collectively are associated with about 21,400 deaths and 29 million injuries annually (CPSC, 1996a). CPSC's purview does not extend to motor vehicles; food and drugs; or alcohol, tobacco, and firearms. The mission of the CPSC is "simple and nonpartisan: saving lives and keeping families safe in their homes" (CPSC, 1996a). The breadth of this mission is reflected by the fact that CPSC enforces five separate statutes, the earliest of which was the 1953 Flammable Fabrics Act.6 CPSC's major activities are to develop product safety standards, most of which are voluntary; to ban products for which safety standards cannot effectively eliminate a hazard and to recall and/or require repair or replacement of defective products; to collect data and conduct research on potential product hazards; and to educate consumers. CPSC also operates a toll-free hotline for consumers to report unsafe products or product-related injuries. The number of calls has gradually escalated in recent years, with 288,000 such calls in FY 1998. Resources and Structure In FY 1998, CPSC had a budget of $45 million and 480 FTEs. For the past five years CPSC's budget has remained stable; however, from 1974 to 1996 its inflation-adjusted budget decreased by about 60 percent (GAO, 1997). CPSC 6 The statutes administered by CPSC are the Consumer Product Safety Act, the Federal Hazardous Substances Act, the Flammable Fabrics Act, the Poison Prevention Packaging Act, and the Refrigerator Safety Act.
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Reducing the Burden of Injury: Advancing Prevention and Treatment houses three operational offices: compliance, field operations, and hazard identification and reduction. The latter office is the site of CPSC's internal research and surveillance activities. CPSC does not provide grant funds to states or universities for injury research or programs. Regulation CPSC, as indicated above, has at its disposal several approaches to regulation through its standard-setting and recall authorities. With respect to the former, CPSC relies far more heavily on voluntary, rather than mandatory, standards for product performance or labeling. Its declining use of formal rulemaking is partially attributable to the Consumer Product Safety Act Amendments of 1981, which made rulemaking requirements more stringent; they require CPSC to employ a voluntary, rather than a mandatory standard when it finds that the voluntary standard can adequately address the hazard and that substantial compliance is likely (GAO, 1997). By its own account, CPSC has worked with industry for the past two decades to develop more than 300 voluntary standards, while issuing less than 50 mandatory standards (CPSC, 1996b). CPSC also has shifted its emphasis from standard setting to recall and informational activities. CPSC's use of product recalls and corrective action programs has significantly increased; from FY 1980 to FY 1989, the annual number of recalls grew from 132 separate actions to 260 such actions (Dewees et al., 1996). Surveillance, Research, and Standards Development CPSC's surveillance, research, and standards development activities are conducted within the office responsible for hazard identification and analysis and hazard reduction. These activities were funded at about $13 million in FY 1996. Most of these funds are devoted to surveillance and standards development. CPSC maintains two surveillance systems, one for fatal injuries, and one for injuries requiring emergency treatment, which captures nonfatal injuries. Deaths caused by product-related injuries are monitored through the purchase and analysis of state death certificates and through CPSC's Medical Examiner and Coroner Alert Project. Surveillance of product-related injuries requiring emergency treatment is captured by CPSC's National Electronic Injury Surveillance System (NEISS). Under NEISS, data are collected at a probability sample of 101 hospital emergency departments, enabling CPSC to generate national estimates of the frequency and severity of product-related injuries. The approximately 330,000 annual reports in this database cover demographic data, the cause of injury, the type of product, and the body part injured, among other information. CPSC uses NEISS and other data collection systems to set priorities, develop standards, ban
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Reducing the Burden of Injury: Advancing Prevention and Treatment and recall products, evaluate the effectiveness of previous standards, and formulate information and educational campaigns. In a recent report, the General Accounting Office (GAO) contends that CPSC's surveillance of injury-related morbidity and mortality underestimates the full extent of product-related hazards because it omits cases not treated in emergency departments and fails to capture information on vulnerable populations and those with chronic conditions. The GAO recommends an assessment of the feasibility, cost, and design of new data systems (GAO, 1997). Research conducted or sponsored by the CPSC has traditionally encompassed two general activities: (1) the testing and evaluation of consumer products to ascertain the nature and cause of any safety hazard and (2) applied research to explore the possibility of developing innovative product designs to reduce existing safety hazards, and to explore the feasibility of new performance requirements. At the present time, the agency's limited resources for research are devoted almost entirely to the first of these activities. Product testing and evaluation are conducted intramurally or by small contracts. The CPSC maintains two laboratories, one in chemistry and the other in engineering, to test and assess the safety of consumer products.7 The FY 1997 budget for contracts to supplement the agency's internal capability was $250,000. CPSC does not support any extramural research grants. Public Education In recent years, CPSC has intensified its educational activities to inform the public about product-related injuries. A noteworthy feature is that the educational activities are frequently undertaken through partnerships. Such partnerships enable CPSC to leverage its resources, given its relatively modest budget in relation to its broad jurisdiction. Two partnerships, highlighted in the CPSC publication Success Stories, are Baby Safety Showers and preventing infant suffocation (CPSC, 1996b). Baby Safety Showers is a national grassroots campaign inaugurated in 1995 to educate prospective parents about injury prevention at home. Predicated on the traditional baby shower, the program offers educational tips for prospective parents and encourages guests to give safety-related gifts instead of traditional gifts. CPSC promotes the program along with other federal partners and national safety and medical groups, while the program's chief financial supporter, Gerber Products Company, prints and distributes for parents, thousands of "how to" kits and checklists for safety. CPSC has sent out over 420,000 kits and checklists since the campaign began. 7 Because of the small scale of the laboratory program (approximately $200,000 annually), CPSC does not routinely peer-review individual research projects unless they are highly complex.
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Reducing the Burden of Injury: Advancing Prevention and Treatment other federal agencies.17 Other major areas may have to be identified, and within each priority area, detailed priorities have to be elucidated. In the past, NCIPC has not systematically incorporated its stakeholders in the ongoing process of setting priorities for its intramural and extramural research programs. Stakeholders include federal research partners; representatives of state, local, and private organizations; public health professionals and practitioners; academic researchers; and the public. The value of a participatory research priority-setting process is that it coordinates diverse research programs, responds to regulatory needs, encourages synergies, and maximizes the use of limited resources. The inclusion of stakeholders and the public helps to enhance the knowledge base for priority decisions and leads to more widely accepted decisions (IOM, 1998). NCIPC is to be commended for having undertaken from 1991 to 1993 a consensus-building planning activity that set forth an agenda for research and programs (NCIPC, 1993), but this activity was time limited and has not been monitored or evaluated in terms of implementation, impact, or cost-effectiveness. NCIPC might wish to consider developing a priority-setting process similar to the award-winning one employed by NIOSH—the National Occupational Research Agenda (discussed above). The inclusion of federal research partners was one of the hallmarks of NORA. Their inclusion led to the single largest infusion of investigator-initiated research funds for occupational safety and health research. NIOSH's contribution of $5 million to this joint endeavor came from a special congressional appropriation in recognition of the value of NORA. At least two separate NCIPC advisory committee reports on firearms and motor vehicle research recommended that research planning be performed in conjunction with federal research partners (NCIPC, 1995, 1997b). Federal regulatory partners such as CPSC also must be included. CPSC has a substantial regulatory interest in preventing residential and recreational injuries caused by consumer products. NCIPC is the primary source of federal funding for research on residential and recreational injuries, including those in which consumer products are implicated. CPSC has only limited funds to conduct research, and the research is restricted to consumer products, which are not the only causes of residential and recreational injuries. Therefore, these areas of research need priority attention by the NCIPC. The committee recommends that NCIPC establish an ongoing and open process for refining its research priorities in the areas of biomechanics, residential and recreational injuries, and suicide and 17 Although NCIPC deserves credit for its support of trauma systems research, the committee believes that this area should be moved to HRSA, to ensure its expansion and linkage to a broader range of federal trauma systems development activities discussed in Chapter 6.
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Reducing the Burden of Injury: Advancing Prevention and Treatment violence prevention, in close coordination with its stakeholders and federal partners. Training Because of funding limitations, NCIPC has been unable to launch a formal grant program for research training. The need for comprehensive training programs was underscored by Injury in America and reiterated in Injury Control (NRC, 1985, 1988). The lack of formal research training programs by NCIPC has inhibited the development of the injury field. (Problems with the paucity of training programs for injury practitioners are discussed at greater length in Chapter 7.) Research training serves as a vital investment in the future of a field. It channels young people into a career pathway, ensures a pipeline of capable researchers, and sustains future progress of a field. Formal training grants either to individuals or to institutions are the hallmarks of NIH's approach to building research careers. Such grants have been employed by NIH for decades to create a critical mass of young researchers, to create curriculum, and to ensure innovation. The establishment of formal training grants represents a defining feature of a field (see Chapter 4 for recommendation regarding support of training and research careers). Today, young researchers cannot look forward to a career in injury research because the funding and award structures are unreliable. In comparison, young people gravitate to careers in cancer and heart research where resources are plentiful for training and for the pathway that ordinarily follows—the receipt of grants for research. In these areas, students can envision a career trajectory as long as they have good ideas. NIH, as described previously, does fund mostly institutional training grants for clinical and basic research in trauma. Yet these training grants are geared mostly to M.D.s at academic medical centers for treatment-related research. There simply are no comparable types of training grants geared to pre-and postdoctoral students in the elements of injury prevention, including epidemiology, biostatistics, biomechanics, behavioral sciences, and program evaluation. NCIPC should establish a program of individual and institutional training grants to schools of public health and other institutions. Furthermore, as fully discussed in Chapter 7, training opportunities are scarce for injury practitioners. The 1993 agenda-setting report Injury Control in the 1990s: A National Plan for Action identified the need for training of injury professionals as one of its critical recommendations (NCIPC, 1993). The committee reasserts the need for training of injury professionals and strongly recommends that NCIPC expand training opportunities for injury prevention practitioners and researchers.
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Reducing the Burden of Injury: Advancing Prevention and Treatment To ensure the success of this recommendation, the committee suggests that the NCIPC work with other relevant federal agencies (e.g., NHTSA, MCHB, NIOSH, CPSC) to implement the training recommendations of the National Plan (NCIPC, 1993). Additionally, to ensure a trained work force to conduct injury research, NCIPC should initiate a formal program of individual and institutional training grants for pre-and postdoctoral candidates. Building State and Community Infrastructure NCIPC has fallen short of expectations for building state and local injury prevention programs. The formation of such programs nationwide was a major force behind the placement of an injury center within CDC. In its 1988 report, the NRC recommended CDC as an opportune location for a federal injury program because of its long-standing and durable relationships with state and local health departments. The NRC envisioned a constellation of programs in every state and community, with the CDC as a focal point for financial and technical assistance. CDC was seen as pivotal to moving injury prevention research into practice (NRC, 1985, 1988). More broadly, the need for vigorous federal efforts to shore up state and local health programs was described in a landmark report (IOM, 1988). NCIPC's shortcomings in cultivating state and local programs are a function of three factors: resource constraints, its policy decision (noted earlier) to steer away from capacity building and towards more focused injury surveillance and interventions (through cooperative agreements); and greater reliance by Congress on earmarked funding for state and local activities. NCIPC estimates that $15 million of the $19 million it disbursed through cooperative agreements in FY 1997 was directly or indirectly related to Congressional earmarks over the past several years (M. Scally, NCIPC, personal communication, 1998). From the point of view of the state and local programs, NCIPC's role does not sufficiently satisfy their needs for technical assistance and is overly prescriptive. With respect to technical assistance, NCIPC has no formal office serving state programs. Most other federal agencies seeking to build state programs have entire offices whose mission is devoted to state and local assistance. The technical assistance should transcend the technical aspects of program design and implementation. It should also entail assistance in identifying and accessing funding from NCIPC as well as other federal and private sources. This report outlines the daunting array of possible funding sources in multiple government agencies. The complexity can be overwhelming even to aficionados of federal injury programs. It is imperative for state and local programs to receive help in identifying an array of potential sources of funding, in both the public and the private sectors, with which to build comprehensive injury programs. The conversion to cooperative agreements is a relatively new development. The transformation of more flexible grants into more circumscribed cooperative
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Reducing the Burden of Injury: Advancing Prevention and Treatment agreements has been especially problematic for states without established injury programs. These states are at a disadvantage in the competitive process to attain funding, a process that favors states with more established programs. Yet states lacking established programs are the very states in need of federal assistance. They see themselves as falling further and further behind, whereas states with an injury infrastructure are seen as more and more successful. They point to an evaluation by Battelle, under contract to NCIPC, that found NCIPC's grants to states from FY 1989 to FY 1993 to have been so valuable that it recommended their expansion to all 50 states. According to the final report, ''Efforts should be instituted to bring those states currently without adequately funded injury control programs at least up to a minimal level" (Hersey et al., 1995). NCIPC, to its credit, responded to state concerns by inaugurating a new program on Basic Injury Program Development in FY 1997 (Chapter 7). This new program is a step in the right direction, but it is not sufficiently ambitious in size or scope to address current needs. In summary, NCIPC should restructure its financial assistance to states to give them more latitude and more technical assistance in building their infrastructure (see recommendation in Chapter 7). The committee recommends that the NCIPC support the development of core injury prevention programs in each state's department of health, and provide greater technical assistance to the states. Nuturing the Injury Field The authors of Injury in America envisioned that the NCIPC would become the locus of an intensified federal effort in injury prevention and treatment (NRC, 1985). Since its inception, the NCIPC has been the main advocate for the public health paradigm of injury prevention and treatment. As described in Chapter 1, this paradigm has enriched the entire injury field—from traffic safety to criminology. Although NCIPC's relationship with other federal agencies requires clarification (see below), its role as a support for public health practitioners and researchers in the injury field should not be diminished, and it should continue to be responsible for and accountable to those constituents. The NCIPC's responsibility for nurturing the field entails a variety of activities, including assembling, synthesizing, and disseminating information concerning current knowledge, programs, policies, and activities and identifying current needs and opportunities in the field (as an example of this clearinghouse function, the NCIPC prepared an inventory of current federal injury research funded in 1995 [NCIPC, 1997a]);
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Reducing the Burden of Injury: Advancing Prevention and Treatment stimulating and facilitating investments and activities that are needed to fill gaps in research and program support identified by NCIPC in collaboration with foundations, states and communities, businesses, and other federal agencies to leverage available resources; promoting communication and exchange among scientists and practitioners (NCIPC's sponsorship or cosponsorship of periodic injury conferences is an important contribution to this objective); and assisting communities, researchers, and other interested groups; identifying potential funding for worthy projects; and facilitating coordination among them. The committee recommends that the NCIPC continue to nurture the growth and development of the public health effort in injury prevention and treatment through information exchange, collaboration with injury practitioners and researchers, and leveraging available resources to promote the effectiveness of programs and research. COORDINATION AND LEADERSHIP The crosscutting nature of the injury problem, as well as of injury research and interventions, has been highlighted throughout this report. Through collaboration and coordination, federal agencies can work jointly to combat related and sometimes overlapping problems and to overcome fragmentation. They can link activities and pool resources, which take the form of expertise, funds, databases, access to patient populations, and technology. They also can avoid unnecessary duplication of effort, although duplication does not currently appear to be a major problem across federal injury programs (U.S. DHHS, 1992; GAO, 1994). Although the committee is not naive about the difficulties facing federal agencies when attempting collaboration and coordination, there are effective mechanisms that may ensure success, such as memoranda of understanding, interagency task forces and committees, and funding for joint projects. In 1985, Injury in America recommended that an injury center at the CDC be established to serve as a "lead agency among federal agencies and private organizations" (NRC, 1985). By using this formulation, the 1985 report appears to have envisioned that the CDC would provide leadership in two ways: (1) by nurturing the public health community's commitment to and interest in the injury field and (2) by coordinating the efforts of the multiple federal agencies involved in injury prevention and treatment. The committee believes that the NCIPC should continue to be a focal point for the public health commitment to the injury field (see above). However, when Congress enacted the Injury Control Act in 1990, it properly recognized that no single agency could "lead" such a diverse federal effort, and instead authorized the CDC to create a program to "work in
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Reducing the Burden of Injury: Advancing Prevention and Treatment cooperation with other Federal agencies, and with public and nonprofit private entities, to promote injury control" (P.L. 101-558). Congress envisioned a cooperative effort because, as a practical matter, an agency in one cabinet department has no authority to direct other agencies in the same department, much less in other departments. It became apparent to the committee during numerous discussions and meetings with individuals representing diverse perspectives,18 that characterization of the NCIPC as "the lead Federal agency" should be redefined by the NCIPC in collaboration with other relevant federal agencies, as it has led to unrealistic expectations about what NCIPC can accomplish with its resources. It also has impeded collaboration by spawning institutional rivalries and resentments, especially from federal agencies whose funding is similar to, or greater than, that of NCIPC. Although there are certainly stellar examples of coordination—for example, between NHTSA and HRSA on the Emergency Medical Services for Children program, and between CPSC and NCIPC on the expansion of emergency department injury surveillance—these examples are more the exception than the rule. An effective federal response to injury requires many agencies to play a leadership role in their areas of strength and jurisdiction. Playing a leadership role means taking the initiative to persuade and induce others to join in collective action toward a common goal. NHTSA, for example, naturally plays a lead role in highway and traffic safety; CPSC naturally plays a lead role in the surveillance and prevention of product-related injuries and product design research; NIOSH naturally plays a lead role in occupational safety research and education; and NCIPC naturally plays a lead role in prevention research related to residential and recreational injuries. Yet playing a lead role is not an exclusive role; it involves collaboration with other agencies to reduce injuries, promote synergies, and harness limited resources. For example, NCIPC and NIMH should both exert leadership on suicide prevention by collaborating with one another and with other groups. NIJ and NCIPC should do the same for violence prevention research and program evaluation by providing joint leadership for the criminal justice and public health communities. In summary, leadership, or playing a lead role, requires each agency to forge partnerships with other federal agencies in a collaborative manner to meet the overall objective of preventing injuries and improving safety. The committee recommends that federal agencies with injury-related programs create mechanisms (e.g., memoranda of understanding between federal agencies, working groups, interagency committees, task forces, funding for collaborative projects) to promote coordination and interagency collaboration. NCIPC recently proposed a new mechanism for coordination that would be 18 The committee met with numerous federal, state, and local government representatives, researchers, practitioners, and public and private organizations during the course of the study.
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Reducing the Burden of Injury: Advancing Prevention and Treatment overseen at a higher level of DHHS by the Assistant Secretary for Health. The new forum is viewed as the primary mechanism within DHHS for promoting the exchange of injury information and activities. The proposal also calls for invited membership from other federal agencies outside DHHS. New mechanisms of this kind should help to facilitate interagency coordination. REFERENCES BLS (Bureau of Labor Statistics). 1997. Lost-worktime injuries: Characteristics and resulting time away from work, 1995. Bureau of Labor Statistics News June 12, 1997. CDC (Centers for Disease Control and Prevention). 1993. Guide for Preparation of Assistance Requests. Atlanta, GA: CDC Grants Management Branch, Office of Program Support. Christoffel T, Christoffel KK. 1989. The Consumer Product Safety Commission's opposition to consumer product safety: Lessons for public health advocates. American Journal of Public Health 79(3):336–339. CPSC (Consumer Product Safety Commission). 1996a. 1997 Budget Request . Submitted to the Congress and the Office of Management and Budget. March 1996. Washington, DC: CPSC. CPSC (Consumer Product Safety Commission). 1996b. Success Stories: Saving Lives Through Smart Government. Washington, DC: CPSC. Dewees D, Duff D, Trebilcock M. 1996. Exploring the Domain of Accident Law. New York: Oxford University Press. Federal Register. 1997. Reporting occupational injury and illness data to OSHA. Final Rule. Federal Register 62(28):6433–6442. Fingerhut LA, Cox CS. 1998. Poisoning mortality 1985–1995. Public Health Reports 113(3):218–233. Fingerhut LA, Warner M. 1997. Injury Chartbook. Health, United States, 1996–97. Hyattsville, MD: National Center for Health Statistics. GAO (General Accounting Office). 1992. Occupational Safety and Health: Penalties for Violations Are Well Below Maximum Allowable Penalties . Washington, DC: GAO. GAO/HRD-92-48. GAO (General Accounting Office). 1994. Agencies Use Different Approaches to Protect the Public Against Disease and Injury. Washington, DC: GAO. GAO/HEHS-9-85BR. GAO (General Accounting Office). 1997. Consumer Product Safety Commission: Better Data Needed to Help Identify and Analyze Potential Hazards . Washington, DC: GAO. GAO/HEHS-97-147. GAO (General Accounting Office). 1998. At-Risk and Delinquent Youth: Multiple Programs Lack Coordinated Federal Effort. Washington, DC: GAO. GAO/T-HEHS-98-38. Graham JD. 1993. Injuries from traffic crashes: Meeting the challenge. Annual Review of Public Health 14:515–543. Hersey JC, Abed J, Butler MO, Diver AR, Mitchell K. 1995. Reducing the Burden of Injury: An Evaluation of CDC Injury Grant Programs. Final Report. Arlington, VA: Battelle. Report to the Centers for Disease Control and Prevention, National
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Representative terms from entire chapter: