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Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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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);

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

(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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×
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

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

To prevent infant suffocation, CPSC contributes to a public-private venture that encourages care givers to put infants to sleep on their backs or sides instead of on their stomachs. CPSC research, conducted in the wake of 35 infant deaths associated with bean bag cushions, found that rebreathing carbon dioxide trapped in bean bags and other soft bedding may contribute to approximately 30 percent of deaths previously determined to be, and probably misdiagnosed as, Sudden Infant Death Syndrome (SIDS) (CPSC, 1996b). Through safety alerts, press conferences, and public health campaigns with the American Academy of Pediatrics, the National Institute of Child Health and Human Development, and the SIDS Alliance, CPSC has sought to warn the public about soft bedding and the importance of placing infants on their backs or sides.

Assessment and Recommendation

In contrast to many other federal regulatory agencies, including OSHA, the CPSC has been criticized more for weakness than for overregulation (see, e.g., Viscusi [1984]; Christoffel and Christoffel [1989]). For the first decade of its existence, the prevailing view among economists was that the CPSC's regulatory actions had little or no effect in reducing product-related injuries, imposing costs on manufacturers and consumers without achieving any significant benefits (Viscusi, 1984). As a result, the agency faced the possibility of elimination. Since 1981, CPSC has suffered from chronic underfunding; its budget has decreased almost 50 percent in inflation-adjusted dollars, and the number of agency staff is less than half of what it was in 1980.

More recently, however, peer-reviewed scientific studies of specific regulatory actions by the CPSC have usually found that product-related injuries were substantially reduced at reasonable cost. Examples include child-resistant packaging of oral prescription drugs (Rodgers, 1996), bicycle safety standards (Magat and Moore, 1996), performance standards for walk-behind power lawnmowers (Moore and Magat, 1996), and the 1988 consent decree for all-terrain vehicles (Rodgers, 1993; Moore and Magat, 1997). Even one of the agency's most persistent critics has ranked CPSC regulation of unvented space heaters as one of the most cost-effective examples of risk regulation (Viscusi, 1992) and has found that behavioral adaptations do not offset the safety benefits of CPSC performance standards for child-resistant cigarette lighters (Viscusi and Cavallo, 1994).

Studies of regulatory success have begun to reshape the reputation of the CPSC. Once considered an ineffectual agency targeted for elimination, it now appears to represent a model of regulatory efficiency. This reputation has been reinforced over the past several years by the agency's efforts to leverage its resources through partnerships with manufacturers and consumer organizations. The committee believes that the CPSC is on the right course, relying heavily upon cooperative efforts with industry to raise prevailing standards of safety, all occurring in the shadow of the agency's regulatory authority. However, the

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

committee believes that the agency's capacity to carry out this strategy needs to be strengthened by increasing its resources for injury surveillance, hazard analysis, and applied research. The key to successful regulation is better information.

Surveillance

Surveillance of product-related injuries is the foundation of CPSC's regulatory activities, including hazard identification, hazard analysis, and priority setting. The backbone of the CPSC surveillance system is NEISS. A recent GAO report questioned the adequacy of NEISS on the grounds that it is incomplete (omitting injuries treated outside emergency rooms) and lacks detail about the injury incidents (GAO, 1997). However, the committee agrees with CPSC that NEISS is adequate to serve the purposes for which it is used by CPSC. The real question raised by the GAO criticism is whether expansion of NEISS to cover other types of injuries would assist the injury field as a whole. From this perspective, the committee believes that the feasibility of expanding NEISS to cover all injury-related emergency department visits should be explored (see Chapter 3).

Additionally, the committee agrees with the GAO suggestion that CPSC's capacity to conduct more internal analysis, in order to identify product hazards, should be strengthened. Data needs identified by the GAO include exposure data and incident-based information bearing on consumer vulnerability. These suggestions should be considered in the context of a broader review of data needs bearing on residential and recreational injuries, conducted collaboratively by CPSC and NCIPC.

Research

When it established CPSC, Congress recognized that research was an important component of the agency's mission. Section 5(b) of the Consumer Product Safety Act authorizes CPSC to "conduct research studies and investigations on the safety of consumer products and on improving the safety of such products." Despite the fact that CPSC is the only government agency that conducts in-depth product hazard research, the agency has limited capacity to carry out this important responsibility. As noted above, CPSC currently uses most of its limited technical resources to test and evaluate specific products and to support development of safety performance requirements. When the agency decides to take corrective action or to develop safety standards, it must present adequate evidence to demonstrate the existence of a safety hazard and the efficacy of proposed regulatory actions. Unfortunately, a few regulatory initiatives can fully deplete the agency's resources, especially if the products utilize newly developed technologies. As a result, the agency rarely has the resources to conduct applied research on generic safety problems that require more extensive study. If

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

"research" is given its customary definition, which would exclude the testing and evaluation of specific products, CPSC's research expenditures, which amounted to more than $6 million in FY 1980, have nearly been extinguished.

CPSC has difficulty funding even some of its basic needs. For example, its guidelines for determining the age-appropriateness of various types of toys are almost 15 years old and should be updated. These guidelines are used for enforcing CPSC's toy regulations and for assessing hazards associated with toys. Since these guidelines were developed, there have been major changes in the design, use, and marketing of different toy types. The agency will have to spread the cost of obtaining this extremely important information over many years, simply because it does not have sufficient funds to obtain new data.

Many significant consumer product hazards that have previously been considered impossible to address may now have potential solutions because of advanced technology. For example, the agency is currently evaluating sensor technology that may be able to detect a pre-fire condition on kitchen ranges and thereby prevent cooking fires, the number one cause of residential fires and fire injuries in the United States. Although this important applied research could save lives, it is being spread over several years because of limited resources. It is clear that CPSC requires upgraded laboratory resources and expanded technical capacity.

The consumer product market often fails to generate sufficient incentives for firms to compete over safety and to invest in research and development of safer product designs. Whatever incentives might otherwise be generated by the market are sometimes weakened by manufacturers' concerns that safety innovation could open the door to liability suits for earlier generations of less safe products (Huber and Litan, 1991). A strong applied research capability at the CPSC is needed to compensate for the weaknesses of market-generated incentives for safety innovation. By exploring new product designs and performance requirements for identified hazards, the agency can encourage further innovation by industry and can stimulate the development of voluntary standards.

The committee recommends that CPSC's capacity to conduct product safety research be significantly strengthened.

Additional resources for research are needed to enhance the CPSC's capacity to study safety problems and stimulate product innovation; examine the feasibility and efficacy of safer product designs and proposed safety standards; and develop and test methodologies for setting performance standards and for monitoring compliance with such standards.

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

The Occupational Safety and Health Administration of the Department of Labor was created by the Occupational Safety and Health Act of 1970 (P.L. 91-

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

596). This legislation separated regulation from research by also creating a research agency, the National Institute for Occupational Safety and Health (NIOSH), within the Department of Health and Human Services. The two agencies are formally linked by the statutory authority encouraging NIOSH to make recommendations to OSHA on the basis of occupational research. OSHA, in turn, contributes both formally and informally to the development of NIOSH research priorities.

OSHA's statutory mission is to "assure so far as possible every working man and woman in the nation safe and healthful working conditions" (Section 2(b)). This mission is carried out by setting mandatory standards, enforcing standards, and offering compliance assistance, 8 training, and education. Surveillance activities, which are also discussed below, are carried out by a sister agency within the Department of Labor. OSHA activities are conducted in 25 states and the District of Columbia, whereas the other 25 states—which contain about 40 percent of the labor force—operate their own occupational safety and health programs that are approved by OSHA. The Occupational Safety and Health Act permits states to implement their own programs as long as they are "at least as effective" as OSHA "in providing safe and healthful employment" (section 18 (c)(2)).

When OSHA was formed, it adopted existing federal safety standards, most of which were promulgated under the Walsh-Healy Act of 1936, and it adopted 20 consensus standards of the American National Standards Institute. Since then, OSHA has issued about five dozen safety standards and two dozen health standards, with many more in various stages of development (OTA, 1985).

OSHA holds the dubious distinction of being one of the most criticized regulatory agencies in the federal government (OTA, 1985). Being a focal point for criticism is a natural outgrowth of a mission that often divides employees and employers in terms of their values, perceptions of risk, and economic interests, amidst a historical backdrop of rancor and distrust. OSHA's rule making is subject to intense scrutiny and frequent court challenges. It is not uncommon for a rule to require more than five years from inception to final rule making, if it even proceeds to the final stage.

As it strives to reduce the burden of workplace fatalities and injury, OSHA has been compelled to adapt to strong historical forces—political, technological, and demographic in origin. Among these are a tide of antiregulatory sentiment ushered in during the 1980s, the transformation of U.S. industries from manufacturing to service orientation, entry into a global economy, expansion in the number of U.S. workers, and technological advances that have brought unanticipated health and safety concerns to the workplace. Another major impetus for change at OSHA is the Government Performance and Results Act (GPRA) of 1993. This

8

Provided at no cost to employers that request help in establishing and maintaining a safe and healthful workplace.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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legislation requires federal agencies to improve their performance and increase their results through the development of strategic plans, annual performance plans, and annual reports on how well performance targets have been met. Under this legislation, OSHA issued in 1997 a performance report for FY 1996 and its first-ever strategic plan for FY 1998–2002 (OSHA, 1997a,d). The strategic plan establishes clear benchmarks for reductions in injury and illness rates, along with the intent to evaluate performance.

Resources and Structure

In FY 1997, OSHA had a budget of $325 million and 2,238 FTEs. Staffing was at its highest level in 1980 (2,951 FTEs), and there has been a gradual decline since then. OSHA has its administrative headquarters in Washington, D.C., while maintaining a presence in 10 regional offices. OSHA and its state partners together have 2,100 inspectors with jurisdiction over 6.5 million employers employing more than 100 million people nationwide (OSHA, 1997a). Injury standard setting is housed in OSHA's Directorate of Construction and Directorate of Safety Standards Programs, two of its seven directorates. These directorates have the scientific and engineering expertise to identify workplace safety hazards, to develop standards, to propose solutions after an assessment of alternatives, and to offer technical assistance. (OSHA administratively separates acute injury from chronic injury; these are handled by the Directorate for Safety Standards and the Directorate for Health Standards, respectively.) Before the issuance of regulations, their economic impact is assessed by a separate office, the Office of Policy. Compliance with existing OSHA regulations is carried out by the Directorate of Compliance Programs.

Regulation

OSHA administers 695 separate rules (OSHA, 1997a), the majority of which relate to safety. Safety rules cover a wide variety of workplace conditions, ranging from concrete masonry construction safety, to electrical safety, to fire prevention, to safety at grain-handling facilities. Rule making, according to the Occupational Safety and Health Act, can be triggered by an interested party, employers or employees, standard-setting organizations, NIOSH, or states. In practice, most regulations have been propelled by labor organizations, NIOSH recommendations, and congressional mandate. Since 1992, 15 final rules have been adopted in the area of safety, while another 8–10 have been proposed (J. Martonik, OSHA Directorate of Safety Standards Programs, personal communication, 1997).

OSHA regulations are fervently contested, typically on the basis of cost of compliance, inappropriateness, ineffectiveness, and rigidity (Dewees et al.,

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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1996). Because of the extensive reach of the OSHA regulations and the health and economic issues at stake, rule making is required by statute to be rigorous and to ensure extensive opportunity for public comment. OSHA's rule-making requirements are "arguably . . . among the most demanding of all of Federal agencies with health, safety, and environmental regulatory responsibilities" (OTA, 1985). As a result of statutory requirements, court decisions, executive orders, and OSHA policy, several criteria govern the development of regulations once OSHA demonstrates a "significant" risk. A significant risk with respect to safety is usually defined qualitatively and supported, where possible, by quantitative risk assessment. After the finding of a significant risk, OSHA proceeds to (1) confirm that the required actions are technologically feasible; (2) demonstrate that the new costs incurred in compliance are economically feasible for the effective sectors; and (3) demonstrate that the standard is cost-effective relative to alternative solutions (OTA, 1985). These are the essential elements of OSHA rule making, which the Office of Technology Assessment (OTA) evaluated in a 1985 report. Based on a retrospective analysis of several cases, OTA found that OSHA relies on credible methods for rule making and that its assessments and forecasts are generally accurate. OTA's chief criticism was that OSHA pays insufficient attention to estimating the potential for technological innovation to address hazards.

More recently, OSHA has announced a new policy of pursuing "common sense" regulations (OSHA, 1997c). Under the rubric of regulatory reform, this policy declares OSHA's intent to change its approach to regulation by tackling the most pressing priorities through a priority-planning process with stakeholders; by streamlining and updating past regulations; and by pledging to interact more with business and labor in the development of rules.

Enforcement

OSHA's traditional enforcement activities include unannounced inspections and the levying of penalties. Past priorities for investigations have been (in order of importance) imminent danger, catastrophe and fatality investigations, employee complaints, special inspection programs, and programmed inspections (OTA, 1985). OSHA's enforcement has drawn fire for a host of reasons, including unnecessary overzealousness and excessive red tape—from the point of view of employers—and insufficient numbers of inspectors and insufficient penalties for violators to act as deterrents—from the point of view of labor. In 1992, the GAO revealed that penalties were substantially below the maximum allowed by law (GAO, 1992).

Under the philosophy that traditional OSHA enforcement has been "driven too often by numbers and rules, not by smart enforcement and results," OSHA recently announced a new enforcement policy that calls for more focused inspections for industries with higher injury rates. It also calls for giving employers

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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a choice as to how they wish to be regulated—through partnerships with OSHA or through traditional enforcement (OSHA, 1997c). This policy expands on one actually begun in the 1980s, the Voluntary Protection Program, an incentive program that recognized and promoted employers who established successful safety and health programs in partnership with OSHA. Employers who created effective programs became exempt from routine inspections, as long as they met OSHA criteria for quality. OSHA has built on this concept by now offering regulatory relief and penalty reductions to firms that join this program. The additional benefits, according to OSHA, are enhanced worker productivity and motivation, reduced workers' compensation costs, and community-wide recognition.

In addition, OSHA has begun to nationalize a program inaugurated with the State of Maine in 1993. This program—entitled the Maine 200 program, for the 200 firms that first participated—focuses on firms with the highest numbers of injuries. It gives them the choice of forming a partnership with OSHA to forge an effective health and safety program or of encountering enhanced enforcement. An evaluation of the Maine 200 program found that injury or illness rates of participating companies declined from 1991 to 1996 by 30 percent (OSHA, 1997b).

Surveillance

For injury surveillance, OSHA has, until recently, relied on another agency of the Department of Labor, the Bureau of Labor Statistics (BLS). BLS collects and analyzes annual data on the number of workplace fatalities, injuries, and illnesses through two surveys: the Census of Fatal Occupational Injuries and the Survey of Occupational Injuries and Illnesses (see Chapter 3). The BLS census is considered the most reliable because it uses diverse sources to identify and verify fatalities (Leigh et al., 1997); the survey compiles questionnaire data from approximately 250,000 private firms. These firms are a sample of more than 5 million establishments, which are required under the Occupational Safety and Health Act to maintain records of injuries and illnesses. In 1995, for example, employers reported 500,000 injuries and illnesses that resulted in 21 or more days away from work (BLS, 1997). Sprains, cuts, and fractures account for most of the injuries reported by employers. However, the BLS survey is widely considered to underreport injuries and illnesses by as much as 70 percent because of economic incentives on the part of employers (NRC, 1987; Leigh et al., 1997). Furthermore, the survey does not cover the self-employed, government workers, and farms with fewer than 11 employees. Since 1992, the survey also has collected demographic and detailed case characteristics on a sample of injuries and illnesses that resulted in days away from work (BLS, 1997).

OSHA has recently acquired surveillance capacity of its own with the publication of a final rule that requires employers to notify OSHA of their reportable

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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injury and illness rates (Federal Register, 1997). This information is similar to that required by the BLS; however, the new rule requires incidence rates rather than just absolute values and also requires that the employer be identified. BLS reporting is, on the other hand, confidential. OSHA sought this surveillance capacity in order to target its enforcement actions to the most hazardous work sites.

Training

Through its Office of Training and Evaluation, OSHA had a training budget of $2.4 million in FY 1997. This office administers training grants to safety and health organizations, employer associations, labor groups, and educational institutions. Grants are geared to employers and employees who are in industries or establishments with significant injuries or hazards. In addition, OSHA offers safety and health courses through the OSHA Training Institute and Education Centers. The Training Institute has outreach education centers in each OSHA region of the United States. The Training Institute fulfills part of OSHA's responsibility to oversee all aspects of health and safety programs for federal employees.

Assessment

OSHA's broad standard-setting authority leaves the agency with a great deal of discretion. Not surprisingly, the agency's approach has varied with changes in presidential administrations, and the efficacy and cost-effectiveness of OSHA health and safety standards have been subject to considerable debate. Critics have claimed that the existing standards tend to regulate trivial risks with unnecessary specificity in a one-size-fits-all mode, with little significant impact on injury rates. They argue that OSHA regulations should be subject to cost-benefit analysis (Viscusi, 1983; Mendeloff, 1979) or that safety standard setting should be abandoned in favor of an ''injury tax," leaving it to employers to take safety precautions to minimize their tax liability (Nichols and Zeckhauser, 1977). OSHA's defenders argue that neither of these proposals will adequately protect worker safety and that OSHA should be strengthened so that it has adequate resources to regulate more effectively (McGarity and Shapiro, 1993).

Outcome studies of OSHA regulation have been inconclusive. Overall, the most reasonable assessment is that OSHA safety regulation has probably had a modest effect in reducing workplace injuries against the general backdrop of a long-term decline (Dewees et al., 1996). Evaluation of OSHA reform proposals lies outside the scope of the present study. However, a key element of any reform strategy is to strengthen the information systems on which employers and the agency rely to identify hazards and make decisions about conducting inspections, proposing corrective action, and standard setting. The challenge is to

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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strengthen employers' incentives to maintain reliable data on all injuries, counteracting the tendency to underreport that may be generated by OSHA enforcement policies.

From this perspective, the committee supports OSHA's balanced approach, which is structured to offer collaborative assistance to employers with elevated injury rates, but still reserves the option to undertake aggressive enforcement and fines. For example, under its Cooperative Compliance Program, OSHA offers employers with the highest injury (and illness) rates the option of working with the agency to improve rates, rather than facing an increased possibility of "wall-to-wall inspection." Although the program has had the support of employee organizations and many employers, it faces a judicial challenge on the ground that it "coerces" participation by employers with high injury rates who otherwise face a near-certain inspection. Whatever the judicial fate of the cooperative compliance program, the committee urges OSHA to continue to develop regulatory strategies that emphasize collaborative efforts between the agency, employers, and employees to achieve reasonable reductions in injury rates based on employer size, current injury rates, industry needs, and safety experience.

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

The National Institute for Occupational Safety and Health is a research agency of the CDC devoted solely to work-related safety and health. NIOSH was created by the Occupational Safety and Health Act of 1970. NIOSH investigates potentially hazardous working conditions at the behest of employers or employees; evaluates and identifies chemical and safety hazards in the workplace; conducts research to prevent occupational disease, injury, and disability; supports training of health professionals; and develops educational materials and recommendations for worker protection. In FY 1997, NIOSH acquired research responsibility in the area of mine safety through the transfer of several research programs formerly within the Bureau of Mines of the U.S. Department of Interior. NIOSH's vision statement is "delivering on the nation's promise: safety and health at work for all people, through research and prevention" (NIOSH, 1998a).

Resources and Structure

NIOSH's total budget in FY 1998 was $153 million. Injury-related funds were spent on research (intramural and extramural), training, prevention, and public education. The majority was devoted to the activities of NIOSH's Division of Safety Research, one of its seven divisions. Most of its research and surveillance activities are performed intramurally, but about 21 percent are conducted in conjunction with state health departments through cooperative agree-

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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ments. Within the division are three branches: (1) the Surveillance and Field Investigations Branch is responsible for injury surveillance and descriptive epidemiology studies (see below); (2) the Analysis and Field Evaluations Branch is responsible for in-depth epidemiological studies; and (3) the Protective Technology Branch develops and evaluates new technologies to protect workers against injuries.

NIOSH administers occupational injury-related grants through the Office of Extramural Coordination and Special Projects. These are traditional investigator-initiated grants. All grants are competitively awarded after a peer-review process conducted by a study section made up of researchers outside the federal government.

Research Priority Setting

NIOSH's intramural and extramural research is being guided by a pioneering national research agenda, the National Occupational Research Agenda (NORA). NORA was spawned by an innovative priority-setting process. It is designed to set the course for national occupational safety and health research, coordinated across the public and private sectors (NIOSH, 1998b; Rosenstock et al., 1998). The development of NORA priorities was performed in partnership with about 500 organizations that represent workers, employers, health officials, health professionals, and the public. The priorities were selected by consensus according to the following criteria: the seriousness of the hazard, the magnitude of the risk, the potential for risk reduction, and the possibility that research will make a difference, among other criteria. Several of the 21 top priorities relate to injury, including traumatic injuries, intervention effectiveness research, emerging technologies, organization of work, and special populations at risk. Within these major priorities, teams of experts from the public and private sectors forge a detailed research agenda. The team on traumatic injuries, for instance, recently released a research agenda, Traumatic Occupational Injury Research Needs and Priorities (NIOSH, 1998c). Plans are under way to track NORA's implementation and to evaluate its impact on research.

Training Grants

The scope of NIOSH training grants is restricted by federal law to occupational injury training for health professionals. The competitively awarded grants are largely for training at the master's, doctoral, and/or resident level. In FY 1997, approximately 18 educational institutions received NIOSH training grants in occupational safety (with "safety" defined programmatically as injury, safety, and ergonomics). About half of these occupational safety grants went to multi-disciplinary programs that are part of larger, university-based research and

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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training grants called Education and Research Center Grants, whereas the other half supported single-discipline academic programs. Together, these two types of training grants totaled about $1.2 million in FY 1997. In addition, NIOSH supported occupational medicine training at about 28 medical schools and schools of public health. Injury was one of a host of covered topics.

Education

NIOSH places high priority on educational materials for worker protection. As a result of the decade-long trend favoring occupational education over regulation (Dewees et al., 1996), NIOSH has come to rely on a variety of documents to disseminate findings and recommendations to the affected industries and the public. These include Alerts and Current Intelligence Bulletins for the general public, and occupational and public health professional communities. An Alert is a brochure for public consumption that describes a threat to worker safety and offers recommendations for prevention. It carries a one-page tear sheet that can be posted readily. NIOSH tailors its dissemination strategy to ensure that Alerts reach the most appropriate audience. For example, the tear page from an Alert on adolescent worker safety was sent to every secondary school principal in the United States.

Beyond publications, NIOSH supports a host of educational activities that include research literature evaluations and community-based projects. An example of the latter is the Young Worker Community-Based Health Education Project, launched in 1995 to promote adolescent worker safety. This community-based project was prompted by surveillance data revealing disturbing evidence of adolescent deaths and injuries in the workplace, mostly in the construction, farm equipment, and food service industries (NIOSH, 1995). Through this project, cooperative agreements were awarded for three community-based health education projects to develop and test interventions that increase community awareness of adolescent worker safety in order to change the knowledge, attitudes, and behavior of organizations delivering services to teens.

Assessment and Recommendation

The committee applauds NIOSH in its paradigmatic approach to research priority setting through NORA. The contemporary scientific community values planning as a tool for setting broad priorities and integrating diverse research programs (NIH, 1994a; IOM, 1998). The key is to set priorities in a way that does not dictate individual research projects, that encourages innovation, and that ensures stakeholder investment in the outcome.

NORA promulgates national priorities for occupational safety and health research for both the public and private sectors (Rosenstock et al., 1998). One

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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shortcoming, however, is that NORA's 21 priorities are themselves not prioritized. NORA's widespread support appears to depend on these key procedural elements: a participatory and consensus-building approach to planning in partnership with stakeholders; criteria for setting priorities; refining of priorities as circumstances change; and plans to evaluate the impact of priority setting. The inclusion of other federal agencies, such as NIH and OSHA, as partners in the priority-setting process is another important milestone. NORA gives OSHA a formal opportunity to fulfill its regulatory needs by influencing the research agenda of a sister agency. Through research planning, NIOSH remains responsive to regulatory demands, while preserving its scientific integrity and commitment to high-quality science.

Congress recognized the importance of NORA by appropriating an additional $5 million to NIOSH in FY 1998 for implementation of research priorities relating to occupational dermatitis, musculoskeletal disorders, and asthma. NIOSH leveraged these resources with an additional $3 million from several NIH institutes to issue a joint announcement seeking research proposals from the extramural community (NIOSH, 1998a). The total allotment of $8 million represents the largest-ever single infusion of research funds for investigator-initiated occupational safety and health research (NIOSH Budget Office, personal communication, 1998).

Traumatic injury research priorities recently developed by the multidisciplinary NORA team assigned to this topic also warrant special consideration by Congress. The NORA team specified detailed research priorities under the general topics of surveillance, analytic injury research, prevention and control, communication and technology transfer, and evaluation (NIOSH, 1998b). Traumatic occupational injuries, which received only about 8 percent of NIOSH's budget, have not attained sufficient priority in light of the magnitude and costs of occupational injuries. A recent study found that the mortality, morbidity, and costs of occupational injuries considerably overshadowed those of occupational diseases (Leigh et al., 1997). The study estimated that 6,500 deaths and 13.2 million occupational injuries occur annually at cost of $145 billion, compared with an annual cost of $26 million for occupational diseases. Therefore, more funding should be accorded to research on traumatic injury in the workplace.

The committee recommends that NIOSH, working in collaboration with other federal partners, implement the NORA research priorities for traumatic and other injury-related occupational injuries, and give higher priority to injury research.

NIOSH also deserves credit for heightened public awareness of occupational safety and health. It initiated an improved dissemination strategy for publications and other educational materials. The strategy targets materials to appropriate audiences, especially employers and workers at risk. For example, NIOSH's Alert of September 1994, Preventing Injuries and Deaths of Fire

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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Fighters, which identified four critical factors for prevention, was distributed to every fire department in the nation (NIOSH, 1994). Other influential Alerts were Preventing Homicide in the Workplace and Preventing Deaths and Injuries of Adolescent Workers (NIOSH, 1993, 1995). NIOSH received a special, $5 million earmarked appropriation in FY 1996, a major portion of which was devoted to the establishment of a research and education center to prevent child agricultural injuries at the National Farm Medicine Center in Wisconsin.

NATIONAL INSTITUTES OF HEALTH

The National Institutes of Health ranks as the world's leading institution for biomedical research and training. Originating as a one-room Laboratory of Hygiene in 1887, the 21 institutes and centers that today comprise NIH started to take shape after World War II, under the authority of the Public Health Service Act. Many NIH institutes and centers are organized around specific diseases, such as cancer, neurological diseases, and alcoholism. The monumental scope and reach of NIH is captured in its budget of about $13 billion in FY 1997 (NIH, 1998). This budget is estimated to support 50,000 researchers at 1,700 institutions nationwide (NIH, 1993). NIH's mission is "science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and reduce the burdens of illness and disability" (NIH, 1997). The mission is accomplished through a profusion of research, training, public and professional education, and technology transfer activities.

Injury is not the primary focus of any single institute at NIH; rather, there are several discrete programs on injury located within a few institutes, and individual projects are funded across virtually all NIH institutes and centers. The collective effort, totaling less than $200 million, is relatively small by NIH standards (see below). More than 30 years ago, the NRC report Accidental Death and Disability recommended the creation of a separate institute, a proposed "National Institute of Trauma," but it never materialized (NRC, 1966). In 1985, the Institute of Medicine (IOM) considered, but rejected, placement of an injury center or institute at NIH; this report noted that the establishment of a sizable injury center or institute would not be accorded high priority because NIH is generally disinclined to establish new institutes (NRC, 1985). Instead, the 1985 report turned to the CDC for an administrative location in which to place an injury center. However, in light of CDC's resource constraints, and a host of unmet needs in basic and clinical research that only NIH can fulfill, many continue to advocate a stronger role for NIH in injury research and training (Mickel, 1990). By the early 1990s, Congress foresaw the need for a larger commitment by NIH in trauma research by authorizing a new research program, but funds were not allocated.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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Resources

The total level of injury-related funding at NIH was about $194 million in FY 1995 (NCIPC, 1997a). Injury funding constitutes less than 2 percent of the NIH budget. NIH supports three relatively small programs with injury or rehabilitation as the sole focus. These three programs, which are described below, represent about two-thirds of the total NIH injury expenditures. They are located within three separate institutes: the National Institute of General Medical Sciences (NIGMS), the National Institute of Neurological Disorders and Stroke (NINDS), and the National Institute of Child Health and Human Development (NICHD). Even though the remaining institutes and centers at NIH sponsor some small degree of injury research related to their particular mission, these three institutes have the most concentrated and identifiable programs. All are extramural programs, meaning that the research and training are conducted via grants and other funding instruments awarded mostly to universities, medical centers, and other academic institutions after a peer-review process. The competitive peer-review process is considered responsible for NIH's reputation for scientific excellence.

NIGMS has the most broad-based program. Its program on trauma and burns, funded at approximately $48 million in FY 1998, supports investigator-initiated grants, center grants, and training grants that span the spectrum of basic and clinical research, including treatment of acute trauma. 9 The NINDS program on trauma, regeneration, and pain—funded at approximately $60 million annually—is almost exclusively focused on neurotrauma. Finally, a center within the NICHD—the National Center for Medical Rehabilitation Research—funds about $20 million annually in rehabilitation research. Yet not all rehabilitation research is injury related, because injury is but one of a constellation of diseases and conditions responsible for functional disability. These three extramural programs (within NIGMS, NINDS, and NICHD) are administered by a total of 3–5 FTEs.

Training

NIH's largest research training program in injury is supported by NIGMS. Under this institute's trauma and burn program, an estimated $3 million is spent annually on about 19 training grants to institutions nationwide. These grants pay

9

The NIGMS program focuses on the following topics: organ, tissue, cellular, and molecular responses to injury; mechanisms of cellular and organ failure; pathophysiologic changes following injury and factors or therapies influencing recovery; factors involved in wound healing, tissue repair, and wound infection; mechanisms of electrolyte and solute transport across cell membranes and mechanisms of resuscitation therapy; cryopreservation of cells and organs; and behavioral consequences of trauma and burn injury (among other areas).

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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for the tuition and stipends of about 60 postdoctoral candidates, most of whom are M.D.s. Predoctoral candidates are not eligible to receive funds under these grants. The grants are for training in basic and clinical research "to improve the understanding of the body's systemic responses to major injury and to foster the more rapid application of this knowledge to the treatment of trauma and burn-injured victims" (NIGMS, 1998).

Assessment and Recommendation

Injury research is not a high priority at NIH, despite NIH's pivotal significance to the injury field. NIH is the only source of funding for certain types of basic and clinical injury research. It also is one of the few sources of funding for research training programs. However, the total level of funding for injury research is not commensurate with the magnitude of the injury problem (see Chapters 2 and 9), nor is the level of funding commensurate with that accorded by NIH to other cardinal contributors to disease and disability. As important, NIH lacks a focal point and a mechanism to coordinate its disparate injury research projects and programs.

Congress has previously recognized that NIH needs to accord trauma research greater priority. Under P.L. 103-43 (1993),10 Congress authorized a major new trauma research program and a coordinating mechanism for its implementation. In response, NIH convened a special task force of trauma experts nationwide to develop a research plan. The final research plan, A Report of the Task Force on Trauma Research , contained recommendations for a comprehensive trauma research program (NIH, 1994b). The report outlined significant opportunities in such areas as basic research, clinical trials, clinical research, health systems research, and translational research (Chapter 6). To implement the program, the report recommended doubling the current number of trauma research centers, without explicitly stating the costs. The research plan was not implemented because the necessary resources were not allocated (although some elements of the plan may have been implemented through the normal course of peer review). Under this legislation, the NIH director was required to "assure the availability of appropriate resources to carry out the program. . . ." The failure to secure funding suggests that a supplementary congressional direction or appropriation is needed.

To fulfill the critically important research opportunities described in the trauma research plan, the committee envisions in its recommendations below an expanded research and training program located within NIGMS. An expanded program also serves to enhance the stature and visibility of injury as a field of inquiry, to promote collaborations, and to attract more researchers. The committee chose NIGMS as the administrative site at which to build a more prominent

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Section 300d-61.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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program because it already has the most broad-based injury program at NIH. Placement within an existing institute capitalizes on prevailing resources and avoids creating an additional bureaucracy. Further, the committee recommends the elevation of NIGMS's current trauma and burn program to its own division. The trauma and burn program is currently located within the NIGMS Division of Pharmacology, Physiology, and Biological Chemistry, one of three NIGMS divisions. The trauma and burn program is among the 12 research programs administered by this division. Any increase in funding must be accompanied by appropriate increases in staff. Since NIH remains under personnel ceilings set by the Office of Management and Budget, increasing the staff level continues to be an NIH-wide problem.

With additional funding, a newly created Division of Trauma and Burns could be charged with conducting the following activities: serving as a focal point for injury research at NIH; implementing the NIH Trauma Task Force Report of 1994 (NIH, 1994b); maintaining a comprehensive extramural research and training program that includes individual grants, center grants, and institutional training grants; ensuring that research gaps and opportunities are filled; and conducting planning and evaluation activities.

An expanded program at NIGMS also would be instrumental for training researchers. Existing NIGMS training grants are very important for basic and clinical research in trauma and burns, but they are only for postdoctoral training. Chapter 6, which discusses trauma care systems, describes the multidisciplinary nature of the research needed to advance injury treatment. This research cannot be accomplished without a cadre of researchers with special training in injury research. Trainees also should include predoctoral candidates who are now excluded from receiving funds under NIGMS's institutional training grants.

The committee supports a greater focus on trauma research and training at NIH and recommends that the National Institute of General Medical Sciences elevate its existing trauma and burn program to the level of a division.

To accomplish this goal, the committee recommends the expansion of research and training grants, the formation of an NIH-wide mechanism for sharing injury research information, and for promoting collaborations spearheaded by NIGMS.

MATERNAL AND CHILD HEALTH BUREAU

The Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration has a long and distinguished history of promoting the health of mothers and children. Although injury is a far more recent component of its programs, MCHB began as the Children's Bureau in 1912. Funds

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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were later authorized to the bureau to provide states with direct funding for personal health services under the Sheppard-Towner Act of 1922. This landmark legislation was the first to establish the practice of giving states the funds to implement their own public health programs (NRC, 1988). In 1935, the role of MCHB was expanded with the enactment of Title V of the Social Security Act, which mandated that the bureau administer both maternal and child health service programs covering a broad spectrum of public health topics. The programs under Title V were converted and consolidated (under the same title) into the federal MCH Block Grant Program in 1981, a transformation that gave states more latitude in the expenditure of funds. The purpose of the block grant ($681 million in FY 1997) is to enable states to develop service systems in maternal and child health that reduce infant mortality, provide preventive and primary care services and immunizations, reduce adolescent pregnancy, and prevent injury and violence, among other goals (HRSA, 1997).

Under the MCH block grant, states are given funds on a formula basis (related to population and poverty indices) and are required to match 3 dollars for every 4 dollars they receive in federal appropriations. As a result of legislation in 1989, states are required to earmark funds for broad categories such as preventive and primary care services for children. Injury is subsumed under each major category, but not directly specified by the legislation. MCHB is committed to injury prevention and treatment through its Injury and Violence Prevention Program, which strives to reduce injury and violence among children and their families through a relatively modest portfolio of discretionary grants and contracts authorized under Title V and other authorities.

Discretionary grants and contracts constitute about 15 percent of the Title V block grant appropriation, but they cover a host of other maternal and child health topics besides injury. Title V grants and contracts fall under two authorities: the Special Projects of Regional and National Significance (SPRANS) and the Community Integrated Service Systems (CISS) (HRSA, 1997). In addition to these discretionary resources, the bureau and a related office within HRSA administers two other categorical grant programs that more directly address state and local injury prevention and control: the Emergency Medical Services for Children (EMS-C) and the Traumatic Brain Injury (TBI) programs.

Resources and Structure

MCHB spent a total of about $17.6 million in FY 1997 for injury prevention through four separate programs (described in the next section). In FY 1997, programs under Title V distributed about $2.3 million in injury-related grants and contracts. Another $12.5 million and $2.8 million were awarded under the EMS-C and the TBI programs, respectively. Funds were awarded for service delivery, research, demonstrations, training, and public education under four different grant and contract programs. All four programs, which make awards

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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after a competitive process, are described in more detail in the following section. MCHB has no internal research or surveillance capacity for injury prevention and control. Given its limited resources and the breadth of its purview (i.e., all facets of occupational and non-occupational injury related to children and families), the bureau strives to stretch its resources through partnerships with many other federal, state, and private sources.

Injury-Related Grants and Contracts

Special Projects of Regional and National Significance

This discretionary grant and contract program has a broad mandate to improve state- and community-based maternal and child health. Grants and contracts are distributed mostly to state and local governments, universities, and nonprofit groups and can take the form of research, demonstrations, and training grants. Of the 500 projects supported under this program, about 20 were injury related in 1997. Although injury projects covered such diverse areas as domestic violence training and playground safety, the largest—and most widely recognized—cluster of grants was awarded to each of the organizations that comprise the Children's Safety Network (CSN).

CSN is a group of organizations that serve to strengthen the state infrastructure for injury and violence prevention and to support policy development at the national and state levels. The CSN acts as a resource for, and provides technical assistance to, state and local public health departments, especially MCH agencies, by helping them assess the injury problem, identify and overcome barriers to implementation of injury prevention programs, evaluate prevention programs, and link with others in the field. CSN also develops and distributes publications and facilitates the development of training and continuing education programs for national organizations and professional groups.

This network evolved from a resource center previously funded by the Carnegie Corporation of New York. It was inaugurated in 1991 with the award of two grants from the federal MCHB, one to the Education Development Center in Newton, Massachusetts, and the other to the National Center for Maternal and Child Health at Georgetown University, Washington, D.C. Currently, the network consists of four national centers: the lead center is responsible for addressing all aspects of child and adolescent injury and violence prevention, and three other centers focus on injury data, rural and agricultural injury, and the costs of injury. The four centers work collaboratively to meet the needs of injury practitioners, to help integrate injury and violence prevention into existing MCH programs and policy, and to conduct research and policy activities that improve the state of the art of injury and violence prevention.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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Community Integrated Service Systems (CISS)

Authorized in 1989, CISS is a grant program aimed at reducing infant mortality and improving maternal and child health via integrated services at the local level. With a special focus on rural areas and families with special needs, CISS seeks to build service systems. Its grants promote public-private partnerships between community-based organizations.

Emergency Medical Services for Children

The EMS-C program was authorized in 1985 under Section 1910 of the U.S. Public Health Service Act. Its overall purpose is to reduce child and youth mortality and morbidity sustained through severe illness or trauma. More specifically, the program strives to ensure state-of-the-art emergency medical care for children with serious illnesses or injuries; to ensure that pediatric services are integrated into an emergency medical services system; and to ensure that children and adolescents receive a constellation of emergency services, including primary prevention, acute care, and rehabilitation. The program was propelled by research that found that, relative to adults, children suffered disproportionately high rates of morbidity and mortality under emergency circumstances. Emergency medical services had overlooked the needs of children and were ill prepared to deal with children's distinct anatomies, physiological responses, vital signs, body proportions, and deficiencies in communication (IOM, 1993). Over the course of the program, 52 states and territories have received grant assistance. NHTSA has also joined the program and supports a variety of grants, especially those targeted at curriculum development. The EMS-C program funds diverse projects ranging from systems development, research, and demonstrations to training, curriculum development, resource centers, and public education. Evaluation components are now routinely integrated into grants (HRSA, 1996). The first broad evaluation of the EMS-C grant program was undertaken by Solloway and colleagues (1996), using case studies of EMSC grants in seven states. The evaluation found the program to be highly successful in enabling states to develop, implement, and sustain EMS-C programs. Grants were most successful at training and education, enabling hundreds of prehospital providers to be specially trained by a cadre of instructors who can continue to train others. The report also made recommendations to improve and refine the program, many of which were anticipated and had already been adopted by MCHB before publication of the evaluation report.

In 1995, MCHB and NHTSA jointly published a five-year plan (1995–2000) to improve EMS-C services nationwide. The plan not only articulates broad objectives, but also lays out concrete action-oriented steps for federal, state, local, and private organizations (HRSA, 1995). The plan was an outgrowth of broad-based recommendations contained in the 1993 IOM report that defined

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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the underlying characteristics of an EMS-C system, the types of data needed for planning and evaluation, and the role of public agencies (IOM, 1993).

Traumatic Brain Injury Demonstration Grants Program

As a result of legislation passed in 1996, MCHB has been mandated to establish and implement a TBI State Demonstration Grant Program. HRSA was one of three federal agencies charged with developing TBI programs under this legislation (P.L. 104-166). The demonstration projects are intended to improve statewide systems for the delivery of coordinated services to TBI victims. The bureau plans to award planning grants and implementation grants, once it establishes the program's goals and objectives with the aid of a specially convened TBI State Demonstration Grant Program Task Force, with membership from national organizations across the service delivery system.

Assessment

MCHB deserves credit for the quality of its programs and quality of its collaborations with other federal agencies. Although they operate with only a handful of staff, MCHB programs have a remarkable impact on building state and local capacity in injury prevention. MCH is adept at developing enduring relationships with state and local health departments and at disseminating information. Its vital role in emergency medical services for children is described more fully in Chapter 6, which recommends an even greater role for HRSA in trauma systems development and evaluation.

OFFICE OF JUSTICE PROGRAMS

The Office of Justice Programs is a large administrative entity of the Department of Justice headed by an Assistant Attorney General. The mission of the OJP is to develop the nation's capacity to prevent and control crime, administer justice, and assist crime victims. Within this broad mandate, OJP ventures into novel areas of crime prevention and control under the Violent Crime Control and Law Enforcement Act of 1994 (Crime Act), which provided for new programs in community policing, violence against women, sentencing and corrections, and drug courts.

Composed of 10 bureaus and offices,11 OJP had an FY 1997 budget of $2.7 billion (U.S. DOJ, 1997b). The funds are largely awarded through formula,

11

The Bureau of Justice Assistance, National Institute of Justice, Office of Juvenile Justice and Delinquency Prevention, Bureau of Justice Statistics, Office for Victims of

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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block, and discretionary grant programs to states, territories, and tribal units for local crime prevention programs.12 Local crime prevention programs consist mostly of service delivery and demonstration programs. These programs are highly complex and variable in scope, eligibility, and legislative requirements, and the committee was unable to determine whether state and local health departments can avail themselves of funding. Given the magnitude of funding, it would be desirable for public health departments to tap into these funding streams for violence prevention programs.

Research and evaluation are beginning to be accorded higher priority by OJP in the wake of the 1994 Crime Act's statutory requirements for program evaluation. Many OJP bureaus have transferred funds to their sister agency, the National Institute of Justice (NIJ), to design and implement program evaluations. Since NIJ is the only unit of the U.S. Department of Justice that is devoted exclusively to research, the following section focuses on this institute and its potential to advance research and evaluate promising violence prevention programs.

National Institute of Justice

The National Institute of Justice was formed by the Omnibus Crime Control Act of 1968. Its mission is to conduct and support research on the causes and prevention of crime; on the improvement of law enforcement and the administration of justice; on the development of new technologies to prevent crime and enhance criminal justice; and on criminal justice surveillance. The mission is carried out mostly through an extramural grant program, although there is a small intramural research program. NIJ also has a modest training program, described later in this section. NIJ has no regulatory responsibilities but is authorized to make recommendations to federal, state, and local governments (U.S. DOJ, 1997a).

Resources and Structure

With an FY 1998 budget of approximately $50 million, NIJ is one of the smallest administrative bureaus within OJP. Yet its core appropriation is overshadowed by funding transfers from other federal crime prevention programs created by the 1994 Crime Act. The act's requirements for program evaluation generated an infusion of funds to NIJ in the form of transfers from other DOJ

 

Crime, Corrections Program Office, Drug Courts Program Office, Executive Office for Weed and Seed, Violence Against Women Grants Office, and Violence Against Women Office.

12

For further description of these funding instruments, see Sherman et al. (1997).

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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offices (NIJ, 1997). By FY 1998, these transfers amounted to $85 million. Therefore, NIJ's total FY 1998 budget was approximately $135 million, about half of which was spent on evaluation of crime prevention programs.

The NIJ is organized into three major offices. The Office of Research and Evaluation supports grants in the social sciences relating to the causes and prevention of crime. The Office of Science and Technology supports investigator-initiated grants for the development, testing, and evaluation of technologies to deter crime and enhance criminal justice operations. It also funds six regional National Law Enforcement and Corrections Technology Centers that provide technical assistance on research and development to help state and local criminal justice agencies. The Office of Development and Dissemination transmits information through publications and conferences geared to practitioners (i.e., judges, prosecutors, police, corrections officials, and victims' advocates).

Research

NIJ supports research in the following areas: criminal behavior, crime control and prevention, and the criminal justice system. The preponderance of NIJ's budget is awarded for extramural projects conducted by academic researchers and researchers at private nonprofit institutions. Grants average about $250,000 per year over a two-year period. All extramural funds are awarded through a competitive selection process carried out by independent peer-review panels in a process similar to that conducted by NIH. The major differences are that NIJ study sections are not standing study sections, and they require that at least one reviewer be a practitioner (i.e., a judge, prosecutor, policeman, correction official, or victim advocate). Investigator-initiated projects are awarded as a result of an open solicitation process, but this avenue represents a minor component of NIJ's extramural grant program (U.S. DOJ, 1997a). The majority of NIJ's research funds, including transfers from other offices, is awarded after a directed solicitation for research proposals targeted to specific topics, many of which are prescribed by the Crime Act of 1994.

One of the few programs of investigator-initiated grants relates to violence against women. The research program began in FY 1998 through the receipt of $7 million in earmarked appropriations to NIJ. It is being undertaken in collaboration with CDC's NCIPC over a five-year period (NIJ, 1998). The purpose of the joint program is to implement the research agenda propounded by the NRC in its 1996 report Understanding Violence Against Women (NRC, 1996). The development of this research agenda was mandated by the Violence Against Women Act of 1994 (Title IV of the Crime Act). The report recommends research on prevention (including longitudinal research), improving research methods, developing the research infrastructure, and the acquisition of new knowledge on all facets of the problem, especially as it affects women of color, disabled women, lesbians, immigrant women, and institutionalized women

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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(NRC, 1996). The joint program also is guided by the research recommendations of Violence in Families: Assessing Prevention and Treatment Programs (NRC, 1998).

Training

NIJ does not administer a program of training grants to institutions but does expend funds for a Graduate Research Fellowship Program and a Visiting Fellows Program. The former consists of individual research fellowships for graduate students working on dissertations in the criminal justice field, whereas the latter allows university researchers to join the NIJ staff to pursue collaborative intramural projects. NIJ's training budget is approximately $300,000 annually.

Assessment and Recommendation

The committee commends NIJ for its commitment to rigorous evaluation of the local crime prevention programs of the Department of Justice. NIJ is in an opportune position to evaluate these massive programs. Through a series of extended internal negotiations beginning in 1994, NIJ began to secure funds from other DOJ offices for program evaluation. The need for stronger program evaluation is abundantly clear. In two recent assessments, DOJ's crime prevention programs have been criticized for insufficient attention to evaluation (GAO, 1998; Sherman et al., 1997). These assessments, although differing somewhat in scope, each concluded that the effectiveness of most federal crime prevention programs is not known.

The report by Sherman and colleagues (1997) from the University of Maryland was most comprehensive and pertinent to DOJ, having been commissioned by NIJ under a mandate from Congress for an independent review of program effectiveness. The report found existing evaluations of DOJ's local crime prevention programs to be inaccessible to researchers and beset by methodological problems, statutory encumbrances, and inadequate funding. It praised the efforts of NIJ, but noted that NIJ has insufficient discretion in the selection of which prevention programs to evaluate. It recommended new legislation that would earmark for rigorous evaluation at least 10 percent of all DOJ local assistance funds for crime prevention (Sherman et al., 1997). The committee agrees with the need for more discretion (see below) and the need for a congressionally authorized set-aside for program evaluation. A congressionally mandated set-aside would provide continuity for evaluation research—a better system than the existing mechanism, which transfers evaluation funds to NIJ and must be renegotiated on a year-by-year basis.

Furthermore, NIJ discretion in program evaluation is imperative because not every promising intervention warrants an evaluation. The determination of which

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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programs to evaluate was the focus of a set of five guiding principles established in a recent report (NRC, 1998). The use of principles such as these is vital, given the daunting array of DOJ programs that could be evaluated. NIJ needs greater flexibility to identify, in a carefully orchestrated manner, those programs that warrant evaluation.

The expansion of NIJ's role in program evaluation has implications for research training. To meet the growing demand for skilled evaluation researchers, more and more individuals from many disciplines require training at the predoctoral and postdoctoral levels. NIJ provides a modest degree of support for individual trainees, but it does not award full-fledged training grants to institutions. Institutional, as opposed to individual, training grants can create a critical mass of trainees at a given institution, draw young people into a career path, augment the field's research capacity, and sustain the field for the future. The Institutional National Research Service Awards established by the NIH provide a model for an institutional training grant.

NIJ should give its highest priority in crime prevention research and program evaluation to studies bearing on prevention of violence, especially lethal violence. While the terms ''violence prevention" and "crime prevention" are often used interchangeably, Zimring and Hawkins (1997) have shown that thinking of violence simply as a subset of "the U.S. crime problem" fundamentally distorts our understanding of the problem and confuses our responses to it. Rates of death and life-threatening injury from assaultive behavior in the United States are 4–18 times higher than those in other developed nations, even though rates of property crime are about the same. Zimring and Hawkins argue that the uniquely higher rate of lethal violence in America is attributable to differences in the social environment, not differences in either the volume of crime or the number or characteristics of offenders. They also argue that the usual tools of criminal justice are not adequate to the task of reducing lethal violence and that undifferentiated emphasis on the prevention and control of "crime" or even "violence" misallocates resources, diffuses the focus of attention, and fails to address the specific factors most likely to reduce lethal violence. Thus, emphasis should be placed on the prevention of lethal violence (i.e., that subset of violent events that present a risk of serious injury or death).

The committee recommends that NIJ continue to give explicit priority to the prevention of violence, especially lethal violence, within its overall activity in crime prevention research and program evaluation, and that NIJ establish new institutional training grants for violence prevention research at academic institutions.

NIJ also is to be credited with its collaborative approach to research support. As described earlier, NIJ sponsored a joint solicitation with NCIPC for extramural research proposals on the topic of violence against women. It also collaborated with NIH, NCIPC, and other federal agencies on a grant solicitation

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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on the topics of violence against women and violence within the family. Another noteworthy example of research collaboration is to be found in the National Consortium on Violence Research. The consortium is a nationwide, multidisciplinary group of 50 violence researchers from many institutions. The group is brought together under the auspices of Carnegie Mellon University, the recipient of a large federal grant to form the consortium. Most of the approximately $2.4 million in annual funding comes from the National Science Foundation, with contributions from NIJ and the Department of Housing and Urban Development. The consortium is a unique program that organizes collaborative research projects on factors contributing to serious violence. It solicits and funds research proposals developed largely by its members and coinvestigators. The scope of the consortium's research solicitations is targeted by an internal steering committee and an advisory committee that engage in peer review of proposals. Members of the consortium also are provided access to a Data Center with linkable data sets and associated software. The consortium bears watching as an innovative model for bringing together outstanding yet dispersed researchers. It is to be evaluated by the National Science Foundation in 1999.

A formal interagency coordinating mechanism is needed to promote and facilitate research collaborations on violence prevention. Some of the above mentioned interagency collaborations were the outgrowth of a previous Inter-agency Working Group on Violence Research. This working group was created in 1995 by the Department of Justice and the Department of Health and Human Services (DHHS), but it has not met for more than a year. A similar type of group needs to be reinstated and expanded to include all federal departments and agencies with an interest in violence prevention. The purpose of such a committee would be to develop systematic and coordinated research strategies for evaluating violence prevention programs. The committee urges the creation of an interagency coordinating committee for violence prevention research. NIJ should take the initiative to establish such a committee in concert with other federal agencies

NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL

The National Center for Injury Prevention and Control (NCIPC) traces its origins to a 1985 NRC report Injury in America. This report prompted Congress to establish a new pilot program at the CDC to address the problem of injury. Placement at CDC was recommended by virtue of its research rather than regulatory emphasis, its strong relationships with state health departments, and its capacity to disseminate new information and technology (NRC, 1985). After three years of operation with funds transferred from the Department of Transportation, the NRC reviewed the program's progress and recommended in a 1988 report that it be made permanent (NRC, 1988). Congress responded with a significant milestone, the Injury Control Act of 1990, which authorized the program

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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within CDC and paved the way for direct appropriations. In 1992, CDC elevated what was then called the Division of Injury Epidemiology and Control to the status of a center.

The mission of NCIPC is "to provide leadership in preventing and controlling injuries, i.e., reducing the incidence, severity, and adverse outcomes of injury" (NCIPC, 1996a). This mission is accomplished through a spectrum of public health activities in research, surveillance, implementation and evaluation of programs, and public education. NCIPC has no regulatory authority. It concentrates on non-occupational injuries to distinguish its role from that of NIOSH (described earlier).

Resources and Structure

In FY 1997, NCIPC commanded a budget of $49.2 million. Its 123 FTEs were divided among three divisions and two staff offices serving the director. The divisions are the Division of Unintentional Injury Prevention; the Division of Violence Prevention; and the Division of Acute Care, Rehabilitation Research, and Disability Prevention. One staff office is responsible for statistics and analyses of injury surveillance data and the other for administration of grants and cooperative agreements (described below).

Research Grants

NCIPC supports a nationwide extramural grant program to universities and other research entities. The grant program awards funds for peer-reviewed research in a manner almost identical to that of the NIH13; it sponsors a 21-member study section composed of extramural researchers whose function is to evaluate prospectively the technical merit of submitted applications and recommend funding levels. NCIPC's study section is one of two administered by CDC, with the other serving NIOSH. NCIPC supports three major types of projects: (1) individual investigator grants (discrete projects by a principal investigator); (2) program projects (a series of related individual projects that have an interdisciplinary study design); and (3) centers. Centers, as the most comprehensive type of grant, perform research in the three core phases of injury prevention and treatment (prevention, acute care, and rehabilitation), and also support public information and some training activities.

13

The overall process begins with an internal staff review of submitted applications (for completeness and responsiveness), followed by the primary review for technical merit by an external study section and a secondary review by the NCIPC's Advisory Committee on Injury Prevention and Control..

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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When the research grant program began in 1987, there was a deluge of applications, but only 8 percent were awarded funding. As the realities of funding became apparent, fewer applications were submitted. Nonetheless, the grant program remains extremely competitive, with only 13 percent of new applications having been awarded in FY 1997. The extramural grant program distributes approximately $15 million per year, about $7 million of which is awarded to 10 injury research centers.

Cooperative Agreements

A cooperative agreement is a mechanism for joint funding of research and demonstrations,14 and may also be used for public education and training. Cooperative agreements amounted to $19 million in FY 1997, representing 39 percent of NCIPC's budget. NCIPC employs cooperative agreements to build state and local programs for injury prevention. Areas covered by some recent cooperative agreements include bicycle head injury prevention, firearm injury surveillance, head and spinal cord injury, and playground safety.

Each year, NCIPC's cooperative agreements fund approximately 50 projects in 28 states. Most projects address either surveillance or public health interventions with annual budgets of about $120,000 to $300,000. More than half of the recipients are state and local health departments; the remainder are community-based organizations and universities. NCIPC defines the scope and purpose of cooperative agreements, solicits proposals, and then makes awards to the best proposals after a competitively reviewed process. CDC's role in a cooperative agreement, which generally accounts for about 50 percent of the total work load, is usually to advise on data collection and methodology, to devise evaluation criteria, and to disseminate findings. The partner's role is generally to tailor the project to the needs of the community it serves and to collect and analyze data.

The injury researchers at NCIPC administer cooperative agreements and provide technical assistance to states and local organizations (outside of a formal cooperative agreement). NCIPC researchers do engage in intramural research, such as analysis of injury data sets, but their own research represents a small fraction of their time. The devotion of their energies mostly to cooperative agreements and technical assistance, rather than to their own research pursuits, is a distinguishing feature of the NCIPC. NCIPC does not have a formal intramural research program of its own, like that at NIH, where institutes have dedicated intramural research budgets expressly designed to enable their researchers to conduct research full-time.

14

A cooperative agreement is formally defined by CDC as an "assistance mechanism" in which "CDC anticipates considerable interaction with the recipient and substantial programmatic involvement by CDC staff" (CDC, 1993).

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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Before the widespread use of cooperative agreements in the mid-1990s, NCIPC awarded other types of grants to states that gave them more latitude in program development and implementation. There previously had been three general types of grants: capacity-building grants, 15 surveillance grants, and incentive grants for intervention projects (Hersey et al., 1995). In 1994, however, NCIPC made a policy decision to exercise greater participation in the building of state and local injury programs. Instead of awarding capacity building grants, NCIPC began to utilize the more focused cooperative agreements on the grounds that the agency's limited funds should be used to provide more guidance to states for introducing into practice, and monitoring the impact of, proven interventions like smoke detectors and bicycle helmets. During the same period, Congress began to earmark a large percentage of NCIPC's budget for program development and related activities at the state and community level. The overall impact of these changes was that NCIPC increasingly came to rely on cooperative agreements to carry out areas of emphasis defined by Congressionally earmarked appropriations.

Review and evaluation of cooperative agreements occur before and during the project. An RFP in the Federal Register announces the availability of funds. Each announcement culminates a mostly internal planning process to formulate and refine research priorities. Submitted proposals are reviewed by NCIPC according to published review criteria through ad hoc review panels.16 A new external review procedure, analogous to a time-limited NIH study section, has been introduced in lieu of the ad hoc review panel when there is insufficient internal expertise to review proposals (U.S. DHHS, 1994). Once an award is made, projects are subjected to annual reviews by NCIPC to ensure that milestones are being met. An evaluation component is routinely incorporated into the cooperative agreement once it begins. The evaluation typically asks, Did this project succeed at accomplishing its objectives? Evaluation criteria are often developed by NCIPC (as indicated earlier), and evaluation findings are required in the final report to NCIPC. Approximately 20–25 percent of submitted applications are approved.

15

Such grants were known as State and Community-Based Injury Control Programs. In FY 1994, these grants were distributed to 15 states and metropolitan areas (about $200,000–300,000 per grant) with the goal of developing, expanding, or improving injury control programs.

16

These panels, which are made up of CDC and other federal employees, rank proposals by merit and recommend funding. In about 20 percent of RFPs, a second review by a similarly constituted panel is invoked by the NCIPC director when more than one ad hoc review panel ranks proposals or when NCIPC's research priorities and/or geographic distribution requirements are not satisfied by the first review. To avoid conflict of interest, none of the reviewers for any of the review panels is from the NCIPC division supporting the cooperative agreement.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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Training

Due to budget limitations, NCIPC has a meager investment in the training of practitioners and researchers. Practitioner training generally refers to educational activities for clinicians or for professionals in state and local health departments, whereas research training generally refers to training of the pre-and postdoctoral students at universities. Practitioner and research training is conducted to a modest degree by NCIPC-supported Injury Control Research Centers, but because of the funding limitations described below, training is subordinated to research activities.

Assessment and Recommendations

The committee's evaluation of NCIPC covers the following crosscutting topics: research accomplishments, priorities for future research, training, building state and community infrastructure, and nuturing the field.

Research Accomplishments

The premier accomplishment of NCIPC is the development and support of the science base of injury prevention. Since its inception, NCIPC has sought to forge a research niche in injury prevention. Consequently, NCIPC's research on unintentional and intentional injuries has emphasized surveillance, risk factors, etiology, and evaluation of prevention programs. A prevention orientation also underlies NCIPC's program on acute care, rehabilitation, and disability. For example, with respect to traumatic brain injuries, the leading cause of death and serious long-term disabilities from injuries, NCIPC focuses on surveillance, whereas other DHHS agencies focus on treatment research and service delivery.

NCIPC has succeeded in generating important new knowledge through its support for high-quality research on injury prevention. NCIPC's contributions to research have been noted in comprehensive evaluations (Hersey et al., 1995) and in more focused evaluations of research programs in rehabilitation and disability, motor vehicle, and firearm research by its advisory committee (NCIPC, 1995, 1996b, 1997b). The committee wishes to draw particular attention to NCIPC's noteworthy development of a strong extramural program of investigator-initiated grants, including its support for injury centers and areas of research largely unaddressed by other agencies (discussed below). This discussion serves as a backdrop for the committee's recommendation for an expansion of NCIPC extramural research in several priority areas.

Extramural research. NCIPC is to be commended for its commitment to extramural research in areas essential to scientific progress in the field, but

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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largely unsupported by other federal agencies. Examples are research on injury biomechanics, trauma system design and performance, and residential and recreational injury prevention. For instance, for more than a decade, NCIPC has funded several biomechanics research programs at universities, a commitment totaling about $2 million to $3 million annually. Grant recipients have used NCIPC funds to leverage support from the private sector. Without NCIPC's consistent support, biomechanics as a field of inquiry would have languished, even though it is critical for understanding injury causation (Chapter 4). Biomechanics and other important areas could easily have been forfeited in favor of fields enjoying stronger constituency support. Instead, NCIPC has sustained and nurtured these fields, despite persistent budget limitations.

NCIPC has cultivated a strong extramural program of investigator-initiated grants. These grants consist of individual investigator grants, program project grants, and center grants. NCIPC's extramural grant program has devised a careful process of independent peer review to fund research of high quality. Unfortunately, the program has suffered from chronically low funding. The extramural program's current funding level, about $15 million annually, is woefully insufficient to address NCIPC's vitally important mission. Competition for grants is so great that only 13 percent of applications were awarded funding in FY 1997. By contrast, research programs at NIH typically experience success rates of 20–30 percent. With increased funding over the long term, NCIPC should be able to establish and sustain a critical mass of injury prevention investigators and attract researchers from related fields. Increased funding should be allocated to all types of grants administered by NCIPC. With respect to center grants, the size of each grant should be increased, as discussed below.

Injury Control Research Centers (ICRCs). ICRCs have advanced injury research by bringing together biomedical scientists, epidemiologists and statisticians, social and behavioral scientists, engineers and specialists in biomechanics, policy experts, economists, and lawyers. Cultivation of ICRCs must be considered one of the major advances in the field of injury prevention since the publication of Injury in America (NRC, 1985). Before this program, there were no broad-based research centers dedicated to injury prevention. Although some strong research programs already had been established at individual universities (e.g., Wayne State University's pioneering program in biomechanics research and Johns Hopkins University's program to train injury researchers), no individual center could have achieved the catalytic role and breadth of the current program. In light of the highly important role of ICRCs, the current funding level of each center grant, about $750,000 annually, is not sufficient to cover the full range of activities for which each grant was intended: research, policy formation, and training and technical assistance for state and local injury prevention agencies. A center with a similarly comprehensive mission supported by the NIH for cancer or heart disease frequently receives more than $1 million annually. The

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

ICRCs' research and practitioner training activities have been especially circumscribed because of curtailed funding.

Priority Areas for Future Research

To advance the injury field, the committee believes that NCIPC needs more resources for extramural research in selected areas. The committee predicated its selection of priority areas on the following criteria: the magnitude of the problem, trends in surveillance, gaps in knowledge, and the degree of support from other federal agencies. On the basis of the foregoing discussion in this chapter and in Chapter 4, the committee urges NCIPC to support an expanded research portfolio in the following areas: biomechanics, residential and recreational injuries, suicide prevention, and violence prevention.

The elucidation of more detailed research priorities within each of these general areas should be undertaken by NCIPC, in close coordination with its stakeholders and federal partners, through a systematic priority-setting process described later.

Biomechanics. Injury biomechanics is a seminal discipline for the study of injury causation (Chapter 4). Biomechanics reproduces patterns of injury under well-controlled laboratory conditions and examines structural and biologic responses. As noted above, NCIPC has provided consistent support for investigator-initiated research in injury biomechanics. This support must continue and should be expanded to ensure advances in our understanding of injury causation. Advances in biomechanics will be especially important in understanding nonfatal injuries that lead to long-term disability including brain injury and arthritis and are likely to lead to improved treatment. It is important to continue to expand the research effort in the study of injuries to the study of children, short women, and the elderly.

Residential and recreational injuries. Residential and recreational injuries are a serious problem. Although there appears to have been some decline in prevalence since 1985, more recent trends suggest a leveling off (Chapter 4). Within these broad trends are more alarming ones, such as apparent increases in unintentional poisonings (Fingerhut and Cox, 1998) and falls in the elderly. Mortality rates for falls in the elderly increased slightly from 1985 to 1995 (Fingerhut and Warner, 1997). Because such falls frequently lead to hospitalization, they represent a costly societal problem (Chapter 2).

It is incumbent on NCIPC to monitor surveillance trends in order to focus research on the most important problems related to residential and recreational injuries. NCIPC's support for these areas of research amounted to $7.5 million in FY 1997 (NCIPC Budget Office, personal communication, 1997). Apart from NCIPC, no other federal agency supports a research program in the prevention

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

of residential and recreational injuries. CPSC has a very small research budget that is restricted to consumer products in particular, rather than the broader category of residential and recreational injuries.

Suicide prevention. The design and evaluation of suicide prevention programs should be a high priority for NCIPC. NCIPC has played a critical role in raising awareness of suicide as a national problem for which prevention research is essential. It has drawn attention to the lack of evidence for effective suicide prevention programs. NCIPC spent approximately $400,000 on suicide research and demonstrations in FY 1997 (NCIPC Budget Office, personal communication, 1997). NCIPC should be given additional funds to establish a suicide prevention research center similar in function to, but more circumscribed in focus than, the ICRCs that it now supports. The expansion of suicide prevention research at NCIPC should not affect the commitment of the National Institute of Mental Health (NIMH) to its program of high-quality research on suicide etiology and treatment, because NCIPC's orientation to suicide surveillance, risk-factor identification, and prevention program development and evaluation complements rather than duplicates that of NIMH. Yet the two agencies must closely coordinate their suicide prevention research portfolios. NIMH expended an estimated $12 million in FY 1997 on extramural research in suicide (NIMH, 1998).

Violence prevention. Since its inception, NCIPC has played a leadership role in galvanizing attention to violence as a public health problem. NCIPC was virtually the only source of support for research on violence prevention until the passage of the Crime Act in 1994. This act led to a rapid expansion of violence prevention research by NIJ (see earlier discussion). NCIPC and NIJ are now the two federal agencies with the greatest emphasis on violence prevention research. For reasons discussed earlier in this chapter, the committee believes that research on the prevention of lethal violence—violence that results in serious injury or death—should merit explicit priority from both agencies. NCIPC and NIJ must coordinate their research portfolios to ensure that each pursues the facets of the problem for which it is best suited or is obligated to pursue (by virtue of intra-agency transfers or congressional mandates). The problem of lethal violence is sufficiently multifaceted, serious, and refractory to simple solutions that duplication of effort is unlikely as long as close coordination occurs.

Research priority-setting process. The committee already has taken the first step by identifying in the preceding section several prominent priority areas in which NCIPC should expand its research investment: biomechanics, residential and recreational injuries, suicide prevention, and violence prevention. The committee recommends these priorities on the basis of the magnitude of the problem, trends in surveillance, gaps in knowledge, and degree of support from

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
×

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]);

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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  • 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

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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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.

Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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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.

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Suggested Citation:"8 Federal Response." Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6321.
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Injuries are the leading cause of death and disability among people under age 35 in the United States. Despite great strides in injury prevention over the decades, injuries result in 150,000 deaths, 2.6 million hospitalizations, and 36 million visits to the emergency room each year.

Reducing the Burden of Injury describes the cost and magnitude of the injury problem in America and looks critically at the current response by the public and private sectors, including:

  • Data and surveillance needs.
  • Research priorities.
  • Trauma care systems development.
  • Infrastructure support, including training for injury professionals.
  • Firearm safety.
  • Coordination among federal agencies.

The authors define the field of injury and establish boundaries for the field regarding intentional injuries. This book highlights the crosscutting nature of the injury field, identifies opportunities to leverage resources and expertise of the numerous parties involved, and discusses issues regarding leadership at the federal level.

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