9
Challenges and Opportunities

Since 1985, significant strides have been taken to implement the vision outlined in Injury in America (NRC, 1985). The national investment in injury research has increased, albeit not as markedly as the report recommended. The field of injury science has developed and matured, attracting the interest of investigators from a wide range of disciplines. Important advances have been made in delivering emergency services and treatment to injured patients, saving lives, and reducing disability. Recent research is beginning to provide information about how cells respond to injury and how their normal functioning can be preserved. Important advances have also been made in demonstrating the efficacy and cost-effectiveness of preventive interventions in the field so that they can be successfully implemented on a wide scale.

One of the most impressive achievements over the past two decades has been a "political" one—through communication, advocacy, and constituency building, a national "community of interest" in promoting safety and preventing injury has emerged. Although injury prevention has achieved higher visibility in government at all levels, most of the energy for social action has come from the private sector and through the recruitment of individuals, businesses, foundations, community groups, and other organizations interested in preventing injuries and implementing safety programs (see Chapter 7). Future advances in the injury field depend on the continued development of the infrastructure of the field through public and private partnerships.

Progress has been made not only in developing a scientific field and generating social investment in injury prevention, but also in reducing injury. Over the past 25 years, injury rates have declined most substantially where the social investment in prevention, including regulatory initiatives, has been strongest.



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Reducing the Burden of Injury: Advancing Prevention and Treatment 9 Challenges and Opportunities Since 1985, significant strides have been taken to implement the vision outlined in Injury in America (NRC, 1985). The national investment in injury research has increased, albeit not as markedly as the report recommended. The field of injury science has developed and matured, attracting the interest of investigators from a wide range of disciplines. Important advances have been made in delivering emergency services and treatment to injured patients, saving lives, and reducing disability. Recent research is beginning to provide information about how cells respond to injury and how their normal functioning can be preserved. Important advances have also been made in demonstrating the efficacy and cost-effectiveness of preventive interventions in the field so that they can be successfully implemented on a wide scale. One of the most impressive achievements over the past two decades has been a "political" one—through communication, advocacy, and constituency building, a national "community of interest" in promoting safety and preventing injury has emerged. Although injury prevention has achieved higher visibility in government at all levels, most of the energy for social action has come from the private sector and through the recruitment of individuals, businesses, foundations, community groups, and other organizations interested in preventing injuries and implementing safety programs (see Chapter 7). Future advances in the injury field depend on the continued development of the infrastructure of the field through public and private partnerships. Progress has been made not only in developing a scientific field and generating social investment in injury prevention, but also in reducing injury. Over the past 25 years, injury rates have declined most substantially where the social investment in prevention, including regulatory initiatives, has been strongest.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Motor vehicle fatality rates have declined markedly over the past 25 years (see Chapter 5). The improvement is attributable to reduction in drunk driving and increased use of occupant restraints, together with a continuation of longer-term influences (improved highway design, increased urbanization, improvement in emergency medical services, and safer vehicle designs) (Graham, 1993). Long-term downward trends in occupational fatalities appear to have accelerated in recent years. Although the long-term trends are probably attributable largely to changes in work-force composition and technological improvements, it seems likely that occupational safety initiatives have played a contributing role (McGarity and Shapiro, 1993) Residential fire death rates have also fallen substantially during this period, at least in part due to improvements in building codes, product safety improvements, and increased use of smoke detectors (U.S. Fire Administration, 1997). By contrast, the suicide rate has remained essentially unchanged for the past 20 years, and the homicide rate is the same as it was 20 years ago, although it has fluctuated considerably over this period (Baker et al., 1992; Kachur et al., 1995; Fingerhut and Warner, 1997). The main challenge for the nation, in the view of the committee, is to consolidate the gains that have been made over the past 25 years, and particularly over the past decade, and to secure the foundation for further advances in injury science and practice. This challenge can be met by adhering to the following plan: Improving coordination and collaboration: Coordinating the diverse efforts currently devoted to injury prevention and treatment, promoting collaboration among interested agencies and constituencies, and clarifying the roles of the main federal agencies. Strengthening capacity for research and practice: Strengthening the infrastructure of the injury field for developing knowledge and for translating knowledge into practice. Integrating the field: Infusing the injury field with a common sense of purpose and a shared understanding of its methods and perspectives, and promoting new channels of communication. Nurturing public understanding and support: Broadening public understanding of the feasibility and value of efforts to prevent and ameliorate injuries and promoting investment in injury prevention by managed care organizations. Promoting informed policy making: Improving the information systems used for identifying and evaluating injury risks and setting priorities for research and intervention.

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Reducing the Burden of Injury: Advancing Prevention and Treatment COORDINATION AND COLLABORATION It did not take very long for the committee to realize that ''injury prevention and control" is a large field, even if "the field" is understood to encompass only people and organizations who embrace this identity. As discussed in Chapter 1, the injury field is defined by its allegiance to the public health perspective and particularly by its use of the tools and methods of public health to prevent or ameliorate injuries. So defined, the injury field is part of a broader array of people and agencies devoted to promoting safety, whose methods and perspectives differ from those of public health, including the tort system, criminal justice, alcohol control, and fire protection. One of the greatest challenges facing the leaders of the injury field is to develop creative and effective ways of coordinating their own efforts and promoting collaboration with agencies and constituencies outside the field. Public-Private Partnerships Many reports in human services and public health in recent years have touted the value, indeed the necessity, of creating "strategic partnerships" between public and private organizations to harness private energy and leverage public resources. Many examples of successful public-private partnerships are mentioned in this report, involving state and local governments, foundations, and advocacy organizations, as well as regulatory agencies and regulated industries. These efforts must be replicated throughout the field. An area that is ripe for public-private cooperation, through public education and advocacy, is raising the salience and visibility of injury prevention and demonstrating program cost-effectiveness to health care payers, including self-insured employers. Roles of Federal Agencies It is also important to clarify the roles of federal agencies and to facilitate coordination among them. Injury prevention and treatment cover a vast terrain. Numerous federal agencies play important roles in supporting injury science or carrying out the national agenda in injury prevention and treatment. This potpourri of federal responsibilities emerged piecemeal over several decades rather than as components of a coordinated national plan. This is not to say that the federal response has been weak or wasteful. To the contrary, the key federal agencies have accomplished a great deal over the past three decades in building a new scientific field and reducing the burden of injury. The problem is one of missed opportunities due to lack of focus, cohesion, and coordination. The committee believes that the federal response could be strengthened significantly by several key refinements of the present organizational architecture of injury prevention and treatment.

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Reducing the Burden of Injury: Advancing Prevention and Treatment In 1966, the National Research Council (NRC) report Accidental Death and Disability: The Neglected Disease of Modern Society recommended creation of a National Institute of Trauma to sponsor a program of injury treatment research at the National Institutes of Health (NIH); this recommendation has never been implemented. What is needed at this time is a mechanism for coordinating, rationalizing, and strengthening these diverse activities. The most sensible step in this direction is to create a new division within the National Institute of General Medical Sciences and to assign this division the responsibility for conducting trauma care and treatment research. Primary responsibility for trauma systems, development and for outcomes research should be assumed by the Health Resources and Services Administration. For injury prevention practice and research, spheres of responsibility emerge rather clearly from statutory arrangements and historical practices. The National Highway Traffic Safety Administration (NHTSA) bears primary responsibility for program support and regulation in highway safety, but responsibility for researchin this area has been shared by NHTSA and the National Center for Injury Prevention and Control (NCIPC) in order to take advantage of the stronger scientific tradition of the Centers for Disease Control and Prevention (CDC). In the committee's view, NHTSA's role in supporting safety research should be strengthened through the introduction of peer-reviewed research, while the NCIPC continues to evaluate community safety interventions unaddressed by NHTSA and supports research in biomechanics as one of its highest priorities. Coordination of activities and cooperation between these two agencies is imperative. The federal role in occupational safety and the responsibilities of the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH) are well defined by the Occupational Safety and Health Act of 1970. There is little overlap between the missions of these agencies and other federal agencies; however, opportunities to translate knowledge from the occupational setting to other settings, and vice versa, should be improved (e.g., the work of NIOSH and OSHA in violence prevention). The statutory relationship between NIOSH and OSHA provides a useful model for enhancing cooperation between the NCIPC and the Consumer Product Safety Commission (CPSC). Although CPSC needs the capability provided by its National Electronic Injury Surveillance System (NEISS) to identify, and respond to, product hazards within its regulatory jurisdiction, the agencies should continue their collaborative efforts to study the feasibility of expanding the NEISS system into an all-injury emergency department surveillance system. The federal investment in preventing lethal violence and suicide should be strengthened through cooperative arrangements between the agencies involved in these areas. Specifically, the National Institute of Justice (NIJ) and NCIPC should coordinate their efforts in violence prevention research, identifying the areas in which each has a comparative advantage. NIJ should be assigned primary responsibility for evaluating the violence prevention initiatives supported by multiple

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Reducing the Burden of Injury: Advancing Prevention and Treatment federal agencies. Similarly, a coordinated research program for suicide prevention should be planned by NCIPC and the National Institute of Mental Health. Overall, the committee believes that greater cooperation and coordination among the many federal agencies involved in injury prevention is an indispensable condition for advancing the field. Unfortunately, cooperative relationships between the NCIPC and other federal agencies involved in injury prevention have too often been impeded by competition and institutional rivalries. To change this pattern, federal agencies involved in injury prevention and treatment should establish partnerships that reflect joint understandings of the missions of the respective agencies and their strengths and limitations. STRENGTHENING CAPACITY FOR RESEARCH AND PRACTICE Resources devoted to injury prevention and treatment have increased significantly since 1985, especially when all of the public and private investment is taken into account. However, some important gaps and inadequacies remain. The three main needs are (1) training for injury researchers and practitioners; (2) opportunities for investigator-initiated research in biomechanics, trauma, and injury prevention to build and maintain the research base of the field; and (3) building and maintaining an adequate infrastructure in public health departments to develop and implement injury prevention programs and to collaborate with partners in other agencies and organizations. Training There seems to be agreement that education is the area in which the field of injury has made the least progress. In 1985, Injury in America identified the shortage of trained injury prevention professionals and scientists as a major impediment to the development of the field (NRC, 1985). Despite repeated recommendations, these training needs have not yet been adequately addressed by the pertinent federal agencies. The two exceptions to this general statement appear to be NIOSH's training grants and education and research centers and NIH's training grants in trauma and burn programs. The committee recommends that NCIPC, NIOSH, NHTSA, NIH, and other federal agencies significantly increase their support for training of practitioners and researchers. Investigator-Initiated Research Numerous reports have pointed out that support for injury research has been seriously inadequate when measured against the magnitude of the injury problem. We do so once again.

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Reducing the Burden of Injury: Advancing Prevention and Treatment In Scientific Opportunities and Public Need, an Institute of Medicine committee on priority setting at the NIH recommended that NIH develop a more systematic process for taking into account the social burden of various diseases and conditions in setting research priorities (IOM, 1998). By any measure of social burden (deaths, years of potential life lost, disability or disability-adjusted life years, and economic costs), injuries exact a major toll. Although other factors, including scientific opportunity and portfolio diversification, must also be considered, the NIH investment in injury research appears to take inadequate account of the magnitude of the problem (see Table 9.1). In 1996, unintentional injury was third leading cause of years of life lost before age 75, after heart disease and malignant neoplasms. With few exceptions, the rank ordering of YPLL for injury follows the ordering for leading causes of injury deaths. Thus, maintenance of an extramural research community is vital and will require adequate funding for investigator-initiated, peer-reviewed research grants. It is also necessary to ensure viable careers for the country's best young researchers and to sustain experienced investigators. Investigator-initiated research should be encouraged to ensure the emergence of innovative approaches to injury research. TABLE 9.1 Leading Causes of Death and Disability in the United States: Estimates of NIH Research Support in Relation to Years of Potential Life Lost (YPLL) Leading Causes of Death and Disability NIH Support in FY 1996 ($ millions) Age-Adjusted YPLL Before Age 75, 1996 (per 100,000 population NIH Support ($millions) FY 1996 per YPLL Before Age 75 (per 100,000 population) Cancer 2,570.6 1,554.2 1.65 HIV infection and AIDS 1,410.9 401.9 3.51 Heart diseases 851.6 1,222.6 0.70 Diabetes 298.9 153.5 1.95 Injurya 194.4b 1,919.0 0.10 Chronic liver disease and cirrhosis 169.8 145.7 1.17 Stroke, cerebrovascular diseases 120.3 210.2 0.57 Chronic obstructive pulmonary diseases 62.4 161.1 0.39 Pneumonia and influenza 61.9 114.5 0.54 SOURCES: IOM (1998), NCHS (1998). a Includes unintentional injuries, suicide, and homicide and legal interventions. b NIH support in FY 1995. SOURCE: NCIPC (1997).

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Reducing the Burden of Injury: Advancing Prevention and Treatment State Public Health Infrastructure Successful efforts undertaken in occupational and traffic safety are characterized by a strong infrastructure for implementing safety programs. To strengthen the nation's capacity to promote residential and recreational safety and to prevent suicide and violence, an adequate infrastructure must be established within public health departments. Most effective interventions require state and local initiatives. Unfortunately, however, many states lack the capacity to undertake these initiatives. A major priority for all federal agencies involved in reducing the injury burden, especially for NCIPC, is to help states establish the necessary public health infrastructure for effective injury prevention and treatment. This can be accomplished by redistributing and leveraging existing resources, as well as by seeking additional resources from federal, state, and private coffers. In the process, public agencies unaccustomed to working together may discover unforeseen efficiencies and the advantages of pooling resources. Resource limitations make it even more imperative for federal leadership in injury prevention and treatment to transcend a strictly federal orientation and assume a broader commitment to the injury field. INTEGRATING THE FIELD Although remarkable progress has been made in developing the injury field over the past decade, continued efforts are needed to establish a common understanding of the mission and perspectives of the field, to promote greater cohesion, and to facilitate scientific interchange. Mission Recognition of the common causal pathway of injury—excessive or unregulated energy transfer—has facilitated the conceptual and scientific integration of injury epidemiology, biomechanics, behavioral science, and treatment. Injury epidemiology is a recognized field of specialization that underpins injury-related research and program development. Scientific study of the pathophysiology, mechanisms, and risk factors of injury facilitates improvements in the design of products, environments, and programs to prevent or ameliorate the severity of injuries. Emergency and trauma care have been consolidated as specialized fields of clinical research and service delivery. The unfinished business in the evolution of the injury field is consolidation of the field around a common understanding of the implications of the transition from accident prevention to injury prevention.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Leaders in medicine and public health have proclaimed that violence is a public health problem. A growing cadre of public health researchers have turned their attention to the study of the causes and prevention of violence and suicide. However, these initiatives have stimulated an intense debate about the proper role of public health in violence prevention and about the policy implications of studies undertaken by public health researchers, particularly in relation to firearms. In the committee's judgment, application of the scientific paradigm of the injury field to suicide and violence represents an important intellectual advance that should be explicitly embraced by the leaders of the field and by its private and public sponsors. Scientific Communication Scientists who work in complex interdisciplinary fields such as injury prevention and treatment face a difficult challenge of maintaining credibility and sophistication within their "home" disciplines as well as within the injury field. Established channels of scientific communication exist within the constituent disciplines, including annual conferences, journals, and electronic networks. Similar channels are developing for the specialized spheres of interest within the injury field, promoting communication among specialists in biomechanics, injury epidemiology, emergency medicine, and other fields. Still missing, however, are channels of scientific communication for injury scientists, highlighting the most sophisticated research being conducted in the entire array of disciplines. Opportunities for cross-fertilization and collaboration are now being missed (see Chapter 8). These problems could be successfully addressed by establishing a new organization of injury researchers (a society for injury research) analogous to scientific organizations that have emerged in other interdisciplinary areas (e.g., the College of Problems of Drug Dependence). Such an organization could hold an annual scientific meeting, establish communication links, and represent the voice of injury science in the political process and in public policy debate. NURTURING PUBLIC SUPPORT Ultimately, the level of social investment in the injury field depends on public recognition of the value and potential payoff from the investment. One positive sign is that focused initiatives (e.g., prevention of drunk driving, spinal cord injury research) have achieved public visibility. However, uncoordinated efforts by component constituencies will not yield a stable public investment. Forces should be joined to promote the common agenda of the field, preventing and ameliorating injury through research and implementation of cost-effective interventions. The American public is increasingly safety conscious, and the time appears right for a sustained media campaign to heighten public awareness of

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Reducing the Burden of Injury: Advancing Prevention and Treatment injury problems, to educate the public on the lifesaving and injury-ameliorating potential of prevention interventions, and to highlight the cost-effectiveness of these interventions. Various national organizations engaged in injury prevention activity should explore the feasibility and usefulness of establishing an umbrella organization to pursue their common agenda, including the formulation and implementation of a long-term media strategy for communicating key messages regarding the preventability of injuries and the cost-effectiveness of preventive interventions. The value of discrete messages about safer storage of firearms, drunk driving, bicycle helmets, and smoke detectors might be enhanced by framing them as part of a broader safety message (that injuries are preventable and that taking steps to reduce risks is worth the effort and the investment). This umbrella organization should also develop a strategy for identifying opportunities to incorporate prevention into evolving health care financing and delivery systems (Mechanic, 1998). In fact, large self-insured employers who are already pursuing preventive approaches would be valuable members of the umbrella coalition. PROMOTING INFORMED POLICY MAKING Improving Surveillance Systems Ideally, regulatory decisions, policy making, and priority setting in injury prevention should be based on sound, readily accessible epidemiological information concerning the incidence and severity of various types of injuries. Too often, however, the available data relate only to fatalities, and fatality rates are not necessarily good proxies for injury rates in general or for rates of serious injuries, significant medical costs, or severe disabilities. A recurrent theme of this report is that attention should be directed to the development of better information on the epidemiology, treatment, and outcomes of nonfatal injuries. As more lives are saved due to more effective prevention and regionalization of care, attention is shifting from a singular focus on survival as the criterion for success to a detailed consideration of nonfatal outcomes as well. Improving data systems for nonfatal injuries is a precondition for informed policy making and must be one of the highest priorities of the field. Protecting Science Freedom of scientific inquiry is a powerful engine for advancing knowledge and promoting technological innovation. Science must be accountable to the public, of course, but political interference with the customary process of scientific inquiry should be avoided. Peer review has traditionally served as the main mechanism for ensuring accountability, even when public funding is at stake.

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Reducing the Burden of Injury: Advancing Prevention and Treatment The merit of a controversial study must be judged by whether it is good science, not whether it is good politics. Whether public policy based on contested research is adopted (e.g., funding for needle exchange programs or sex education programs) is properly a political judgment, but whether research does or does not show that these programs reduce HIV (human immunodeficiency virus) transmission (and whether the question is studied at all) should be primarily scientific questions, not political ones. By this measure, case-control studies on the risks associated with the presence of firearms in the home or the effect on injuries of restrictions on the possession of weapons, for example, should be judged by the yardstick of scientific excellence, not according to preconceived positions on the virtues or vices of gun ownership. Priority Setting for Research and Social Action The committee has already noted the comparatively lower priority assigned to injury in the overall federal investment in health-related research and the comparatively lower priority assigned to prevention in public expenditures for health and public safety. Prevention and amelioration of injury should be given a higher priority in the allocation of monies for research and in the array of programs funded by public health and public safety agencies. Whatever the overall level of public investment, however, priorities for research and social action must be set. Questions are raised not only about who should be setting priorities, but also what the priorities should be. The challenge facing the field is developing criteria for setting these priorities. In such a diverse field, completely centralized priority setting would not be desirable even if it were achievable. Federal initiatives regarding program implementation should allow substantial leeway for priority setting at the state and community levels. Although research priorities should be set at a national level, criteria for setting priorities at NIH might properly differ from those used at CDC, NHTSA, or other mission-oriented agencies, because of their different areas of expertise, statutory missions, and constituencies. Priorities for regulatory action might sensibly differ among regulatory agencies, particularly in light of differences in the statutory framework. However, even if priorities differ among communities, among federal agencies, and across spheres of activity, they still must be set. Priorities will emerge by happenstance if they are not established by planning and choice. In all of these contexts, the priority-setting process should be transparent and subject to public participation and review. The committee was struck by the lack of attention given to the criteria for guiding priority setting in the injury field—for research funding, for program support and choice of interventions, and for regulatory action. Regulatory agencies have been criticized for weaknesses in their respective priority-setting processes (Mashaw and Harfst, 1990; Office of the Vice President, 1993; GAO, 1997), and NIH has been urged to open up its process to greater public partici-

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Reducing the Burden of Injury: Advancing Prevention and Treatment pation (IOM, 1998). Among federal agencies that support injury research, public involvement and explicitness of criteria for setting priorities have varied widely. The recent undertaking by NIOSH provides a useful model of how to engage public and private partners to set research priorities based on explicit criteria. Through the National Occupational Research Agenda, NIOSH was able to examine broadly perceived needs and systematically address those topics that were most likely to yield gains to protect workers. NCIPC has also facilitated public involvement through its own efforts, although mechanisms for follow up have not been established. Despite differences in context and emphasis, many common questions arise in setting priorities for research and social action in the injury field. How should the severity of particular injury problems be measured (deaths, disability) and taken into account? Under what circumstances should recent trends (rises or declines in incidence or rates) affect priority setting? Of what significance is the proportion of the population exposed to any given risk? Of what significance are various factors associated with increased risk, such as the voluntariness of exposure or the vulnerability of the population affected? When priorities are being set for interventions, including regulatory action, how should cost and cost-effectiveness be measured and taken into account? Although consideration of these issues is beyond the mandate of this committee, they should receive more systematic attention by federal agencies and their public and private partners than they have thus far. Exploration of common problems in priority setting for research and social action provides an important opportunity for a collaborative venture. Finally, this report has presented the committee's considered recommendations for further developing the field of injury prevention and treatment and for reducing the burden of injury in America. We trust that our findings will take their place alongside other IOM-NRC reports that have highlighted the need to strengthen the injury field and to assist public and private agencies as they develop their priorities. We commend the diverse array of public and private agencies who embrace the mission of injury prevention and treatment, and applaud the many accomplishments the field has achieved. We are confident that the field will continue to make great strides in reducing the burden of injury. REFERENCES Baker SP, O'Neill B, Ginsburg MJ, Li G. 1992. The Injury Fact Book . New York: Oxford University Press. Fingerhut LA, Warner M. 1997. Injury Chartbook. Health, United States, 1996–97. Hyattsville, MD: National Center for Health Statistics. GAO (General Accounting Office). 1997. Consumer Product Safety Commission: Better Data Needed to Help Identify and Analyze Potential Hazards . Washington, DC: GAO. GAO/HEHS-97-147.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Graham JD. 1993. Injuries from traffic crashes: Meeting the challenge. Annual Review of Public Health 14:515–543. IOM (Institute of Medicine). 1998. Scientific Opportunities and Public Needs: Improving Priority Setting and Public Input at the National Institutes of Health. Washington, DC: National Academy Press. Kachur SP, Potter LB, James SP, Powell KE. 1995. Suicide in the United States, 1980–1992. Atlanta, GA: NCIPC. Violence Surveillance Summary Series, No. 1. Mashaw JL, Harfst DL. 1990. The Struggle for Auto Safety. Cambridge, MA: Harvard University Press. McGarity TO, Shapiro SA. 1993. Workers at Risk: The Failed Promise of the Occupational Safety and Health Administration. Westport, CT: Praeger Press. Mechanic D. 1998. Topics for our times: Managed care and public health opportunities. American Journal of Public Health 88(6):874–875. NCHS (National Center for Health Statistics). 1998. Health, United States, 1998 with Socioeconomic Status and Health Chartbook. Hyattsville, MD: NCHS. DHHS Publication No. (PHS) 98-1232. NCIPC (National Center for Injury Prevention and Control). 1997a. Inventory of Federally Funded Research in Injury Prevention and Control, FY 1995. Atlanta, GA: NCIPC. NRC (National Research Council). 1966. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy Press. NRC (National Research Council). 1985. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press. Office of the Vice President. 1993. Improving Regulatory Systems. Accompanying Report of the National Performance Review. Washington, DC: Office of the Vice President. U.S. Fire Administration. 1997. Fire Death Rate Trends: An International Perspective . Washington, DC: Federal Emergency Management Agency, U.S. Fire Administration, National Fire Data Center.

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