THE INJURY FIELD
Injury morbidity and mortality have been persistent problems in the United States. Recent findings report that in 1995 alone, injuries were responsible for 147,891 deaths, 2.6 million hospitalizations, and over 36 million emergency room visits (Fingerhut and Warner, 1997). Societal costs of injury-related morbidity and mortality were estimated at $260 billion in FY 1995.1 Unintentional injuries and violence account for about 30 percent of all lost years of productive life before age 65, exceeding losses from heart disease, cancer, and stroke combined (CDC, 1991; Waller, 1994). Given the staggering costs of injury morbidity and mortality, the Robert Wood Johnson, W.K. Kellogg, and John D. and Catherine T. MacArthur foundations, requested that the Institute of Medicine (IOM) establish a committee to make recommendations for advancing the injury field and reducing the burden of injury in America. In this report, the IOM Committee on Injury Prevention and Control characterizes the injury problem in the United States, assesses the current response by the public and private sectors, and presents recommendations for reducing the burden of injury in America.2
The Mission and the Boundaries of the Injury Field
The mission of the injury field is prevention, amelioration, and treatment of injury and the reduction of injury-related disability and death. The field is defined by its focus on the injury, whatever the mechanism by which it was immediately caused and regardless of the contributing role of human intent. This understanding, which emerges clearly from Injury in America (NRC, 1985), has profoundly important implications for the boundaries of the field because, by drawing no distinction between unintentional and intentional injuries (i.e., homicide, assaultive injuries), it broadens the reach of prevention research and practice beyond the traditional domain of "accident prevention."
Despite its emphasis on the need for greater attention to assaultive and self-inflicted injuries, Injury in America focused mainly on unintentional injuries, primarily those caused by motor vehicle crashes. Three years later [with the publication of Injury Control; (NRC, 1988)], the IOM reviewed the status and progress of the injury control programs at the Centers for Disease Control and Prevention (CDC); that report reiterated the need to intensify the study of intentional injury.
The committee decided, unanimously, to reaffirm the views expressed in Injury in America and Injury Control regarding the scope and mission of the injury field. Despite important differences associated with intentionality, the committee strongly endorses the continued integration of all injury prevention activities within a common framework of research and program development. The injury field has much to contribute to scientific understanding of firearm injuries and to the prevention of violence, complementing the contributions made by criminal justice, mental health, and other approaches. The public health investment in these areas should be strengthened, not abandoned or diminished.
The committee notes that there have been major accomplishments in the injury field over the past 25 years. Future advancements are dependent on the continued development and support of the infrastructure of the field. Investment in priority areas (discussed below) will ensure further advances in injury science and practice.
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.
SURVEILLANCE AND DATA NEEDS
Surveillance data are needed at the national, state, and local (community) levels. National data are critical for drawing attention to the magnitude of an injury problem, for monitoring the impact of federal legislation, and for examining variations in injury rates by region of the country and by rural versus urban or suburban environments. They are also useful in aggregating sufficient numbers of rare cases of a particular type of injury to identify patterns and mechanisms of injury. State and local data better reflect injury problems in specific communities and are therefore more useful in setting program priorities and evaluating the impact of local policies and expenditures.
As the availability, accessibility, and quality of the data have improved, they have played an increasingly important role in the development and evaluation of interventions at national, state, and local levels. However, significant impediments to effective injury surveillance remain, notably the high costs of development and maintenance of surveillance systems. Therefore, priority attention should be given to the improvement or expansion of existing data systems and to the development of efficient strategies for linking data across systems to gather additional and more complex information. Additionally, surveillance systems are dependent upon the quality of coded data.
The committee recommends that a high priority be directed at ensuring uniform and reliable coding of both the external cause and the nature of the injury using the International Classification of Diseases (ICD) on all health systems data, particularly on hospital and emergency department discharge records. Special efforts should be directed at training to ensure optimal use of the tenth revision of the ICD.
An important source of information on product-related injuries is the National Electronic Injury Surveillance System (NEISS) maintained for 25 years by the Consumer Product Safety Commission (CPSC). NEISS obtains statistical information through surveillance of 101 hospital emergency departments and through follow-up studies. The committee believes that an expansion of NEISS data collection to include all injuries treated in emergency departments will increase knowledge of the causes and severity of nonfatal injuries. Furthermore,
an expanded NEISS could greatly benefit the injury field because it would provide a new and important tool for gathering national estimates and monitoring national trends in injury morbidity, for identifying emerging problems, for evaluating interventions through follow-up studies, and for providing data for policy decisions. If NEISS is expanded to collect all injury data, the committee believes that the system should remain at CPSC since the system is vital to its mission.
The committee recommends that CPSC expand its NEISS system to gather nationally representative data on all injuries treated in emergency departments, to increase knowledge of the causes and severity of nonfatal injuries.
To ensure the success of an expanded NEISS, the CPSC should convene a steering committee (with representation from CPSC, the National Center for Injury Prevention and Control [NCIPC,], the Department of Justice, and other relevant federal and state agencies) to set policies and procedures for the expanded NEISS and its uses.
The committee noted that an ongoing federally sponsored system of surveillance for all intentional injuries (homicides and suicides) is conspicuously absent from the array of data systems available on a national level. Given the success of the Fatality Analysis Reporting System (FARS) in monitoring motor vehicle fatalities, and the utility of occupational surveillance systems (e.g., Census of Fatal Occupational Injuries), it seems reasonable to consider a system for recording detailed data on injury deaths that are ordinarily the subject of police investigations, such as suspected homicides and suicides. However, suicide is not a crime in all jurisdictions, and police do not necessarily investigate deaths that are clearly self-inflicted. Therefore, a system depending on police reports for case identification could miss a large proportion of the 31,000 suicides annually. In addition to police reports, medical examiner's and coroner's investigations and reports are another source of data about the nature and cause of death.
The committee recommends the development of a fatal intentional injury surveillance system, modeled after FARS, for all homicides and suicides. The committee urges the CDC (specifically, the NCIPC, the National Center for Health Statistics [NCHS] and the National Center for Environmental Health [NCEH]) in collaboration with the National Institute of Justice (NIJ) and the National Highway Traffic Safety Administration (NHTSA) to conduct a feasibility study for establishing such a system as an extension of the medical examiner and coroner systems.
The study should examine the medical examiner and coroner systems for ways to standardize, computerize, and centralize data, examine policies and
practices of police investigations of both homicides and suicides to maximize the collection of pertinent data, and make realistic estimates of the costs in time and money to establish such a system. The development of a fatal intentional injury surveillance system, based on medical examiner and coroner systems, would have to address the variability in the completeness, quality, and reporting of death investigations and concerns about the underreporting of certain types of injury deaths in medical examiner reports.
The committee believes that the development of a fatal intentional injury surveillance system is essential for a nationwide effort in reducing fatal intentional injuries. It will identify common mechanisms and situations resulting in such deaths and will enable researchers to develop preventive interventions.
The value of prevention research lies in its contribution to the design and implementation of interventions that successfully reduce injuries or ameliorate their consequences. Over the past quarter century, research has contributed in this way to actual reductions in injury mortality rates (Baker et al., 1992), most clearly in relation to motor vehicle injuries. Additionally, injury research has documented the effectiveness of many interventions (i.e., programs and policies) designed to reduce injury. Research also makes an important contribution when it demonstrates that interventions do not achieve the desired results or have unintended consequences. Such research helps to refine and improve interventions and to enhance the conceptual foundation for prevention.
Scientific inquiry has transformed our notions of injury from accidental, unavoidable occurrences to events that are predictable and amenable to prevention. The development of future prevention interventions to address injury and the evaluation of the success of those interventions require a national commitment to expanding the scientific foundation for injury prevention. Support for injury prevention research should be commensurate with the enormous toll of injury on society.
Prevention research is accomplished through a burgeoning variety of disciplines. Disciplines at the core of injury prevention research—epidemiology, behavioral science, biomedicine, and biomechanics—continue to be critical to the advancement of the field. Other disciplines are playing increasingly important roles, including economics, criminology, sociology, engineering, law, and molecular biology. As the scope of injury prevention is broadened to incorporate concepts and methodologies from many diverse fields, there is the potential for the development and testing of a far-reaching variety of new and better interventions and a fuller, multipronged approach to reducing the incidence and consequences of injury.
The committee strongly recommends the utilization of rigorous analytical methods in injury research. Collaborations between research centers are critical for assembling populations and cohort groups necessary for conducting large-scale randomized control trials, cohort studies, and case-control studies.
The committee also recommends intensified research in three promising areas for the injury field, specifically:
the continued development of physical, mathematical, cellular, and biofidelic models of injury, particularly for high-risk populations (such as children and small women) while continuing to use animals and cadavers to validate biomechanical models of injury;
the pathophysiology and reparative processes necessary to further the understanding of nonfatal injury causes and consequences, in particular, those that result. in long-term disability; and
differences in risk perception, risk taking, and behavioral responses to safety improvements among different segments of the population, particularly among those groups at highest risk of injury.
The lack of research training is a major barrier to the development of the field of injury prevention research. Training attracts young people to a field and equips them for a lifelong commitment to research and education. A cadre of talented young researchers ensures the growth, innovation, and continuity of a field, yet funding has not been forthcoming to train injury researchers.
In addition to funds for training, the maintenance of a vital extramural research community will require adequate funding for investigator-initiated, peer-reviewed research grants. It is 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. To ensure the scientific rigor of this research, proposed projects should be peer reviewed by scientists outside the sponsoring federal agencies.
The committee recommends the expansion of research training opportunities by the relevant federal agencies (e.g., NCIPC, the National Institute for Occupational Safety and Health [NIOSH], and NHTSA). This includes an increase in the number of individual and institutional training grants for injury prevention; research grant proposals should have independent peer review. Adequate federal funding must be forthcoming to sustain careers in the injury field.
A national, long-term commitment to the expansion of training and interdisciplinary research in injury prevention is essential to public health. Without this commitment, injury research will not achieve the sophistication necessary for effective intervention development; talented new researchers will not be attracted to the field; and existing injury researchers may be forced to leave the field. In short, without a national commitment, the field of injury science will stagnate and the unnecessary toll of injury will persist.
CASE STUDIES ON PREVENTION
The two leading mechanisms causing fatal injury in the United States are motor vehicles and firearms; in 1995, 42,452 people died from motor vehicle traffic injuries and 35,957 people died as a result of firearm injuries (Fingerhut and Warner, 1997). Over the past three decades, dramatic progress has been made in reducing motor vehicle injuries by understanding the factors that increase the risk of injury; designing interventions to reduce these risks; implementing and evaluating a wide array of interventions; assessing their benefits and costs; and providing a scientific foundation for individual and business choices and public policy judgments. However, a similar comprehensive multidisciplinary approach has not been taken in relation to firearm injuries.
Over the long term, an effective national policy directed at reducing the risk and severity of firearm-related injury requires a strong federal presence. The multipronged approach used to develop federal motor vehicle safety policy—surveillance, regulatory action, multidisciplinary research, support for state and local prevention initiatives, and public support—provides a useful model.
The committee recommends the implementation of a comprehensive approach for preventing and reducing firearm injuries that includes firearm surveillance, firearm safety regulation, multidisciplinary research, enforcement of existing restrictions on access by minors and other unlawful purchasers, prevention programs at the state and local levels, and mobilization of public support.
A workable political consensus has not yet developed on the balance that should be struck between the prerogatives of firearm ownership and the reduction of firearm-related injuries, especially in a social context in which about 192 million firearms, including 65 million handguns, are in circulation (Cook and Ludwig, 1996). In the committee's view, a workable consensus is most likely to emerge if the discussion is focused less on ownership issues and more on the steps that can be taken to reduce the adverse health consequences of firearms use and to strengthen the scientific basis of policy making. In short, the points of departure for national firearms policy should be harm reduction and better science.
Within the overall framework, initial priority should be given to measures that reduce the risk of harm to the most vulnerable segments of the population, particularly children and adolescents and that curtail the risk of firearm injury caused by children and adolescents. Even in the absence of a broad consensus about the aims of national policy, few people are likely to contest the ethical legitimacy of aggressive measures designed to reduce gun-related injuries to and by youths.
A youth-centered injury prevention strategy is needed that would have several components: reducing the number of locations in which youth have access to guns; restricting their ability to gain access to the guns and ammunition in these settings; building features into guns that will reduce the risk of accidental or unauthorized use if the gun does get into the hands of youth; and building community coalitions to make youth environments safer.
The committee recommends the development of a national policy on the prevention of firearm injuries directed toward the reduction of morbidity and mortality associated with unintended or unlawful uses of firearms. An immediate priority should be a strategic focus on reduction of firearm injuries caused by children and adolescents.
To ensure the success of a youth-centered prevention initiative, Congress and relevant federal agencies (e.g., the Departments of Health and Human Services [DHHS] and Justice) should set national goals for reducing assaultive injuries, suicide, and unintentional injuries by young people using firearms. As a long-term commitment to this goal, consideration should be given to appointing a high-level task force for implementing and evaluating such an initiative.
Great strides have been made over the past decades in developing trauma systems covering a continuum of prehospital, acute care, and rehabilitation services. Public health organizations and providers have embraced the need for a broader, more inclusive philosophy that shifts the focus from the trauma center to a system of trauma care that attends to the needs of all trauma patients over the full course of treatment.
A focal point at the federal level has to be reinstated to support research and to cultivate the growth of state and regional trauma systems. A federal program had been in place until 1995, when budget pressures led to the program's demise. Consequently, there is no longer a focal point at the federal level to cultivate trauma systems development.
The committee supports a greater national commitment to, and support of, trauma care systems at the federal, state, and local lev-
els, and recommends the reauthorization of trauma care systems planning, development, and outcomes research at the Health Resources and Services Administration (HRSA).
To ensure the success of this recommendation, resources should be provided to stimulate the development and evaluation of trauma systems in states and regions with the greatest need for systems development.
Trauma care is lifesaving, yet expensive. The costs of trauma systems development should be shared by federal, state, and local governments. About half of the states report having some kind of trauma system, although their nature and extent are not well documented. Some of the most successful statewide trauma systems have flourished with dedicated sources of funding through motor vehicle fees and other creative approaches. Research has begun to demonstrate that the investment in systems of care can be cost-effective in terms of long-term health care costs and productivity.
The committee recommends intensified trauma outcomes research, including research on the delivery and financing of acute care services and rehabilitation. The committee envisions that HRSA and other appropriate federal agencies (e.g., NCIPC, and the Agency for Health Care Policy and Research [AHCPR]) will collaborate on this research.
Specific areas of research that have to be addressed include the following:
the cost-effectiveness of specific clinical and service interventions to establish best practices in trauma care;
the most efficient and effective strategies for organizing and financing the delivery of both acute care services and rehabilitation, including the impact of managed care arrangements on access to services, quality of care, and outcomes; and
the development of improved methods for measuring the severity of injury, particularly for those at high risk of adverse outcomes.
STATE AND COMMUNITY RESPONSE
Further progress in reducing the burden of injuries not only depends on concerted research and treatment efforts but also requires a strengthened focus on prevention implementation. Great strides have been made in developing injury prevention strategies that have been shown to be successful in promoting safety and reducing injury morbidity and mortality. In most cases, injury prevention is best achieved through a multifaceted approach that utilizes the range of available prevention strategies. However, the state and community response is often ham-
pered by federal and state funding constraints and a lack of awareness of injury prevention measures. The committee has identified five areas that, if successfully addressed, could optimize proven strategies for prevention: (1) strengthening the public health infrastructure; (2) building and encouraging collaboration and coalitions of state and local safety agencies and organizations; (3) improving training and technical assistance; (4) better translating of research findings into practice; and (5) increasing public awareness and advocacy.
Although it is difficult to quantify the total extent of government, community, and private-sector endeavors in the injury field, there is a wide range of ongoing efforts, many of which have begun or expanded within the past 20 years. Although the current response is impressive, it is also fragmented. A core injury prevention program is needed in each state that can implement (and assist other agencies and organizations in implementing) injury prevention interventions. State injury prevention programs require a sustained federal commitment to funding and to providing technical assistance to the states.
The committee recommends strengthening the state infrastructure in injury prevention by development of core injury prevention programs in each state's department of health. To accomplish this goal, funding, resources, and technical assistance should be provided to the states. Support for such programs should be provided by the NCIPC in collaboration with state and local governments.
Additionally, training opportunities for state and local injury prevention practitioners should be expanded. Consideration should be given by multiple federal agencies to the expansion of training opportunities for state and local injury prevention professionals.
The committee recommends the expansion of training opportunities for injury prevention practitioners by the relevant state and federal agencies (e.g., NCIPC, NHTSA, the Maternal and Child Health Bureau [MCHB], and NIOSH) in partnership with key stakeholders such as the State and Territorial Injury Prevention Directors' Association (STIPDA). Training should emphasize program development, implementation, and evaluation as well as participation in program research.
As new prevention interventions are developed and evaluated, ongoing information exchange between researchers and practitioners is needed that will facilitate the implementation of new interventions and the refinement of these interventions to meet real-world demands. A final component of strengthening the state and local response is raising public awareness and increasing advocacy efforts. Both the general public and policy makers need information on the effectiveness of injury prevention measures in order to make informed decisions and choices.
It is 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 important refinements of the present organizational architecture of injury prevention and treatment, in the following key agencies, NHTSA, CPSC, NIOSH, NIH, NIJ, and the NCIPC. The refinements are listed as recommendations in Box 1.
BOX 1 The Federal Response
COORDINATION AND LEADERSHIP
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 recommendation in Box 1). 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 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 perspectives3 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. 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. 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 to promote coordination and interagency collaboration.
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
Since 1985, significant strides have been taken to implement the vision outlined in Injury in America (NRC, 1985). The national investment in injury re-
search 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. Future advances in the injury field depend on the continued development of the infrastructure of the field through public and private partnerships. 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 report emphasizes, as did Injury in America and Injury Control , that the nation's current investment in injury research is not commensurate with the magnitude of the problem. Throughout the report, the committee has recommended additional funding for surveillance, research, training, and program evaluation supported by a variety of federal agencies. Abundant opportunities for scientific advances in all aspects of the field fully justify a substantially higher level of funding for injury research. Trauma research (basic and applied) should receive a higher share (compared with current allocations) of increases in the NIH budget, and funding outside NIH (e.g., CDC, AHCPR) for extramural research in all aspects of injury prevention and treatment should be increased. The committee also concluded that there is a yawning gap between what we already know about preventing or ameliorating injuries and what is being done in our communities, workplaces, and clinics. Funding for prevention program support, emergency medical services and trauma systems, and public health infrastructure should be significantly increased. Thousands of lives could be saved every year if interventions already known to be successful were more widely implemented. Although the committee has not attempted to develop cost estimates for its recommendations, carrying them out will clearly require the investment of new funds. The committee has provided adequate support for the programmatic goals and objectives of its recommendations; additional funds and resources must be forthcoming from the Congress for the relevant federal agencies and the states. For a summary of all recommendations, see Box 2.
The challenge confronting us today is to enhance the impact and effectiveness of the field. Doing so requires a broad matrix of collaboration with other agencies and constituencies, and careful priority setting within the field in order to focus efforts and resources on areas of research and action that optimize the specialized contribution of public health.
BOX 2 Summary of Recommendations
Surveillance Systems (see Chapter 3)
Training and Research (see Chapter 4)
Firearm Injury Prevention (see Chapter 5)
Trauma Care Systems (see Chapter 6)
Training and State Infrastructure (see Chapter 7)
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Cook PJ, Ludwig J. 1996. Guns in America: Results of a Comprehensive National Survey on Firearms Ownership and Use. Washington, DC: Police Foundation.
Fingerhut LA, Warner M. 1997. Injury Chartbook Health, United States, 1996–97. Hyattsville, MD: National Center for Health Statistics.
GAO (General Accounting Office). 1994. Agencies Use Different Approaches to Protect the Public Against Disease and Injury. Washington, DC: GAO. GAO/HEHS-9-85BR.
NRC (National Research Council). 1985. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press.
NRC (National Research Council). 1988. Injury Control: A Review of the Status and Progress of the Injury Control Program at the Centers for Disease Control. Washington, DC: National Academy Press.
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