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Executive Summary
Injuries are the leading cause of death and disability
in children and young adults. They destroy the health,
1 Ives, and 1 ive}ihoods of millions of people, yet they
receive scant attention, compared with diseases and other
hazards.
injury.
· Injury is the last major plague of the young.
Injuries kill more Americans aged 1-34 than all diseases
combined, and they are the leading cause of death up to
the age of 44.
· In jut ies cause the loss of more work ing years of
life than all forms of cancer and beer t disease combined.
· One of every eight hospital beds is occupied by
an injured patient.
· Each year, more than 140,000 Americans die from
injuries, and one person in three suffers a nonfatal
.
Every year, more than 80~000 people in the United
States join the ranks of those with unnecessary, but
permanently disabling, injury of the brain or spinal cord.
.
Injuries constitute one of our most expensive
health problems, costing S75-S100 billion a year directly
and indirectly, but research on injury receives less than
2 cents out of every federal dollar for research on
health problems.
In jury is not an insoluble problem. Exciting oppor-
tunities to understand and prevent injuries and reduce
their effects are available. By taking advantage of such
opportunities, we can save or improve the lives of
countless Americans who otherwise will die or become
disabled because of injury.
1
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:
2
The committee found serious, but remediable, inadequa-
cies in the understanding of and approach to injury as a
health problem.
· Injury has traditionally been regarded primarily
as an unavoidable accident or a behavioral problem,
rather than a health problem.
· No central agency has responsibility for reducing
the incidence of injuries.
· Injury control, including research, has not been
given high priority.
· Reducing injuries requires coordinated effort
among specialists in epidemiology, prevention, bio-
mechanics, treatment, and rehabilitation; trained
manpower is inadequate.
· Funding for injury control is disproportionately
low and discontinuous, in comparison with that for
cancer, heart disease, and other major health problems
Without funding continuity, centers of excellence in
iniurv research and care cannot curers ve and prow.
_ ~ _ _ .. _ _ ~
· Funding Is not only inadequate, but widely and
unevenly distributed; some crucial subjects, such as
biomechanics, receive scant attention.
.
The result of those inadequacies is that research
efforts in injury are unfocused, lack continuity , and ar e
undersupported. Many gaps exist in efforts to prevent
and treat injury and deal with its aftermath.
· Almost no current research deals with the
mechanisms and prevention of injury from falls (the
leading cause of nonfatal injury) and many other
important injury-related causes of death, such as
injuries associated with farm machinery and light
aircraft.
· m e causes and circumstances--and even the
numbers--of assaultive injuries are not known.
· Injury-prevention measures have been poorly
implemented, and the effectiveness of many such measures
has not been evaluated.
· Knowledge of the tissue-injury thresholds of
children, women, and middle-aged and elderly men is
sparse.
· Little is known of the mechanism of functional
damage to the brain and spinal cord.
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3
The committee found one recurrent theme in i ts exami-
nation of the current research effort on injury--the lack
of a single coordinated focus of activity that would give
visibility to this important public health issue and
permit an organized program of effective action to address
the problems.
The committee recommends the establishment of a center
for injury control within the federal government. The
Centers for Disease Control of the Department of Health
and Human Services is recommended as the location for
that center.
The second overriding problem the committee has
identified is the lack of f inancial support for research
on injury. The committee recognizes that competition for
available dollars is already severe in this time of
financial constraint, but contends that research on
injury has been undersupported historically and that vast
sums could be saved by a relatively small investment in
this f ield.
The committee recommends that funding for research on
injury be commensurate with the importance of injury as
the largest cause of death and disability of children and
young adults in the United States.
Chapter 1 of this report introduces the subject by
defining and describing injury and the magnitude of the
injury problem. Chapters 2 through 6 describe the state
of knowledge of various facets of the injury problem and
identify the kinds of research that are required. Chap-
ters 7 and 8 deal with the research funding and organi-
zational arrangements for research and training related
to injury. Appendix A contains some examples of the
general research problems associated with injury control
and the committee's recommendations for address ing them,
and Appendix B contains brief biographies on the
committee members.
INJURY: MAGNITUDE AND C~ARAC-~RISTICS OF The PROBLEM
Injury is caused by acute exposure to energy, such as
heat, electricity, or the kinetic energy of a crash,
fall, or bullet. It may also be caused by the sudden
absence of essentials, such as heat or oxygen, as in the
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4
INJURY (X)
~ "% ~
~ 31% ~
-
~-~
- ~4 46 64
:
i
NONI NJURY
|{X} _
55%
15-24
- ~79% /
2%
66+
25-34
/ _
/ ~
62% _~
, . . ..
Congenital Pneumonia/ Heart Liver
Age Injuries Anomalies Cancer Influenza Disease Disease Stroke Other
. .
14 46%
5-14 55%
15 24 79%
25-34 62%
35 44 31%
45~64 7%
2%
V
13%
5%
3%
4%
3%
3%
6%
20%
36%
3% 4B%
4%
5%
10%
27%
23%
13%
19%
t8%
16%
18%
FIGURE 1 Percentages of deaths from in jury and other
causes in the United States in 1980, by age . Modif fed
from Baker, S. P., B. O'Neill, and R. Rarpf. The Injury
Fact Book (Lexington, Mass .: Lexington Books , 1984 ) .
case of drowning. Injury may be either unintentional
(accidental) or deliberate (assaultive or suicidal).
Each year, more than 140 , 000 Americans die from
injuries and 70 million sustain nonfatal injuries.
Injury causes almost half the deaths of children aged
1-4, more than half the deaths; of children aged 5-14, and
nearly four-fifths of the deaths of persons aged 15-24
(Figure 1). Thus, injury is the leading cause of death
among children.
As infectious diseases have come under control during
the last century, the relative importance of injury teas
increased to the point where it is now the most prominent
cause of death for more than half the human lifespan
(ages 1-44). For more than three decades of life (ages
1-34), motor-vehicle crash injuries alone are the leading
cause of death. For all ages combined, the injury death
rate is surpassed only by the rates for heart disease,
cancer, and stroke.
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s
/ Al I Other
/ Diseases
24.8%
Heart
Disease
1 6.4%
_t
1\1
n)ury
40.8%
/ Ca ncers\\
18.0% \
FIGURE 2 Percentages of years of potential life lost to
injury, cancer, heart disease, and other diseases before
age 65. Modified from Centers for Disease Control. Table
V. Morb. Mart. Weekly~p. 31:599, 1982.
Injury greatly surpasses all ma jor disease groups as a
cause of prematurely lost years of life, because it is
the preeminent cause of death among children and young
adults.- More years of future worklife are lost to injury
than to heart disease and cancer combined. Each year,
over 4 million years of future worklife are lost to
injury, compared with 2.1 million to heart disease and
1 .7 million to cancer (Figure 2 ) . The impact of nonfatal
injury is of similar proportions.
Injury is the leading cause of physician contacts. It
is the most common cause of hospitalization among people
less than 45 years old. The personal, family, and
societal costs of mental and physical disability and
disfigurement are huge.
Although injury is the most costly of all major health
problems (about S75-S100 billion per year), support for
injury research has been minimal. The total annual
expenditure for injury-related research by the Hational
Institutes of Health (NIB), about S34 million, is less
than 2 percent of the NIB researab budget. The total
expenditure by all nonmilitary federal agencies is about
S112 million--less than $2 for every Sl,OOO of the cost
of in jur ies themselves.
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~6
EPIDEMIOLOGY OF INJURY:
THE NEED FOR MORE ADEQUATE DATA
A prerequisite for the scientific study of injury is
the acquisition of data on which to base pr for ities and
research. Despite the obvious importance of injury as a
public health problem, information to permit the study of
the epidemiology of most in jur ies is not available.
Although there are basic data on time, place, and person
for some injuries and deaths, even basic information is
often lacking as to the numbers and characteristics of
people injured and the factors that influence injury
causation, especially in nonfatal events. Detailed
information on the groups that are particularly sus-
ceptible to injuries and their effects is not adequate.
Injuries from motor-vehicle crashes constitute the only
exception to this limitation. The incidence, prevalence,
and effects of motor-vehicle injuries, as well as measures
to counter them, are moderately well understood, compared
with the epidemiology of other injuries, although even
here information about long-term effects is sparse. The
acquisition of knowledge about motor-vehicle injuries is
a direct result of the funding of research on injury
epidemiology from two sources whose primary mandate is
the study of automobile injuries--the National Highway
Traff ic Safety Administration and the Insurance Institute
for Highway Safety. Little funding has been available
for researab into the epidemiology of other injuries;
consequently, our knowledge of these other injuries is
slight.
Continuous, systematic data collection is essential
for planning and evaluating preventive programs. The
lack of appropr late data systems has led to the institu-
tion of some expensive but ineffective preventive
programs.
Recommendations
· The United States requires effective in jur y
surveillance systems for gathering and integrating
information from a variety of sources on which to base
the planning and evaluation of control efforts. This
would include long-term longitudinal 'studies of injuries
and the collection of more ref ined data on specif lo types
and causes of injuries and exposures to injurious
environments .
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7
· A national capacity should be developed for the
quick identification and control of outbreaks of specific
injuries.
· A consistent and accurate system for coding the
causes of injuries needs to be used by hospitals.
· More refined data on the specific types and
causes of injuries are needed to develop effective
interventions.
· Research is needed to determine the short- and
ong-term costs of injuries.
PREVENTION OF INJURY
Injuries can be prevented with a variety of strategies.
The effectiveness of these strategies varies inversely
with the extra effort required to keep people from being
harmed and the degree to which people must change their
usual behavior patterns.
Three general strategies are available to prevent
injuries:
· Persuade persons at risk of injury to alter their
behavior for increased self-protection--for example, to
use seatbelts or install smoke detectors.
.
Require individual behavior change by law or
administrative rule--for example , by laws requiring
seatbelt use or requiring the installation of smoke
detectors in all new buildings.
· Provide automatic protection by product and
environmental design--for example, by the installation of
seatbelts that automatically encompass occupants of motor
vehicles or built-in sprinkler systems that automatically
extinguish fires.
Each of these general strategies has a role in any
comprehensive injury-control program; however, a basic
finding from research is that the second strategy--
requiring behavior change will generally be more
effective than the first, and that the third--providing
automatic protection--will be the most effective. A
fundamental reason for this is that members of high-risk
groups tend to be the hardest to influence with
approaches that involve either voluntary or mandated
changes in individual behavior . Teenagers, for example,
are much less likely than adults to wear seatbelts,
whether or not a law requires them to do so. Programs
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Q
: V
intended to change alcohol-related behavior value tar fly
have not produced sustained reductions in death rates.
Elderly pedestr fans admonished by police for jaywalk ing
were no less likely to do it sea i a- Scofflaw drivers
snore Licenses nea seen revoked were more likely than the
average licensed dr iver to be involved in fatal crashes .
And not only are young children hard to influence, but
intensive ef forts at a well-baby clinic, for example, had
no effect on dangerous maternal behavior, such as leaving
knives and matches within the reach of small children.
The shortage of health professionals and scientists
with relevant training is ~ major impediment to injury
control. Without knowledgeable and interested persons
trained in the relevant sciences, the injury toll will
continue e
~ ~ _ ~ ~ ~ ~ ~ ~ e
_ _~ _ _ _ ~ ~
Recommendations
· Education, training, and information programs
intended to control injuries should be evaluated
exper imentally .
· Laws and regulations aimed at controlling
injuries should be scientifically evaluated. The
separate influences of degree of enforcement, severity of
punishment, and speed of administration of punishment
should also be researched.
.
· Continuing research is needed on ef f icacy of
product des igns and environmental modifications in
protecting people effectively and automatically.
Research is needed to understand the barriers to
implementing existing effective injury-control measures
that are not widely applied.
Research is needed in the prevention of injuries
in the recreational, occupational, and home environments.
· Training health professionals and other scientists
in injury research and the basic concepts of injury
control is crucial, if we are to develop and apply new
knowledge about the prevention of injury.
.
.
INJURY BIOME:CHANICS RESEARCH AND
THE: PREVENTION OF IMPACT INJURY
Impact injury of the human body occurs by deformation
of tissues beyond their failure limits, which results in
damage of anatomic structures or alteration in normal
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9
function. Injury biomechanics research uses the prin-
ciples of mechanics to explore the mechanisms of physical
and physiologic responses to impact, including both
penetrating and nonpenetrating blows to the body.
Although in jury can occur by slow deformation, in
crushing, the predominant feature of impact in jury is
ache fast, violent nature of the event, whether it is the
rapid impact of a person's chest on the instrument panel
of an automobile or a bullet 's penetration of the chest
cavity.
Improved protection could be realized with a better
understanding of the biomechanics of in jury and disabil-
ity. Design of less injurious environments depends partly
on knowledge of the effects of specific k inds and amounts
of energy on specif ic human tissues . Although we know
the approximate limits of forces that can be tolerated by
young healthy males in rapid deceleration, we do not have
ref ined data on other elements of the population, on the
extent of reversibility of damage, or on effects on
nervous tissues or tissues outside particular size and
structural ranges.
Recononenda t ions
· High pr for i ty should be ~ iven to research that can
provide a clearer understanding of injury mechanisms.
Crucial sub jects are the relative con tr ibutions of linear
and angular acceleration of the head to deformation and
injury of the brain and the body deformations that cause
injury of the spinal cord, thoracic and abdominal viscera,
and the joints.
· Quantification of the injury-related responses of
or itical body areas--nervous system, thoracic and
abdominal viscera, joints, and muscles- to mechanical
forces is needed.
High priority should be given to obtaining and
defining limits of human tolerance to injury, particularly
with regard to segments of the population on which data
are extremely limited, including children, women, and the
aged; both whole-body and regional tolerances; the effect
of human and environmental variables on tolerance;
long-term effects of impact deceleration on the body; and
survival of extreme impact.
· Improvement in injury assessment technology is
needed, including development of means for assessing the
important debilitating in juries and causes of fatality,
.
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i: ~
10
improvemen t of anthropomorphic dummies, and developmen t
of computer models to predict in jury in complex crash
conditions .
· There is a need for an organization to administer
r esearch on in jury mechan isms and in j ury b iomechan ics
and ensure a supply of 'scientists trained in injury
b iomechanics .
TREATMENT
Except when death occurs immediately, the outcome of
an injury depends not only on its severity, but also on
the speed and appropriateness of treatment. Communication
systems are needed to facilitate decision making, injury
management at the site, and the rapid delivery of the
patient to a hospital that can provide the needed care.
Once a severely in jured person arrives at a hospital,
treatment requires the effort of a team that includes
specialists in various aspects of injury management.
Designated trauma centers with experienced teams avail-
able and necessary backup facilities, such as well-stocked
blood banks, are essential. In addition to the develop-
ment and evaluation of such systems, there is a need to
ensure that patients treated in hospitals other than
trauma centers receive the most up-to-date care, so the t
unnecessary morbidity, mortality, and residual disability
are avoided.
The most important topic to be addressed with regard
to treatment is control of swelling of the brain ; improve-
ments could substantially reduce injury mortality. Under-
standing of Ache immune system and prevention and control
of infection also warrant high priority as does control
of spinal coed swelling and research in spinal cord
regeneration.
Recommendations
· Long-term collaborative studies should be insti-
tuted by epidemiologists, statisticians, biomedical
engineers, trauma physicians, rehabilitation physicians,
behavioral scientists, and health economists, to identify
and evaluate factors that produce optimal results, to
identify factory that result in less than optimal results,
and to institute programs for promulgating optimal
management techniques.
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11
· Programs in basic research should be instituted
and supported, in collaboration with morphologists,
biochemists, membrane physiologists, pharmacologists,
neurobiologists, bacter iologists, virologists, and
others, to study shock, infection, tissue responses and
healing, and brain and spinal cord swelling.
· Biomedical and biomechanical programs should be
instituted and supported in relation to injury mechanism
and prevention and the development and evaluation of
biomedical materials, including prostheses and artificial
organs.
.
Clinical studies should be instituted and
supported in development and evaluation of pharmacologic
options, of surgical techniques, and of management
options.
· Programs designed to train professionals in the
research and care of injury should be instituted and
supported.
REHABILITATION
Rehabilitation is the process by which physical,
sensory, and mental functional capacities are restored or
developed af ter damage . In the context of ire jury control,
rehabilitation is the process by which biologic, psychos
logic, and social functions are restored or developed to
permit an injured person to achieve maximal personal
autonomy and an independent noninstitutional lifestyle.
Rehabilitation is achieved not only through functional
change in the person (e.g., development of compensatory
muscular strength, use of prosthetic limbs, and treatment
of postinjury behavioral disturbances), but also through
changes in the physical and social environment, such as
reductions in architectural and attitudinal barriers that
h ~ er those requiring use of a wheelchair.
In the last decade, improvements in emergency medical
systems, in immediate management by trauma centers, and
in care of the injured en route to hospitals have
increased the survival of persons with nervous system
injuries, multiple injuries of the mu-=culoskeletal system
and viscera, or extensive burns. Trauma units have
increased the need for def ined referral to special
rehabilitation programs and follc~w-up services. More
persons survive major injuries, and survivors often have
severely disabling effects from the injuries; themselves
and from untreated complications. Many need functional
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12
restoration of cognition, sensation, movement control,
and mobility after brain, spinal cord, and musculoskeletal
injury. Further negative effects on health and perfor-
mance in daily life that result from the loss of body
per to and from inactivity and immobility must be
prevented.
Preventable disability is not an uncommon consequence
of inadeguate management of the injury patient--for
example, limitation of motion due to contracture in
burned patients or paralysis in patients with unrecog-
nized injury of cervical vertebrae. Pressure sores, or
~bedsores, ~ are an entirely preventable complication that
occurs in 35-40 percent of persons with spinal cord
injury, at an average cost of $25,000-$28,000 per pressure
sore, inestimable misery, and increased debilitation.
With comprehend ive care, the profound biologic, psycho-
logic, and social responses to paralysis and movement
disorders, disfigurement, and loss of body parts are
controllable to a remarkable extent. Although limited
resources for clinical programs have been provided
through private and publicly supported efforts, parallel
research and educational resources for the development
and dissemination of knowledge and technology have been
seriously inadequate. The development of expanded
special regional centers and programs has been lacking
for the large number of unserved persons who could
benefit.
Recommendations
· Major research centers should be de~reloped for
clinical neurophysiology programs on evaluation and
management of neural injury residue, neural 'system
function, and ethnologic replacement of lost function.
· Funding priority should be given to research on
Me identification and preservation of residual functions,
de~relop~ent of substitute functions, psychosocial manage-
ment of the patient and family, and deinstitutionaliza-
tion.
· Research programs aimed at minimizing the effects
of injury to the musculoakeleta1 system, including both
bone and soft tissue, that result from physical, chemical,
and tberaul causes should be promoted.
· Research program; should be established in the
behavior al and social sciences for cross-disciplinary
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13
studies of adaptive behavior and its relationship to
brain function in environmental adjustment and learning.
· Wider application of existing knowledge related
to rehabilitation and prevention of second injury is
needed.
Development and evaluation of model systems of
rehabilitation should be promoted.
· Research should be greatly expanded on behavioral
and social factors related to stigmatization of and
discrimination against the disabled.
.
.
A system is needed that can identify disabled
persons and persons with injuries that are likely to
produce severe disability, so that services for those who
might benefit can be planned. Linked local, regional,
and national reporting systems for the disabled are
necessary to go beyond social security studies limited to
work disability; these systems could be built into the
surveillance systems recommended in Chapter 2.
CURRENT FEDERAL EXPENDITURES
FOR INJURY-RELATED RESEARCH
To assess federal support for in jury-related research,
the committee reviewed federal research expenditures for
fincal 1983.
The total federal expenditures for nonmilitary
research on injury were approximately S112 million in
fiscal 1983. Expenditures in 1 year are more relevant
when compared with over expenditures in the same year.
For example, although injury research in fiscal 1983
accounted for approximately ~t34.4 million of expenditures
at the National Institutes of Bealth (NISI), that was less
than 2 percent of the total NJ}! research budget. Although
injuries are responsible for the loss of more economically
productive years of life than heart disease and cancer
combined, the federal expenditure for research in injury
control is relatively small approximately one-tenth of
that for cancer and less than one-fifth of that for heart
disease and stroke (Figure 3). Thus, when one compares
the relative research expenditures and the years of life
lost to these causes of death before age 65, it is
apparent that the smallest portion of the funds is being
allocated to the largest problem injury.
The committee believes that substantial decreases in
current injury rates would result from research requiring
substantially less support than iE; now expended on cancer
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:
~ 14
S1 12 Million
Resear ch
E xpend~tures
_
::::::
::::::
:,:,:
:::
...
i:
;; ;-,, . ;-. ~
4.1 Million
Years of
Life Los'
.
:::::::::::::::::::::::::::::::::
:.:2:~:::::::::::2:,:.,:::,:~:,:.: :~:.:.:~:2:2: :~:.'.
.. ......... ~ 2 ~: ~
·::,:::,:,:,:.:.:~:,::::::::::::::::
:::::::::::::::::::,:~:~:.: :.: :.::.:,:.:.:.:.:.: :,
:,:.:~: :::.::.:::: ::::::::::::::::::::::::::::
:;::: : .2 . 2:: :2:.::::: :~:: :~:
,:2:,:,:: :.::::::::::::: arm::::
. , ~. ~ . ~ .. ..
:.:.:.::::::: :.:::::::,. :~:.:.:.:~:~:~:~:,:.:,:.
:::.: ::: :.::::.::::::~:.:.:~:,:~:.:,:~:.:.:,:~::
::: :::,: :::::~:.:.::::::::::: :::::::::::::::.
S998 Million
',Remarch Expenditures
...........................
:::::::::::::::::::::::: ::::::::::::::::: .
::::: ::: :.: :,:~:~:~:.:~:.:~:,:,:.:.:.:.:~:.:
:::::::::::::::::: ::::::::::::::::::
: :-:::::::::::::::: ::::::::::::::::::
2:,: :~:~:2:.:,: :::.:.::.: :.:.:~:~:~:~:.:.:::::.:
:::::::::::::::::::::::::::::::::::: :~:.:~: :
::,:.:::::2:2::::. .:.:. ::.:::: .
:::::::::::::: : ~ .: .
:::::::::::::::::-::::::::::
:.:~.:,: :.:~:.:.:.:.:.:.:,:.:.:.:.:.:.::::: :.2::::::: .
::::::::::::::::::::::::::::::: ::,:: :.:.:::
:.:~:,::~:2:::~::::.: . .:::::::::.:
::::::::::::::::::~::::~:~::~:.:.
:.:,:,:':.:.: :.:.:,:,:.: :.:.:.:2:.:~:.:.:.:~: :,:: .
::.:.:,:.:: :~:: :.:.:2 ' .: ~ ~ . .:: :
::::::::::::::::::.:::::::,:.:,
.:~:2:,:.:~:,: :.:.: :,:~:~:.:~:.:~:~.:,:.:2:~:.:::::.: .
::::::::::::::::::::::::::::::::::: :2:.: :
:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:~:. .:: ~ .:.::::
. ~. ~.
·:~:~:~:~:~:~:~:~:~: : :~:~:~:~:~:~:~: :~:~:~.~: :~:~:
::::::::::::::::::: :::::::-::::::::
::::::::::::::-.::::::::::::::::::
·:.:~:.:~:::,:,:~:~:,:: :.: :.,: :~:.:2:.:~:.:.:2:,:~: .
I
............
::::::::::::::::::::::::::::
::::::::::::::::::::::::::::
:::::: .. .e ... . . ::
2 2
::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::::::: :
:S624 Million :
. Research E xpenditures
· -
: :.:::::::::::::::::::::::::2 .
:::::~:::::~:::~:::,:.:.:.:~:~:~: :~:,:.:.:.:.:.:~:~:~:
::::,:.::.::,:::::::::::::::::::
,:::~:.:2:~: :~:.:~:~:~:.:,:.:~:.:~:~:,:~:2:~:~:.:.:~:. .
: .:: :,:.:.:.:.: :~:2:~:~:: :,:,:,:.:~:2:,:~:~:e2: :
::::::::::::::::::::::::::::
:: .2 :.:::::::: :.:.:2:,:.:.:..
.:::::::::::: :::::::::::::::::::::::::::::::: .
:: ::::::::::::::::::::::::::::::::::::::::::::::::::::
:.: :.:,:::~:~:.:.:,..:~.:.:.:.:~: :.:.:,::: .:,:::.2:~:
:::::.::::::::::::::::.::::-:::
...... .................... .. .
~ l-2
:,:. 2.1 Million I:,:::
, Late Lost ~
Injury Cancer l~lears D~/Stroke
FIGURE 3 Preretirement years of life lost annually and
federal research expenditures for ma jor causes of death
in the United States. Years of life lost derived from
age-at-death distributions in the National Center for
Bealth Statistics Vital Statistics of the United States,
1978, Volume II. Mortality (Ryattsville, Md.: U.S.
Department of Bealth and Human Services, 1981). The total
federal expenditure for injury research is the sum of the
amounts discussed in Chapter 7 plus a ~ percent increment
for administration, the latter in line with NIB adminis
tration costs. Expenditures for research on neoplasms
and cardiovascular diseases are the 1983 fiscal year
budgets of the National Cancer Institute and the National
Heart, Lung, and Blood Institute from the Institute of
Medicine's Response to Health Needs and Scientific
Opportunity The Organizational Structure of the
National Institutes of Health (Washington, D.C. : National
~-
Academy Press, 1984 ) .
OCR for page 15
15
and cardiovascular disease. An increment in current
funding with close monitoring of the application of the
research results could illustrate the investment value of
such expenditures for the entire population.
The committee does not advocate a reduction in federal
expenditures for health researob in cancer or heart
disease and stroke. It does feel, however, that federal
expenditures for injury research and injury control are
seriously inadequate. The committee believes that
substantial progress could be made in the reduction of
the incidence of in jury and its associated morbidity and
mortality if adequate funding, direction, and support
were given to a coordinated federal program of injury
r esearch .
ADMINISTRATION OF INJURY RESEARCH
The committee discussed the advantages and dis-
advantages of various model'; for managing injury research
in the federal government. Criteria were established for
a unit that could effectively manage a large-scale federal
program in injury research, and the selected models were
compared for suitability. After consideration of the
various alternatives, the committee recommended the
establishment of a new Center for Injury Control. (CIC)
in the Centers for Disease Control (CDC). The function
of the Center for Injury Control would be to carry out a
national injury research program in the following manner:
.
Support research in biomechanics, injury epidemi-
ology and prevention, acute care, and rehabilitation.
· Establish injury surveillance systems and conduct
injury prevention projects.
~ Improve and expand professional education and
training .
· Establish centers of excellence in injury bionic
mechanics, prevention, and care.
· Collect and analyze data on injury.
· Serve as a clearinghouse and lead agency among
federal agencies and private organizations interested in
injury research and prevention.
The structure of CIC it; visualized along Me lines of
the diagram in Figure 4. Divisions dedicated to the
major sectors of needed research--epidemiology, preven-
tion, biomechanics, acute care, and rehabilitation- would
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Assistant Secretary for Health
Public Health Service
| Director |
Director | Advisory
CIC ~ ~ Council
~ ~ Prevention | | Eliomechanics | ~ Acute Care ~ ~ Rehabilitation
FIGURE 4 Suggested location and organizational structure
of proposed center for injury control.
be coordinated by a director. The CIC director would
report administratively to CDC and would convene an
advisory council consisting of representatives of federal
agencies and other organizations engaged in injury
research.
The CIC director and staff would review priorities,
establish specific research goals, identify scientists
capable of implementing the research, and coordinate peer
review. It is imperative that all appropriate disciplines
be represented and that the CIC director be a scientist
with recognized research accomplishments and successful
experience in interdisciplinary investigations of injury.
No single discipline or disciplinary orientation can
produce the broad spectrum of researab needed for injury
control.
Clearinghouse and coordinating functions in CIC are
essential, although the in jury research problem is much
more than a matter of insufficient coordination.
CIC should foster and support research directed to
filling the knowledge gaps that inhibit the control of
injury. To do this, it should contain special study
sections and a granting mechanism in each that would
provide for continued, rather than year-by-year, funding
of research projects. Funding should cover demonstration
programs, multiple centers of excellence, and training of
researchers in appropriate fields. CIC funds should
supplement, rather than replace, funds currently allocated
to other agencies, such BB the Department of Transporta
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tion (DOT), the Department of Defense tDOD), and NIH; and
their funding related to injury research should not be
channeled through CIC.
The director and the advisory council should be
charged with the development of an annual plan and report
to Congress--an approach similar to that followed by the
National Toxicology Program. This administrative mechan-
ism would encourage the CIC director and representatives
of other agencies to consider the scope of what is being
done, in view of the various agency mandates, and to
avoid inappropriate duplication of effort.
An independent review of CIC should be conducted
within 5 years of its establishment to assess its progress
in accomplishing the objectives recommended in this
report. At that time, consideration should also be given
to the elevation of th is center to independent agency
status.
Injury is the major health problem facing young
Amer icans today . The oppor tunity exists to create a
focused, coordinated research effort with the potential
to save lives, improve productivity, and reduce costs and
long-term losses to the injured, their families, and
society. The alternative is the continued loss of health
and life to predictable, preventable, or modifiable
injuries. The committee firmly believes that it is time
to plan and undertake a national program to address this
problem.
Representative terms from entire chapter:
injury control
