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OCR for page 109
8
Administration of Injury Research
As part of its charge, the committee was asked to
examine whether and how the federal government could
efficiently manage an injury research program and to
consider among the alternatives the possible benef its of
an interdisciplinary, comprehensive approach to injury
research.
Research on the various aspects of injury outlined in
this report has been fragmented and poorly financed.
Although the field has been 'substantially defined in
terms of the scope of the problem and ache enormous costs
to society, important parts of the field beve lacked the
recognition of the scientific community and the support
of the go~rernment--recognition and 'support that have
contributed to the amelioration of other health problems.
Effective research on injury control and prevention
requires strategies and program that differ from those
used for other leading public health problems. An
integrated multidisciplinary approach involving physi-
cians, epidemiologists, engineers, physicists, behavioral
scientists, and others is needed. The present fragmented
approach, winch various agencies handling some of the
piece" of the problem, virtually guarantees that injuries
will continue to constitute a major public health problem
and that progress in combating the problem will continue
to be slow and inefficient. With injury research spread
among a variety of institutes, departments, and regulatory
agencies, there is no means of considering the implica-
tions of research on one aspect of the problem for the
others, and unnecessary duplication of effort is a strong
possibility.
Although reasonably large current expenditures for
injury-related research can be identified in the budgets
of a number of federal agencies, the amounts are mis
109
OCR for page 110
110
leading. Much of that research is only peripherally
related to injury, and its principal focus is other
health problems. In addition, because of the narrowly
defined missions of the individual agencies that do the
research, it is not nearly as comprehensive as is needed.
Much important research is never funded at all, because
it does not fit the programs of any of the agencies that
support injury research.
Nothing short of a program with principal responsibil-
i~cy for injury research will suffice. Leaving the effort
fragmented will mean that yet another opportunity to
reduce a continuing public health problem will have been
lost. The foregoing chapters of this report have defined
the dimensions of the field and identified numerous
research needs and opportunities that merit the attention
of the scientific community. (It should be noted that
important factors that have been less neglected, such as
alcohol and drug research, have not been discussed at
length.)
The various agencies of the federal government use
several approaches to administering research. Some
agencies are engaged in both research and regulation (for
example, the Food and Drug Administration and the Environ-
mental Protection Agency); others are limited to research
(the National Institutes of Bealth, NIB) or regulation
(the Occupational Safety and Health Administration, OSAKA).
In occupational health, the research function is performed
by the National Institute for Occupational Safety and
Health, a part of the Department of Health and Human
Services, and the regulatory function is carried out by
OSEA, a part of the Department of Labor. In addition,
research programs like the National Toxicology Program
tNTP) comprise research components from more than one
agency.
This chapter examines a number of those approaches and
recommends ~ means by which research on injury could be
efficiently and effectively administered.
CRITERIA FOR ORGANIZTNG INJURY RESEARCH
The committee first sought to identify criteria by
which to find the organizational structure that would
best meet the need to make research on injury efficient
and effective. The criteria established by the committee
reflect its recognition, gained in its examination of
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111
current efforts on injury research, that these efforts
are too narrowly focused and underfunded.
To correct the present situation, the committee
considered the following criteria for determining the
organizational setting and structure for the study of
· ~
Injury:
.
Research efforts should be organized in such a
manner that all aspects of injury can be addressed by one
unit-- .e., research on epidemiology, prevention, bio-
mechanics, treatment, and rehabilitation; information
gathering and dissemination; and training.
.
The unit should be so placed in the federal
organizational structure that it fits the mission of the
department that houses it, can receive continuing
attention, and has a degree of visibility commensurate
with the importance of injury to the nation 's public
health.
.
The unit should be so placed that it will be
recognized as the leader in in jury research and will be
able to initiate cooperative efforts among appropriate
federal agencies and serve as a contact point for private
organizations and individuals.
.
It should be so placed that it will be able to
improve communication, management, pr for ity-setting, and
accountability .
· It should be part of a research organization,
rather than part of a regulatory organization, and should
itself be organized accordingly.
FUNCTION OF A FEDERAL CENTER TO
ADMINISTER INJURY RESEARCH
Agencies are not uniform in their definitions of
injury, and many agencies consider some of their
activities in this field to be oriented toward ~service.
or ~operations,. rather than ~research.. The solutions
to problems addressed by injury research program-c often
involve many disciplines. The objectives of a research
program must consider the diverse elements of present
research efforts, fully assess the resources available,
establish priorities, and address the solutions that have
the best cost-effectiveness relationship. But the
objectives should not focus solely on cost. They should
recognize the necessity of a balanced national program,
consider all projects that might prove fruitful, and
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112
support projects that have the potential to reduce injury
morbidity, even if the benef icial ef feats will be evident
only in the longer term.
The program objectives of the unit must be related to
specific injury problems and focus on timely solutions.
The program must include data collection, as well as
research on and implementation of injury prevention,
treatment, and rehabilitation.
analysis are critical factors
Data collection and
in enabling the new unit to
focus its research efforts on specific problems.
On the basis of evaluation of the needs for research
on injury, examination of the existing models for the
organization of research, and the criteria for a unit
that could effectively manage research on injury, the
committee believes that it is essential to establish an
injury research unit that would be administered by an
agency of the federal government and whose sole interest
is reduction of injury morbidity and mortality.
The function of the unit would be to carry out a
national injury research program in the following manner:
· Conduct and support research in biomechanics,
injury epidemiology and prevention, and treatment and
rehabilitation of the injured.
· Establish injury surveillance syste s , collect
and analyze data on injury, and conduct injury prevention
projects.
· Promote professional education and training in
injury control.
.
Establish centers of excellence in in jury bio-
mechanics, epidemiology, prevention, treatment, and
rehabilitation.
.
Serve as a clearinghouse, coordinator, and lead
agency among federal agencies and private organizations
interested in injury research and control.
I,OCATION OF A FEDERAL CENTER
TO AI~STNISTER INJURY RESEARCH
The committee considered the placement of a new entity
in the private sector, but believed that no single private
industry, foundation, or university could be expected to
undertake a research program of the scope and magnitude
necessary to pursue the wide-ranging needs outlined in
this report. Although individual citizens would be the
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113
ultimate consumers of the product of injury research, the
committee thought that location of the new unit within
the federal government would be in keeping with its
responsibility to promote public health. For that reason
and because the government would be a major beneficiary
if the costs associated with federally funded health-care
programs were reduced, the committee concluded that the
new unit should be estate, ished in the federal government
structure. Having the federal government administer and
coordinate the research would also facilitate communica-
tion with executive and legislative agencies of the
government .
Many federal agencies already have in jury research
programs, and development of a new organizational struc-
ture must consider the consequences of leaving those
programs in place or incorporating them into the new
unit. The committee felt that existing agency programs
should not be moved, but rather coordinated with the new
unit to support the overall objectives. Part of the new
unit 's mission, therefore, would be to serve in a coordi-
nating role for the vat ious agencies that have research
programs.
The location of the unit is of the utmost importance,
if it is to be successful in carrying out the functions
enumerated above. If it is placed in an existing agency,
the primary concerns are compatibility of mission, recep-
tivity to the research approach, and possibilities for
application of research f inding';. The committee discussed
many possible locations for the unit and concluded that
five existing federal agencies could reasonably be con-
sidered: the National Institutes of Health (NIB), the
Department of Defense (DOD), the Department of Transpor-
tation (DOT), the National Bureau of Standards (NBS), and
the Centers for Disease Control (CDC). The committee
offers the following opinions on how well the placement
of the unit to administer injury research in each of
these agencies would meet research program needs.
National Institutes of Health
Persons concerned about the neglect of injury research
have recently advocated the establishment of a national
institute of trauma research in NIB. Although NIH is an
attractive model to follow, the committee re jounced this
approach for two main reasons:
OCR for page 114
114
.
NIH is or tented more toward basic research than
toward the problem-or tented research essential for in jury
control. The traditional focus of NIB on basic bio-
medical research does not match the interdisciplinary
needs of injury research, e.g ., the need for research in
biomechanics and rehabilitation.
· The establishment of additional institutes does
not have priority. A recent reported by the Institute
of Medicine on the organizational structure of NIB stated
that KNIN is now at a stage where there should be a
presumption against additions at the institute levels
Department of Defense
DOD is the only agency that might currently have
extensive programs in all the fields of research needed.
However, its efforts concentrate on defense-related
applications of injury research. The committee rejected
DOD as a home for the new unit, because the department's
mission does not match the needs of injury research.
Department of Transportation
Although NOT has the largest and most comprehensive
injury-related program, the committee rejected placement
of the new unit in DOT, because of its regulatory
responsibilities and because its transportation-related
mission was too narrow to fit the needs of the new unit.
The committee acknowledges, however, that separation from
the regulatory setting might reduce the unit's ability to
influence regulatory decisions with relevant data.
National Bureau of Standards
NBS is highly respected for its research activities
and could be considered to administer many technical
aspects of an in jury research program. However, much as
NIR focuses on basic biomedical sciences, the NBS research
programs are too narrowly focused on engineering appli-
cations.
OCR for page 115
115
Centers for Disease Control
The mission of CDC is the prevention of disease,
disability, and premature death through interdisciplinary
r esearch and dissemination of information. That is the
type of approach needed in injury control and injury
r esearch . Tn CDC, both laboratory and f ield research are
integrated into a comprehensive public health program.
CDC has authority to give grants, but most of the research
funds are allocated by contract or cooperative agreement.
Specific instructions for a proportion of funds to be
used for investigator-initiated, peer-reviewed grants
would be necessary, to guarantee a more complete range of
research ideas. Although CDC has modest regulatory
responsibility, it maintains a strong liaison with state
health departments and can quickly disseminate information
and technology nationwide. The committee acknowledges
that location outside the Washington, D.C., area could be
a disadvantage with respect to coordinating with other
research efforts or maintaining informed support in
Congress. However, the committee points to CDC and the
National Toxicology Program (NTP) as examples of
successful research programs which are administered
outside Washington, D.C.
CONCLUS TONS AND RECOMMENDATIONS
The committee believes that improvements are needed in
the current approach to administering injury research in
the federal government. The nation needs a coordinated
injury research program with clear objectives and more
focus on critical needs, with adequate funding, and with
the support of Congress and the executive branch.
The substance of a national injury research program is
important, but the organizational structure established
to administer Me program is also importance Adequate
communication among the agencies involved in injury
research and the ability to focus research efforts on
problems are essential. The structure of the organization
should be such that it would facilitate the achievement
o f those ob jectives .
in keeping with the federal government ~ ~ interest in
promoting the public welfare, the committee concludes
that the new entity should be in the federal government
structure. Such placement would facilitate communication
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116
with the executive and legislative agencies of the federal
government.
The committee believes that a new independent agency
modeled after components of the Centers for Disease
Control could best provide the needed national focus for
injury research--focus that is difficult to obtain in any
other way.
The committee concludes that a Center for Injury
Control (CIC) should be established as part of CDC. This
would take advantage of the existing mission-oriented
epidemiologic interests and data-collecting abilities of
CDC. Although CDC does not now have programs in bio-
mechanics, emergency care, acute care, and rehabilitation.
it does have authority to give grants and a mechanism to
establish study sections. It can also conduct demonstra-
tion projects.
The general miss ion of CIC would be to direct a
coordinated research program to reduce morbidity, mortal-
ity, and disability from injury. To accomplish these
ob jectives, CIC must be a visible organizational entity
in the government.
Clear inghouse and coordinating functions in CIC are
essential, although the in jury research problem is much
greater than a problem simply of coordination. CIC
should coordinate information on the efforts of various
agencies now supporting injury research to avoid inappro-
priate duplication of effort and to identify gaps in
knowledge. It should also develop and maintain liaison
with public and pr ivate agencies involved in in jury
control, to disseminate the knowledge and technology
developed in their efforts, to redirect efforts known to
be ineffective, and to provide expertise in the study of
efforts of unknown effectiveness.
Because of the complex and broadly based scientific
tasks that would be within the mission of CIC and the
need to integrate the programmatic activities of several
agencies, CIC should have an advisory council that
includes representatives of federal agencies and other
organizations engaged in injury research, as well as
those which implement injury control programs. The
council would provide guidance in identifying research
subjects that need additional work and help to avoid
inappropriate duplication of effort. CIC research
priorities, however, should be established from within
CIC.
CIC must have a clearly identified budget authorization
within that for CDC. It would be justified by identi
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117
f table research and training needs and by the availability
of competent researchers required to meet those needs.
The mission for CIC should be established by statute
ithin CDC.
The director and staff of CIC would be appointed to
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
director be a scientist with recognized research accom-
plishments and successful experience in interdisciplinary
investigation of injury. No single discipline or dis-
ciplinary orientation will produce the broad spectrum of
research needed for injury control.
An appropriate structure of CIC is shown in Figure
8-1. Divisions dedicated to the major fields of needed
research--epidemiology, prevention, biomechanics, acute
care, and rehabilitation--would be coordinated by the CIC
director. The center would report administratively to
CDC, and the director of the center would have authority
to appoint and convene the advisory council.
CIC should foster and suppor t 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
Assistant Secretary for Health
Public Health Service
Director
l CDC
in!
Advisory
CIC | | Council
| Epidemiology | | Prevention | | Biomechanics 1 | Acute Care 1 | Rehabilitation
FIGURE 8-1 Suggested location and organizational
structure of proposed center for injury control.
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118
supplement, rather than replace, funds currently
allocated to other agencies, such as DOT, DOD, and NIB;
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 mech-
anism 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 this center to independent
agency status.
Representative terms from entire chapter:
injury control
