Reducing the Burden of Injury Advancing Prevention and Treatment (1999) / Chapter Skim
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8 Federal Response
8 Federal Response
Pages 204-257
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of the Department of Transportation; (2) the Consumer Product Safety Commission (CPSC)
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The committee identified the following overarching themes: the need to strengthen research at some agencies; the need to encourage more emphasis on research planning and priority setting; and the need to enhance funding for research, training, and programs in select areas. NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION The National Highway Traffic Safety Administration was created by the Highway Safety Act of 1970 as the successor to the National Highway Safety Bureau, itself the product of highway safety legislation passed in 1966.
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. 1nJury Rehabilitation Drugs, violence Wounds, shock, burns Suicide, abuse Spinal cord injury, CNS injury Violence and suicide prevention
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Fire Administration National Science Foundation National Transportation Safety Board Crime, violence, and justice Statistics Violence Juvenile crime and justice Occupational safety statistics Occupational safety Aviation safety Highway safety Railroad safety Public transportation safety Highway and traffic safety Boating safety Alcohol and firearms Rehabilitation, treatment of .
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merged its Section 402 highwayrelated safety grant program with NHTSA's Section 402 traffic safety grant program and the resulting State and Community Formula Grants Program is now administered by NHTSA. From 1992 to 1998, a total of $887 million was allocated to the states.
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Begun in 1975, it is used to monitor trends in traffic safety and evaluate the impact of motor vehicle safety standards. FARS relies on a designated person within each state who, under contract to NHTSA, extracts and codes 100 data elements on the crash, the vehicles, and the people involved.
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NHTSA studies have found some state programs to be not only highly effective but also cost-effective in terms of lives saved relative to costs incurred (NHTSA, 1991, 1995~. In addition to its grant programs, NHTSA plays a leadership role through the conduct of national evaluations that guide states and communities in moving interventions into practice.
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Following the creation of the federal highway safety program in 1966, there was an expansion of extramural research capacity that endured through the early 1970s. When funding leveled off and actually decreased somewhat in constant dollars, many researchers left the field.
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The committee recommends that NHTSA expand its investigatorirndated research program, conduct periodic and independent peer review of its research and surveillance programs, and provide training and research support to sustain careers in the highway traffic safety field. CONSUMER PRODUCT SAFETY COMMISSION The Consumer Product Safety Commission is an independent regulatory, research, and educational agency established in 1972 by the Consumer Product Safety Act.
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With respect to the former, CPSC relies far more heavily on voluntary, rather than mandatory, stan dards for product performance or labeling. Its declining use of formal rulemaking is partially attributable to the Consumer Product Safety Act Amendments of 1981, which made rulemaking requirements more stringent; they require CPSC to employ a voluntary, rather than a mandatory standard when it finds that the voluntary standard can adequately address the hazard and that substantial compliance is likely (GAO, 1997~.
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Research conducted or sponsored by the CPSC has traditionally encompassed two general activities: (1) the testing and evaluation of consumer products to ascertain the nature and cause of any safety hazard and (2)
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. Through safety alerts, press conferences, and public health campaigns with the American Academy of Pediatrics, the National Institute of Child Health and Human Development, and the SIDS Alliance, CPSC has sought to warn the public about soft bedding and the importance of placing infants on their backs or sides.
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of the Consumer Product Safety Act authorizes CPSC to "conduct research studies and investigations on the safety of consumer products and on improving the safety of such products." Despite the fact that CPSC is the only government agency that conducts in-depth product hazard research, the agency has limited capacity to carry out this important responsibility. As noted above, CPSC currently uses most of its limited technical resources to test and evaluate specific products and to support development of safety performance requirements.
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OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION The Occupational Safety and Health Administration of the Department of Labor was created by the Occupational Safety and Health Act of 1970 (P.L.
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Surveillance activities, which are also discussed below, are carried out by a sister agency within the Department of Labor. OSHA activities are conducted in 25 states and the District of Columbia, whereas the other 25 states which contain about 40 percent of the labor force-operate their own occupational safety and health programs that are approved by OSHA.
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Safety rules cover a wide variety of workplace conditions, ranging from concrete masonry construction safety, to electrical safety, to fire prevention, to safety at grain-handling facilities. Rule making, according to the Occupational Safety and Health Act, can be triggered by an interested party, employers or employees, standard-setting organizations, NIOSH, or states.
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In 1992, the GAO revealed that penalties were substantially below the maximum allowed by law (GAO, 1992~. Under the philosophy that traditional OSHA enforcement has been "driven too often by numbers and rules, not by smart enforcement and results," OSHA recently announced a new enforcement policy that calls for more focused inspections for industries with higher injury rates.
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The BLS census is considered the most reliable because it uses diverse sources to identify and verify fatalities (Leigh et al., 1997~; the survey compiles questionnaire data from approximately 250,000 private firms. These firms are a sample of more than 5 million establishments, which are required under the Occupational Safety and Health Act to maintain records of injuries and illnesses.
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Training Through its Office of Training and Evaluation, OSHA had a training budget of $2.4 million in FY 1997. This office administers training grants to safety and health organizations, employer associations, labor groups, and educational institutions.
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NIOSH was created by the Occupational Safety and Health Act of 1970. NIOSH investigates potentially hazardous working conditions at the behest of employers or employees; evaluates and identifies chemical and safety hazards in the workplace; conducts research to prevent occupational disease, injury, and disability; supports training of health professionals; and develops educational materials and recommendations for worker protection.
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In FY 1997, approximately 18 educational institutions received NIOSH training grants in occupational safety (with "safety" defined programmatically as injury, safety, and ergonomics)
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The key is to set priorities in a way that does not dictate individual research projects, that encourages innovation, and that ensures stakeholder investment in the outcome. NORA promulgates national priorities for occupational safety and health research for both the public and private sectors (Rosenstock et al., 1998~.
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. The total allotment of $8 million represents the largest-ever single infusion of research funds for investigator-initiated occupational safety and health research (NIOSH Budget Office, personal communication, 1998~.
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Instead, the 1985 report turned to the CDC for an administrative location in which to place an injury center. However, in light of CDC's resource constraints, and a host of unmet needs in basic and clinical research that only NIH can fulfill, many continue to advocate a stronger role for NIH in injury research and -training (Mickel, 1990~.
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NIGMS has the most broad-based program. Its program on trauma and burns, funded at approximately $48 million in FY 1998, supports investigatorinitiated grants, center grants, and training grants that span the spectrum of basic and clinical research, including treatment of acute trauma.9 The NINDS program on trauma, regeneration, and pain-funded at approximately $60 million annually is almost exclusively focused on neurotrauma.
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As important, NIH lacks a focal point and a mechanism to coordinate its disparate injury research projects and programs. Congress has previously recognized that NIH needs to accord trauma research greater priority.
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The committee supports a greater focus on trauma research and training at NIH and recommends that the National Institute of General Medical Sciences elevate its existing trauma and burn pro gram to the level of a division. To accomplish this goal, the committee recommends the expansion of research and training grants, the formation of an NIH-wide mechanism for sharing injury research information, and for promoting collaborations spearheaded by NIGMS.
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(HRSA, 1997~. In addition to these discretionary resources, the bureau and a related office within HRSA administers two other categorical grant programs that more directly address state and local injury prevention and control: the Emergency Medical Services for Children (EMS-C)
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Injury-Related Grants and Contracts Special Projects of Regional and National Significance This discretionary grant and contract program has a broad mandate to improve state- and community-based maternal and child health. Grants and contracts are distributed mostly to state and local governments, universities, and nonprofit groups and can take the form of research, demonstrations, and training grants.
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Its overall purpose is to reduce child and youth mortality and morbidity sustained through severe illness or trauma. More specifically, the program strives to ensure state-of-the-art emergency medical care for children with serious illnesses or injuries; to ensure that pediatric services are integrated into an emergency medical services system; and to ensure that children and adolescents receive a constellation of emergency services, including primary prevention, acute care, and rehabilitation.
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The bureau plans to award planning grants and implementation grants, once it establishes the program's goals and objectives with the aid of a specially convened TBI State Demonstration Grant Program Task Force, with membership from national organizations across the service delivery system. Assessment MCHB deserves credit for the quality of its programs and quality of its collaborations with other federal agencies.
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These programs are highly complex and variable in scope, eligibility, and legislative requirements, and the committee was unable to determine whether state and local health de partments can avail themselves of funding. Given the magnitude of funding, it would be desirable for public health departments to tap into these funding streams for violence prevention programs.
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Therefore, NIJ's total FY 1998 budget was approximately $135 million, about half of which was spent on evaluation of crime prevention programs. The NIJ is organized into three major offices.
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Assessment and Recommendation The committee commends NIJ for its commitment to rigorous evaluation of the local crime prevention programs of the Department of Justice. NIJ is in an opportune position to evaluate these massive programs.
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. The committee recommends that NU continue to give explicit priority to the prevention of violence, especially lethal violence, within its overall activity in crime prevention research and program evaluation, and that NU establish new institutional training grants for violence prevention research at academic institutions.
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The purpose of such a committee would be to develop systematic and coordinated research strategies for evaluating violence prevention programs. The committee urges the creation of an interagency coordinating committee for violence prevention research.
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The grant program awards funds for peer-reviewed research in a manner almost identical to that of the NIH~3; it sponsors a 21-member study section composed of extramural researchers whose function is to evaluate prospectively the technical merit of submitted applications and recommend funding levels. NCIPC's study section is one of two administered by CDC, with the other serving NIOSH.
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injury research centers. Cooperative Agreements A cooperative agreement is a mechanism for joint funding of research and demonstrations,~4 and may also be used for public education and training.
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In 1994, however, NCIPC made a policy decision to exercise greater participation in the building of state and local injury programs. Instead of awarding capacity building grants, NCIPC began to utilize the more focused cooperative agreements on the grounds that the agency's limited funds should be used to provide more guidance to states for introducing into practice, and monitoring the impact of, proven interventions like smoke detectors and bicycle helmets.
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Practitioner and research training is conducted to a modest degree by NCIPC-supported Injury Control Research Centers, but because of the funding limitations described below, training is subordinated to research .
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These grants consist of individual investigator grants, program project grants, and center grants. NCIPC's extramural grant program has devised a careful process of independent peer review to fund research of high quality.
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The committee predicated its selection of priority areas on the following criteria: the magnitude of the problem, trends in surveillance, gaps in knowledge, and the degree of support from other federal agencies. On the basis of the foregoing discussion in this chapter and in Chapter 4, the committee urges NCIPC to support an expanded research portfolio in the following areas: biomechanics, residential and recreational injuries, suicide prevention, and violence prevention.
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NCIPC has played a critical role in raising awareness of suicide as a national problem for which prevention research is essential. It has drawn attention to the lack of evidence for effective suicide prevention programs.
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CPSC has only limited funds to conduct research, and the research is restricted to consumer products, which are not the only causes of residential and recreational injuries. Therefore, these areas of research need priority attention by the NCIPC.
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There simply are no comparable types of training grants geared to pre- and postdoctoral students in the elements of injury prevention, including epidemiology, biostatistics, biomechanics, behavioral sciences, and program evaluation. NCIPC should establish a program of individual and institutional training grants to schools of public health and other institutions.
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Additionally, to ensure a trained work force to conduct injury research, NCIPC should initiate a formal program of individual and institutional training grants for pre- anal postdoctoral candidates. Building State and Community Infrastructure NCIPC has fallen short of expectations for building state and local injury prevention programs.
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, its role as a support for public health practitioners and researchers in the injury field should not be diminished, and it should continue to be responsible for and accountable to those constituents. The NCIPC's responsibility for nurturing the field entails a variety of activities, including · assembling, synthesizing, and disseminating information concerning current knowledge, programs, policies, and activities and identifying current needs and opportunities in the field (as an example of this clearinghouse function, the NCIPC prepared an inventory of current federal injury research funded in 1995 ENCIPC, 1997a]
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The committee recommends that me NCIPC continue to nurture the growth and development of the public heals effort in injury prevendon and treatment through information exchange, collabo" ration ninth Bury practitioners and researchers, and leveraging available resources to promote the effectiveness of program and research. COORDINATION AND LEADERSHIP The crosscutting nature of Be injury problem, as well as of injury research and interventions, has been highlighted throughout this report.
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Playing a leadership role means taking the initiative to persuade and induce others to join in collective action toward a common goal. NHTSA, for example, naturally plays a lead role in highway and traffic safety; CPSC naturally plays a lead role in the surveillance and prevention of product-related injuries and product design research; NIOSH naturally plays a lead role in occupational safety research and education; and NCIPC naturally plays a lead role in prevention research related to residential and recreational injuries.
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American Journal of Public Health 79~3~:33~339. CPSC (Consumer Product Safety Commission)
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1993. Workers at Risk The Failed Promise of the Occupational Safety and Health Administration.
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Washington, DC: NHTSA. NHTSA (National Highway Traffic Safety Administration)
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1998c. Traumatic Occupational Injury Research Needs and Priorities: A Report By the NORA (National Occupational Research AgendaJ Traumatic Injury Team.
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1984. Regulating Consumer Product Safety.
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