Success Stories

David's Book Blog

April 21, 2009

Underappreciated and underfunded

Public health has long been underappreciated; indeed, surveys show that few Americans have any idea what it is. Although public health has been far more important than medicine (curative care) in improving our nation's health, all college undergraduates know about career possibilities in medicine, but few know about careers in public health.

Why did I decide to write While We Were Sleeping? It was to increase knowledge about public health by highlighting some of its successes. Public health involves assuring that drinking water is safe, that pollution does not despoil the air, and that diseases such as smallpox, polio, measles and tuberculosis are kept in check. It involves reducing rates of substance abuse, heart disease and obesity.

The book illuminates the public health approach for dealing with one particular subset of health issues-injuries (including violence). Although disease kills more people in the United States than injury, injury disproportionately kills the young. If you die before the age of 40, you are more likely to die of an injury rather than a disease.

The focus of public health is prevention. While almost all the resources for medical care go to treating individual patients after they become ill or injured, public health deals with entire populations- while they are healthy. The community is the patient, and the goal is to keep everyone in the community healthy.

To explain the difference in approach between public health and medicine, I often use an example from public health research on suicide. When I give presentations to psychiatrists and other mental health professionals in Massachusetts, I ask why they think Arizona and many other states have higher suicide rates than Massachusetts. The response is typically not an explanation, but a "they do? I didn't know that." The focus of mental health providers is on the treatment of individual patients. By contrast, public health is interested in understanding and improving the health of populations. Both approaches are important. By the way, the answer to the question is NOT that people in Massachusetts have better mental health than those in Arizona.

One reason that public health is so underappreciated is that we can't usually identify which specific individuals have been helped by public health measures. If you don't get sick at work because of improvements in indoor air quality, not only do you not know whom to thank, you rarely realize that you have been helped. The same is true if you don't get poisoned because the food is safe, or you don't get run over because the walkway has been separated from the road. These are all public health initiatives.

Thus a problem for public health funding, particularly compared to funding for medical care, is that there are no grateful public health patients. I recently spent a few days at one of the leading Boston teaching hospitals. Not only is every building named-after some rich benefactor rather than an outstanding physician or nurse-- but so is virtually every wing, floor, alcove and seminar room. By contrast, two of the four buildings at Harvard School of Public Health remain unnamed.

The goal of While We Were Sleeping is to increase appreciation of, and maybe even funding for, an underappreciated activity that has been crucial for our societal advancement-- public health.

April 1, 2009

Lessons for Activists

I gave a talk in the James Marsh Professor-at-Large lecture series at the University of Vermont this year, discussing "While We Were Sleeping: Success Stories in Injury and Violence Prevention." A woman in the audience-whose passion is promoting breast feeding (La Leche)-asked if I could briefly summarize some of the lessons learned from the book for successful activism. Here are a half-dozen:

1) First, and most important, is that a determined individual can make a difference, can change the world for the better. That is the principal lesson of the book.

2) Second, it won't be easy. It is amazing that for virtually every success in the book, there was determined opposition. Perhaps someone should write a book on the "anti-heroes" who fought so hard to prevent the elimination of phossy jaw to child workers or eye injuries to child hockey players. The lesson for activists is to never tire of protesting.

3) A third lesson is to try to find committed leaders, or high-profile people, to push for the change. Suicide prevention in the Air Force was successful because the chief of staff decided it was a high priority; goalies in hockey began wearing protective facemasks because the greatest goalie of them all led the way.

4) A fourth lesson is to focus on vulnerable populations. Many of the success stories involve protecting children-from motor vehicle injuries, scalds, fires, electrocution, poisoning and falls. It is much harder to "blame the victim" when the victim is under 5 years old.

5) A fifth lesson is to involve as many groups as possible to support the effort. Many of the major successes-reducing youth homicide in Boston, reducing pedestrian injuries in the Netherlands, lowering the child injury rate in Sweden-were due to many individuals and agencies acting together in a shared mission.

6) A sixth lesson is to get good data. Data are critical for gaining the support of the media, the public and politicians; for helping to determine the optimal initiatives; and for evaluating those initiatives.

Of these six lessons, I believe the most important is Lesson #2. It always takes longer than you hope, so you should never give up hope. In the words of the bastardized Latin version of the Harvard fight song: "Illegitimi non carborundum," or "don't let the bastards grind you down."

March 19, 2009

Research Matters

I describe more than 30 public health heroes in While We Were Sleeping. Almost all of these individuals were activists, who struggled to make the world safer-and succeeded. But I feel a little bad, because I barely mention the injury experts and researchers who also do such important work. So last year when I gave a talk about the book to an audience of injury researchers at an international conference in Mexico, I emphasized how data and research studies were critical for most of the successes.

Data and research are crucial for (1) documenting the problem, (2) targeting policies and (3) evaluating the interventions. Here are a couple of examples from just one injury area-motor vehicle crashes.

Graduated Drivers Licensing: Young drivers are very dangerous. Data showed that 16 year-old drivers had almost ten times the crash risk of 40 year-olds, and almost three times the crash risk of 19 year-olds. One reason for the higher risk was lack of experience, but the way to gain experience was by driving. What was needed was a way to gain experience while minimizing risk. Research also showed that young drivers were at particularly high risk (a) during the first few months of driving, (b) at night, and (c) when other young people (and no adults) were in the car. So graduated licensing systems were created to allow youth driving, but limit their driving in these high-risk situations. Studies of states that initially adopted these systems showed such large benefits (e.g., 30% decreases in injuries and death) that within a decade every U.S. state adopted Graduated Licensing.

Third Brake Light: Data showed that rear-impact collisions accounted for more than 20% of all collisions. In the late 1970s, in scientific trials with taxicab and telephone company passenger cars, a random sample was provided with center, high-mounted brake lights. Those cars with the new brake light were rear-ended about half as often as cars without the third brake light. Based on these studies, the federal government mandated a center high-mounted stop lamp on all new passenger cars. Studies find that this requirement prevents some 25,000 motor vehicle injuries per year.

One of my favorite injury prevention heroes is John Paul Stapp (1910-1999). A physician and Air Force colonel, in the 1950s he became the fastest man on earth, traveling faster than a speeding bullet. Using himself as a human guinea pig, on a test track in New Mexico in 1954, Stapp strapped himself in for his twenty-ninth and final sled ride. In five seconds he accelerated to 632 mph, then was brought to a complete halt-in 1.4 seconds. He suffered (temporarily) complete red out, as nearly every capillary in his eyeballs burst. But his feat showed that humans could tolerate more than 25Gs, and that air force cockpits needed to be re-designed so that pilots would survive such a deceleration.

Stapp became an instant celebrity, featured on the cover of Life magazine and in a Hollywood movie. He used his fame to promote automobile safety. He even persuaded the Air Force to build an automotive testing facility, and he conducted the first-ever crash tests using dummies. How did he persuade the Air Force to spend so much money on automobile safety? By providing data and studies showing that more Air Force pilots were being killed in traffic accidents than in plane crashes.

Data and research are key to policies that improve safety. While my book hardly discusses the work of injury control researchers, there is little doubt that good data and good science typically provide the foundation for endeavors that successfully save lives.

March 9, 2009

Everything is about economics?

Last week I gave a lecture about "While We Were Sleeping" at Saint Michael's, a small liberal arts college in Vermont. The talk was to a full house of economics faculty and students, a number of whom who were being inducted into the Omicron Delta Epsilon honor society. There was also a dinner with students, faculty, the president and other college administrators. Everyone was so welcoming, and I was extremely impressed by the caliber of the students, and how much they liked their college experience.

Because the audience was primarily economics majors, I tried to make my talk relevant to their studies. What does a talk about advocates and activists who have helped make the world safer-by helping to reduce motor vehicle deaths, burn injuries, violence, suicide, industrial accidents, etc-have to do with what the students were studying?

Fortunately I am an economist, so I made sure that one of the heroes I talked about was a labor economist-John B. Andrews-who successfully promoted taxation rather than prohibition as a way to reduce the use of white phosphorous, which was causing an horrific workplace poisoning known as "phossy jaw." One historian has written that Andrews "orchestrated the most significant legislative success achieved by advocates of workers' health in the early twentieth century."

I also talked about some possible lessons for economists. Some of the successes illustrated the power of the market. For example, improved ski boots and bindings (something these Vermont students had an interest in) dramatically reduced lower leg injuries between 1960 and 1980. Sometimes, however, the market cannot be relied on, when, for example there is poor consumer information or large externalities. The U.S. government had to require that automotive manufacturers install collapsible steering columns in cars in the 1960s, and that tobacco manufacturers produce cigarettes that were fire-safe in the 2000s. Vermont was the second state to pass such a cigarette law.

Often, however, the issue is not more or less government, but smarter government. For example, when the government buys or builds mass transit, roads or bridges, they can make them more or less safe for workers and for travelers. The Washington D.C. metro, for example, was specifically -and successfully--designed to deter crime and violence.

Finally, I talked about the "law of unintended consequences." While economists often emphasis the bad unintended consequences of attempts to improve on the market, the unintended consequences of many of the successes in "While We Were Sleeping" were beneficial. For example, the passage of motor cycle helmet laws not only reduces motor cycle injury, but almost invariably reduces motor cycle theft. I had the students think about and explain why this would be the case.

One of the nicer aspects of writing this book has been the opportunity of making presentations in various locations and to various audiences. I did not even know Saint Mike's existed before my talk there, but it seems like a hidden gem.

Harvard School of Public Health

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