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Accidents—the foremost problem in preventive medicine
PREVENTIVE
MEDICINE
2, 106-122 (1973)
Accidents
- the Foremost
in Preventive NORVIN
Medicine
C. KIEFER,
2400 Se&wick
Problem
Ace.,
M.D., Bronx,
N.Y.
M.P.H. 10468
Accidents, heart disease, cancer and stroke are the four most important and unresolved problems in preventive medicine and, of these, accidents should be ranked first. We already know far more about how to prevent accidents than we know about how to prevent these diseases, but we are not applying what we know. This is a serious, major omission in preventive medicine on the part of all types of health workers. Accidents are considered under four main headings based on age groups: childhood, old age, teen-age and young adults, and the middle or “in-between” years. Illustrative accident problems common to all four, or largely limited to only one of these groups are described, with suggestions for positive action by health professionals. The consequences of continued neglect are implied; and the conviction is expressed that all health workers, and particularly preventive medicine experts, must greatly increase their knowledge, interest and endeavors in accident prevention.
As a despoiler of expected years of life, a producer of human misery, a waster of national financial and other economic resources, and a degrader of the quality of human existence, accidents probably rank first among all health problems of American people. Accidents cause the deaths of about 114,000 Americans each year. They are the leading cause of death from ages 1 to about 37; and they never drop below sixth place in any age group. Because they produce so many deaths at younger ages, accidents cause an even more enormous loss of years of life than is apparent on cursory examination of mortality data. We are justifiably concerned over the reality that the executive in his forties or fifties, “in his prime” of usefulness, is subject to having his life snuffed out suddenly by a myocardial infarction, or slowly by a cancer; or having his great usefulness quickly transformed into a burden of disability by a cerebrovascular accident. Although it does not ameliorate the seriousness and tragedy of such losses of active, mature citizens, the fact is that they are nearing, or at the zenith of their careers, following which they would begin to decline-precipitously or, among the more fortunate ones, over years or even decades. But consider the results of accidental deaths: the 5-year old, killed by a fall or in a fire; the IO-year old, killed while riding a bicycle; the teen-ager killed while driving or riding in an automobile or on a motorcycle; the 20-year old who is drowned while swimming or boating, or electrocuted by faulty home equipment; or the 30-year old who loses his life in a senseless accident while at work. What of their careers, whose span should have been measured in decades, not just years? Who knows? The chance to develop them has been terminated, forever. Over 36,000 Americans, aged l-24, die annually from accidents - approxCopyright All rights
0 1973 by Academic Press, Inc. of reproduction in any form reserved.
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imately as many as die, at the same ages, from all other causes combined. This is an enormous and wasteful loss of future years of life expectancy. After adjusting for the probability that those who died accidentally would have been exposed, had their fatal accidents been prevented, to the usual, other mortality causes at these ages, these accidental deaths produce an annual loss of roughly a million man-years of future, useful life. As a waster of future years of active life, accidents far exceed, in importance, any other cause of death. The relative lack of concern, nationally, about prevention of deaths from accidents, by comparison with those from diseases, forms an astounding paradox that becomes all the more baffling when it is recognized that we already possess substantial knowledge of how to prevent accidental deaths but we are by no means fully utilizing what we know. By contrast, against chronic degenerative diseases we are utilizing, to a major extent, all that we currently know or postulate. That some of today’s knowledge and methods may appear ludicrous and almost primitive to the health expert of A.D. 2000 is interesting to reflect upon; but at least we are employing, with increasing success, what we have learned, and we are utilizing both our successes and failures to open doors on new vistas of knowledge that may be expected to lead to more and more gratifying results in the future. Not so in accidents. Why? Why is interest in accidents only luke warm in an otherwise health-program-conscious nation? Currently, we are in a turmoil over the problem of providing adequate health services to all people. Why, then, are we less interested in assuring all people freedom from accidental injury and death? Much of the answer lies in public attitudes, among them belief that accidents are chiefly the result of bad luck and are inevitable; and smug, individual confidence that “accidents happen to someone else.” This posture is built on ignorance, disregard of reality, egocentrism, bravado, fear and, sometimes, self-destructiveness, among others. With extremely few exceptions, no accident ‘j’ust happens.” Each accident is produced-by someone’s thoughtlessness, foolhardiness, negligence, or lack of a required skill or ability. Even defective machinery is only a medium of accident production: The real fault lies with one or more human beings involved in its design, manufacture, maintenance or use. Many who talk enthusiastically about the promises of preventive medicine still are inclined to view accidents, in general, as “Acts of God.” This is a ridiculous attitude but, unfortunately, it also is a fact of current life. It is clearly evidenced by the rather feeble efforts for, and the lack of sustained interest in the total area of safety, when compared to the dollars, emotion and oratory poured into activities against heart disease or cancer (2). The fact that most accidents cause no significant injury undoubtedly contributes to apathy about them. It has been estimated that about 29,000 accidents must occur to produce 2800 minor injuries, 97 major injuries, and one death (8). People fail to recognize that today’s unsafe but noninjurious act may be tomorrow’s fatal blunder; and that often an accident that produces no injury can be so described purely by courtesy of statistical probability-the next time, the same accident may result in severe injury or death. Hawthorne
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expressed Sleeping
this vividly: or waking,
we hear
not the airy
footsteps
of the strange
things
that almost
happen.
Deaths, in actual numbers and as mortality rates, are the most accurately measurable adverse effects of accidents, just as they are for diseases, but they tell only part of the grim story. The National Safety Council estimate (1) of 10.8 million disabling injuries’ in 1970 is so overwhelming in magnitude that even if it were considerably overstatedand probably it is not- it still should be shocking to anyone who pauses for a moment to reflect upon it. The National Health Survey estimates for 1967-69 are even higher (1). The cost of these accidents is enormous. The National Safety Council estimated it at $27 billion in 1970 [$16 billion for wage losses, medical expenses and insurance costs, $11 billion for property damage and related items (l)]. Deaths, injuries, property damage, and wasted billions of dollars clearly and shockingly indicate the enormous penalty exacted by accidents. No matter how much has been done to promote safety, by some highly competent people, working alone or in groups, it clearly has not been enough. Their total efforts have fallen woefully short of the mark- 114,000 deaths and 10,800,OOO injuries short of it, each year. And the health professions .are among those that are guilty of neglect of their proper roles. There are notable exceptions -people who have plunged into safety work with full zest and faithfulness, and who continue to work hard at it, frequently at substantial personal sacrifice in leisure hours and money. Some of the great national professional medical and other health organizations have aggressively devoted much effort to the cause. What national organizations advocate, however, does not necessarily determine what their individual members are willing to carry out. This paper is concerned with prevention of accidents or, where prevention of occurrence fails, prevention of significant injury or death to people. When first aid to and definitive medical treatment of accident victims are required, preventive efforts have failed; and consideration of treatment measures, essential as they are, is not properly a function of this article. It is not possible to provide a detailed review of every type of accident, and its prevention, in a relatively brief article. The discussion, therefore, will be confined to mention of participation in community safety efforts, followed by summaries of important areas of accident prevention, with illustrations of some important preventive medicine problems and appropriate counter measures. Safety research, which for long was badly neglected, now is steadily coming into its own. It will not be considered here, however, except where it forms the basis of recommendations for action. In the last few years, published literature on health aspects of safety has been becoming more and more voluminous. Only a few, pertinent, representative articles out of the many excellent ones available could be listed in the bibliography. 1 A disabling injury, in National manent disability, or any degree
Safety Council nomenclature, of temporary total disability
is any injury (1).
causing death,
per-
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ACTIVITIES
The long-established role of national voluntary and professional organizations in safety now has been considerably augmented by activities of government agencies-in the Federal government, for example, by the Departments of Transportation (highway and motor vehicle safety); Health, Education and Welfare (alcoholism, product safety, and others); and Labor (occupational health and safety). Essential nation-wide leadership, planning, standards, monetary grants, media of communications, research and pilot projects are, thereby, becoming increasingly available. In general, however, safety is something that must be practiced and promoted by individual citizens, industrial plants, local officials, and local organizations. Accidents can be prevented only where they might occur, not on drawing boards at a remote point. Participation of individual health practitioners and health department workers is necessary to full success of organized community safety endeavors of all kinds -and, unfortunately, is offered far less than it should be by such professionals, including those who specialize in, or have major interest in preventive medicine. This deficiency is intolerable in consideration of the high rank of accidents among challenges to preventive medicine. The health worker who enlists in this sort of work will find it to be a rewarding-although sometimes frustrating-experience; and will have a pleasant and instructive opportunity to meet and work with a variety of safety engineers and related experts. ACCIDENTS
Accidents can be categorized in many ways. In this paper, for purposes of considering preventive medicine problems and activities, they are divided into four groups based on approximate ages. Although many threads in the pattern of accidents run from birth to old age, each of these four groups also presents some of its own unique problems; and, to a lesser extent, each needs, for its solution, some distinctive skills of professional categories and specialties.
I. Accidents
in Childhood
The mature adult usually, but not always, has learned, through survival of past experiences, to avoid many dangerous situations and actions that to a child’s mind and imagination promise fascinating adventures and outlets for young curiosity. A can under a kitchen sink, an open window, a bottle full of brightly colored pills or liquid, a cheerful flame, an appliance with a fascinating electrical cord-all of these things, and many more, are to be explored, actively, through all of a child’s senses. He therefore indulges himself in what to an adult are irrational and, therefore, often unpredictable acts- with painful, and sometimes serious or even fatal consequences. Even the pediatrician may view the environment only through adult vision, not from the perspective of a toddler, who interprets what he encounters only within the bounds of his own past, brief experience. But the pediatrician does have the advantage of seeing a total of untoward experiences of many children
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and, assuming he inquires sufficiently into the causes, can make more comprehensive and objective, important conclusions than perhaps anyone else can. The regular medical examinations, including immunization procedures, that pediatricians provide infants and small children, with guidance to parents, are one of the outstanding, genuine preventive medicine activities in today’s practice of clinical medicine. Yet, the most important of all hazards to the lives of these small patients frequently goes largely or completely unmentioned in the advice the doctor gives. The mother who faithfully adheres to a program for her child’s dietary regulation, weight observations, immunizations, and other salutary procedures, and who may be extremely sensitive to and solicitous over psychological influences in her offspring’s life, often is not even aware that the most important threat to that life is accidents. From ages l-14, accidents cause incomparably more deaths than do infectious, or any other category of diseases, and nearly as many as all other causes combined. The very least that a pediatrician can do is to select an adequate number of trustworthy pamphlets and leaflets, familiarize himself with their contents, and then personally hand them to a parent of each of his small patients, with a stem admonition to read and heed, and why. Some of this task can be delegated to a nurse or other competent worker on his staff, but the physician’s own conviction about, and concern over the subject should be made fully apparent through an initial, personal, oral message from him. Although accidents are not the greatest hazards to lives of infunts under age 1, they nevertheless kill 2500 of them each year [one third by ingestion of improper food or foreign objects, and one third by mechanical suffocation (l)]. From 1-4 yeurs, the most common causes of death are, in order: motor vehicle accidents, congenital anomalies, pneumonia, fires and burns, and drowning (1). Motor vehicle accidents. At these ages, problems of accident prevention are considerably different. As Burdi et al. have shown, “a child’s body dimensions, proportions, and biomechanical properties are so markedly different from an adult that a child cannot [for automobile safety] design purposes, be considered as a scaled-down adult.” Automobile restraining devices, e.g., belts and car seats, for infants and children are, at best, judged to provide a “fair degree of protection in forward impact,” and, at worst, they are ineffective and dangerous (4-8). Pediatricians can help by collecting their own observations of both successful and unsuccessful devices and transmitting them to people who can study their findings more extensively and devise new equipment (9). Burns. Each year, about a thousand children die when their clothing catches fire (10). Few patients are more pitiable than a badly burned child, whether during the acute phase of bewildered suffering or, among those who survive, the long agonizing periods of plastic and reconstructive surgery followed in many instances by a life-time of both physical and psychological scars. Consumers Union made a survey (11) in which 76 models of children’s sleepwear, sizes up to 6X, were bought in the New York City area and tested
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for flammability. The test was not unduly severe, but 75 of the 76 samples failed to pass it. New regulations will prevent much of this difficulty in the future, but will not remove the hazard of items already on store shelves or in homes. Another factor contributing heavily to fires and fire deaths is leaving small children unattended, even for a few minutes, while the parent goes to a neighbor’s house or on some other brief errand (12). Often, such seeming dereliction of parental duty arises solely from ignorance of the rapid rate at which a fatal fire can be created by a child. Drowning. A related danger is failure to provide constant vigilance over a small tot in a bath tub or near a swimming pool. In much less time than is required for the mother to answer a telephone call or door bell, a child may be drowned. Fdsfiom heights. In 201 deaths from falls from approximately one story or higher, by New York City children under 15 years old (132 under 5 years old), 85% were from windows (13). Educational campaigns and installation of safety devices in windows are necessary. Toys. Designed to give pleasure to children, toys often turn out to be dangerous. Consumer Reports (14) reviewed 39 toys ordered off the market because they were mechanical hazards: four toy rattles “with parts able to cause puncture wounds or with loose parts capable of being swallowed or sucked into the lungs,” 18 “breakable dolls, animals and others, with sharp pointed parts,” 10 “noise-making toys with detachable noisemakers that could lacerate, puncture or be swallowed or inhaled,” and 11 darts and archery games in which sharp points might wound youngsters. Most toy makers conscientiously strive to make their toys safe, but the design engineers cannot foresee every possibility of a child converting a supposedly innocuous toy into a dangerous instrument. First-hand observations by those who care for children, followed by prompt reporting of untoward events, are needed to fill gaps in the evaluation of the safety of any toy. Poisoning. Children under age 5 lead all other age groups in rates of deaths from poisoning by liquids and solids (as opposed to gas) and 90% ingest products commonly found in and around the home-about one half are medicines (aspirin in one fourth of the total cases); and the rest are household products (cleaning and polishing agents, pesticides, turpentine paints, petroleum products, cosmetics, etc.). The younger ones are more likely to ingest household products; the older ones, medicines. A frequent contributing factor is transference of products from original containers to soft-drink bottles, cups and glasses (15). This must be avoided, along with assurance that medicines and dangerous household products are properly labeled and stored, and are in tamperproof receptacles. In today’s seemingly unlikely event that the pediatrician makes a home call on his patient, he should not miss the opportunity to note and comment on safety hazards in the surroundings. Nurses, social workers and related professionals who visit homes should be given thorough instructions in inspection for safety hazards and how to eliminate them.
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From ages 5-l 4, the leading causes of death are, in order, motor vehicle accidents, cancer, drowning and congenital abnormalities (1). Accidents of all types cause over one half (over 8000 per year) of the deaths. Hit by automobile. Shaw and Rezwi (16) reported that in New York City, 9000-10,000 children are hit by cars each year: about one third of these required hospitalization, and 80-100 die. Those 6-8 years old, particularly boys, are most likely to be involved. Shaw, a pediatric surgeon working extensively in Harlem, questioned what we really know about the ability of a 6-year old to absorb a safety lesson, and wondered how well he can retain what he does absorb. He also urged that safety education be applied at the local level because of the significant differences between communities and regions: If an abrupt rise in accidents involving children occurs in the spring, as it does in New York City, it is pointless to have the best safety programs for parents and children in September or October.
II. Accidents
to the Elderly
The fundamental differences in causes of accidents to elderly citizens result largely from physiological and pathological deterioration of aging, rather than from the incomplete physical and mental development and lack of life experience that give rise to accident hazards in the very young. Mean life expectancy at birth has increased (17) and enough more people are surviving to the age of 65 or more that there now are over 20 million Americans in this category-roughly 10% of the population. At these ages, accidents drop in their comparative rank as causes of deaths, not because of better accident prevention but because diseases, particularly the so-called “chronic degenerative diseases,” increase so rapidly in both prevalence and lethality. Nevertheless, accidents each year kill about 11,000, aged 65-74; and about 18,000, aged 75 and over (1). Just as in other age groups, we know far more about how to prevent accidents to these elderly people than we know about how to prevent either the occurrence of progression of their diseases; and we are not by any measure sufficiently employing that knowledge. Motor vehicle accidents, falls and fires are, in order, the leading causes of accidental death in those 65-74 years old; but in those 75 and over, falls lead the list and cause well over half of all their accidental deaths. Falls. Some of the most important reasons have to do with visual difficulties. Even without cataracts or chronic glaucoma, visual acuity, side vision and night vision decrease with age. Between the ages of 16-90, recovery time from exposure to glare is about doubled every 13 years (17). Corrective lenses can improve visual acuity in most cases, but not remove the other deficiencies; and they may add their own special hazards, such as falls while descending stairs by people wearing bifocal lenses. Arteriosclerosis, atherosclerosis and neurological changes. These t&e their increasing tolls, with inevitable consequences to many normal functions. Loss of muscle efficiency, slowed reflexes, diminution of proprioceptive sensation, and vertigo may result, and predispose to falls and other accidents.
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Sheldon (18) studied 500 falls of 202 individuals from 50 ,to over 85 years old. His findings so well describe the problems that they are considered here at some length. 1. Accidental falls (a) On stairs (b) Slipping (c) Falling over objects (d) Caused by darkness (e) Miscellaneous Total 2. “Drop attacks” 3. Tripping 4. Vertigo 5. Recognizable central nervous 6. “Head back” episodes 7. Postural hypotension 8. Weakness in leg 9. Falling from bed or chair 10. Uncertain cause Total
63 49 16 12 31
lesions
171 125 53 37 27 20 18 16 10 23 500
Fulls on stairs. The risk of missing a last step comes to everyone at some time but, Sheldon stated, unlike in earlier life in old age it frequently is not possible to preserve “a balance suddenly placed in jeopardy.” Hand rails are requisite to safe stairways, and they must be properly constructed and attached in order to offer a quick and secure hand grasp. Vertigo, blackouts, etc. Sheldon thought that the occurrence of only 37 falls because of vertigo was not an accurate index of the frequency of this condition but, rather, that its onset often is slow enough to allow its victim to sit down or grab a support. By contrast, in the “drop-attack” the victim suddenly falls to the ground, without warning and therefore so quickly that there is no time to try to break the fall. Wehrmacher has written (19) about sudden incapacitation of the elderly from “grayouts” or “blackouts” caused by a variety of heart conditions that suddenly interrupt adequate supply of blood to the brain. Postural hypotension. This may occur in older people when they arise from bed suddenly, at night, to go to the bathroom; and it is likely to result in a fall. Tripping. This is common, too, and one reason is that elderly people, when walking, are likely to shuffle, or not lift their feet sufficiently. Head-back episodes. Sheldon’s cases were blackouts that occurred while the subjects were looking upwards, with head hyperextended, and usually with arms held above head level. Sudden cerebral anoxia can thus be caused by decreased blood circulation through the vertebral arteries, when their already narrowed, sclerotic lumens are compressed by hyperextended vertebrae (20). Osteoarthritis of the cervical spine increases this hazard. Standing on a wobbly stool or a chair to reach a ceiling light fixture or a high shelf or cabinet obviously is to be avoided but, unfortunately, in old people
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this precaution is not enough. The best of step ladders, with hand rails and nonskid bases, will not prevent a bad fall in an elderly person with a momentary blackout. Ceiling light fixtures, high shelves or cabinets, and anything else that invites such reaching by an older person, should be eliminated from his surroundings. Sufeguards should be assured in uny home-private, commercial or publicwhere elderly people live. These include adequate lighting, with easily accessible, illuminated switches; removal of all items, including long extension cords, that present a tripping hazard, elimination of all loose and easily kicked-up rugs; convenient shelving; good hand rails on stairs and color differentiation of top and bottom steps of all stairways; and adequate, firm hand grips for both bathtubs and toilet seats. Falling from bed. For the elderly person, too low a bed is difficult to arise from and predisposes to stumbling, and too high a bed is even more dangerous. Sideboards only add to the hazard when the elderly person tries to climb over them. A bed that can be raised or lowered, mechanically or hydraulically, provides the best existing countermeasure. Nocturnal wandering. This is the unexpected, confused excursion, from apparent sleep. The elderly person may wander purposely about the house or, worse, set out to look for his old home, long-deceased spouse, or old friends. It is heart-breaking enough for the family to have to observe this pitiable, seemingly demented physical activity; but it is made tragic when, during such an Odyssey, the elderly wanderer falls down the stairs. Geriatricians and other physicians and health workers may make visits to nursing homes and residential homes for the elderly. Careful inspection for accident hazards, and instructions on eliminating them, should be an integral part of such visits. III.
Accidents
to Teen-Agers
Among teen-agers and adults in their early twenties, the magnitude of the impact of accidents is almost beyond comprehension: 23,000 young lives snuffed out each year (1). The nature of accidents in this group is similar to that of older adults, but they require special consideration because to deal with the problems demands understanding and skills quite different from those needed to combat accidents to older people. The problems are the most complex and, at times, seemingly insoluble ones in all of accident prevention. The curiosity and explorer’s spirit of childhood still persists, but now is compounded by increased intellectual and physical capacities and the ingenuity to devise more bizarre and daring ways of trying to express them. This is a turbulent period of adjustment to the transition from childhood to adult life. It always has been a difficult stage in human development, but today’s extremely complex problems, to which young people seem to be more sensitive than ever before, have magnified the traditional conflicts. The teen-ager who experiments with use of drugs, in spite of his knowledge of the risks-legal and punitive, family and social, and mental and physical, including possible sudden death- will not easily heed warnings about dire
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consequences of risking accident hazards. Much can be done, with gratifying success, to steer the intelligent and responsible teen-ager away from unsafe acts of all kinds. The overriding problem is first to provide the teen-ager with full opportunity to develop into a responsible citizen, but recognizing that the modern youngster’s knowledge is in many ways so phenomenally advanced that sometimes it is awesome, to reason with him requires thought and understanding, not reliance on old bromides. Motor vehicle accidents. These are by far the greatest hazard of any kind to these young people, and are responsible for about 70% of their accident deaths and over 40% of all of their deaths. This is the age of learning and being licensed to drive motor vehicles. It therefore seems logical to postulate that, in spite of the cost in time and money, good driver education courses in schools are essential. Yet this has become a controversial activity. Although objections to such programs arise from a variety of motives, much is based on honest and fundamental questions about their real value. Do such courses truly produce safer drivers, and reduce accidents and fatalities? Are the most effective teaching methods being used? What is needed in this field is less emotion and oratory and more objective appraisal. Also, it is important to recognize that the young person who believes in safety and is actively doing something about it- there are many of them-has a right to demand to know why adults do not better recognize, respect and encourage the role of young people in safety programs, as well as why adultoperated programs are accomplishing so little. Discussion of methods to solve or alleviate the extreme problems of unrest among young Americans is hopelessly beyond the scope of an article on accidents as a problem in preventive medicine. Those who are dedicated to safety programs can only join hands with all others who truly are interested in the future of our young people. They must help in all feasible general ways while concentrating on improved methods of accident prevention that can make sense to, and thereby become acceptable to, adolescents and young adults. Their future is bright but their accidents must be controlled in order that they can enter that future. IV. Accidents
in the “Zn-Between”
Ages
This fourth group consists of all people at other ages, i.e., adults from their early or mid-twenties to retirement age. Accidents are their leading cause of death until about the age of 37, following which heart disease, cancer and stroke take their increasingly and comparatively higher toll and become more frequent killers. Motor vehicle accidents. Our annual toll of deaths from motor vehicle accidents at all ages is about 56,000 (1). Nearly half of them occur in this broad “in-between” age group. It is more than coincidence that this also is the age group in which addiction to alcohol is most prevalent. Alcoholism. Recently, the U.S. Department of Health, Education and Welfare reported to the Congress (21) that alcohol abuse is the nation’s top drug problem. Although this claim is hardly profound, it is helpful that it was made and widely publicized.
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There perhaps are nine million problem drinkers in the United States. The adverse effects of significant alcohol intake on driving ability no longer have to conjectured at: they have been abundantly demonstrated in competent tests and experiments, in the laboratory and on the road. Survey after survey has shown that about one half of fatal motor vehicle accidents are associated, directly or indirectly, with the abuse of alcohol. Pedestrian deaths. These account for about 20% of motor vehicle accident deaths. Alcoholism has been clearly demonstrated to be a major factor in these deaths, when the pedestrians are adults. Reliable studies have shown (22,23) that in contrast to study groups of drivers and pedestrians killed in accidents, control groups showed no blood alcohol or, among those who did have positive findings, substantially lower levels than in those who were killed. Alcoholism is preventable, but once it develops it rarely is curable. It is controllable, nevertheless, in perhaps two thirds of its victims, with intensive and long-term treatment. No policeman, judge, prison official, or legislator can do more than temporarily isolate or otherwise punish a victim of alcoholism. This traditional method of handling public drunkenness -the cause of one third of police arrests (24)-accomplishes nothing more than to remove the alcoholic from contact with the public for a few hours or, at most, months; it does not cure his disease, and it contributes little or nothing to prevention of the next episode of drinking to excess. Drivers who are addicted to alcohol cannot be effectively removed from the highway by removing their driving licenses; 50% of them continue to drive without licenses. Eelkema et al. (25) called these people “punitive immune.” Experienced law-enforcement officers and judges feel frustrated by the seemingly insoluble problem. Abuse of alcohol also is imcompatible with safe operation of most anything else that moves or has motorized parts: a private airplane, pleasure boat, motorcycle, snowmobile, power tool at home or at work, rotary mower, or any of a number of others, including human beings, themselves. In the teen-age and young adult groups, an increasing tendency toward alcohol addiction is being observed, although the major prevalence remains in the mature adult group. In addition, the young person is likely to have a low tolerance to alcohol, and even moderate “social drinking” therefore is more hazardous to driving ability than it is to an older, experienced occasional or moderate drinker. Since roughly one half of accident fatalities are motor vehicle accident deaths, of which one half are associated with alcohol abuse of some kind, separation of alcohol abuse of all kinds from driving motor vehicles should result in a greater return in reduced accidental deaths, not to mention injuries, than could be obtained from any other accident-prevention measure. This concept is intriguing, but of limited immediate, practical usefulness. Prevention of alcoholism must come chiefly from health education, effectively and extensively conducted to bring about a drastic reduction in new cases of alcoholism that otherwise will continuously develop; to assure increasing separation of drinking from driving in adult social drinkers; and to provide specialized programs for the teen-agers.
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But health education alone can have little effect on the person who causes most of the problem-the one who already is a victim of chronic alcoholism. For him, drinking is compulsive. After his first drink in any episode, practically all of the effects of any amount of educational efforts are negated. As in other diseases, the primary need is to discover a means of preventing its development, without resorting to the obvious but impossible method of preventing any use of alcohol by anyone; and also to find a drug that will cure alcoholism permanently. Thus far, not only do we not have such preparations, but they are not even in distant sight. Treatment. At this time, the only useful method of handling the alcohol addict is to rehabilitate him to the end that although still an alcoholic, he will become a nondrinking one. This will require far more extensive facilities, and skilled people to staff them, than now exist. Even if no new cases developed, the nation would be left with an awesome, only gradually decreasing residue of the nine million people already afflicted-people who come from all types of positions and all social and economic levels. The role of preventive medicine experts cannot be limited to educational endeavors to prevent development of this disease in the first place, but must be extended to provision of early recognition and diagnosis, followed by ascertaining that effective treatment is promptly instituted. None of these tasks is easy, but all of them are essential if any headway is to be made. Because not only is alcoholism a disease of the utmost significance, but also is a primary cause of accidents, one could postulate that each accomplishment against the disease earns double rewards. A recent advance that should aid understanding of, and communications concerning alcoholism is the publication of “Criteria for the Diagnosis of Alcoholism.” Prepared chiefly for the use of physicians, this publication (26) should be of great help to courts, law-enforcement officers, legislators and many others, as well as health workers, in dealing with alcoholism victims. More than for any other group, the onus of devising and carrying out nationwide rehabilitation programs for alcoholism victims falls on the health professions. Because of the close relationship between alcoholism and all types of accidents, fulfilling this responsibility seems to be the largest, single contribution that health workers can make toward reducing America’s accidents and accidental deaths. Other drugs and accidents. The President’s Task Force on Highway Safety recommended (27) that the Departments of Transportation and of Health, Education and Welfare “should obtain the cooperation of the medical profession to warn drivers when the medications prescribed might impair driving ability.” Use of illegal drugs is too complex a sociological problem to discuss it here; and the relationship to accident causation, although currently being studied, has not been clearly defined. But there also are safety hazards inherent in drugs that are professionally and legitimately prescribed for ill people. Drugs may be prescribed for their sedative effects: or they may produce such effects only incidentally, but, usually, not undesirably-except when the patient operates a motor vehicle or other machinery. That such drugs may diminish certain skills requisite to such activities has been demonstrated
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experimentally, but there is a dearth of corroborating evidence, from actual experience, of the extent to which they produce accidents. This allows for no complacency, however, and every health worker who prescribes such medication has an obligation to warn his patients of the potential hazards. Disease and uccidents. Conditions that may cause temporary dizziness, faintness or blackouts are true dangers to safety, and all patients with such conditions should be adequately warned and instructed by their physicians. If this is neglected, not only is the patient’s own life endangered, but the hazard also may be extended to others who might be injured by accidents that he may cause. To deprive anyone of the right to drive his motor vehicle, particularly when it is essential to his transportation and livelihood, without well-founded reasons is unthinkable. Extensive studies of the relationship of specific diseases to real hazards in driving a passenger vehicle are imperative. There is mounting evidence that drivers in significant numbers die of natural causes at the wheel; and then produce accidents that are sufficiently severe to have killed the vehicle driver, were it not that an already dead man cannot be killed a second time (28). In a study of 1026 drivers (29) killed in motor vehicle accidents, 146 were judged to have died from natural causes. It appeared that two thirds of them knew that they had heart disease, but only 17 were under a physician’s care (one was on his way to consult his physician when he died and another had an appointment with his doctor on the following day). In another group of drivers who died of natural causes at the wheel (70% were 50-69 years old; 90% were males) heart disease was the cause of death in 87% (30). A s more such studies of this type are made, it seems likely that the seriousness of this problem will be even more firmly established. Recreation und accidents. The shortened work week is resulting in increased exposure of working people to traditional accident hazards at home, in recreation or on the highway; and new methods of spending leisure time are creating hazards faster than they can be studied and controlled. As one example, the few hundred snowmobiles in use in 1960 had increased to nearly two million by early 1972 (31). Home m&dents. Over 300 years ago, Sir Edward Coke declared: The house of every injury and violence
one is to him as his castle as for his repose.
and fortress,
as well
for his defense
against
his
Current high incidence of burglaries and other personal violence have resulted in many houses taking on the appearance of fortresses, lacking only moats; and it seems likely that in 1972, an American home also presents far more injury potentials than Coke ever dreamed of. Nearly 27,000 deaths are caused each year by home accidents (1). Those occurring at the extremes of age previously were discussed, but each year about 7500 adults 25-64 years old are killed at home. The causes are, in order: falls, fires, poisoning by liquids and solids, suffocation by ingested objects, poisoning by gases, and firearms accidents. In a study of an employee population of about 8000 people engaged in cleri-
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cal tasks, in 5 years there were-in spite of a good safety program- 1563 onthe-job accidents, of which 195 were disabling, with 1158 lost work days (32,33). The causes and nature of these accidents were similar in many respects to those of home accidents: slipping, tripping, falls from unnecessary running, open drawers, extension cords, and many others. Occurrence or recurrence of home accidents cannot, however, be subjected to the same discipline that can be applied in industry; it would be somewhat unorthodox to discharge a housewife for repeated carelessness. Any family that is willing to discipline itself can find an abundance of reliable information about home safety hazards and how to eliminate them. The same hazards usually exist in any office for professional health workers. Hospital accidents now are under extensive study, as they well should be. The home, office, and hospitalthese are appropriate places for the health worker to start his participation in safety. If he cannot develop sufficient interest to do that, he can hardly be expected to assume an active role in community endeavors for accident prevention. Among home hazards should be mentioned power tools of all types, as well as other hardware. They are involved in 6% of personal injuries occurring in or about the home. And defective electrical equipment introduces an electrocution hazard that is considerably greater than is commonly supposed. On-the-job accidents. These are only briefly mentioned in this paper, because they are of a specialized nature. Death rates from such accidents have been greatly reduced during this century, but there were 14,200 in 1970, with an estimated 2.2 million disabling injuries (1). Such accidents must be of great concern to the industrial physician, full- or part-time, who shares responsibility for adequate countermeasures with company safety engineers. The literature on plant safety is voluminous. The Occuputional Sufety und Health Act. This is making full attention to on-the-job safety ever more essential, in fact, mandatory, in all types of industry. Many companies are being or will be forced to make major improvements in ,currently inadequate safety measures. It therefore is incumbent on all health professionals to update their knowledge in this field. Many short, intensive courses or seminars on the subject are available. “Accident proneness.” This subject is introduced here only with the hope of aiding in eliminating it from plans and actions to prevent accidents. It provides a convenient but unacceptable alibi for accidents. On the other hand, involvement of a person in a series of accidents does indicate a strong likelihood of a deep-seated cause that must be exposed and treated. Any person who, to justify his accident, says -often with a sheepish grin- “I guess has raised a danger signal that should be given full I’m just accident-prone,” and prompt attention. Emotional upsets, personality defects, aggressiveness, job dissatisfaction, and many other selfishness, psychological “hangups,” emotional disturbances, as well as physical illness, play huge roles in all types of accident production, just as in causation of many other untoward life experiences. Waller, for example, showed a relationship between production of hunting accidents, alcohol abuse, and minor to serious traffic offenses and accidents (34).
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The truth is that everyone, at some time and to some extent is, at least temporarily, accident-prone. ROLE
OF
PREVENTIVE
MEDICINE
IN
ACCIDENT
in his lifetime
PREVENTION
Improvements and refinements in equipment, machinery and environmental and associated influences, in order to make all of them less likely to cause or lead to accidents to people, are essential to progress in safety; and to attain them requires the help and interest of health experts-both research workers and practitioners. Basically, however, much of this lies in the fields of engineering and design, as well as legislation and law enforcement. Health education to prevent well-adjusted and healthy humans from injuring themselves or others, and activities to discover and point out hazards to people, and full consideration of how to protect people from injuries in accidents that do occur certainly are tasks of great importance for health experts, even though help from teachers, parents, communications media specialists, and others also is requisite. Recognition and management of emotionally disturbed people is primarily-but, again, not solely-a job for health professionals. Wellcoordinated teamwork is essential to success of any safety endeavors. It seems obvious that accidents are one of the most important challenges-if not the most important-to preventive medicine. So obvious, perhaps, that it is being overlooked. Fortunately, in accident prevention there already exists a great deal of knowledge of how to proceed effectively; but unfortunately, it is not being sufficiently translated into useful action. In view of the enormous cost- in lives, injuries and financial loss-that accidents exact each year, and because they are preventable, it is an obligation of preventive medicine experts to devote far more effort than they now do to aid in assuring safety for American citizens. Protection of health and the quality of life is the objective of preventive medicine. If prevention of accidental injuries and deaths is neglected, the term “preventive medicine” becomes just a euphemism, instead of being the dynamic factor in American life that it should be. REFERENCES 1. “Accident Facts.” National Safety Council, Chicago, IL, 1971. 2. KIEFER, NORVIN C. Accidents-a preventable epidemic. Arch. Enuironment. Health 13,468 (1966). 3. HEINRICH, H. W. Basic philosophy of accident prevention, in “Industrial Accident Prevention” 4th edition, pp. 27-28, McGraw-Hill, New York. 4. BURDI, A. H., HUELKE, D. F., SNYDER, R. G., AND LOWREY, G. H. Infants and children in the adult world of automobile safety design: Pediatric and anatomical considerations for design of child restraints. J. Biomechan., 2,276-280 (1969). 5. SNYDER, R. G. A survey of automotive occupant restraint systems: Where we’ve been, where we are, and our current problems. Paper #690243, International Automotive Engineering Congress, Society of Automotive Engineers, Inc., 1969. 6. ROBBINS, D. H., AND ROBERTS, V. L. Maximizing occupant protection using integrated seatrestraint design concept, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. 7. NHTSA urged to move faster on improved child seats, in “Status Report,” Insurance Institute for Highway Safety, Washington, DC, 1972.
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8. “What to Buy in Child Restraint Systems.” National Highway Transportation Safety Administration,” U. S. Government Printing Office, Washington, DC. 9. “Stop Risking Your Child’s Life.” Publication of Physicians for Automotive Safety, Irvington, NJ, 1972. 10. “Family Safety Magazine.” National Safety Council, Chicago, IL, 1965. 11. Children’s flammable sleepwear. A progress report, in “Consumer Reports,” Consumers Union, Inc., Mount Vernon, NY, February 1972. 12. WHEATLEY, GEORGE M. Relationship of home environment to accidents, in “Proceedings, Third American Medical Association Congress on Environmental Health Problems,” American Medical Association, Chicago, IL, 1966. 13. BERGNER, LAWRENCE, MAYER, SHIRLEY, AND HARRIS, DAVID. Falls from heights: A childhood epidemic in an urban area. Amer. J. Pub. He&h 61, 1 (1971). 14. Uncle Sam moves on unsafe toys (slowly), in “Consumer Reports,” Consumers Union, Inc., Mount Vernon, NY, March 1971. 15. VERHULST, HENRY L., AND CROTTY, JOHN L. Childhood poisoning accidents. J. Amer. Med. Ass. 203, 12 (1968). 16. SHAW, ANTHONY, AND REZRI, AZRA. Child pedestrian accidents in central harlem, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969,” Highway Safety Research Institute, Ann Arbor, MI, 1972. 17. KIEFER, NORVIN C., AND RODSTEIN, MANUEL. Aging-facts and fallacies. Sight Saoing Rev. 35, 2 (1965). 18. SHELDON, J. H. On the natural history of falls in old age. Brit. Med. J. 5214, 1685 (1966). 19. WEHRMACHER, WILLIAM H. Accident-or apparent accident. I. Amer. Geriut. Sot. 20, 2 (1972). 20. HUTCHINSON, E. C., AND YATES, P. O., quoted By Sheldon. J. H. (Ref. 18) from article in Bruin 79, 139 (1956). 21. News Item, New York Times, February 19, 1972. 22. MCCARROLL, JAMES R., AND HADDON, WILLIAM, JR. A controlled study of fatal automobile accidents in New York City. I. Chronic Dis. 15,6 (1962). 23. HADDON, WILLIAM, JR., VALIEN, PRESTON, MCCARROLL, JAMES R., AND UMBERGER, CHARLES J. A controlled investigation of the characteristics of adult pedestrians fatally injured by motor vehicles in Manhattan. J. Chronic Dis. 14, 5 (1961). 24. MITCHELL, JOHN N. To Heal, and Not to Punish. Address at testimonial dinner honoring R. Brinkley Smithers, New York, Dec. 9, 1971. 25. EELKEMA, ROBERT C., BROSSEAU, JAMES, KOSHNICK, ROBERT, AND MCGEE, CHARLES. A statistical study of the relationship between mental illness and traffic accidents -a pilot study. Amer. I. Pub. Heulth 60, 3 (1971). 26. National Council on Alcoholism. Criteria for the diagnosis of alcoholism. Amer. J. Psychiut. 129, 2 (1972). 27. “Mobility Without Mayhem.” Report of the President’s Task Force on Highway Safety. U. S. Government Printing Office, Washington, DC, Pub. o-404-376, October, 1970. 28. BAKER, SUSAN B., AND SPITZ, WERNER U. Age, disease and the driver, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. 29. WEST, &MA, NIELSEN, GEORGE L., RYAN, JOHN R., AND GILMORE, ALLEN E. Natural death at the wheel, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. DOMINICK J. A survey of sudden, unexpected deaths in automobile drivers, in “Pro30. DIMAIO, ceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. 31. RICE, BERKELEY. The snowmobile is an American dream machine. New York Sunday Times Magazine, February 13, 1972. 32. KIEFER, NORVIN C. Office safety. J. Occup. Med. 9, 11 (1967). 33. KIEFER, NORVIN C. Industry’s orphan-office safety. Enoiron. Control Management 138, 18 December, 1969.
122 34. WALLER, JULIAN A. Unintentional ior paradigm, in “Proceedings, of Motor Vehicle Accidents, 1972.
KIEFER shootings, highway crashes and acts of violence: A behavThird Triennial Congress on Medical and Related Aspects 1969.” Highway Safety Research Institute, Ann Arbor, MI,
MEDICINE
2, 106-122 (1973)
Accidents
- the Foremost
in Preventive NORVIN
Medicine
C. KIEFER,
2400 Se&wick
Problem
Ace.,
M.D., Bronx,
N.Y.
M.P.H. 10468
Accidents, heart disease, cancer and stroke are the four most important and unresolved problems in preventive medicine and, of these, accidents should be ranked first. We already know far more about how to prevent accidents than we know about how to prevent these diseases, but we are not applying what we know. This is a serious, major omission in preventive medicine on the part of all types of health workers. Accidents are considered under four main headings based on age groups: childhood, old age, teen-age and young adults, and the middle or “in-between” years. Illustrative accident problems common to all four, or largely limited to only one of these groups are described, with suggestions for positive action by health professionals. The consequences of continued neglect are implied; and the conviction is expressed that all health workers, and particularly preventive medicine experts, must greatly increase their knowledge, interest and endeavors in accident prevention.
As a despoiler of expected years of life, a producer of human misery, a waster of national financial and other economic resources, and a degrader of the quality of human existence, accidents probably rank first among all health problems of American people. Accidents cause the deaths of about 114,000 Americans each year. They are the leading cause of death from ages 1 to about 37; and they never drop below sixth place in any age group. Because they produce so many deaths at younger ages, accidents cause an even more enormous loss of years of life than is apparent on cursory examination of mortality data. We are justifiably concerned over the reality that the executive in his forties or fifties, “in his prime” of usefulness, is subject to having his life snuffed out suddenly by a myocardial infarction, or slowly by a cancer; or having his great usefulness quickly transformed into a burden of disability by a cerebrovascular accident. Although it does not ameliorate the seriousness and tragedy of such losses of active, mature citizens, the fact is that they are nearing, or at the zenith of their careers, following which they would begin to decline-precipitously or, among the more fortunate ones, over years or even decades. But consider the results of accidental deaths: the 5-year old, killed by a fall or in a fire; the IO-year old, killed while riding a bicycle; the teen-ager killed while driving or riding in an automobile or on a motorcycle; the 20-year old who is drowned while swimming or boating, or electrocuted by faulty home equipment; or the 30-year old who loses his life in a senseless accident while at work. What of their careers, whose span should have been measured in decades, not just years? Who knows? The chance to develop them has been terminated, forever. Over 36,000 Americans, aged l-24, die annually from accidents - approxCopyright All rights
0 1973 by Academic Press, Inc. of reproduction in any form reserved.
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imately as many as die, at the same ages, from all other causes combined. This is an enormous and wasteful loss of future years of life expectancy. After adjusting for the probability that those who died accidentally would have been exposed, had their fatal accidents been prevented, to the usual, other mortality causes at these ages, these accidental deaths produce an annual loss of roughly a million man-years of future, useful life. As a waster of future years of active life, accidents far exceed, in importance, any other cause of death. The relative lack of concern, nationally, about prevention of deaths from accidents, by comparison with those from diseases, forms an astounding paradox that becomes all the more baffling when it is recognized that we already possess substantial knowledge of how to prevent accidental deaths but we are by no means fully utilizing what we know. By contrast, against chronic degenerative diseases we are utilizing, to a major extent, all that we currently know or postulate. That some of today’s knowledge and methods may appear ludicrous and almost primitive to the health expert of A.D. 2000 is interesting to reflect upon; but at least we are employing, with increasing success, what we have learned, and we are utilizing both our successes and failures to open doors on new vistas of knowledge that may be expected to lead to more and more gratifying results in the future. Not so in accidents. Why? Why is interest in accidents only luke warm in an otherwise health-program-conscious nation? Currently, we are in a turmoil over the problem of providing adequate health services to all people. Why, then, are we less interested in assuring all people freedom from accidental injury and death? Much of the answer lies in public attitudes, among them belief that accidents are chiefly the result of bad luck and are inevitable; and smug, individual confidence that “accidents happen to someone else.” This posture is built on ignorance, disregard of reality, egocentrism, bravado, fear and, sometimes, self-destructiveness, among others. With extremely few exceptions, no accident ‘j’ust happens.” Each accident is produced-by someone’s thoughtlessness, foolhardiness, negligence, or lack of a required skill or ability. Even defective machinery is only a medium of accident production: The real fault lies with one or more human beings involved in its design, manufacture, maintenance or use. Many who talk enthusiastically about the promises of preventive medicine still are inclined to view accidents, in general, as “Acts of God.” This is a ridiculous attitude but, unfortunately, it also is a fact of current life. It is clearly evidenced by the rather feeble efforts for, and the lack of sustained interest in the total area of safety, when compared to the dollars, emotion and oratory poured into activities against heart disease or cancer (2). The fact that most accidents cause no significant injury undoubtedly contributes to apathy about them. It has been estimated that about 29,000 accidents must occur to produce 2800 minor injuries, 97 major injuries, and one death (8). People fail to recognize that today’s unsafe but noninjurious act may be tomorrow’s fatal blunder; and that often an accident that produces no injury can be so described purely by courtesy of statistical probability-the next time, the same accident may result in severe injury or death. Hawthorne
108
KIEFER
expressed Sleeping
this vividly: or waking,
we hear
not the airy
footsteps
of the strange
things
that almost
happen.
Deaths, in actual numbers and as mortality rates, are the most accurately measurable adverse effects of accidents, just as they are for diseases, but they tell only part of the grim story. The National Safety Council estimate (1) of 10.8 million disabling injuries’ in 1970 is so overwhelming in magnitude that even if it were considerably overstatedand probably it is not- it still should be shocking to anyone who pauses for a moment to reflect upon it. The National Health Survey estimates for 1967-69 are even higher (1). The cost of these accidents is enormous. The National Safety Council estimated it at $27 billion in 1970 [$16 billion for wage losses, medical expenses and insurance costs, $11 billion for property damage and related items (l)]. Deaths, injuries, property damage, and wasted billions of dollars clearly and shockingly indicate the enormous penalty exacted by accidents. No matter how much has been done to promote safety, by some highly competent people, working alone or in groups, it clearly has not been enough. Their total efforts have fallen woefully short of the mark- 114,000 deaths and 10,800,OOO injuries short of it, each year. And the health professions .are among those that are guilty of neglect of their proper roles. There are notable exceptions -people who have plunged into safety work with full zest and faithfulness, and who continue to work hard at it, frequently at substantial personal sacrifice in leisure hours and money. Some of the great national professional medical and other health organizations have aggressively devoted much effort to the cause. What national organizations advocate, however, does not necessarily determine what their individual members are willing to carry out. This paper is concerned with prevention of accidents or, where prevention of occurrence fails, prevention of significant injury or death to people. When first aid to and definitive medical treatment of accident victims are required, preventive efforts have failed; and consideration of treatment measures, essential as they are, is not properly a function of this article. It is not possible to provide a detailed review of every type of accident, and its prevention, in a relatively brief article. The discussion, therefore, will be confined to mention of participation in community safety efforts, followed by summaries of important areas of accident prevention, with illustrations of some important preventive medicine problems and appropriate counter measures. Safety research, which for long was badly neglected, now is steadily coming into its own. It will not be considered here, however, except where it forms the basis of recommendations for action. In the last few years, published literature on health aspects of safety has been becoming more and more voluminous. Only a few, pertinent, representative articles out of the many excellent ones available could be listed in the bibliography. 1 A disabling injury, in National manent disability, or any degree
Safety Council nomenclature, of temporary total disability
is any injury (1).
causing death,
per-
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ACTIVITIES
The long-established role of national voluntary and professional organizations in safety now has been considerably augmented by activities of government agencies-in the Federal government, for example, by the Departments of Transportation (highway and motor vehicle safety); Health, Education and Welfare (alcoholism, product safety, and others); and Labor (occupational health and safety). Essential nation-wide leadership, planning, standards, monetary grants, media of communications, research and pilot projects are, thereby, becoming increasingly available. In general, however, safety is something that must be practiced and promoted by individual citizens, industrial plants, local officials, and local organizations. Accidents can be prevented only where they might occur, not on drawing boards at a remote point. Participation of individual health practitioners and health department workers is necessary to full success of organized community safety endeavors of all kinds -and, unfortunately, is offered far less than it should be by such professionals, including those who specialize in, or have major interest in preventive medicine. This deficiency is intolerable in consideration of the high rank of accidents among challenges to preventive medicine. The health worker who enlists in this sort of work will find it to be a rewarding-although sometimes frustrating-experience; and will have a pleasant and instructive opportunity to meet and work with a variety of safety engineers and related experts. ACCIDENTS
Accidents can be categorized in many ways. In this paper, for purposes of considering preventive medicine problems and activities, they are divided into four groups based on approximate ages. Although many threads in the pattern of accidents run from birth to old age, each of these four groups also presents some of its own unique problems; and, to a lesser extent, each needs, for its solution, some distinctive skills of professional categories and specialties.
I. Accidents
in Childhood
The mature adult usually, but not always, has learned, through survival of past experiences, to avoid many dangerous situations and actions that to a child’s mind and imagination promise fascinating adventures and outlets for young curiosity. A can under a kitchen sink, an open window, a bottle full of brightly colored pills or liquid, a cheerful flame, an appliance with a fascinating electrical cord-all of these things, and many more, are to be explored, actively, through all of a child’s senses. He therefore indulges himself in what to an adult are irrational and, therefore, often unpredictable acts- with painful, and sometimes serious or even fatal consequences. Even the pediatrician may view the environment only through adult vision, not from the perspective of a toddler, who interprets what he encounters only within the bounds of his own past, brief experience. But the pediatrician does have the advantage of seeing a total of untoward experiences of many children
110
KIEFER
and, assuming he inquires sufficiently into the causes, can make more comprehensive and objective, important conclusions than perhaps anyone else can. The regular medical examinations, including immunization procedures, that pediatricians provide infants and small children, with guidance to parents, are one of the outstanding, genuine preventive medicine activities in today’s practice of clinical medicine. Yet, the most important of all hazards to the lives of these small patients frequently goes largely or completely unmentioned in the advice the doctor gives. The mother who faithfully adheres to a program for her child’s dietary regulation, weight observations, immunizations, and other salutary procedures, and who may be extremely sensitive to and solicitous over psychological influences in her offspring’s life, often is not even aware that the most important threat to that life is accidents. From ages l-14, accidents cause incomparably more deaths than do infectious, or any other category of diseases, and nearly as many as all other causes combined. The very least that a pediatrician can do is to select an adequate number of trustworthy pamphlets and leaflets, familiarize himself with their contents, and then personally hand them to a parent of each of his small patients, with a stem admonition to read and heed, and why. Some of this task can be delegated to a nurse or other competent worker on his staff, but the physician’s own conviction about, and concern over the subject should be made fully apparent through an initial, personal, oral message from him. Although accidents are not the greatest hazards to lives of infunts under age 1, they nevertheless kill 2500 of them each year [one third by ingestion of improper food or foreign objects, and one third by mechanical suffocation (l)]. From 1-4 yeurs, the most common causes of death are, in order: motor vehicle accidents, congenital anomalies, pneumonia, fires and burns, and drowning (1). Motor vehicle accidents. At these ages, problems of accident prevention are considerably different. As Burdi et al. have shown, “a child’s body dimensions, proportions, and biomechanical properties are so markedly different from an adult that a child cannot [for automobile safety] design purposes, be considered as a scaled-down adult.” Automobile restraining devices, e.g., belts and car seats, for infants and children are, at best, judged to provide a “fair degree of protection in forward impact,” and, at worst, they are ineffective and dangerous (4-8). Pediatricians can help by collecting their own observations of both successful and unsuccessful devices and transmitting them to people who can study their findings more extensively and devise new equipment (9). Burns. Each year, about a thousand children die when their clothing catches fire (10). Few patients are more pitiable than a badly burned child, whether during the acute phase of bewildered suffering or, among those who survive, the long agonizing periods of plastic and reconstructive surgery followed in many instances by a life-time of both physical and psychological scars. Consumers Union made a survey (11) in which 76 models of children’s sleepwear, sizes up to 6X, were bought in the New York City area and tested
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for flammability. The test was not unduly severe, but 75 of the 76 samples failed to pass it. New regulations will prevent much of this difficulty in the future, but will not remove the hazard of items already on store shelves or in homes. Another factor contributing heavily to fires and fire deaths is leaving small children unattended, even for a few minutes, while the parent goes to a neighbor’s house or on some other brief errand (12). Often, such seeming dereliction of parental duty arises solely from ignorance of the rapid rate at which a fatal fire can be created by a child. Drowning. A related danger is failure to provide constant vigilance over a small tot in a bath tub or near a swimming pool. In much less time than is required for the mother to answer a telephone call or door bell, a child may be drowned. Fdsfiom heights. In 201 deaths from falls from approximately one story or higher, by New York City children under 15 years old (132 under 5 years old), 85% were from windows (13). Educational campaigns and installation of safety devices in windows are necessary. Toys. Designed to give pleasure to children, toys often turn out to be dangerous. Consumer Reports (14) reviewed 39 toys ordered off the market because they were mechanical hazards: four toy rattles “with parts able to cause puncture wounds or with loose parts capable of being swallowed or sucked into the lungs,” 18 “breakable dolls, animals and others, with sharp pointed parts,” 10 “noise-making toys with detachable noisemakers that could lacerate, puncture or be swallowed or inhaled,” and 11 darts and archery games in which sharp points might wound youngsters. Most toy makers conscientiously strive to make their toys safe, but the design engineers cannot foresee every possibility of a child converting a supposedly innocuous toy into a dangerous instrument. First-hand observations by those who care for children, followed by prompt reporting of untoward events, are needed to fill gaps in the evaluation of the safety of any toy. Poisoning. Children under age 5 lead all other age groups in rates of deaths from poisoning by liquids and solids (as opposed to gas) and 90% ingest products commonly found in and around the home-about one half are medicines (aspirin in one fourth of the total cases); and the rest are household products (cleaning and polishing agents, pesticides, turpentine paints, petroleum products, cosmetics, etc.). The younger ones are more likely to ingest household products; the older ones, medicines. A frequent contributing factor is transference of products from original containers to soft-drink bottles, cups and glasses (15). This must be avoided, along with assurance that medicines and dangerous household products are properly labeled and stored, and are in tamperproof receptacles. In today’s seemingly unlikely event that the pediatrician makes a home call on his patient, he should not miss the opportunity to note and comment on safety hazards in the surroundings. Nurses, social workers and related professionals who visit homes should be given thorough instructions in inspection for safety hazards and how to eliminate them.
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112
From ages 5-l 4, the leading causes of death are, in order, motor vehicle accidents, cancer, drowning and congenital abnormalities (1). Accidents of all types cause over one half (over 8000 per year) of the deaths. Hit by automobile. Shaw and Rezwi (16) reported that in New York City, 9000-10,000 children are hit by cars each year: about one third of these required hospitalization, and 80-100 die. Those 6-8 years old, particularly boys, are most likely to be involved. Shaw, a pediatric surgeon working extensively in Harlem, questioned what we really know about the ability of a 6-year old to absorb a safety lesson, and wondered how well he can retain what he does absorb. He also urged that safety education be applied at the local level because of the significant differences between communities and regions: If an abrupt rise in accidents involving children occurs in the spring, as it does in New York City, it is pointless to have the best safety programs for parents and children in September or October.
II. Accidents
to the Elderly
The fundamental differences in causes of accidents to elderly citizens result largely from physiological and pathological deterioration of aging, rather than from the incomplete physical and mental development and lack of life experience that give rise to accident hazards in the very young. Mean life expectancy at birth has increased (17) and enough more people are surviving to the age of 65 or more that there now are over 20 million Americans in this category-roughly 10% of the population. At these ages, accidents drop in their comparative rank as causes of deaths, not because of better accident prevention but because diseases, particularly the so-called “chronic degenerative diseases,” increase so rapidly in both prevalence and lethality. Nevertheless, accidents each year kill about 11,000, aged 65-74; and about 18,000, aged 75 and over (1). Just as in other age groups, we know far more about how to prevent accidents to these elderly people than we know about how to prevent either the occurrence of progression of their diseases; and we are not by any measure sufficiently employing that knowledge. Motor vehicle accidents, falls and fires are, in order, the leading causes of accidental death in those 65-74 years old; but in those 75 and over, falls lead the list and cause well over half of all their accidental deaths. Falls. Some of the most important reasons have to do with visual difficulties. Even without cataracts or chronic glaucoma, visual acuity, side vision and night vision decrease with age. Between the ages of 16-90, recovery time from exposure to glare is about doubled every 13 years (17). Corrective lenses can improve visual acuity in most cases, but not remove the other deficiencies; and they may add their own special hazards, such as falls while descending stairs by people wearing bifocal lenses. Arteriosclerosis, atherosclerosis and neurological changes. These t&e their increasing tolls, with inevitable consequences to many normal functions. Loss of muscle efficiency, slowed reflexes, diminution of proprioceptive sensation, and vertigo may result, and predispose to falls and other accidents.
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Sheldon (18) studied 500 falls of 202 individuals from 50 ,to over 85 years old. His findings so well describe the problems that they are considered here at some length. 1. Accidental falls (a) On stairs (b) Slipping (c) Falling over objects (d) Caused by darkness (e) Miscellaneous Total 2. “Drop attacks” 3. Tripping 4. Vertigo 5. Recognizable central nervous 6. “Head back” episodes 7. Postural hypotension 8. Weakness in leg 9. Falling from bed or chair 10. Uncertain cause Total
63 49 16 12 31
lesions
171 125 53 37 27 20 18 16 10 23 500
Fulls on stairs. The risk of missing a last step comes to everyone at some time but, Sheldon stated, unlike in earlier life in old age it frequently is not possible to preserve “a balance suddenly placed in jeopardy.” Hand rails are requisite to safe stairways, and they must be properly constructed and attached in order to offer a quick and secure hand grasp. Vertigo, blackouts, etc. Sheldon thought that the occurrence of only 37 falls because of vertigo was not an accurate index of the frequency of this condition but, rather, that its onset often is slow enough to allow its victim to sit down or grab a support. By contrast, in the “drop-attack” the victim suddenly falls to the ground, without warning and therefore so quickly that there is no time to try to break the fall. Wehrmacher has written (19) about sudden incapacitation of the elderly from “grayouts” or “blackouts” caused by a variety of heart conditions that suddenly interrupt adequate supply of blood to the brain. Postural hypotension. This may occur in older people when they arise from bed suddenly, at night, to go to the bathroom; and it is likely to result in a fall. Tripping. This is common, too, and one reason is that elderly people, when walking, are likely to shuffle, or not lift their feet sufficiently. Head-back episodes. Sheldon’s cases were blackouts that occurred while the subjects were looking upwards, with head hyperextended, and usually with arms held above head level. Sudden cerebral anoxia can thus be caused by decreased blood circulation through the vertebral arteries, when their already narrowed, sclerotic lumens are compressed by hyperextended vertebrae (20). Osteoarthritis of the cervical spine increases this hazard. Standing on a wobbly stool or a chair to reach a ceiling light fixture or a high shelf or cabinet obviously is to be avoided but, unfortunately, in old people
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this precaution is not enough. The best of step ladders, with hand rails and nonskid bases, will not prevent a bad fall in an elderly person with a momentary blackout. Ceiling light fixtures, high shelves or cabinets, and anything else that invites such reaching by an older person, should be eliminated from his surroundings. Sufeguards should be assured in uny home-private, commercial or publicwhere elderly people live. These include adequate lighting, with easily accessible, illuminated switches; removal of all items, including long extension cords, that present a tripping hazard, elimination of all loose and easily kicked-up rugs; convenient shelving; good hand rails on stairs and color differentiation of top and bottom steps of all stairways; and adequate, firm hand grips for both bathtubs and toilet seats. Falling from bed. For the elderly person, too low a bed is difficult to arise from and predisposes to stumbling, and too high a bed is even more dangerous. Sideboards only add to the hazard when the elderly person tries to climb over them. A bed that can be raised or lowered, mechanically or hydraulically, provides the best existing countermeasure. Nocturnal wandering. This is the unexpected, confused excursion, from apparent sleep. The elderly person may wander purposely about the house or, worse, set out to look for his old home, long-deceased spouse, or old friends. It is heart-breaking enough for the family to have to observe this pitiable, seemingly demented physical activity; but it is made tragic when, during such an Odyssey, the elderly wanderer falls down the stairs. Geriatricians and other physicians and health workers may make visits to nursing homes and residential homes for the elderly. Careful inspection for accident hazards, and instructions on eliminating them, should be an integral part of such visits. III.
Accidents
to Teen-Agers
Among teen-agers and adults in their early twenties, the magnitude of the impact of accidents is almost beyond comprehension: 23,000 young lives snuffed out each year (1). The nature of accidents in this group is similar to that of older adults, but they require special consideration because to deal with the problems demands understanding and skills quite different from those needed to combat accidents to older people. The problems are the most complex and, at times, seemingly insoluble ones in all of accident prevention. The curiosity and explorer’s spirit of childhood still persists, but now is compounded by increased intellectual and physical capacities and the ingenuity to devise more bizarre and daring ways of trying to express them. This is a turbulent period of adjustment to the transition from childhood to adult life. It always has been a difficult stage in human development, but today’s extremely complex problems, to which young people seem to be more sensitive than ever before, have magnified the traditional conflicts. The teen-ager who experiments with use of drugs, in spite of his knowledge of the risks-legal and punitive, family and social, and mental and physical, including possible sudden death- will not easily heed warnings about dire
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consequences of risking accident hazards. Much can be done, with gratifying success, to steer the intelligent and responsible teen-ager away from unsafe acts of all kinds. The overriding problem is first to provide the teen-ager with full opportunity to develop into a responsible citizen, but recognizing that the modern youngster’s knowledge is in many ways so phenomenally advanced that sometimes it is awesome, to reason with him requires thought and understanding, not reliance on old bromides. Motor vehicle accidents. These are by far the greatest hazard of any kind to these young people, and are responsible for about 70% of their accident deaths and over 40% of all of their deaths. This is the age of learning and being licensed to drive motor vehicles. It therefore seems logical to postulate that, in spite of the cost in time and money, good driver education courses in schools are essential. Yet this has become a controversial activity. Although objections to such programs arise from a variety of motives, much is based on honest and fundamental questions about their real value. Do such courses truly produce safer drivers, and reduce accidents and fatalities? Are the most effective teaching methods being used? What is needed in this field is less emotion and oratory and more objective appraisal. Also, it is important to recognize that the young person who believes in safety and is actively doing something about it- there are many of them-has a right to demand to know why adults do not better recognize, respect and encourage the role of young people in safety programs, as well as why adultoperated programs are accomplishing so little. Discussion of methods to solve or alleviate the extreme problems of unrest among young Americans is hopelessly beyond the scope of an article on accidents as a problem in preventive medicine. Those who are dedicated to safety programs can only join hands with all others who truly are interested in the future of our young people. They must help in all feasible general ways while concentrating on improved methods of accident prevention that can make sense to, and thereby become acceptable to, adolescents and young adults. Their future is bright but their accidents must be controlled in order that they can enter that future. IV. Accidents
in the “Zn-Between”
Ages
This fourth group consists of all people at other ages, i.e., adults from their early or mid-twenties to retirement age. Accidents are their leading cause of death until about the age of 37, following which heart disease, cancer and stroke take their increasingly and comparatively higher toll and become more frequent killers. Motor vehicle accidents. Our annual toll of deaths from motor vehicle accidents at all ages is about 56,000 (1). Nearly half of them occur in this broad “in-between” age group. It is more than coincidence that this also is the age group in which addiction to alcohol is most prevalent. Alcoholism. Recently, the U.S. Department of Health, Education and Welfare reported to the Congress (21) that alcohol abuse is the nation’s top drug problem. Although this claim is hardly profound, it is helpful that it was made and widely publicized.
116
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There perhaps are nine million problem drinkers in the United States. The adverse effects of significant alcohol intake on driving ability no longer have to conjectured at: they have been abundantly demonstrated in competent tests and experiments, in the laboratory and on the road. Survey after survey has shown that about one half of fatal motor vehicle accidents are associated, directly or indirectly, with the abuse of alcohol. Pedestrian deaths. These account for about 20% of motor vehicle accident deaths. Alcoholism has been clearly demonstrated to be a major factor in these deaths, when the pedestrians are adults. Reliable studies have shown (22,23) that in contrast to study groups of drivers and pedestrians killed in accidents, control groups showed no blood alcohol or, among those who did have positive findings, substantially lower levels than in those who were killed. Alcoholism is preventable, but once it develops it rarely is curable. It is controllable, nevertheless, in perhaps two thirds of its victims, with intensive and long-term treatment. No policeman, judge, prison official, or legislator can do more than temporarily isolate or otherwise punish a victim of alcoholism. This traditional method of handling public drunkenness -the cause of one third of police arrests (24)-accomplishes nothing more than to remove the alcoholic from contact with the public for a few hours or, at most, months; it does not cure his disease, and it contributes little or nothing to prevention of the next episode of drinking to excess. Drivers who are addicted to alcohol cannot be effectively removed from the highway by removing their driving licenses; 50% of them continue to drive without licenses. Eelkema et al. (25) called these people “punitive immune.” Experienced law-enforcement officers and judges feel frustrated by the seemingly insoluble problem. Abuse of alcohol also is imcompatible with safe operation of most anything else that moves or has motorized parts: a private airplane, pleasure boat, motorcycle, snowmobile, power tool at home or at work, rotary mower, or any of a number of others, including human beings, themselves. In the teen-age and young adult groups, an increasing tendency toward alcohol addiction is being observed, although the major prevalence remains in the mature adult group. In addition, the young person is likely to have a low tolerance to alcohol, and even moderate “social drinking” therefore is more hazardous to driving ability than it is to an older, experienced occasional or moderate drinker. Since roughly one half of accident fatalities are motor vehicle accident deaths, of which one half are associated with alcohol abuse of some kind, separation of alcohol abuse of all kinds from driving motor vehicles should result in a greater return in reduced accidental deaths, not to mention injuries, than could be obtained from any other accident-prevention measure. This concept is intriguing, but of limited immediate, practical usefulness. Prevention of alcoholism must come chiefly from health education, effectively and extensively conducted to bring about a drastic reduction in new cases of alcoholism that otherwise will continuously develop; to assure increasing separation of drinking from driving in adult social drinkers; and to provide specialized programs for the teen-agers.
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But health education alone can have little effect on the person who causes most of the problem-the one who already is a victim of chronic alcoholism. For him, drinking is compulsive. After his first drink in any episode, practically all of the effects of any amount of educational efforts are negated. As in other diseases, the primary need is to discover a means of preventing its development, without resorting to the obvious but impossible method of preventing any use of alcohol by anyone; and also to find a drug that will cure alcoholism permanently. Thus far, not only do we not have such preparations, but they are not even in distant sight. Treatment. At this time, the only useful method of handling the alcohol addict is to rehabilitate him to the end that although still an alcoholic, he will become a nondrinking one. This will require far more extensive facilities, and skilled people to staff them, than now exist. Even if no new cases developed, the nation would be left with an awesome, only gradually decreasing residue of the nine million people already afflicted-people who come from all types of positions and all social and economic levels. The role of preventive medicine experts cannot be limited to educational endeavors to prevent development of this disease in the first place, but must be extended to provision of early recognition and diagnosis, followed by ascertaining that effective treatment is promptly instituted. None of these tasks is easy, but all of them are essential if any headway is to be made. Because not only is alcoholism a disease of the utmost significance, but also is a primary cause of accidents, one could postulate that each accomplishment against the disease earns double rewards. A recent advance that should aid understanding of, and communications concerning alcoholism is the publication of “Criteria for the Diagnosis of Alcoholism.” Prepared chiefly for the use of physicians, this publication (26) should be of great help to courts, law-enforcement officers, legislators and many others, as well as health workers, in dealing with alcoholism victims. More than for any other group, the onus of devising and carrying out nationwide rehabilitation programs for alcoholism victims falls on the health professions. Because of the close relationship between alcoholism and all types of accidents, fulfilling this responsibility seems to be the largest, single contribution that health workers can make toward reducing America’s accidents and accidental deaths. Other drugs and accidents. The President’s Task Force on Highway Safety recommended (27) that the Departments of Transportation and of Health, Education and Welfare “should obtain the cooperation of the medical profession to warn drivers when the medications prescribed might impair driving ability.” Use of illegal drugs is too complex a sociological problem to discuss it here; and the relationship to accident causation, although currently being studied, has not been clearly defined. But there also are safety hazards inherent in drugs that are professionally and legitimately prescribed for ill people. Drugs may be prescribed for their sedative effects: or they may produce such effects only incidentally, but, usually, not undesirably-except when the patient operates a motor vehicle or other machinery. That such drugs may diminish certain skills requisite to such activities has been demonstrated
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experimentally, but there is a dearth of corroborating evidence, from actual experience, of the extent to which they produce accidents. This allows for no complacency, however, and every health worker who prescribes such medication has an obligation to warn his patients of the potential hazards. Disease and uccidents. Conditions that may cause temporary dizziness, faintness or blackouts are true dangers to safety, and all patients with such conditions should be adequately warned and instructed by their physicians. If this is neglected, not only is the patient’s own life endangered, but the hazard also may be extended to others who might be injured by accidents that he may cause. To deprive anyone of the right to drive his motor vehicle, particularly when it is essential to his transportation and livelihood, without well-founded reasons is unthinkable. Extensive studies of the relationship of specific diseases to real hazards in driving a passenger vehicle are imperative. There is mounting evidence that drivers in significant numbers die of natural causes at the wheel; and then produce accidents that are sufficiently severe to have killed the vehicle driver, were it not that an already dead man cannot be killed a second time (28). In a study of 1026 drivers (29) killed in motor vehicle accidents, 146 were judged to have died from natural causes. It appeared that two thirds of them knew that they had heart disease, but only 17 were under a physician’s care (one was on his way to consult his physician when he died and another had an appointment with his doctor on the following day). In another group of drivers who died of natural causes at the wheel (70% were 50-69 years old; 90% were males) heart disease was the cause of death in 87% (30). A s more such studies of this type are made, it seems likely that the seriousness of this problem will be even more firmly established. Recreation und accidents. The shortened work week is resulting in increased exposure of working people to traditional accident hazards at home, in recreation or on the highway; and new methods of spending leisure time are creating hazards faster than they can be studied and controlled. As one example, the few hundred snowmobiles in use in 1960 had increased to nearly two million by early 1972 (31). Home m&dents. Over 300 years ago, Sir Edward Coke declared: The house of every injury and violence
one is to him as his castle as for his repose.
and fortress,
as well
for his defense
against
his
Current high incidence of burglaries and other personal violence have resulted in many houses taking on the appearance of fortresses, lacking only moats; and it seems likely that in 1972, an American home also presents far more injury potentials than Coke ever dreamed of. Nearly 27,000 deaths are caused each year by home accidents (1). Those occurring at the extremes of age previously were discussed, but each year about 7500 adults 25-64 years old are killed at home. The causes are, in order: falls, fires, poisoning by liquids and solids, suffocation by ingested objects, poisoning by gases, and firearms accidents. In a study of an employee population of about 8000 people engaged in cleri-
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cal tasks, in 5 years there were-in spite of a good safety program- 1563 onthe-job accidents, of which 195 were disabling, with 1158 lost work days (32,33). The causes and nature of these accidents were similar in many respects to those of home accidents: slipping, tripping, falls from unnecessary running, open drawers, extension cords, and many others. Occurrence or recurrence of home accidents cannot, however, be subjected to the same discipline that can be applied in industry; it would be somewhat unorthodox to discharge a housewife for repeated carelessness. Any family that is willing to discipline itself can find an abundance of reliable information about home safety hazards and how to eliminate them. The same hazards usually exist in any office for professional health workers. Hospital accidents now are under extensive study, as they well should be. The home, office, and hospitalthese are appropriate places for the health worker to start his participation in safety. If he cannot develop sufficient interest to do that, he can hardly be expected to assume an active role in community endeavors for accident prevention. Among home hazards should be mentioned power tools of all types, as well as other hardware. They are involved in 6% of personal injuries occurring in or about the home. And defective electrical equipment introduces an electrocution hazard that is considerably greater than is commonly supposed. On-the-job accidents. These are only briefly mentioned in this paper, because they are of a specialized nature. Death rates from such accidents have been greatly reduced during this century, but there were 14,200 in 1970, with an estimated 2.2 million disabling injuries (1). Such accidents must be of great concern to the industrial physician, full- or part-time, who shares responsibility for adequate countermeasures with company safety engineers. The literature on plant safety is voluminous. The Occuputional Sufety und Health Act. This is making full attention to on-the-job safety ever more essential, in fact, mandatory, in all types of industry. Many companies are being or will be forced to make major improvements in ,currently inadequate safety measures. It therefore is incumbent on all health professionals to update their knowledge in this field. Many short, intensive courses or seminars on the subject are available. “Accident proneness.” This subject is introduced here only with the hope of aiding in eliminating it from plans and actions to prevent accidents. It provides a convenient but unacceptable alibi for accidents. On the other hand, involvement of a person in a series of accidents does indicate a strong likelihood of a deep-seated cause that must be exposed and treated. Any person who, to justify his accident, says -often with a sheepish grin- “I guess has raised a danger signal that should be given full I’m just accident-prone,” and prompt attention. Emotional upsets, personality defects, aggressiveness, job dissatisfaction, and many other selfishness, psychological “hangups,” emotional disturbances, as well as physical illness, play huge roles in all types of accident production, just as in causation of many other untoward life experiences. Waller, for example, showed a relationship between production of hunting accidents, alcohol abuse, and minor to serious traffic offenses and accidents (34).
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The truth is that everyone, at some time and to some extent is, at least temporarily, accident-prone. ROLE
OF
PREVENTIVE
MEDICINE
IN
ACCIDENT
in his lifetime
PREVENTION
Improvements and refinements in equipment, machinery and environmental and associated influences, in order to make all of them less likely to cause or lead to accidents to people, are essential to progress in safety; and to attain them requires the help and interest of health experts-both research workers and practitioners. Basically, however, much of this lies in the fields of engineering and design, as well as legislation and law enforcement. Health education to prevent well-adjusted and healthy humans from injuring themselves or others, and activities to discover and point out hazards to people, and full consideration of how to protect people from injuries in accidents that do occur certainly are tasks of great importance for health experts, even though help from teachers, parents, communications media specialists, and others also is requisite. Recognition and management of emotionally disturbed people is primarily-but, again, not solely-a job for health professionals. Wellcoordinated teamwork is essential to success of any safety endeavors. It seems obvious that accidents are one of the most important challenges-if not the most important-to preventive medicine. So obvious, perhaps, that it is being overlooked. Fortunately, in accident prevention there already exists a great deal of knowledge of how to proceed effectively; but unfortunately, it is not being sufficiently translated into useful action. In view of the enormous cost- in lives, injuries and financial loss-that accidents exact each year, and because they are preventable, it is an obligation of preventive medicine experts to devote far more effort than they now do to aid in assuring safety for American citizens. Protection of health and the quality of life is the objective of preventive medicine. If prevention of accidental injuries and deaths is neglected, the term “preventive medicine” becomes just a euphemism, instead of being the dynamic factor in American life that it should be. REFERENCES 1. “Accident Facts.” National Safety Council, Chicago, IL, 1971. 2. KIEFER, NORVIN C. Accidents-a preventable epidemic. Arch. Enuironment. Health 13,468 (1966). 3. HEINRICH, H. W. Basic philosophy of accident prevention, in “Industrial Accident Prevention” 4th edition, pp. 27-28, McGraw-Hill, New York. 4. BURDI, A. H., HUELKE, D. F., SNYDER, R. G., AND LOWREY, G. H. Infants and children in the adult world of automobile safety design: Pediatric and anatomical considerations for design of child restraints. J. Biomechan., 2,276-280 (1969). 5. SNYDER, R. G. A survey of automotive occupant restraint systems: Where we’ve been, where we are, and our current problems. Paper #690243, International Automotive Engineering Congress, Society of Automotive Engineers, Inc., 1969. 6. ROBBINS, D. H., AND ROBERTS, V. L. Maximizing occupant protection using integrated seatrestraint design concept, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. 7. NHTSA urged to move faster on improved child seats, in “Status Report,” Insurance Institute for Highway Safety, Washington, DC, 1972.
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8. “What to Buy in Child Restraint Systems.” National Highway Transportation Safety Administration,” U. S. Government Printing Office, Washington, DC. 9. “Stop Risking Your Child’s Life.” Publication of Physicians for Automotive Safety, Irvington, NJ, 1972. 10. “Family Safety Magazine.” National Safety Council, Chicago, IL, 1965. 11. Children’s flammable sleepwear. A progress report, in “Consumer Reports,” Consumers Union, Inc., Mount Vernon, NY, February 1972. 12. WHEATLEY, GEORGE M. Relationship of home environment to accidents, in “Proceedings, Third American Medical Association Congress on Environmental Health Problems,” American Medical Association, Chicago, IL, 1966. 13. BERGNER, LAWRENCE, MAYER, SHIRLEY, AND HARRIS, DAVID. Falls from heights: A childhood epidemic in an urban area. Amer. J. Pub. He&h 61, 1 (1971). 14. Uncle Sam moves on unsafe toys (slowly), in “Consumer Reports,” Consumers Union, Inc., Mount Vernon, NY, March 1971. 15. VERHULST, HENRY L., AND CROTTY, JOHN L. Childhood poisoning accidents. J. Amer. Med. Ass. 203, 12 (1968). 16. SHAW, ANTHONY, AND REZRI, AZRA. Child pedestrian accidents in central harlem, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969,” Highway Safety Research Institute, Ann Arbor, MI, 1972. 17. KIEFER, NORVIN C., AND RODSTEIN, MANUEL. Aging-facts and fallacies. Sight Saoing Rev. 35, 2 (1965). 18. SHELDON, J. H. On the natural history of falls in old age. Brit. Med. J. 5214, 1685 (1966). 19. WEHRMACHER, WILLIAM H. Accident-or apparent accident. I. Amer. Geriut. Sot. 20, 2 (1972). 20. HUTCHINSON, E. C., AND YATES, P. O., quoted By Sheldon. J. H. (Ref. 18) from article in Bruin 79, 139 (1956). 21. News Item, New York Times, February 19, 1972. 22. MCCARROLL, JAMES R., AND HADDON, WILLIAM, JR. A controlled study of fatal automobile accidents in New York City. I. Chronic Dis. 15,6 (1962). 23. HADDON, WILLIAM, JR., VALIEN, PRESTON, MCCARROLL, JAMES R., AND UMBERGER, CHARLES J. A controlled investigation of the characteristics of adult pedestrians fatally injured by motor vehicles in Manhattan. J. Chronic Dis. 14, 5 (1961). 24. MITCHELL, JOHN N. To Heal, and Not to Punish. Address at testimonial dinner honoring R. Brinkley Smithers, New York, Dec. 9, 1971. 25. EELKEMA, ROBERT C., BROSSEAU, JAMES, KOSHNICK, ROBERT, AND MCGEE, CHARLES. A statistical study of the relationship between mental illness and traffic accidents -a pilot study. Amer. I. Pub. Heulth 60, 3 (1971). 26. National Council on Alcoholism. Criteria for the diagnosis of alcoholism. Amer. J. Psychiut. 129, 2 (1972). 27. “Mobility Without Mayhem.” Report of the President’s Task Force on Highway Safety. U. S. Government Printing Office, Washington, DC, Pub. o-404-376, October, 1970. 28. BAKER, SUSAN B., AND SPITZ, WERNER U. Age, disease and the driver, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. 29. WEST, &MA, NIELSEN, GEORGE L., RYAN, JOHN R., AND GILMORE, ALLEN E. Natural death at the wheel, in “Proceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. DOMINICK J. A survey of sudden, unexpected deaths in automobile drivers, in “Pro30. DIMAIO, ceedings, Third Triennial Congress on Medical and Related Aspects of Motor Vehicle Accidents, 1969.” Highway Safety Research Institute, Ann Arbor, MI, 1972. 31. RICE, BERKELEY. The snowmobile is an American dream machine. New York Sunday Times Magazine, February 13, 1972. 32. KIEFER, NORVIN C. Office safety. J. Occup. Med. 9, 11 (1967). 33. KIEFER, NORVIN C. Industry’s orphan-office safety. Enoiron. Control Management 138, 18 December, 1969.
122 34. WALLER, JULIAN A. Unintentional ior paradigm, in “Proceedings, of Motor Vehicle Accidents, 1972.
KIEFER shootings, highway crashes and acts of violence: A behavThird Triennial Congress on Medical and Related Aspects 1969.” Highway Safety Research Institute, Ann Arbor, MI,