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- Reducing Environmental Risk In the two preceding chapters, strategies were outlined that sought to influence the supply of alcohol, drinking premises, and drinking prac- tices and thereby to reduce some of the problematic consequences of drinking. These discussions centered on ways to diminish the quantity of consumption or the pairing of intoxication with certain activities, by using taxation, the law, training, and so forth. The focus in this chapter shifts from the management of drinking practices as such to ways of modifying environments so that when drinking or drunken activities occur, they are less likely to cause or exacerbate damage. We are interested in this approach because even the most strenuous efforts that might be taken to reduce hazardous consumption or episodes of drinking cannot realistically be expected to eliminate or radically curtail them. Therefore it is sensible to investigate an additional set of mechanisms that will extend to people and events unaffected by other prevention policies. This approach manipulating the environment so that risks of harmful effects are reduced even in the presence of drunken behavior has been characterized as "making the world safe for drunks," a characterization that tends to evoke moral uneasiness or even outrage in some quarters, rooted in a long-standing view of drun- kenness as moral error that should get its just deserts. This view is sufficiently widespread and seductive that it must be explicitly countered if we are to contemplate the use of this strategy. The approach can be more accurately, if more awkwardly, described as "making the world safer for, and from, people who are affected by 100

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Reducing Environmental Risk 101 alcohol intoxication or other impairments." This elaborate description is meant to emphasize two important features. First, the world can be made safer not only for but also from drunkenness. When a person drinks too much, whether frequently or only once in a lifetime, hazards may be created not only for the drinker, but also for many others with whom the drinker has contact. To give a dramatic example, "dead man" controls, which automatically stop a train run by an intoxicated engineer who has passed out, may not only save the engineer's life, but also the lives of many others. On a more mundane level, passive restraints in cars protect drunken drivers as well as "innocent" passengers and drivers in other cars so equipped. Second, impairments due to drunkenness are not unlike those due to fatigue, absent-mindedness, anger, previous minor injuries, etc. They are routine matters, and the world is in many ways arranged to keep them from causing further harm. When drunkenness enters the equa- tion, however, the normal calculus of risks is revised or suspended, because drunkenness is seen as a moral issue, implying intentionality with respect to any consequences. For example, statistics on alcohol's involvement in casualties other than auto accidents are not collected or kept; this is apparently due, at least in part, to avoidance of the moral loading that the involvement of drunkenness would put on these situ- ations. Whatever the moral evaluation, it seems clear to us that infor- mation about drunkenness as a cause of accidents would be a significant aid in detecting potentials for "human error" and making products and structures safer from its results. Thus, the benefit of this approach is not limited by the degree to which alcohol is involved in particular hazardous consequences. If there were a moral justification for "making drunks pay" for their errors, the debtors would include everyone who has ever had "a bit too much," which includes a substantial majority of the adult U.S. popu- lation. As indicated in chapter 2, while very heavy drinkers, including the minority who are definitely alcoholics, account for a disproportionate share of drunken episodes, the far larger numbers of less heavy drinkers account for the majority of such episodes. In any case, a "let them pay" attitude clashes with long-standing medical and public health values. Just as a private doctor does not refuse to care for a patient because the illness or disability is the patient's fault, there is a public health com- mitment to limiting morbidity and mortality irrespective of other moral issues. We do not withhold public funds from the treatment of heart disease in smokers or obese people, or discourage the spread of car- diopulmonary resuscitation training or blood pressure testing, on the grounds that many or even most of the people at risk may contribute

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102 REPORT OF THE PANEL to their own problems by dietary indulgence and deficient physical dis- . . Clp lne. The rationale that a "let them pay" approach acts as a deterrent to drinking is analogous to banning public clinics for treatment of venereal diseases on the basis that they encourage promiscuity. We do not make policy, deliberately or by default, that syphilis is a just and useful plln- ishment for the sins of fornicators and adultererseven in jurisdictions in which their acts may be crimes. In general, our national policy is to enhance public health without special regard to the morality or even legality of contributory actions. We do not passively permit deaths and injuries that can be prevented. Assuming that these points neutralize the main ideological obstacles to an approach focused on minimizing the harmful consequences of drinking, how can it be done? As mentioned earlier, this chapter is primarily concerned with environmental modifications based on the premise that hazardous drinking takes place. The range of possible modifications is extensive, taking account of both the psychobiological and cultural properties of alcohol. There are two principal areas of such modifications: first, ones that try to reduce the likelihood of traumatic injuries from mechanical causes, either by making the physical environment more forgiving or by placing social "cushions" around the drinker; second, ones that try to reduce damage wrought by interpersonal events either by physically isolating the drinker from certain hostile reactions or by trying to reduce the intensity of such hostility. DAMAGE IN THE PHYSICAL ENVIRONMENT PHYSICAL SAFETY MEASURES Alcohol intoxication beyond a minimum level makes one clumsy and inattentive, and it is therefore directly implicated in a certain proportion of casualties due to ineptness in dealing with the environment: burns, drownings, falls, and other momentum injuries, notably motor vehicle accidents. These alcohol-related problems can thus be reduced by mak- ing the created physical environment more tolerant of inept (including drunken) behavior. If everyday materials are made less likely to burn' cut, trip, or gash people who are temporarily operating below normal levels of efficiency, the rate of alcohol-related casualties will decline. Since alcohol-related casualties tend to be concentrated in the most severe categories- deaths and permanent disabilities safety improve- ments will affect alcohol-related injuries most dramatically.

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Reducing Environmental Risk 103 Our society has chosen to give substantial attention to making the environment safer through such public and private agencies as the Na- tional Safety Council, the Occupational Safety and Health Administra- tion, the Underwriter's Laboratories, the Consumer Product Safety Commission, and a myriad of others. Traditionally, safety standards have been set assuming adults are alert and active and, in many sit- uations (including driving), trained in specific skills needed in the sit- uation. Gradually, it has been recognized that engineering standards should take more realistic account of "human factors," including the likelihood of occasional failures of people to live up to the ideal of an alert, active, and skillful adult. So far, such factors have primarily been taken into account in policy making for children and for the physically handicapped or enfeebled. Virtually no attention has been paid to those handicapped by drunkenness or other mental states seen as voluntarily assumed. This gap in official policy contrasts with the great deal of unofficial action by drinkers and their associates to arrange circumstan- ces so as to minimize damage around drinking. Alcohol-related accidents are important contributors to morbidity and mortality statistics, particularly in younger age groups, in which death or disablement affects many years of expected life. One-half of all deaths among people aged 15-24, and one-third of all deaths among people aged 25-34, occur as a result of accidental injury (National Center for Health Statistics 1977~; the overall death count from accidental injury was 103,000 in 1979 (National Center for Health Statistics 1980), about evenly divided between road crashes and other types of fatalities. The most important class of technological devices for the prevention of traumatic deaths related to alcohol is probably passive restraints (such as air bags) for auto passengers. Due to the nearly universal practice (in the United States) of routinely determining the BAC of decedents in auto fatalities and the funding of research to develop comparison samples of drivers (Borkenstein et al. 1974, Farris et al. 1976, Holcomb 1938, McCaroll and Haddon 1962, Perrine et al. 1971), we are able to estimate with some confidence that there are about 12,000 deaths due to drunken driving annually in the United States (Reed, in this volume). A large fraction of these would probably be prevented by sound passive restraint systems. This is not the only automobile safety technology possible, nor is auto safety the only area in which alcohol contributes to traumatic injury. Mosher and Mottl (in this volume) indicate a series of fireproofing technologies that have not been used by manufacturers of home fur- nishings and cigarettes, despite the involvement of these ignition sources in many residential fires. The connection of alcohol-aided fatigue and

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04 REPORT OF THE PANEL carelessness in these fires is well documented (Aarens et al. 1977), although there are insufficient data to estimate as narrow a range of attributable deaths, injuries, or property damages as can be done with auto accidents. There is in fact a welter of potentially hazardous environments and circumstances, and there is a corresponding array of safety and other relevant agencies involved or potentially involved in this strategy. This variety poses a problem for public policy: how can these many oppor- tunities to favorably affect the rate of alcohol-induced injury be detected and evaluated for efficient returns? In other circumstances, this type of problem has been handled by making a "watchdog," oversight, or coordinating unit responsible for energizing and prodding the relevant agencies to take account of the specific issues that reach across jurisdictions for which consumer pro- tection in regard to alcohol is relevant. Thus, for example, the National Transportation Safety Bcard has jurisdiction with respect to safety in the regulatory territory of a variety of other agencies, from the Coast Guard to the Federal Railway Administration. In a different mode, the White House Interdepartmental Task Force on Women has served as a coordinating center across all federal agencies for issues of concern to women as an interest group. What is needed, either as a specific function of the National Institute on Alcohol Abuse and Alcoholism or in some other form, is an institutional focus on environmental modifi- cations to reduce the hazards of drunkenness. The first item on the agenda for such an effort would be to bring the same attention given to BAC in auto fatalities to other accident reporting systems. An attempt to build a comprehensive overview of the role of alcohol in traumatic death and injury at the national level would be quite valuable (cf. Haberman and Baden 1978~. The fact that a given sequence of events or product design features is found to be important in producing or reducing injury does not answer the question of what course of government action is appropriate. To use the example of passive restraint technologies in automobiles, it is pos- sible to promote their use by the following: educating consumers to buy or demand them; providing research and development grants to improve them; differentially taxing autos that are not equipped with them; requiring that manufacturers make one or more of them available as optional equipment; or requiring every automobile sold or licensed to be furnished with one of them.

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Reducing Environmental Risk 105 This list is neither exhaustive nor mutually exclusive; it serves as a reminder that there are no automatic connections between knowledge about damage and subsequent government action. Moreover, the cost of even the least expensive action may be so high as to make doing nothing an important option. An agency broadly interested in the role of alcohol-induced and other impairments in accidental injury, by fos- tering the development of more suitable accident reporting systems, could provide a focus for investigating the value of alternative policies suggested by this information. SOCIAL SAFETY MEASURES Apart from the emphasis on consumer product safety, the social envi- ronment can be manipulated to decrease the exposure of drinkers to alcohol-induced casualties. The intervention of third parties to keep the intoxicated individual from performing potentially hazardous acts (e.g., saving an intoxicated friend from having to drive home from a party; training bartenders to carry out a similar function for their customers; routine checks by supervisors of personnel reporting for work in situ- ations in which their job entails a potentially dangerous task)) are ex- amples of alterations in the social environment aimed at avoiding the consequences of drinking. They are, in essence, strategies to persuade those in potential settings for drunkenness to take active steps to insulate the drinker from harm, and thus to put a social cushion between drinkers and potentially hazardous environments. These measures do not seek to basically alter or interfere with drinking or drunkenness but to limit certain consequences that are generally aversive or at best ambiguously regarded. 'This approach undoubtedly raises serious issues of civil liberty, but the pros and cons of the "intrusion" must be weighed. Checks can be applied in an objective and nondis- criminatory manner, using, for example, a breathalyzer for all personnel with certain responsibilities. Although the check-in may be regarded as odious, the occupational safety rationale should make it more acceptable. Clearly it would be a message about the hazards of certain jobs, a warning to those who know that they drink excessively, and a com- munication that drunkenness will not be covered up or implicitly condoned in jobs in which certain risks are involved Specific identification of such jobs is not a task that this panel has undertaken, but categories such as air traffic and flight control, missile guidance, heavy crane operation, surgery, and medical intensive care come to mind. More generally, 36 percent of the labor force in 1971 was engaged in work involving a fairly complex relationship to "things" (i.e., machines, tools, equipment, products), and 15 percent of all the occupations listed in the Dictionary of Occupational Titles involve working under hazardous conditions (U.S. Department of Labor 1977; see Miller et al. 1980 for further specification and analysis).

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106 DAMAGE IN THE SOCIAL ENVIRONMENT VICTIMIZATION REPORT OF THE PANEL Associated with its physiological effect of producing clumsiness, alcohol makes people vulnerable to harm or exploitation. The least arguable connection between alcohol and crime is that drunks are easy and tra- ditional prey for criminal harm and exploitation. There is a specific and ancient criminal profession the jackrollerthat specializes in mugging drunks. The tendency of American culture to enclave public drunken- ness (and, for that matter, tourist and convention activities) conveniently concentrates victims of the jackroller and allied trades in particular city districts. Victimization of the drunk, of course, extends beyond skid row inhabitants into all social strata. Despite the evidence that drunkenness leads to victimization, there has been little public discussion of the issue or of its implications for public policy, primarily because of the morality and culpability issues seen as attached to drunkenness. The substantial recent literature on victimization makes little or no reference to drunkenness of victims. Much of this literature is ideologically oriented toward increasing social assistance and benefits for victims of crimes, and it may be that drun- kenness is seen as detracting from the deservingness of victims (Miers 1978~. When San Francisco police initiated a decoy program to catch muggers, in which police posed as semicomatose drunks with wallets half-visible, commentary in local newspapers tended to depict this as a waste of police resources, and there was even some sympathy for the criminals thus caught as somehow being victims of entrapment. While there is clearly a strong association of drunkenness and victim- ization, it is poorly quantified it is not even included in such general accountings of the costs of drinking as the Berry and Poland (1977) study and there has been no study of the possibilities of protecting the environment of drunkenness against criminal activity. This seems a po- tentially fruitful area for study under the auspices of the National In- stitute of Justice and the National Institute on Alcohol Abuse and Al- coholism. PUBLIC DRUNKENNESS AND THE URBAN ENVIRONMENT By definition, public drunkenness is a problem that is in part a matter of environment; private drunkenness is generally not in itself illegal. One potential strategy for diminishing the problem of public drunken- ness is thus to rearrange the environment of drunkenness so that it is

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Reducing Environmental Risk 107 inconspicuous or out of public view. This strategy is, of course, widely pursued by individual drinkers and their associates; it is also clearly available as an instrument of social policy. In core areas of American cities, however, the trend in the last 35 years has been one of urban renewal, demolishing the traditional institutions of skid row, often forc- ing the habitues into the street, with the intention of obliterating any haven for impoverished drunks in the city. In many cities, it was during the heyday of urban renewal that arrests for public drunkenness reached their peak. Social policy toward skid row drunkenness in the past has mainly tried to treat the problem out of existence. Despite the many humane efforts and arrangements pursued along this line, it cannot be said to be a policy that solves the problem. On a local, not federal, level, there have been scattered attempts at environmental solutions. Reinventing the older tradition of municipal lodging houses, San Francisco for a time used federal Model Cities money to run a "wet hotel," i.e., a residential hotel in which the poor, like the rich, had the right to drink on the premises. An approach tempered by the modern alcoholism perspective would modify the "wet hotel": after an initial detoxification (affording an opportunity to begin a healing process, physically and emotionally), those desiring to continue treatment could do so on a voluntary basis in a setting of their choice, while those opting to resume drinking could do so, in the hotel if they wished, with access to an ongoing possibility of care. DEEMPHASIZING HOSTILITY The collective informal social norms that largely govern drinking be- havior in the United States tend to operate within wide margins of tolerance. Typically, the broad post-repeal accommodation of alcohol in this society and the fact that most adult Americans have personal exposure or experience with being drunk make most people hesitant either to intervene directly, or too roundly to criticize, the drunken behavior of others. In short, the typical reaction to intoxication in this country tends to be underreaction, especially if we consider the known health effects of excessive consumption. There are occasions, however, when the range of tolerance becomes too narrow. This occurs when evidence of past or present drinking behavior is used as an excuse to treat people who drink, or some segment of drinkers, as though they were not deserving of their full civil liberties. Where unwarranted hostility to some people's drinking, intoxication, or past drinking problems leads to denial of their normal opportunities

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108 REPORT OF THE PANEL for work or leisure, an effort to defuse or Reemphasize this hostility is well worth consideration. It can be argued that the reduction of an alcohol problem by deem- phasis in fact occurred in the course of the 1960s in the United States. Well before the promulgation in 1971 of the model Uniform Alcoholism Intoxication Treatment Act by the National Conference on Uniform State Laws, police in a number of cities were becoming more tolerant of street drinkers, and this tolerance was reflected in a declining arrest rate (Federal Bureau of Investigation, annual). It can be argued that the still-high rate of arrests for this offense reflects an intolerance, not so much on the part of the public at large as on the part of local mer- chants. Of course, such a policy of Reemphasis poses sharp value con- flicts for instance, between the potential benefit to health from com- pulsory treatment versus the deprivation of liberty involved in such benefits. In addition to public drunkenness, there are three other areas in which Reemphasis may prove to have advantages, although empirical evidence is scarce: teenage drinking, regional differences, and recovery from alcoholism. Teenage drinking has been widely publicized in our society in the past decade. Some students of alcohol policy have suggested that this problem has been exaggerated by governmental agencies and that it has diverted public attention from problems of adult drinking (Chaun- cey 1980~. Certainly the criteria used to discern drinking problems among teenagers are far less tolerant of drunkenness than the criteria used for adults (NIAAA 19784. It is notable that the level of public concern with teenage drinking has risen appreciably in the 1970s, yet there is substantial evidence that the national quantity and pattern of teenage drinking has remained about the same from 1965 to the present (Blanc and Hewitt 1977a, Abelson et al. 1977, Johnston et al. 1979; there may have been significant local departures from this trend: see, e.g., Blackford 1977~. It is doubtful that the increased level of concern has contributed to the prevention of teenage drinking as such, although it may have been instrumental in the reversal of statutes lowering the . . . . . minimum c iron sing age In several states. Rates of drinking are disproportionately distributed throughout the country that is, the southern prairie and mountain areas are relatively dry, and the northeast and coastal regions are much wetter. Hence, policies that focus public attention on drinking may be inappropriate and may needlessly arouse concern in the drier regions. It has been found that, particularly in the traditionally dryer parts of the country, some drinkers report family or other complaints about relatively light patterns of drinking (Cahalan and Room 1974~. Whether these reports are indicative of a serious problem of overreaction is not now known.

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Reducing Environmental Risk 109 The third area in which strategies of Reemphasis might prove valuable is occupational opportunities for recovered alcoholics. Irrespective of current drinking status, recovered alcoholics often face discrimination when seeking employment and quickly learn to conceal their past drink- ing history. A similar concern about exposure and its impact on their jobs, reputations, etc. contributes to the reluctance of some otherwise interested alcoholics to seek treatment or hospitalization. Alcoholism treatment was not covered, until recently, by the majority of health insurance plans. In the past five years, however, alcoholics have gained certain legal protections. Legislation forbidding discrimination against them in hous- ing and employment, legislation regulating the confidentiality of the medical records of alcoholic and drug abuse patients, and legislation providing Blue Cross/Blue Shield coverage are now on the books.2 Government policy on alcohol in the last 10 years or so has tilted very firmly toward the identification of an ever-broadening range of behaviors as problems and toward an increased likelihood that the problems will be identified as alcohol problems. The current practice of raising the threshold of people's worries about their own and others' drinking is often taken for granted as a policy imperative, without recognizing that there are potential costs as well as benefits from such an approach. To define more and more drinking behaviors as unacceptable may reduce somewhat the rate of those behaviors; it also tends to make deviants of those who persist in the behaviors, which accelerates the development of an isolated subculture at odds with the larger society, requiring in- creased attention of legal agencies to the reduction of this conflict. CONCLUSION Public concern about alcohol problems has centered on two specific areas. First is the recurrent default of major social roles in the family and at work that accompanies long-term loss of control over drinking behavior, which is the existential experience at the heart of the disease concept of alcoholism. Second is drunken driving, which is seen to overlap with the problems of alcoholism as well as to constitute an issue in its own right. The emphasis in both of these areas has been on influencing the drinker getting the alcoholic to stop drinking and the drunken driver to not pair the two activities. Whatever progress may be made, pre- vention and recovery efforts directed at these problems will not eliminate 2 The panel did not investigate and takes no position regarding recent changes in health insurance coverage for alcoholism treatment.

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110 REPORT OF THE PANEL either of them. Recognizing this reality, the approach suggested in this chapter is to consider how these and related effects of hazardous drinking can be lessened in severity: to examine ways of modifying humanly built, humanly formed environments to make them safer for, and from, drun- kenness and other impairments. In the area of accident prevention, it is clear that alcohol intoxication is a prominent form of human factor error in the most severe categories of injury. Alcohol intoxication has been investigated in depth only in the area of road accidents, although a number of limited studies (see Aarens et al. 1977, Mosher and Mottl, in this volume for detailed bib- liography and review) have suggested that some other accident cate- gories may have as high or higher overall rates of alcohol involvement. Further inquiry into these areas would be greatly facilitated by systematic attention to BAC in the reporting of accidents by various agencies. These reports ought to be monitored to discover information useful to product design and public policy formation. A marriage of technological safety innovations specifically adapted to human factors, with accident reporting systems that attend to BAC as a major indicator of impair- ment, seems to us a quite promising strategy. Depending on cost and acceptability, informed choices could then be made among a variety of ways of achieving safer environments. Accident prevention by increased social buffering of drunkenness is another area of potential intervention. These strategies are similar to a number of those discussed in chapter 5, but they differ in that the focus is not on the drinker as such but on third parties who may be in a position to help prevent drinkers from engendering serious damages. Moving from the area of traumatic accidents to the realm of damaging societal reactions, we find that the data, although much scarcer are suggestive of important policy issues. The notion that alcohol is a cause of violent attacks has been discussed in chapter 5, where the cultural rather than the strictly pharmacological basis of this connection has been stressed. In looking at alcohol as contributory to victimization, we find a similar phenomenon, that the undoubted impairment of functioning induced by intoxication is converted into risk of victimization by a series of sociocultural arrangements, arrangments that are subject to change. The recent shifts in policy dealing with public intoxication are exemplary of such changes. We argued previously that drinking practices are indigenous, collec- tive complexes that have long histories and that they are both autono- mous and variously resistant to the efforts of government to change them quickly. Nevertheless, some actions of government can affect drinking practices, in predictable, important' and even desirable ways.

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Reducing Environmental Risk All of this applies as well to the range of economic and other practices that shape the safety of environments in which drinking and intoxication occur. While government agencies such as NIAAA need to act forcefully if they are to have any impact, they need not batter blindly at one side of a problem and ignore any undesirable results that may be created at its other side. For this reason we think it is important to improve current knowledge about how increased sensitivity to alcohol problems may have negative effects, sobering reminders that sometimes problems are better approached by dealing with symptoms as they occasionally occur, rather than raising alarms at any indication that possible causes are present. 111