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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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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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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 adulterers—even 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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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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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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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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DAMAGE IN THE SOCIAL ENVIRONMENT
VICTIMIZATION
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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 jackroller—that 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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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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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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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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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
Representative terms from entire chapter:
environmental risk
