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8 Reducing Environmental 1~1~1\ TO MAfTER HOW EFFECTIVE an educational campaign, no |\ | matter how the availability of alcohol is changed, some people will still drink in dangerous, careless, or just un- lucky ways. As a result, alcohol-related problems will always occur. But there is another way to reduce the number or severity of these problems. This third category of preventive instru- ments does not focus on how much or where people drink, as do educational programs, increased taxation, and so on. In- stead, these preventive actions ask how the physical and social environment might be changed to protect people from the harmful consequences of drinking. Changing the environment rather than behavior has long been seen as a way to protect people from their own actions, and not only in the area of drinking. "When we have a dan- gerous traffic intersection we very seldom mount a campaign to educate the public about the dangers of the intersection," says Robert Reynolds of San Diego County's Department of Health Services. "Instead, we install a traffic light or in serious instances we construct an overpass. In short, we alter the phys- ical environment in lieu of attempting to modify individual behavior through increased awareness of the problem." , . . ~ 95

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96 / ALCOHOL IN AMERICA Such steps to make the environment more forgiving benefit everyone, not just those who have been drinking. Drunkenness is only one of a number of impairments, including fatigue, absent-mindeclness, illness, anger, or previous minor injuries, that can increase the danger in certain activities. If the world is made safer for people who have been drinking, it is made safer for everyone. Changes in the Physical Environment Accidents are a major cause of death in the United States. Approximately 100,000 people die each year as a result of ac- cidentsabout ~ in every 20 deaths. Many more people are left with serious injuries, some of which will impair them for the rest of their lives. As noted in Chapter 3, roughly half of these 100,000 acci- dental deaths per year involve motor vehicles. But that leaves in excess of 50,000 deaths a year that are caused by other kinds of accidents falls, fires, cirownings, and so on. Limited studies have suggested that alcohol may be involved in as many or moreof these deaths as in traffic accidents. This is a hard statistic to pin down, however, because blood alcohol mea- surements, which are routinely made after traffic accidents, are not as commonly made after other kinds of fatal acciclents. The most efficient physical devices now available for pre- venting accidental deaths are passive restraints in automobiles. If every automobile were equipped with airbags or automatic restraining belts, a substantial fraction of the people now killed in traffic accidents wouIcl be saved. Just how many people would be saved, and at what economic and social costs, have long been subjects of debate within government and the au- tomobile industry. Other environmental modifications could also have a signif- icant effect on safety. An example is that of fires in homes caused by cigarettes and other smoking materials. Accorcling to James Mosher and Joseph Mott] of the University of Cali- fornia at Berkeley, residential fires caused by smoking "are surprisingly common in the Unitecl States." In ~L97S, according to the U.S. Fire Administration, some 70,000 smoking-related

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REDUCING ENVIRONMENTAL RISK / 97 Fires and other accidents kill as many people as do traffic accidents, and similar proportions of these deaths may be related to alcohol abuse. fires caused 1,800 deaths, 4,000 injuries, and $130 million in economic losses. The U.S. per capita rate of fire deaths is one of the highest in the world. Moreover, note Mosher and MottI, alcohol is involved in many of these cleaths. In one study in Maryland, 67 percent of the people aged 30-59 killed in resi- dential fires were legally drunk. There are many ways to reduce the risk of residential fires in the United States. According to Mosher and MottI, manu- facturers of home furnishings and cigarettes do not use a variety of fireproofing techniques that are available. For instance, for several years the Consumer Product Safety Commission sought to institute regulations requiring that cigarettes be manufac- tured to go out if not smoked within a few minutes. These proposals were backed by most of the major fire prevention lobbying groups. But the cigarette industry exerted enough pressure to keep them from becoming law.

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98 / ALCOHOL IN~ERICA The debates over passive restraints in automobiles and self- extinguishing cigarettes are two examples of how public policy affecting safety is established in the United States. The process involves a delicate balancing of concern for the public, pressures from private inclustry, and general ideas about the role of gov- ernment in society. It is a clifficult, inevitably political process. Yet in the area of alcohol-related problems it determines the realm in which preventive initiatives will be able to take effect. The Government's Role in Safety Since the federal government passed the Pure Food and Drug Act in 1906, its involvement in various aspects of safety has continually increased. Today a variety of federal, state, and local governmental agencies are charged with safeguarding the pub- lic health. At the federal level these include the Occupational Safety and Health Administration, the Consumer Product Safety Commission, the Food and Drug Administration, the Environ- mental Protection Agency, the National Highway Traffic Safety Administration, the Nuclear Regulatory Commission, and the National Transportation Safety Board. Many other agencies within the federal government have also been given heightened responsibilities for safety. This increased involvement with safety has had a measurable impact on mortality rates. "The federal concern for safety has made our society much safer than it was at the turn of the century in at least some regards," write Mosher and MottI. "Working conditions in many industries have become less haz- ardous; dangerous pesticides and canning chemicals have been banned; the number of fatal accidents (including automobile deaths) has been reduced by nearly one-half proportionate to the population." But this expansion of governmental oversight has not come without controversy. "While reducing potential risks of harm may be a proper goal for government, providing overprotection has its own social costs," write Mosher and MottI. "Individual freedoms may be jeoparclized; creativity, both of individuals and business, may be stifled; the viability of a small business may be eroded by the prohibitive costs of safety requirements.

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REDUCING ENVIRONMENTAL RISK / 99 Defining when and how to intervene to promote safety, then, - is an important topic of current federal practice." Consider the case of passive restraints in automobiles. The government has a number of options to try to encourage their use. It can educate consumers to buy or demand them. It can sponsor research to improve them. It can tax automobiles that do not have them. It can require that manufacturers offer them as options. It can require them outright. Or, if the government sees the costs of action as too high, it can do nothing. Not all governmental initiatives involve as much controversy as do passive restraints in automobiles. In fact, Mosher and Mott! believe that many federal agencies are overlooking fairly straightforward ways to significantly reduce alcohol-related problems. In the field of transportation, for instance, several agencies including the Department of Transportation, the Federal Aviation Administration, and the Coast Guardrec- ognize the role that alcohol plays in accidents yet have not moved forcefully to deal with the problem. "There appears to be a heavy emphasis on safety and a general recognition of alcohol involvement in transportation accidents among most of the federal agencies we stuctied," write Mosher and MottI. "It is therefore surprising that there has been so little effort to evaluate the scope of the problem or to plan and implement programs to contend with it." To some extent, these agencies are hamstrung by their own limited view of what can be done about alcohol problems. In general, safety-related federal agencies see alcoholism as the major problem to be addressed. When solutions are pursued, they almost invariably involve treatment and rehabilitation pro- grams directed at alcoholics. Such treatment has little or no chance of affecting the many accidents that happen to people who are not alcoholics. Moreover, even when governmental agencies do become aware of preventive options, they may fail to act out of a belief that such initiatives are not included in their mandate. One way to overcome these institutional barriers is through an oversight, coordinating, or watchdog body. Such an au- thority could encourage the relevant agencies or groups to take action where alcohol-related accidents are a problem. One ex-

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100 / ALCOHOL IN AMERICA ample of such a body is the National Transportation Safety Board, which has a specific jurisdiction in the activities of a number of federal agencies. The National Institute on Alcohol Abuse and Alcoholism could be the tomcat site of a similar watchdog body focused on alcohol. One of the first responsibilities of such a body should be to bring the same attention given to reporting blood alcohol con- tent after traffic deaths to nontraffic deaths. This information would be a valuable guide in designing safer products and surroundings, not only for drinkers but for nondrinkers as well. Such an agency could also explore alternative policies to deal with alcohol-related problems, thus clarifying some of the trade- offs involved. Public Drunkenness Another important place where drinking and environmental factors intersect is in the laws and attitudes surrounding public drunkenness. There are two general justifications for such laws. The first is that they keep people who are drunk in public from harming or offending others. The second is that they keep these people from being the victims of crime, exposure, or illness. These laws constitute one of the most significant involve- ments of the government in shaping drinking practices. Ac- cording to the Federal Bureau of Investigation, over one minion arrests are made each year for public intoxication. This offense and drunk driving are the two most common reasons for arrest in the United States. in recent years a social movement has developect to decrim- inal~ze public drunkenness. This movement has argued that people drunk in public need social and medical services more than they need to be locked up in jail. To the extent that public violence and disorcler related to alcohol use are a problem, laws against these offenses are more specific than blanket laws against drunkenness. Persuaded by these arguments, about half of the cities and states in the United States have decriminalized public drun- kenness. However, the actual way in which people drunk in public are handled has changed little. In many places, police

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REDUCING ENVIRONMENTAL RISK / 101 are still the only public servants trained to handle such people. Even if intoxicants are now more often taken to detoxification units than to jail, they are still usually taken there by the police. Moreover, the police can hold people they pick up in protective custody before releasing them or transferring them to a treat- ment facility. Finally, the treatment facilities that were to pro- vide the social and medical services still for the most part do not exist. There are virtually no data on how the decriminalization of public drunkenness has affected public violence. in fact, the only clear effect of these changes has been the often repeated assertion that drunken people are more visible on city streets. Decriminalization does not seem to have made much difference to the health and welfare of chronic violators, though this may reflect the lack of services for them. It is possible that public drunkenness has increased, and that violence, vandalism, and disorder are associated with this increase. But the lack of studies in this area makes it almost impossible to suggest directions for reform. The other side of the public drunkenness laws concerns the victimization of such people. Someone who is drunk in public is an easy mark for a criminal. As long as there has been drink- ing there have been jackrollers- people who mug and steal from drunken victims. Furthermore, American cities make it easier for jackrollers by concentrating their victims in certain districts. There has been little discussion among the general public about such victimization. This is partly due to the issues of morality and culpability associated with intoxication. Drunk- enness somehow seems to implicate the victim in the crime, to suggest that the victims deserve what they get. No one has yet studied the possible ways to shield people drunk in public from crime. It has not even been included in general accountings of the costs of alcohol abuse. Some of the local, environmental approaches to public drunk- enness that have been taken in the past may be a good starting point for such study. One problem is that urban renewal has demolished the traditional institutions of skid row, obliterating the old havens for impoverished drinkers. For several years

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102 / ALCOHOL IN AMERICA San Francisco used federal Mode! Cities money to run a "wet hotel," similar to the old municipal lodging houses. There the poor, like the rich, had a residential hose! in which they couic! drink. An improvement on this idea would be to offer the possibility of treatment on a voluntary basis through the facility. Those who continued to drink in the hotel could do so, but they could have access to care if they so desired. Reducing Hostility Toward Drinking Most adult Americans have been drunk or have been around someone who has been drunk. These experiences have prob- ably helped to make many people hesitant to criticize or inter- vene in the drunken behavior of others. Given the potential of excessive drinking to cause harm, most people probably un- derreact to intoxication. But the opposite situation can occur. People can use drinking as an excuse to deny another person's civil liberties or human rights. Hostility toward alcohol can reduce a ctrinker's normal opportunities for work or leisure. In some cases, a reduction in this hostility would be a step forward. The most prominent area in which reducing hostility toward drinking could have a beneficial effect is that of recovery from alcoholism. Recovered alcoholics need tolerance and under- standing as they try to reenter society. Even if they are currently abstemious, recovered alcoholics often face discrimination when looking for work and quickly learn to conceal their drinking histories. At the same time, this concern about stigmatization keeps some alcoholics from seeking treatment in the first place. This prejudice against recovered alcoholics also has an insti- tutional component. Until recently, the majority of health in- surance plans did not cover treatment for alcoholism. Now this has begun to change. Laws in some states require that Blue Cross/Blue Shield cover alcoholism treatment. Other legislation forbids discrimination against alcoholics in housing and em- ployment and regulates the confidentiality of medical records. Another possible problem concerns attitudes about drinking in different parts of the country. The South, the Great Plains, and the mountain areas of the United States are much drier

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REDUCING ENVIRONMENTAL RISK / 103 than the Northeast and West Coast regions. A nationwide gov- ernmental program to raise the level of concern about drinking may be out of place in these drier parts of the country. Similarly, someone who drinks in these parts of the country may fee} unnecessarily condemned for doing so, although it is not known if this is a serious problem. In general, there are potential risks in raising people's level of concern about their own and others' cirinking. As more and more drinking behaviors are defined as unacceptable, the rate of those practices may decline. But the people who continue to drink in those ways will have a greater chance of being labeled as deviants and feeling at odds with the larger society. For some problems caused by drinking, it may be wiser to continue to deal with symptoms as they occasionally occur than to tackle an underlying cause.