Cover Story
Public Health Enemy No. 1?
By Carmen Peota
Although more people are killed on the roads every month than died in the World Trade Center attack in 2001, Americans can’t seem to muster much outrage about the death rate from motor vehicle crashes.
Jon Roesler is awash in numbers. The state’s keeper of statistics on injuries can drum up data on everything from bites to burns. But he can’t quite put his finger on one number—the figure that will help people view traffic crashes as public health enemy No. 1.
“If we could come up with one graph that would just tell the story,” the epidemiologist in the injury and violence prevention unit of the Minnesota Department of Health says wistfully, noting that in his line of work there’s usually an “aha” moment when a number or a set of numbers vividly depicts a problem, making it clear in the public’s mind. “What’s the ‘aha’ for motor vehicle crashes?” he asks.
That’s a question that vexes nearly everyone working on traffic safety. The head counts, although impressive, don’t seem to be doing the trick. Worldwide, more than a million people die on roadways every year, according to the World Health Organization. The United States accounts for 40,000 of these deaths, and Minnesota close to 600.
So the experts often turn to comparisons: More Americans die in traffic crashes each month than were killed in the terrorist attacks on 9/11. Fourteen teenagers died in the Columbine High School shootings in 1999, yet about 16 die every day in traffic crashes. About 650,000 Americans have died in all the wars involving the United States since 1775, but more than 3 million have died in traffic crashes in the years since the automobile was invented.
Yet traffic safety is considered a rather ho-hum topic, and the public remains largely disinterested in mortality rates for motor vehicle crashes. That is, until the phone rings, and you’re told you’d better come to the hospital.
Loni and David Kjos of Alexandria have twice taken such calls, first in 2000 when their son Grant, then 18, was injured in a crash at an intersection near their home on Lake Geneva, and again in 2004, when their daughter Kelsey, 17, was thrown from a car on that same road. Both were rushed to the Douglas County Hospital emergency room and then airlifted to Hennepin County Medical Center in Minneapolis. Grant, who had been wearing a safety belt, lived. Kelsey, who wasn’t wearing one, didn’t.
Traffic Medicine
Traffic safety ought to be on the radar screen of medical providers, according to safety experts, who would like physicians to advise their patients to wear their seatbelts and drive the speed limit. “We need to prime communities,” says Nancy Franke Wilson, community health liaison for the Minnesota Office of Traffic Safety, if we are to change people’s behaviors.
Wilson is quick to acknowledge how difficult it is to get people to change their behaviors. “When I look at this from a health provider’s point of view, it’s really a frustrating topic,” she says, noting that even when patients have life-threatening diseases they don’t easily make lifestyle changes. “How do we get people to change their behavior when they don’t foresee impending doom?” she asks.
Fridley-based Columbia Park Medical Group has done more than many clinics to cast traffic safety as a health issue. The group routinely works with Unity Hospital and local fire departments to offer demonstrations and education about child safety seats. And in 2004, Columbia Park clinics in Fridley and Andover worked in conjunction with local police on a month-long effort to elevate the importance of traffic safety. The clinics surveyed patients about their seat belt use, showed traffic-safety videos in their lobbies, and distributed “prescriptions” for buckling up. Wilson would like to see similar programs instituted at other clinics around the state. “We really need people to get this,” she says.
Anne Beers, assistant commissioner of Minnesota’s Department of Public Safety, thinks physicians have a role to play in getting people to take driving safely seriously because they’re leaders in their communities. And she thinks there are natural opportunities to educate patients. “If you have a patient involved in a crash, what an opportunity to talk about prevention,” she says, “to talk about what they did to protect themselves.”
A 1996 article on teen drivers published in the journal Pediatrics recommends that pediatricians repeatedly emphasize to teenagers the “paramount importance of safe driving behavior.” The article recommended that pediatricians also advise parents that their responsibilities include setting a good example when driving, establishing driving limits and behavior expectations for teens, and ensuring the mechanical safety of the car.
To find out about Minnesota Office of Traffic Safety resources for physicians and clinics, or for help in developing a program for your clinic, contact Nancy Franke Wilson at 763/545-2684 or nancyfranke@comcast.net.—C.P.
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Kelsey’s death converted Loni Kjos into a crusader for seat belt use. She’s joined the Douglas County Safety Coalition, testified before the Minnesota Legislature, and is telling her family’s story to anyone who will listen.
Kjos is hoping that Kelsey’s story can cut through the apathy about traffic safety. “It needs a face,” she says. “Unfortunately, there are way too many.”
What’s in a Word?
Roesler blames part of the apathy on common parlance, use of what he disdainfully calls the “A-word”—accident. We view car crashes as if they were acts of God, he says. That makes traffic safety experts bristle. “It’s almost impossible to find a traffic crash that’s truly an accident,” says Nancy Franke Wilson, a community health liaison for the state’s Office of Traffic Safety. “We go too fast, we don’t pay attention, we follow too closely. We do things as drivers that cause collisions.” Traffic crashes, she says, are completely preventable.
Nic Ward, Ph.D., director of HumanFirst, a program at the University of Minnesota that looks at driver impairment and how technology can be used to support safe driving, believes the large number of crashes each year actually contributes to our disinterest in them. They seem mundane unless they involve a loved one or a celebrity. The problem, Ward acknowledges, is that statistically the risk of crashing is quite low for any individual driver. “In an average person’s driving year, they probably have no accidents and very few near misses. So they have no personal experience that driving is risky,” he says.
Ward believes the news media contribute to the public’s skewed view of the risk by not only under-covering traffic crashes but over-emphasizing other events that are less common. “They tend to make rarer catastrophes more salient,” he says. “And therefore, people presume they’re more common.” Thus, acts of terrorism or school shootings are what capture our collective imagination.
Ward is particularly disappointed that money is channeled away from traffic safety research and toward solving problems that are less likely to happen. “For example, it just seems that there is disproportionately more money per fatality going to areas such as homeland security that are important but do not constitute the same level of fatality risk in general as driving,” he says.
Data Driven
Part of the public relations challenge in communicating anything meaningful about traffic safety may be the overabundance of data on the topic. There are statistics on crashes, injuries, and deaths sliced and diced by age, sex, county, state, city, and country; by type and cause; and by resulting injury, hospitalization, and disability.
Those figures show that the state has made headway in reducing traffic fatalities. The number per year is dramatically lower than it was in 1968, when Minnesota reached its all-time high of 1,060. The modern-day low was 530 in 1987. Since then, the state has struggled to keep the number below 600. In 2004, the last year for which the number is confirmed, the state recorded 567 deaths, down from 650 in 2003, and it looks as if there were fewer in 2005. The fatality rate per 100 million vehicle miles traveled (VMT), which accounts for the fact that more people are driving more cars than ever before, has also fallen. During the 1970s, the rate was three per 100 million VMT. Today, it has dropped to one per 100 million VMT. When you take a long view, things are improving, says Kathryn Swanson, director of the state’s Office of Traffic Safety. Cars are safer, roads are better, and 84 percent of the population now buckles their seat belt when they drive. “Nevertheless,” she adds, “it’s hard to be complacent about 560-some deaths on our highways.”
It’s even harder to be complacent when you realize that crashes disproportionately affect certain segments of the population. Fatality rates are higher in rural areas than urban ones. More men are killed on the roads than women. And crashes take their biggest toll on young people.
Last December, in an article titled “Roadway Reality,” the St. Paul Pioneer Press published national data showing motor vehicle crashes as the No. 1 killer of people ages 3 to 33. (Heart disease and cancer are the big killers of adults age 34 and older.) “Americans often worry about exotic diseases or a natural disaster taking them from this life,” the article stated. “But, in fact, a national report released earlier this year shows that road accidents claim the most lives of people age 3 to 33.”
“The societal impact of motor vehicle crashes is that they kill people in the prime of life,” Roesler says. Not only are they the leading cause of death for people in the first three decades of life, they are also a leading cause of hospitalized injury, traumatic brain injury, and spinal cord injury. The Department of Health estimated the economic cost of both fatal and nonfatal car crashes in Minnesota in 2004 to be $2.5 billion. That figure includes the cost of medical care, rehabilitation, lost productivity, legal services, and insurance payments.
Roesler says that one way to realize the impact of crashes on the young is to look at potential years lost, a measure of estimated life expectancy at the time of death. Gauged this way, motor vehicle crashes come in third after cancer and heart disease in terms of lost human potential.
Another way to understand the impact on the young, according to Swanson, is to realize that the next four leading causes of death for young people, which include suicide and cancer, added together don’t come close to the number for traffic crashes. “Most 15- to 19-year-olds who die in Minnesota are coming to an early end because of crashes,” she says.
Of course the primary way people realize the impact is when someone close to them is killed. The students at Alexandria’s Jefferson High School, where Kelsey Kjos was a junior, took her death very hard, says her mother Loni. In response, a group of classmates launched the Klick-It-for-Kelsey campaign, selling green wrist bands to raise money to educate young people about seat belt use. “Until it hits your heart, you go along day by day, and you don’t think about the bigger picture,” Loni Kjos says.
That picture is a bleak one for teenagers. About a quarter of Minnesota’s 567 fatalities in 2004 involved people between the ages of 16 and 24, according to the Office of Traffic Safety. Half of those were 15- to 19-year-olds.
Young male drivers are especially at risk when they climb behind the wheel. In 2004, more than twice as many men as women were killed in car crashes. And of fatalities among 20- to 24-year-olds, 60 of 71 were men. “The typical accident-waiting-to-happen is a young, male driver,” Swanson says.
That crash, she continues, is likely to occur during rush hour and may involve alcohol. But it’s almost sure to involve a driver who is not attending to the task at hand. Swanson says this is especially true of young drivers, whose brains, researchers have discovered, aren’t yet adept at processing multiple pieces of information and making quick decisions. “Somehow, we need to get people to realize that the only goal they should have behind the wheel is that they get to where they’re going safely,” she says.
Remedies for the Road
The big question is what should be done to prevent crashes and fatalities. Where should effort and money be directed in order to do the most good?
The obvious way to prevent deaths among young drivers would be to ban them from the roads. “From a public health perspective, if we could do one thing, we’d say no drivers under the age of 18,” Roesler says. But society is not ready for that. “The soccer moms would toss us out,” he says, explaining that busy parents are often the ones who want their children to drive.
Swanson, too, doesn’t think the state is ready to raise the driving age. But she’d like to see a more graduated licensing system implemented. Such systems require teens to get a learner’s permit and provisional license before a permanent one. During the provisional period, a parent might be required to supervise a teenager during high-risk hours; and there might be nighttime curfews, restrictions on the number of passengers in the car, and limits on the distances they’re allowed to drive.
Loni Kjos, whose children’s lives have hinged on seat belt use, has worked with representatives from the law enforcement, emergency medical services, and public health communities to urge lawmakers to toughen the Minnesota’s seat belt law. Currently, only passengers in the front seat and children younger than 11 years are required to buckle up. Kjos wants lawmakers to make seat belt use mandatory for everyone and not wearing a seat belt a primary offense.
Max Donath, Ph.D., director of the University of Minnesota’s Intelligent Traffic Systems Institute, believes technology can help keep young drivers safe. Researchers at the institute have developed devices that can monitor driving performance including speed, acceleration, and braking, and offer feedback. Such systems could be used to help change driver behavior and might be useful if the state moved to a graduated licensing system. When teens prove certain competencies, they could move to the next level of driving privileges. Devices could even alert parents by cell phone when there’s a problem.
“Technology is not the only answer,” he says. But he’s not holding out hope for either education—“that’s been tried”—or stiffer laws—“we can’t seem to get simple things enacted or enforced.” He points out that the courts ended Minneapolis’ use of cameras for catching red-light runners a few weeks ago. “One of the problems is that we all drive and just assume that we can beat the system,” he says. “What are the odds that a police officer will catch us?”
Failing Grade
In a March speech to members of Minnesota’s traffic-safety community, author and former General Motors engineer Leonard Evans stated that U.S. traffic-safety policy is a failure. Evans said that gains in fatality and crash rates in this country need to be looked at not in comparison with where the country was 50 years ago but in comparison with where the rest of the world is today. Had we kept pace with other motorized countries such as Great Britain, Canada, and Australia, he says, the United States would be killing 15,000 fewer people each year on our highways.
Evans, who wrote the 2005 book, Traffic Safety, said the United States has focused on vehicle design, when other countries have worked at changing driver behavior through tough laws and enforcement of them, including use of technologies such as cameras and radar to automatically monitor driver behavior. Evans made the controversial charge that the United States has spent too much and pinned too many hopes on airbags, which he says deliver too few safety benefits. According to Evans, airbags cost the nation $6.3 billion a year and provide fewer than $2 billion a year in benefits, and they have killed more than 200 people.
Evans compared the government’s mandate of airbags in all vehicles to the FDA’s requiring everyone to use of an expensive and dangerous drug. “It’s like forcing a patient to buy a pill,” he said.—C.P.
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Donath believes that ubiquitous automated enforcement that’s uniformly applied may be one answer. “If everybody knew that if they went over the speed limit, they’d automatically be fined after a warning or two, we’d have a whole different world out there. … I bet insurance premiums would be reduced significantly if people drove the way they were supposed to drive.”
He says that coming up with the gadgets to protect drivers is easier than making the societal changes needed to use them, such as figuring out who should pay for new devices, who should be required to use them, and whether they should become standard features in new cars. He says, for example, the technology to keep someone from driving drunk following a DWI—an ignition switch that detects alcohol on a driver’s breath—is widely available but not used by the judicial system until people have multiple offenses, and even then under limited circumstances. As a result, one in nine Minnesotans of driving age has a DWI. “I just don’t understand why our culture says it’s OK to have one DWI after another and still allows you to go back and drive,” he says.
Zero Tolerance
Focusing on any single solution won’t solve the problem, according to the university’s Nic Ward. “If you want to reduce fatalities, you need to consider the entire system, which is the vehicle, the road, and the driver,” he says.
That’s the idea behind a Minnesota initiative called Toward Zero Deaths, which for the last three years has brought together officials from the state’s departments of Transportation and Public Safety and the University of Minnesota. “We have set zero as a goal not because it’s something we’re likely to reach in my career,” says Swanson, a co-chair of the effort, “but rather because it seems unconscionable to have any lesser goal when we’re talking about something so often predictable and because it [a motor vehicle crash] could be prevented.”
One of the things the organization has done is look at how the state deploys law enforcement related to DWIs. The funds, which used to be distributed evenly, are now targeted at the counties with the highest numbers of alcohol-related fatalities and the most DWIs. Those counties include the seven in the Twin Cities metro area, as well as a half dozen in rural Minnesota such as St. Louis, Cass, and Wright. Alcohol-related deaths are down statewide from 39 percent of fatalities in 2003 to 31 percent in 2004, according to Swanson. “It’s a little bit smarter deployment of resources,” she says.
Collaborative work is also being done to reduce cross-median crashes, which often result in the most serious injuries or death. The Department of Transportation has installed high-tension steel-cable median barriers along a stretch of Interstate 94 north of the Twin Cities. The fence-like barriers, which are said to be strong enough to stop a semi-trailer truck yet more forgiving than concrete or other steel barriers, prevent vehicles from veering into oncoming traffic. Film footage shows cars going out of control and being snagged by the barrier instead of crossing the median and hitting large trucks. “You can fix the driver behavior so people are driving in a calm, sane manner, or you can fix the engineering side so that if they’re not calm and sane, their actions don’t get them into trouble,” Swanson says. “We’re finding that what we need to do is a little of both.”
But reducing the number of deaths from car accidents may be more difficult now than it has been in the past. “To a large degree, the low-hanging fruit has been picked,” Roesler says. “The easy things have been done.”
Roesler believes implementation of the statewide trauma system might do more to cut fatalities than other measures. The trauma system is a plan for upgrading the level of care in hospitals throughout the state, but particularly in small towns and rural areas, and coordinating emergency transportation of the injured. The Department of Health estimates that 30 lives a year might be saved as emergency personnel are trained and transport plans are put into place.
Roesler notes that the trauma system will likely have its greatest impact in rural areas, which have higher fatality rates than urban areas. “This is really the right intervention for where the crashes are occurring,” Roesler says. “This doesn’t prevent the crash,” he admits. But he believes helping the state’s rural hospitals become trauma centers will save some of the people hurt in crashes.
Anne Beers, assistant commissioner in the Department of Public Safety and former head of the State Patrol, says the public needs to become energized about changing the culture around traffic safety. She emphasizes that people need to see driving as a full-time task, not something that can be done in addition to talking on the phone or tending to the kids. She insists we need to become intolerant of impaired driving and make it mandatory for people to wear seat belts and for motorcyclists to wear helmets.
Then, as if countering the argument that stiffer traffic-safety laws infringe on individual rights and freedoms, she asks: “When you’re the victim of someone else’s egregious behavior, haven’t we done the ultimate in infringing on your freedom?” MM
Carmen Peota is managing editor of Minnesota Medicine.