In my role as state health officer, I m asked what I consider the most pressing problem for health in Kansas. My answer, like that of most other public health and health care professionals, is rooted in my past. (The fact that you can never escape your roots is best exemplified by Britney Spears, whose child-raising skills have made K-Fed look like a more scraggly version of Captain Kangaroo who himself began his professional career as Clarabelle the Clown on the Howdy Doody Show, so perhaps the comparison isn t too far off.) For example, if you started your career caring for infants, it s maternal and perinatal health; pediatricians tend to place immunizations at the top of their lists. Family practice and internal medicine types rank chronic disease as the choice topics of the day, social workers and community health advocates focus on the socioeconomic components of health, and those who started life as environmental engineers rightfully see clean water and air as the true priorities for action.
So it shouldn t be too surprising that, as an emergency physician before I became a government worker, I fret most about trauma. Trauma is the leading killer of all Kansans from birth to age 34. It cuts down people who are on the cusp of their most productive years of life, and the statistical dweeb in me recognizes it as a leading cause of Years of Productive Life Lost (YPLL s), a key measure of the burden of disease on society. My personal emphasis on trauma isn t to diminish the priorities of others. I fully recognize that the reason trauma is the leading cause of death in young people is because we have clean water and immunizations, eliminating the leading causes of infant and child deaths of a century ago. I also understand that the leading killers of all Americans are chronic diseases such as heart disease, cancer, stroke and diabetes more properly thought of as the results of specific health behaviors such as tobacco use and a lack of nutrition and physical activity resulting in obesity. But the world of trauma is where I lived for years, so it would be odd if it hadn t become one of my passions. To me, injury prevention laws offer cheap, cost-effective, efficacious and experience-proven no-brainers that save lives, prevent injuries and impact health care costs. That s what makes it so frustrating that we have so much farther to go — in Kansas and the nation.
I don t want to spend this piece talking about whether primary seat belt laws, motorcycle helmet laws, or Graduated Driver s License (GDL) programs for novice drivers work. The evidence is incontrovertible that they do. Yet while 26 states have primary seat belt laws, 21 have motorcycle helmet rules and 45 feature some kind of three-stage GDL scheme, in light of the overwhelming data of the positive effects of these types of laws it s amazing to me that the remaining states don t.
Why People Resist
One of the things I ve tried hard to do since I got into the public world is to try to understand why people think — and sometimes vote — the way they do. I m convinced that in public health and health policy, too often we wave piles of evidence at people, beat them over the head with it, and then vilify them when they don t do exactly what we suggest. We do this because it s easier than asking ourselves whether we re addressing something they consider to be a problem and if they re even amenable to the beating that we re more than pleased to inflict. I find this even more intriguing because so much of our clinical practices now focus on the concept of cultural competency, or understanding the belief systems of those we serve in order to provide more effective and individualized care. I guess we re supposed to do that with the paying customers, but not with those who write the rules.
So to address these critical issues, I try to figure out where those who don t feel the same about the need for injury prevention laws are coming from. The theory is that if you understand their belief system, you can adapt your argument to be congruent with the decision-maker s paradigms, thus making your argument more effective. If you do it well, the other party may even feel as if their belief system is being supported and reinforced by your suggestions.
What are the beliefs that underlie a reluctance to advance vital traffic safety laws? The first relates to the relationship between the individual and the state, summarized bluntly as don t tell me what to do. Then there are those who use experience as their guide; they survived an auto accident without a seat belt, or they fared just fine as a teenage driver. Others see injuries as self-inflicted rather than imposing a burden on society as a whole. Some relate traffic safety to other issues. For example, seat belt laws might be used as an excuse for traffic stops based on racial profiling, or certain traffic safety laws may be seen as unenforceable.
See anything in common? For a while, neither did I. I could come up with individual arguments to rebut each of these contentions, and I could group a few of them together in general themes, but many of these arguments became an exercise in rhetoric. I ve testified to legislators that rarely do they literally have a chance to save a life, but with traffic safety laws they do. And each year I will continue to say how many lives have been left on the table until traffic safety laws improve. As the state health officer whose job it is to identify and prevent causes of death and disability in the state, I wouldn t be living up to my charge if I didn t.
The ‘Crazy Driver Hypothesis’
A comment made by Washington State Health Officer Mary Seleckey helped me combine these responses. I was in a small group discussion that drifted into the area of how people perceive certain words associated with public health. Mary was relating the results of marketing work in her state. She noted (and I m paraphrasing here) that people don t want government to prevent something they know about, but to protect them from things they don t.
(Interestingly, lots of research has shown that people don t like the term public health, either. To the majority of the population, public health implies a government agency that operates clinics for poor people and takes care of people with such diseases as tuberculosis or a sexually transmitted disease. As a result, they don t see public health agencies as having any relevance to their lives. Community Health seems like a better term.)
Granted, Washington and Kansas are two different places. But, I think the same principle may be at work. These are all things they re familiar with, things they know. They know how to drive a car or ride a motorcycle; they know how to wear a helmet or fasten a belt; those with children know that the teenage brain is addled with hormones. These are the things they don t want us to prevent. They want protection from what the next guy might do (like the drunk driver in the next car), for his actions are an unknown quantity.
Should all the evidence we have be able to sway the argument? It absolutely should. But in an age where Entertainment Tonight passes for journalism and You re fired counts as commentary, we need to play not only to the facts but to the perceptions. So, if we re going to advance the cause of traffic safety, it seems reasonable to try to couch the argument in terms of the dangers of the unknown, those things that an individual simply can t control. That s why we have legislation to punish those who drive drunk; we want to protect other drivers from the uncertain action of the person under the influence. It s also why most states have legislation addressing the use of booster seats for infants and children; the children can t make a choice for themselves, and they need to be protected from the uncertain actions of others.
I think the way to do this is to research what I call, for lack of a more academic term, the Crazy Driver Hypothesis. I have this idea in my head that those drivers who choose not to use a seat belt, or those who refuse to wear a helmet while riding a motorcycle, are careless drivers and are more likely to cause multi-vehicle accidents, resulting in harm to those who have no part of the decisions to not use the safety device. The statistical data probably wouldn t show a direct cause and effect relationship but would be able to show an association that starts to address the need to protect the innocent from the unknown. Granted, it s only a hypothesis. But I would be indebted to anyone who could find a way to study the issue by looking at multi-vehicle accidents, who is determined to be at fault, and the seat belt status of the offending driver. I m not sure how to explore the hypothesis for motorcycle riders, but I m sure that someone with more of a research background could figure out a way to do so.
Is this called thinking out of the box — or out of the belt?
Toothpicks and Trauma
I have to confess that what got me thinking about injury control was someone I saw at Tampa International Airport I ll call the Stalking Toothpick Man. STM was a white male with just a hint of lipid sepia to his skin, of undetermined age with a flabby, undistinguished face featuring protruded jaws, widely-spaced forward-jutting teeth, and a toothpick wedged in one of the gap as if holding it open so whatever it was in there and I m not really asking could get out.
STM managed to follow me from the rental car lot to the check-in counter to the tram that takes you to the departing gates. He stared straight ahead, rolling the toothpick around in his mouth, occasionally chewing on the shaft, taking it out from time to time as if it were a newly discovered treasure, then inserting it between still another gap in his garden of yellowed enamel. I m certain that Freudian scholars would have a field day explaining his fixation with the sliver. (As for me, I tend to shy away from Freudian explanations of anything. I have this habit of continually lusting after Hostess products of every shape and size, and Lord only knows what that signifies.)
So I m on the tram, and the car starts with a little jerk and the recorded voice says to hold on, and I see STM sway a little and the toothpick quiver, and suddenly I m trying to figure out what happens if he loses his grip on the handrail and tumbles face first to the floor. Where does the toothpick go? If it s angled upwards, does it get through the hard palate and scramble the optic nerves? If it s pointed down, is there enough force to reach the brainstem?
STM lost me, or I lost him, somewhere between the gate and baggage claim when we landed in Kansas City. For the record, KCI is the best large airport in the world for getting on and off flights. It was built in the early 1970 s, before deregulation and hubs and spokes, with the idea that it would be no more than 100 yards from where you got out of your car to where you got on to your plane. To a great extent, that theory still works. But the gift shops are suffering since the TSA no longer allows you to take barbecue sauce home in your carry-on bag, even if you put it in a clear plastic quart-sized bag. When the War on Terror impedes the free flow of condiments across this nation, it s really gone too far. But I digress.
Driving back to Topeka that night, I kept wondering about the trauma implications for the likes of STM. The next day, I took a spin through PubMed, the journal search engine of the National Library of Medicine.
It turns out that when you search for articles mentioning toothpick injuries, you get more than 100 separate citations. Someone has even calculated a toothpick injury rate of 3.6 per 100,000 people per year. (This means if you are only 0.6 of a person, you may be at special risk.) Swallowed toothpicks in humans have penetrated the stomach, lodged in the duodenum, produced abcesses in the liver, perforated the colon and inflamed the pancreas. Toothpicks have caused renal colic, hematuria, ureteral obstruction and kidney infections. They may stray into the cardiovascular system and perforate coronary arteries, lodge in the inferior vena cava, cause pericardial tamponade and be a source of pleurisy. Other toothpicks have caused cellulitis, septic arthritis and osteomyelitis. Especially creative splinters have even produced passages (fistulae) between the duodenum and the kidney. There has even been a case report of Toothpick in Ano: An Unusual Cause of Syncope, which is exactly what you think it is, and which you probably wish you didn t know. (Can you imagine trying to incorporate a question about this into your assessment of a patient who fainted? Nope, I m not going there, either.) However, as far as I can tell, there have been no reports of intracranial or intraspinal toothpicks.I suppose STM is safe for now.