David Hemenway is Professor of Health Policy at the Harvard School of Public Health and Director of the Harvard Injury Control Research Center. He has published extensively on aspects of public health prevention, including Private Guns, Public Health in 2006 and While We Were Sleeping in 2009.
Prevention can be Grimm – send in the elves!
The comparison may seem odious at first hearing: if only we could make a difference in the field of child maltreatment to match the recent improvements in airline safety.
In the US, for example, average yearly fatalities have been cut from 9.5 per million aircraft miles traveled to 0.2. Airplanes are many more times safer than other modes of transport.
The unlikely parallels between child and passenger protection are described in a sometimes startling catalog of technological advances assembled by Harvard Professor of Public Health David Hemenway.
One of his themes is a potent variation on the adage “small is beautiful”: small differences in human behavior will often bring about disproportionately important advances in population health.
Hemenway calls his book While We Were Sleeping, a reference to a Grimms’ fairy tale in which a poor shoemaker is saved from penury by hard-working elves who sew while he sleeps.
The good elves of Hemenway’s own profession who toil to prevent death or serious injury, largely unnoticed by the general public, are some of the silent heroes of his lists.
He celebrates, for example, the achievement of those who in 1970 were responsible for raising the minimum age of drinking in the US from 18 to 21. Europeans may haggle about the human rights aspect of the change, but they cannot dispute the fact that, as a result of it, many young people are alive who would otherwise be dead.
A smaller number of lives – he estimates around 200 a decade, mostly children’s – are being saved as a result of a modification in the manufacture of hairdryers. Not impressed? Well, what about the 18,000 fewer injuries each decade prevented by an improvement in the design of baby walkers, or the 11,000 people a year, still breathing and driving thanks to the introduction of car seat-belts?
One may start to wonder how things might have gone for humanity had the automobile and the baby walker never gone into mass production at all, but the range of Hemenway’s spotlight is impressive nonetheless, and for prevention science, which is too often mired in complexity, the evidence in favor of simplicity is compelling.
With baby-walkers the breakthrough was making them slightly too wide to fit through a doorway leading to the stairs. Mixer taps have reduced scalds. Hockey masks have protected the face.
His discussion of the role of the law in all of this is also striking. In the UK we fret about the specter of the “Nanny State,” often forgetting what Nanny has done for us over the years.
In most of Hemenway’s examples, the law has been changed less to enforce than to permit a change in behavior. Car manufacturers wanted to put the new seat-belt technology into their vehicles, he suggests, but companies did not want to lose a competitive advantage by doing so unilaterally. Drivers, similarly, were reluctant to use the technology until others around them were doing so.
Sometimes a successful intervention can be an accidental spin-off from quite other interests. The switch to natural gas in the UK reduced the number of gas oven suicides from 2,638 in 1963 to 23 in 1975. Didn’t desperately unhappy people simply end it some other way? For the most part they did not. Suicide rates by other means stayed the same.
Hemenway has much to say about “blame culture” We should refrain from pursuing those who do wrong, and concentrate instead on understanding the environmental and social forces that produce common problems, and the potential for technological and managerial solutions.
And so to flight safety and child protection: some of the preventive components are already common to both. In-depth investigations of every accident and of “near-misses” by an independent agency, for example, which also happens to some extent in the context of serious injury to children.
But investment in the prevention of plane crashes reflects a disparity of interest: every mile traveled by an airliner results in $1.50 being invested in airline safety, meaning that the US Federal Aviation Administration has an annual budget of $14 billion.
Blame-free reporting is another crucial difference: a pilot who reports a near miss has some immunity from prosecution and will not be identified in reports. Reporting is voluntary. Expert observers often travel in the cockpit; here, too, the record is confidential and it reveals that errors are common. The information is routinely used in problem solving and in simulator training.
The climate of social work is highly punitive by comparison. It is not unusual for the pictures and names of social workers and their bosses to be featured on the front page of national newspapers. It is hardly surprising that errors are hidden, that learning from mistakes is restricted and the number of avoidable child deaths remains more or less as it did in 1950.
Hemenway’s endpoint is drawn from one of his Harvard lectures on injury prevention. The messages translate nicely to the prevention of other social ills. He concludes:
- injuries are a major public health problem
- injuries follow predictable patterns and are often preventable
- many interventions are possible; the trick is to pick the most cost-effective ones (usually modifying the product or the environment rather than trying to change human nature)
- individuals or small groups of dedicated individuals can make an enormous difference.
The last word he leaves to the to the cultural anthropologist Margaret Mead: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed it is the only thing that ever has”.
See:Hemenway D, While We Were Sleeping: Success stories in injury and violence prevention, University of California Press, Berkeley, 2009
Public health approaches seek to prevent impairments to health and development by changing the behavior or exposure to risks of a specified population. Examples include immunization programs which, if accepted by a sufficient proportion of the population, will provide protection against exposure to disease. In social contexts, the effectiveness of public health approaches often depends on people wanting to behave like other people. For example, a public health approach might seek to reduce the amount of alcohol consumed by the average drinker, on the assumption that consumption among heavier drinkers will follow suit.
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