CHAPTER 9
HEALTH PROTECTION

The American environment today contains health
hazards with the potential to kill, injure and
disable individuals and substantially affect the
health of entire communities.

Some estimates hold that perhaps 20 percent of
all premature deaths--and a vast amount of disease
and disability--could be eliminated by protecting
our people from environmental hazards.

We have seen past improvements in protection--
through better sanitation, better housing, better
water--contribute greatly to the increased life
expectancy of the Jast 80 years.

But, during this same period, rapid industrial
and technological development, social changes, and a
larger United States population, concentrated in-
creasingly in urban areas, have increased the com-
plexities of maintaining a healthy and safe physical
environment.

Nevertheless, measures are available to com-
munities to provide better health protection.

Many communities and States have begun to
develop health and safety standards to protect their
citizens. And Federal laws and Executive Branch
initiatives during the past 15 years have created an
extensive Federal regulatory effort to help them.*

* Health protection responsibilities are presently
distributed among several Federal regulatory and
research organizations: the Environmental Protec-
tion Agency; the Department of Labor's Occupational

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This chapter is concerned with five areas in
which National, State and local efforts can signifi-
cantly improve health and the quality of life for
this and future generations of Americans: toxic
agent control, occupational safety and health,
accidental injury control, fluoridation of community
water supplies, and infectious agent control.

Toxic Agent Control

Toxic factors in today's environment present
formidable challenges.

During a lifetime, people are exposed, often
unwittingly, to hazards from many sources.

Although how all of these hazards interact is
not known, for some it is known that their destruc-
tive potential can increase markedly when people are
exposed to more than one.

Exposure Sources

Many of the agents posing new threats. to
American health are chemicals developed for indus-
trial and agricultural purposes.

Safety and Health Administration; the Nuclear
Regulatory Commission; the Consumer Product Safety
Commission; the Department of Transportation's
National Highway Traffic Safety Administration; the
Department of Treasury's Bureau of Alcohol, Tobacco
and Firearms; the Department of Agriculture's Food
Safety and Quality Service; and the Department of
Health, Education and Welfare's Food and Drug
Administration, Center for Disease Control, National
Institute for Occupational Safety and Health,
National Institute of Environmental Health Sciences,
and National Cancer Institute.

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The growth of synthetic chemicals in the last 25
years has been extraordinary: more than four mil-
lion chemical compounds are now recognized; more
than 60,000 are commercially produced; about 1,000
new ones are introduced each year.

Some make their way into water and food sup-
plies. While there are now substantially fewer
dangers from contamination of drinking water by
bacteria, the dangers of contamination by oil, fuel
and organic chemicals are very real.

With the growth in use of chemicals for industry
and farming, the Nation's waterways have become
vulnerable dumping grounds for wastes from these
uses. Food supplies as well are subject to
contamination or treatment with chemicals in the
course of growth, fertilizing, harvesting,
processing and storage.

The dangers are demonstrated by recent incidents
involving Kepone, polychlorinated biphenyls (PCBs),
and polybrominated biphenyls (PBBs).

The insecticide Kepone, discharged from the
Virginia plant in which it was manufactured,
contaminated edible fish as it spread in unknown
quantities to the James River, Chesapeake Bay, and
the Atlantic Ocean. It caused serious neurologic
and reproductive effects in workers exposed to
it--and, in experimental animals, has caused cancer
as well. It is no longer manufactured.

PCBs have been produced in huge quantities for
use as plasticizers and insulation for electrical
equipment. Not until tens of millions of pounds
were produced and released into the environment was
there any realization of how toxic and persistent
these substances are.

Despite limited restrictions imposed in the

early 1970s by industry to reduce production and
use, high PCB levels continue to persist in the

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Great Lakes and other major waters across the na-
tion. In the past few years, PCBs have been found
in tissues of humans and in the milk of nursing
mothers. When fed experimentally to nursing mon-
keys, PCBs have led to serious injury of offspring.

Similarly, in 1973, the accidental mixing of the
fire retardant polybrominated biphenyl in cattle
feed resulted in contamination of food and livestock
throughout Michigan. Growth deformities occurred in
many of the cattle; thousands had to be destroyed.
The health effects on the population which consumed
contaminated food are still under study, but large
numbers of people have been found to have elevated
levels of PBB in their bodies.

Air pollution is another major source of hazard.

About 80 percent of Americans now live in urban
areas where toxic gases or particulate matter
pollute the air. Most of the pollution results from
combustion of fossil fuels by automobiles and in
industrial activities.

Four groups of air pollutants are of major
concern: sulfur oxides, including sulfur dioxide
(S09) and sulfur-containing aerosols; carbon mon-
oxide; photochemical oxidants, particularly ozone;
and nitrogen oxides such as NOo, NO and nitrite
aerosols.

Increased air pollution has been associated with
debilitating respiratory diseases such as acute and
chronic bronchitis and pneumonia, and exacerbation
of symptoms in people who already have pulmonary
disease. Of concern, too, are poisoning from lead
emitted to the air and the possibility of cancer
from pollutants such as asbestos, beryllium, ben-
zene, and other synthetic organic chemicals with
carcinogenic potential.

Chemicals can be hazardous not only during their
manufacture, formulation and use, but also during

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transportation and disposal. Community-wide expo-
sures have resulted from accidents during movement
of large volumes of chemicals across and and
waterways.

And exposure problems are exacerbated by many
community waste disposal sites containing large
quantities of unkown chemical products. Many of
these sites have been in use since the mid-1940s and
their deposits may include highly toxic materials
that can contaminate surface or ground water
supplies or the atmosphere itself.

Leakage of chemicals from the Love Canal site in
upstate New York reveals the risks to public health
from chemical wastes disposed of before the initia-
tion of regulatory controls. As chemicals began to
leak out of the land-filled canal, concern arose
about exposure for residents of homes built on the
site. More than 80 different compounds have been
identified, 11 of them known or suspected carcino-
gens. There has been a significantly higher rate of
spontaneous abortions among exposed women. An asso-
ciation with congenital abnormalities is also
suspected.

Several thousand such disposal sites exist
throughout the country and close monitoring is
needed to safeguard against harmful exposures.

Radiation is another environmental source of
human illness. About half of all ionizing radiation
to which the general population jis exposed comes
from naturally occurring radioactive materials in
the water, soil and air. Another 45 percent is from
medical and dental use of x-rays and from radioac-
tive materials used for diagnosis and treatment.
The remaining five percent comes from fallout,
industrial uses, production of nuclear power, and
consumer products.

Ionizing radiation from nuclear energy and me-
dical diagnosis and treatment can, if there is expo-
Sure to large enough doses, cause cancer, genetic
defects, and tissue injury. The entire population
is also at potential risk as the cumulative dose of
exposure to low-level ionizing radiation grows.
Non-ionizing radiation, such as from ultraviolet
rays and microwaves, carries lesser risk with single
exposure, but the possibility of harmful effects is
increased because total potential exposure is large.

Health Effects

It takes at least 20 years to determine full
effects of many new compounds on human health--and
health problems caused by some compounds in use
today may not be known until the 21st century.

But it is clear that toxic compounds can have
diverse, serious effects. They are capable of
producing reproductive and developmental impair-
ments, mutagenesis, cancer, chronic degenerative
diseases, neurologic and behavioral impairments, and
immunologic diseases.

Evidence for such capability comes from the
experience of occupational groups exposed to greater
chemical or physical hazards than those to which the
general population is exposed. If high exposure
causes serious disease, the same ill effects may
occur in people exposed to much lower doses over a
long period. For example, a single intense exposure
to nuclear radiation produced very high rates of
certain cancers and other illnesses among the
populations of Hiroshima and Nagasaki, but radiation
in much smaller doses also causes cancer over time
in susceptible individuals.

Because successful reproduction and development
are essential to healthy propagation of the species,
agents that affect reproductive capacity or fetal
development are of concern. Recent data show, for
example, that men exposed to toxic agricultural
chemicals such as Kepone and dibromochloropropane
are at greater risk for impotence and infertility.
In addition, more than 20 agents are known to be
associated with human birth defects and many times
that number cause birth defects in laboratory
animals.

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Of possibly even greater concern is the poten-
tial occurrence of mutations from exposure to envi-
ronmental agents. A mutation--a change in the
genetic material of a cell--can alter biologic
development. If a mutation involves non-sex cells
or is so drastic as to be lethal, effects are
confined to a single generation. But if the
mutation involves egg or sperm cells of either
parents or fetus, the effects can be passed along
indefinitely from generation to generation.

Probably the most widely discussed effect of
hazardous substances is cancer. Statements that up
to 90 percent of human cancers are due to environ-
mental factors have received much attention but
these estimates include as environmental sources
such factors as diet, alcohol, and cigarette smoking.

Nevertheless, there are substantial threats from
chemicals and radiation. The National Cancer
Institute currently lists at least 20 chemicals and
compounds for which there is epidemiological evi-
dence of human cancer causation. Among them are
asbestos, benzene, vinyl] chloride, and arsenic. In
addition, over 2,300 specific chemicals are sus-
pected carcinogens, including some insecticides,
herbicides, asphalt fumes, wood dust, and coal tar
volatiles. They are believed to work through varied
mechanisms.

Some produce mutations in the genetic material
of cells which then reproduce unchecked; others may
suppress the immune mechanism which usually destroys
tumor cells; and others may stimulate the prolifera-
tion of tumor cells themselves. More than one mech-
anism may work at one time; the effects of exposure
to single agents may be additive; and concurrent
exposure to multiple agents may be more hazardous
than the sum of the individual exposures.

In addition to cancer, environmental agents can
cause other degenerative diseases, including arte-
riosclerosis, heart disease, hypertension, emphy-
sema, chronic bronchitis, kidney disease, liver
disease, diabetes, anemia, neurologic and behavioral
disorders, and immunologic diseases.

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There is virtually no major chronic disease to
which environmental factors do not contribute,
directly or indirectly. Some of the most striking
effects noted to date have been the neurologic and
behavioral problems of workers exposed to certain
pesticides, organic solvents, and inorganic metals.

Detection and Control

Protection against toxic environmental agents
depends upon reliable methods of identifying hazards
to health. Clinical and epidemiologic research has
helped recognize harmful substances by finding
unusually high rates of disease occurrence in
certain population groups with unique exposure
histories.

But disease generally occurs after a long latent
period during which large numbers of people may be
exposed to what will turn out to be the hazardous
agent. Methods are needed to demonstrate biologic
changes with potential for leading to disease--
before disease actually occurs.

Animal studies provide one such method. With
one or two possible exceptions, all agents known to
produce human cancer also produce cancer in exper i-
mental animals. There is a popular misconception
that under laboratory conditions any compound can
cause cancer in animals. A study conducted for the
National Cancer Institute found, however, that fewer
than 10 percent of 120 common pesticides caused more
tumors than expected when fed continuously to mice
in high doses for 18 months, beginning in infancy.

Actually, animal studies have more often proved
prophetic than not. That estrogen replacement
therapy for women would increase risk of uterine
and, possibly, breast cancer was predicted accur-
ately by studies on several species of animals in
the 1930s. Studies on quail in 1964 showed that
Kepone could cause reproductive failure and nervous
system disease. And studies on rats indicated that
vinyl chloride gas would prove to be carcinogenic in
the industrial setting.

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A principal drawback to current animal testing
procedures is the time and expense they require. A
complete animal test of any suspected substance can
take upwards of three years and cost several hundred
thousand dollars. Several billion dollars would be
needed to fully test the backlog of organic chem-
icals now in the environment but still untested.

Fortunately, encouraging progress is being made
in developing rapid, Jess expensive tests for
carcinogenicity and mutagenicity. Such approaches
are designed to observe the short-term effects of
toxic agents at the cellular or biochemical level.

They include tests for mutagenesis in mammalian
cells, insects, and microorganisms; identification
of any damage to or repair of DNA; malignant
transformation of cells in culture; and chemical
reactivity of activated substances. The rapid
procedures can be used to screen large numbers of
suspected toxic agents to determine which to subject
to more intensive animal studies.

When it comes to implementing measures to
improve the quality of the environment, the chal-
lenge falls to all sectors of our society--indi-
viduals, health professionals, private industry,
community groups, and government.

At the Federal level, several departments and
agencies, noted earlier, conduct programs to iden-
tify, monitor, evaluate, and control harmful
environmental contaminants.

Although these programs appear to have broad
public support, their economic and technological
impact can be substantial, and they are an in-
creasingly common subject of debate inside and
outside government.

Nevertheless, it is clear that the Federal
government must continue to bear major responsi-
bility for setting and enforcing pollution standards
and for dealing with health risks related to
environmental contamination. A strong emphasis on

9-9
refinement of tests which can help’ identify
potential new hazards is especially important.

State and municipal governments can _ reduce
environmental hazards by monitoring the safety of
air and drinking water; controlling use of ionizing
radiation; providing adequate sewage disposal;
requiring auto safety and emission inspections; and
regulating the use of pesticides and other agricul-
tural chemicals.

At the local level, individuals, community
groups, and government agencies, including public
health departments and health planning bodies
(health systems agencies), can identify health
hazards unique to a particular community. Easily
observable effects on chronic diseases may. on
occasion be detected by community surveillance.
Local education programs can help inform people
about the hazards of toxic agents in the environment
and how to protect themselves against them.

Although some significant environmental reforms
have been achieved in recent years and the Nation's
air and water are cleaner, environmental programs
are frequently challenged and need stronger support.

Part of the problem in controlling environmental
hazards is that they are produced as individuals or
industries pursue diverse activities which have
become parts of our daily lives. The automobile,
electric power generation, plastics manufacture, and
construction are all integral parts of present
lifestyles and the economy--and all pose health and
safety hazards.

The challenge is to reduce the hazards without
undue sacrifice. But some changes in lifestyle may
be necessary. Reduced use of automobiles is one.
Eliminating waste in the use of energy is another.
Reducing consumer demand is a third, and recycling
is a fourth.

Because of the strength of competing interests,
health does not always emerge as the top priority.

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But achievements of the past few years indicate
that, notwithstanding obstacles, environmental
Changes can produce substantial health benefits.

Occupational Safety and Health

There are more than 97 million American
workers--many of them exposed to some kind of
occupational health hazard: carcinogenic agents,
pulmonary or other physical disease incitant, or
job-related pressures of noise, crowding, stress or
boredom which can have adverse psychological effects.

Each year 100,000 Americans die from occupa-
tional illnesses and almost 400,000 new cases of
occupational disease are recognized, according to
National Institute for Occupational Safety and
Health estimates. And the actual extent of occupa-
tional disease is probably much greater because the
link between job and disease is often unrecognized
or unreported.

Occupational exposures to toxic chemicals--as
well as such physical hazards as excessive noise,
radiation, sunlight and vibration--can produce
chronic Jung disease, cancer, degenerative disease
in a number of vital organ systems, birth defects,
and genetic changes that may be transmitted to
future generations. Some hazards also increase
frequency of stillbirths, spontaneous abortions,
reduced fertility, and sterility.

These health effects are often linked with par-
ticular jobs. For example, workers engaged in
manufacturing the pesticide dibromochloropropane
have experienced an infertility rate twice to three
times as great as for the general population.
Examples of job exposure to carcinogens are noted in
Chapter 6. Of nearly 34,000 chemicals in the work-
place which have reported toxic effects, over 2,000
have been reported to be potential human carcinogens.

Yet, despite risks of serious disease or injury,
most workers are unprotected. Worksite exposure
standards have been established for only a few toxic
substances.
Nine of every 10 American industrial workers are
not adequately protected from exposure to at least
one of the 163 most common hazardous’ industrial
chemicals, according to a recent occupational hazard
survey.

And now under careful review is a recent esti-
mate that, if the full consequences of both present
and recent past occupational exposures are taken
into account, perhaps 20 percent of all cancers may
be related to carcinogens encountered in_ the
workplace.

Not all occupational hazards are found in
factories or exposure to toxic substances.
Work-related injuries kil? about 13,000 Americans
each year and affect nine million more so severely
that they require medical care or are at least
temporarily unable to work.

People in mining, agriculture (including
forestry and fishing), and construction are six,
three, and three times respectively, more likely to
die from a work-related injury than other private
sector workers. And work-related problems are
reported by a wide variety of employee groups,
including medical technicians, cosmetologists,
flight attendants, dentists, air traffic  con-
trollers, and many others.

Health Protection Measures

Occupational hazards can be controlled by
modifying work environments, patterns of job
performance, or both.

Altering the work environment--plant, processes,
materials used--is the most effective. © Protection
against hazards can be facilitated by requiring
appropriate engineering controls, particularly as
new plants are built.

For success, prevention strategies must rely

heavily on employer efforts and support from
employees, unions, and government regulatory bodies.

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Worker protection may also require special pro-
tective equipment when other means are unavailable--
and careful monitoring of workers exposed to hazards
in order to ensure that safety controls are effec-
tive. Sometimes, however, conditions and circum-
stances hamper efforts to protect workers. Personal
protective equipment, for example, often is uncom-
fortable and encumbering.

Effective protection also depends on the design
and maintenance of equipment and proper training of
employees.

It must be recognized that higher pay for
hazardous jobs may lead employees to choose imme-
diate financial benefit over long-term safety and
health protection. And the concentration of indus-
tries with hazardous conditions in certain geogra-
phic areas, or their location in otherwise economic-
ally depressed communities, or their presence as the
only industry in a community gives workers, in
effect, no opportunity to choose a safer job.

Furthermore, development of hazard control tech-
nology has lagged behind the growth in industrial
use of hazardous chemicals and sources of physical
energy such as microwaves, nuclear energy, lasers,
and ultrasound.

Even when controls are available, there are few
incentives for employers to install or maintain
them. Positive incentives that could be provided
include low-cost loans, tax benefits, and technical
assistance. Regulation is a negative incentive but
occupational safety standards, important to preserv-
ing the health of millions of workers, should be
strongly and consistently enforced.

It was recognition of the increasingly compel-
ling importance of assuring worker protection that
led to passage in 1970 of the Occupational Safety
and Health Act.

The Act established the Occupational Safety and
Health Administration (OSHA) in the Department of

9-13
Labor, with responsibility for mandating and
enforcing health and safety standards for the
workplace and for educating workers about potential
hazards. Scientific support for the Administra-
tion's work is provided by the Department of Health,
Education and Welfare's National Institute for
Occupational Safety and Health.

Pressures on OSHA are often conflicting, with
some groups urging fewer and less restrictive stan-
dards and others requesting faster and more aggres-
sive action. Clearly, enforcement of the Act,
especially for workers facing significant health
hazards--asbestos workers, textile workers, chemical
workers, and many others--deserves high national
priority.

Health Promotion Measures

Many firms and some government agencies have
taken steps to provide worksite programs for
promoting health through health education, physical
fitness activities, and preventive medicine. Some
provide screening for hypertension, high blood
cholesterol, and heart disease. Some conduct or
refer employees to groups to help them stop smoking
or lose weight.

Encouraging results have come from a number of
programs, and indicate the utility of establishing
these programs for employees from the assembly line
to the executive suite.

Some companies have become concerned about
stress in and out of the workplace and are insti-
tuting measures to help employees deal with its
adverse effects. Training in meditation and other
relaxation techniques, and seminars on how to cope
with stress at home and at work are examples of
measures provided by some companies. Many employ
company psychologists or psychiatrists, or pay for
such services outside the firm. The extent to which
such efforts actually reduce stress is still under
study.

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Beyond helping employees handle the pressures of
work, a few firms try to modify the nature of the
work. Some redesign jobs and organizational struc-
tures to try to make jobs more meaningful and ful-
filling. For example, instead of assembly lines
which require each worker to deal with smaller and
smaller elements of a whole, some employers allow
workers to assemble entire products.

Among other experimental measures showing
promise are programs that allow workers to work in
small face-to-face groups with a good deal of
autonomy. The groups may be responsible for a given
level of output but decide among themselves how to
accomplish their goal, including deciding which
hours to work. Supervisors concentrate less on
giving detailed orders and more on making sure the
groups have the resources they need.

Although they do not solve every problem of
occupational stress, such measures have the
potential to decrease job dissatisfaction and its
costly consequences--absenteeism, employee turnover,
alcoholism, waste of materials, sabotage, and plant
Shut downs-- and presumably thereby increase
productivity.

Gaps and Needs

Despite increasing research into occupational
safety and health, many gaps exist.

Inadequate data make it difficult to determine
accurately the extent of occupational health
problems and to measure the effectiveness of
prevention efforts.

Because of long latency periods before disease
develops, knowledge is lacking about the risks of
the approximately 1,000 new chemicals introduced
each year and how they may interact.

One problem in collecting statistical data about
occupational exposures jis the variety of ways in
which people come in contact with hazardous
agents--by ingestion, inhalation, skin contact, or
some combination of these.

Another problem is Jack of recorded information
about the intensity, duration and combinations of
exposures.

The difficulties are compounded by concerns for
confidentiality--of employers over trade secrets,
and of workers and occupational physicians over
personal health records. Often, too, workers are
not told the names, particularly the common names,
of chemicals with which they work or simply do not
know of toxic substances to which they are or were
exposed. And when they do know, they may prefer to
face possible health risks rather than the prospects
of job loss.

Among critical areas that need study are the
role of occupational exposures in producing birth
defects and the special problems of women exposed to
hazardous substances. Others include: occupational
causes of respiratory disease, alone or in combina-
tion with smoking; the role of job stress and expo-
sure to physical and chemical agents in cardiovas-
cular disease; and the behavioral changes induced by
chronic exposure to low levels of chemicals; the
health effects of occupational exposure to such
physical agents as heat and radiation and _ the
interaction between these and chemical agents; and
methods for analyzing thresholds of exposures to
hazardous workplace conditions.

Finally, we need to learn what combinations of
regulations and incentives work best to bring about
changes in both employer and employee attitudes and
practices to reduce known occupational risks.

That the work environment can play a major role
in compromising health has been known for many
decades. It is time now for substantially increased
efforts to contro? known hazards, treat those
afflicted, and develop techniques to identify and
prevent harm from materials and processes not now
recognized as dangerous.

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It is time, too, to act on the recognition that
the workplace not only should not contribute to
physical or mental disease, but is also a legitimate
and highly useful place for promoting health.

Accidental Injury Control

More than 100,000 Americans Jost their lives to
injuries in 1977--nearly half of them from motor
vehicle accidents, the rest from falls, burns,
poisonings and other causes. In 1977, too, 65
million people suffered non-fatal accidental
injuries, requiring medical treatment--and in terms
of damage, injury and lost productivity, the
estimated cost of accidents in 1977 was $62 billion.

The leading cause of death beween ages one and
44, accidents account for roughly 50 percent of
fatalities for those 15 to 24. But the highest
death rate for accidents occurs among the elderly
whose risk of fatal injury is nearly double that of
adolescents and young adults.

Educational approaches advocating changes in
behavior have been generally ineffective in pre-
venting accidents among those at highest risk~- young
children, teenage males, problem drinkers, and the
elderly.

More effective measures involve changing the
manmade environment to reduce risk for those unable
to take adequate precautions. Such efforts are
certainly not unprecedented. Examples include
insulated tools, childproof medication containers,
lead-free paints, and automobile airbags.

Motor Vehicle Accidents
Highway accidents in 1977 killed 49,000 people
and led to 1,800,000 disabling injuries. The total
cost, as estimated by the Department of Transporta-
tion was more than $43 billion.

Teenagers and young adults--the 15 to 24 year
olds--have the highest motor vehicle death rate of

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any group, accounting for one-third of all motor
vehicle deaths.

Like many other types of accidents, motor
vehicle crashes traditionally have been blamed on
human error, and prevention strategies have con-
sisted primarily of driver education programs. But
more recently, injury control experts have identi-
fied a range of factors in vehicle collisions which
occur with imbalances between the demand of the
highway system, the characteristics of individual
vehicles, and the age and other characteristics of
the driver.

Moreover, it appears that injuries often can be
prevented or reduced even when collisions occur. A
number of preventive strategies emerge--some aimed
at preventing collision, others at minimizing their
consequences,

Many collisions obviously can be prevented by
reducing vehicle numbers and miles traveled by auto-
mobile through encouraging people to travel by air,
rail or bus--all safer modes of transportation.

Similarly, lower speed limits, if observed,
would reduce both the number and severity of
crashes--and, for several years after it was imposed
in 1974, the national 55 mph speed limit saved an
estimated 4,000 to 5,000 lives each year.

The greatest risk factor for fatal accidents is
driver alcohol use. In about 50 percent of drivers
involved in fatal crashes, blood alcohol levels have
been found to be excessive. Although driver
education and strict penalties such as mandatory
license suspension have the potential to reduce
alcohol-related accidents, those measures have not
been very effective to date. Clearly important are
the general preventive measures to reduce problem
drinking discussed in Chapter 10.

Vehicle design is another major factor in high-

way injury and death. To reduce crash impact on
driver and passengers, automobile bumpers, front

9-18
ends, and steering columns can be designed to absorb
energy. Passenger compartments can be better de-
signed to withstand accidents, with protruding knobs
and handles eliminated and hard surfaces padded.
Although some of these design features have been
adopted, most cars are not designed to fully protect
occupants from injury in crashes that occur at legal
let alone high speeds.

Combined Jap and shoulder belts can almost halve
the likelihood of serious injury or death, and
although al] passenger vehicles sold in the United
States are equipped with seat belts, fewer than 20
percent of drivers use them.

Current Federal law requires that by 1983 a1]
new cars contain devices that automatically protect
front seat Passengers in frontal collisions. The
devices--such as airbags and belts that are auto-
matically positioned when the car door is closed--
Promise substantial protection. The National
Highway Traffic Safety Administration recently
reported a fatality rate for one type of car
equipped with automatic belts only half that for the
Same type equipped with conventional safety belts.

If no child died in an automobile accident, the
death rate for children could be reduced by fully
one-fifth. Now, about 1,000 youngsters under age
five die, and more than 50,000 suffer serious injury
each year.

A number of devices specially designed for
children provide the best protection. Their use
Should begin with a newborn's trip home from the
hospital. In the absence of the special restraints,
adult seat belts are better than nothing. Beyond
reducing risk of serious injury or death, use of
restraints may help ensure that children acquire a
lifelong habit of wearing protection.

Yet--in the face of evidence showing their
effectiveness--a 1974 survey by the Insurance
Institute for Highway Safety found proper restraints
in use for only seven percent of almost 9,000
Passengers under age 10.

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Because efforts to convince most people to use
child restraints have not been successful, it is
important that passive protection devices be devel-
oped with children in mind.

An additional action is suggested by the success
that changing school hours to non-rush hours has had
in some European countries in helping to reduce
automobile-related deaths for children.

The motorcycle helmet has proved to be the most
effective device for protecting riders from death or
serious injury in a collision. Riders using safety
helmets have less than half as many moderate to
severe head injuries and three to nine times fewer
fatal head injuries.

Although helmets are worn 90 to 99 percent of
the time in States which require them, they are used
Tess than 60 percent of the time in States which
have repealed such laws.

Motorcyclists often contend that helmet laws
infringe on personal Jliberties--and opponents of
mandatory laws argue that since other people usually
are not endangered, the individual motorcyclist
should be allowed personal responsibility for risk.

But the high costs of disabling and fatal
injuries, the burdens on families, and the demands
on medical care resources are borne by society as a
whole. And society has a legitimate concern for
protecting the individual.

In Colorado, Kansas and South Dakota--states for
which pre- and post-repeal crash data are avail-
able--head injuries rose and fatal head injuries
doubled after helmet laws were repealed.

The interstate highway system has achieved a
halving of death rates compared to all other roads
by eliminating crash-precipitating features such as
sharp curves, steep grades, blind intersections,
uncontrolled access, and lack of physical separation
between opposing traffic lanes.

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Other measures for preventing death and injury
include removing fixed objects or shielding such
structures as bridge abutments with ener gy-absorbing
barriers, locating essential signs and poles at
sufficient distance from traffic, and designing
guardrails to guide vehicles away from hazards.

The importance of these measures is underlined
by the fact that almost half of all motor vehicle
deaths involve only one vehicle.

Firearms

Second only to motor vehicles as a cause of
fatal injury, firearms in 1977 claimed some 32,000
lives. About 13,000 deaths were homicides; 2,000
resulted from firearm accidents; 16,000 people took
their own lives with firearms; the remaining 1,000
deaths were of undetermined cause. Estimates of
non-fatal firearm injuries--many of them permanently
disabling--range from 18,000 to more than 100,000.

Although homicides committed with firearms have
recently declined after a 10-year period during
which the rate doubled, FBI statistics show that in
1976 firearms were used in about 63 percent of
homicides, almost half of which were committed with
handguns.

Meanwhile, firearm suicides have risen, increas-
ing by 25 percent between 1970 and 1976, while sui-
cides by other methods increased three percent.

Measures that could reduce risk of firearm
deaths and injuries range from encouraging safer
storage and use to a ban on private ownership.

Evidence from England suggests that prohibiting
possession of handguns would reduce the number of
deaths and injuries, particularly those unrelated to
criminal assaults. Both assaults and suicide
attempts are less likely to be fatal without
firearms--and firearm accidents would decrease.

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About 20 percent of American households contain
a handgun. Even if reducing handgun availability
did not substantially reduce the number of murders
committed during violent crimes, it would likely
reduce both accidental deaths and murders of passion
involving family members and acquaintances.

For those who feel compelled to keep handguns,
certain safety measures can be useful--security
locks, use of non-lethal (wax) bullets, and weapon
storage in a location separate from ammunition and
inaccessible to children.

Falls

Fifteen thousand Americans are killed and about
14 million are injured each year by falls.

Fatal falls occur primarily in the home but are
also. a prominent cause of work-injury deaths,
especially among construction workers. People over
age 75 account for about 60 percent of the deaths
resulting from falls and an even greater proportion
of the hospital days and disability.

Preventing such deaths and injuries requires
preventing the falls themselves by attention to
safer walking surfaces and footgear, better illu-
mination, handrails, and window guards--or reducing
the potential for injury by minimizing the distances
people fall (lower beds for the elderly) or modi-
fying the surfaces they fall against (softer floors,
rounded edges and corners on furniture).

Substantial reductions in injuries from falls
can be achieved through elementary and inexpensive
changes in housing and furniture design.

Burns

Each year more than a million Americans are
burned, 60,000 severely enough to require hospitali-
zation. About 5,000 deaths result from fires--pre-
dominantly house fires--and an additional 2,500 are
from other burns such as electrical and scalds.

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Fifty-six percent of fatal residential fires--
and a substantial number of burn injuries--are
Cigarette-related, often due to smoking in bed.
Even in the non-fatal incidents, the consequences
are often tragic: painful recovery, disfigurement,
and disability.

Many deaths and injuries from residential fires
could be prevented through a number of measures:
effective fire or smoke detection systems; less
flammable furnishings and structural materials;
buildings designed for ease of escape; developing
and practicing fire evacuation procedures; and Jess
smoking.

Deaths and injuries from ignited clothing have
been greatly reduced in the past decade, partly
through changes in fabrics and styles, but the
problem still warrants attention. Other preventive
measures are available but seldom used: matches
that burn with less heat and go out when dropped,
and fabrics whose weave, finish, composition or
chemical treatment makes them less likely to ignite,
melt or burn.

Scalds which cause about 40 percent of hospital
admissions for burns, often occur in showers and
bathtubs. They could be prevented if water heaters
in homes, nursing homes, dormitories, and hotels
were modified with automated cut-offs so water
temperatures remain below those likely to scald.

A recent study for the Consumer Product Safety
Commission indicates that this approach, even though
it requires larger hot water storage facilities,
saves both money and energy.

Poisoning

Once a leading cause of death for young
children, poisoning has decreased significantly as
paint lead content has been reduced and drugs and
household products have been packaged in childproof
containers.

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Of 4,000 fatal poisonings in 1977, less than one
percent involved children under five. Even as the
number of children increased between 1968 and 1976,
childhood deaths from poisoning dropped from 284 in
1968 to 105 in 1976.

Still, some two million ingestions of poten-
tially dangerous substances by American children
come to the attention of health professionals every
year.

Poison Control Centers, now active in a number
of localities, provide immediate information on
poison antidotes and other emergency measures.
Helpful precautionary measures include storing toxic
substances separately from food supplies, ensuring
that safety caps are fastened, and refraining from
introducing medicine to children as "candy."

Currently, treatment of lead poisoning makes use
of chemicals that bind to the metal in the body and
help in its removal.

But more important is primary prevention of
potentially lethal lead poisoning by removal of
airborne lead from the environment and rehabili-
tation of old housing with lead-free paint. Public
health screening of high-risk children is important
to prevention of adverse health effects, since lead
poisoning is usually asymptomatic.

Drug Reactions

Some 70,000 prescription drugs (with 2,000
individual ingredients) are now on the market, along
with 200,000 over-the-counter preparations. Each
year 15 to 20 new chemical entities are introduced.
In 1977, 1.4 billion prescriptions were filled at a
cost of about $8 billion.

Adverse reactions--ranging from moderate rashes
or nausea to birth defects or death--can occur with
almost any drug. For some drugs, reactions are
frequent enough to warrant warning labels.

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The potential for adverse reactions, coupled
with the volume and frequency of drug use, requires
the Food and Drug Administration to oversee regular
premarket screening and testing for user protection.

Product-Related Accidents

A broad range of consumer products used at home
or in the workplace can cause injury, either because
of faulty construction or inappropriate and careless
use,

In 1976, product-related accidents caused about
30,000 deaths and 37 million injuries, according to
Consumer Product Safety Commission estimates.

Among the leading causes of injuries were glass,
bicycles, skateboards, nails, knives, playground
equipment, furniture, and construction and flooring
materials.

Measures to reduce injuries and deaths can start
with product design and engineering standards--and
the education of those developing the designs and
Standards. They can include improved construction
and packaging; testing and development of protective
devices; inspection procedures to ensure safety
prior to marketing or operation; and better
instruction of operators of machinery as well as
more complete and clear information provided for
consumers and users.

Because unsafe toys, electrical devices, and
home swimming pools injure many chidren, toys with
sharp edges or small and swallowable parts should be
discarded, electrical outlets should be covered, and
swimming pools fenced.

Increased protection for children requires
better surveillance of injuries so their causes can
be clearly understood and preventive measures
applied. It also requires teaching safe behavior
and providing barriers that separate children from
as many hazards as possible.

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Recreational Accidents

The population at risk for recreational acci-
dents has grown steadily as the amount of leisure
time available to Americans has increased.

According to the National Safety Council, acci-
dents other than motor vehicle, work and home acci-
dents caused approximately 21,500 deaths in 1976,
with most occurring in recreational or leisure
settings.

Disabling injuries in that year numbered some
2,700,000 and about 100,000 sports team injuries
were serious enough to require medical attention.
Some 7,000 drownings also occur each year, mostly
during water sports such as swimming and boating.

Safety measures can help. Children can be
taught to float and swim at early age and should
learn water safety measures. Adults can avoid water
sports when intoxicated (in almost one-third of
adult drownings, there are high blood levels of
alcohol). Young people participating in team sports
can be taught safety measures and ways to prevent
injuries as part of their training. Better protec-
tive equipment can be developed. Football helmets,
for example, which caused 12 percent of all injuries
sustained by 9,000 high school players, should be
designed to reduce injuries to other players.

Modification of surroundings can help in some
cases. Again, in football it is estimated that
seven percent of hospitalized players are injured as
the result of striking a fixed obstacle outside the
playing field and that 95 percent of such injuries
could be prevented by establishing an obstacle-free
zone around the playing field.

Much can be done to prevent unnecessary injuries
annually suffered by Americans.

Fluoridation of Community Water Supplies

With tooth decay affecting 95 percent of
Americans, it is the most common health problem,

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costing an estimated $2 billion yearly for treat-
ment. Adverse consequences include pain, infection
and tooth loss.

Fluoridation is one of the most effective--and
cost-effective--preventive measures known. By
making teeth less susceptible to decay through
increasing resistance to the action of bacteria-
produced acid (it may have an antibacterial effect
as well), optimal level fluoridation of drinking
water can prevent 65 percent of decay that would
otherwise occur. And it can do so for 10 tc 40
cents per person per year, depending upon the size
of the community.

Currently, less than half of Americans have
access to fluoridated water. About a third are
served by fluoride-deficient community water sys-
tems. An additional 35 to 40 million are on indi-
vidual (noncommunal) water systems with undetermined
fluoride content.

Where community water supplies are not fluori-
dated or where there is no central source of
drinking water, as in many rural areas, other means
may be used. In some localities, school drinking
water is fluoridated--a help in reducing decay but
less effective than community-wide fluoridation
since it does not reach pre-school children and is
not available to any child when school is not in
session.

Fluoride mouth rinses are effective but require
regular, continued use for maximum benefits. In
carefully controlled clinical studies, fluoride
rinsing has produced 35 percent decay reduction.

If dietary fluoride supplements are given
conscientiously from birth on a daily basis, the
protection against decay approaches that of water
fluoridation.

Fluoride applied directly to teeth twice a year
by a dental professional in a_ school program or
dentist's office also is effective as is daily use
of an appropriately formulated fluoride toothpaste.

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But none of these approaches is as effective or
economical as fluoridated drinking water.

Part of the delay in fluoridation of community
water supplies stems from concerns of some groups
that it may pose a hazard to health. But substan-
tial research over the past 35 years has produced no
evidence to support this concern.

It is important that every community ensure pro-
vision of fluoridated drinking water for its
citizens.

Infectious Agent Control

 

Some 291 million illnesses from infectious
disease occurred in the United States in 1975--more
than one for every person. Because of them, each
year at least 156 million work days are lost and the
cost for treatment and lost productivity is esti-
mated at $24 billion annually.

In a typical year, the Center for Disease
Control investigates, upon request, about 1,700
outbreaks of infectious diseases throughout the
country.

Most of the deaths and illnesses related to
infectious diseases are due to the viral, bacterial
and other microbial agents of influenza, pneumonia,
the common cold, urinary tract infections, gastro-
enteritis, hepatitis, childhood infectious diseases,
sexually transmissible diseases, tuberculosis, and
hospital-acquired infections.

There has been substantial success, as noted
earlier, in minimizing the infectious diseases as
threats to life. In 1977, only influenza and
pneumonia together continued to rank as one of the
10 leading causes of death.

But new diseases appear and even familiar

diseases may change periodically, making existing
protective measures ineffective.

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Legionnaires’ disease is an example of a newly
identified infection. The emergence of strains of
gonococcal bacteria resistant to penicillin, and the
periodic shifts in strains and virulence of influ-
enza viruses, are examples of changes in familiar
diseases,

These changes demand close monitoring and sur-
veillance of infectious disease incidence.

Surveillance--a basic tactic for disease con-
trol--requires four activities.

e finding cases of disease or significant
exposures through the efforts of physicians
and other health workers;

e reporting cases to a responsible health
authority, generally a public health offi-
Cial--traditionally done by physicians, but
now also done by schools and industries;

e analyzing and interpreting the reported
information to determine its implications;
and

e responding appropriately to the interpreted
information with measures to control the
source of the problem.

Examples of response measures include an immunj-
zation campaign in the face of a polio outbreak,
closing a restaurant found to be serving contami-
nated food, and providing substitute water Supplies
until a polluted source can be purified.

Today, about five percent of all patients
admitted to hospitals acquire an infection while
there, incurring an added $1 billion in treatment
Charges. It is anticipated that Stronger surveil-
lance and control techniques now available can
reduce incidence of these infections by 20 percent.

The United States has the most sophisticated
infectious disease surveillance system in the

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world--and it is possible to target surveillance for
many conditions--infectious and non- infectious--that
are either preventable or amenable to effective
intervention.

KKKKKKKKKE

In a broad prevention strategy, the concept of
health protection must extend beyond traditional
disease control measures to include protection
against environmental and occupational hazards and
reduction of accidental injuries.

These hazards are threats to all Americans,
regardless of age, health status, or socioeconomic
factors.

Yet many accidents can be prevented, toxic
agents can be reduced, occupational safety and
health programs can be implemented, community water
supplies can be readily fluoridated, and infectious
diseases can be effectively controlled and in some
cases eliminated.

A commitment to safety and elimination of
hazards--by everyone from government officials to
parents to children--would save millions of Ameri-
cans from needless pain and disability.

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