Day 1 (May 28, 2003)
Dan Hungerford: It is my distinct pleasure to introduce Dr. Jeffrey Runge, the administrator of the National Highway Traffic Safety Administration (NHTSA). He will talk about some of the primary issues that we will be addressing in the conference. Dr. Runge is an emergency physician and an educator whose research has focused on injury prevention and control, with particular emphasis on injuries sustained in motor vehicle crashes. Before becoming the NHTSA administrator, he served on the faculty of the Emergency Medicine Residency at the Carolinas Medical Center in Charlotte, North Carolina.
Jeffrey W. Runge, MD, NHTSA Administrator: Good morning. It’s nice to see so many choir members here today. I want to welcome all of you. Let me begin by giving you a little history about myself and why I’m standing here. In August 2001, I was nominated by President Bush and confirmed by the Senate to be the 12th administrator of the National Highway Safety Administration. This agency has a long history of being headed by physicians. Our first administrator, Dr. Bill Haddon, now deceased, was former commissioner of the Department of Public Health in New York State. He was tapped by Congress to head the national Traffic Safety Bureau in 1966, when traffic deaths were 55,000 per year and the rate of motor vehicle fatalities was 5.5 per 100 million vehicle miles traveled. This was a national epidemic that had gotten very little attention before the advent of the Traffic Safety Bureau. One of the things that changed my life as a young practitioner in the early 1980s was reading Dr. Haddon’s seminal article on injury as a treatable disease. I know many of you have read the article and many of you knew Dr. Haddon personally. His influence lives on. We still believe in Haddon’s matrix approach to injury control with the preevent, event, and postevent phases of the host, agent, and environment interaction. Therefore, we use countermeasures in crash avoidance, crashworthiness, and emergency medical systems and trauma systems in the aftermath of the injury. We deal with the entire range of human factors, vehicle factors, and environmental factors. This is a time-tested methodology that works very well, and I’m committed to it. Thus, today you find yourselves in the “precrash host” cell of the Haddon Matrix—that is, attempting to positively influence the precrash behavior of the driver by studying and addressing alcohol problems.
When I came to the first of these meetings that Dan organized in this city in March 2001, I spoke on behalf of myself and my colleagues in emergency medicine and about our work on a screening and intervention project. I’m in different shoes today. Now I speak for my bosses—President Bush and Secretary Mineta. As I look around the room, I see a lot of public servants and civil servants who feel very passionately about safety as the primary reason for their life’s work. This dedication comes from the top. President Bush says that the safety and security of the American people is his number one priority, and Secretary Mineta, my immediate boss, reminds us that safety is a number one priority of the U.S. Department of Transportation (DOT). Why? Because motor vehicle crash injuries are the leading cause of death in Americans aged 1 to 34. Thus, we must believe, as Secretary Mineta does, that the safety and security of the American people begins with traffic injury control.
If we look at the Centers for Disease Control and Prevention’s Web-based Injury Statistics Query and Reporting System (WISQARS) regarding the 10 leading causes of death in the United States in the year 2000, injury is shown to be the leading cause of death for every age group from 1 to 34 years old.* In 2002, it’s even worse. In fact, if you separate motor vehicle crash injury from unintentional injury, motor vehicle crash injury would have the same top position. This is an epidemic. However, it’s an epidemic with a cure. At the kick-off press event for our national “Click It or Ticket” campaign, Secretary Mineta, appearing with Dr. Richard Carmona, one of our colleagues who is now surgeon general, made a very important policy statement. Secretary Mineta reminded everyone that the events of 9/11 changed the entire focus of the DOT. Aviation safety became paramount. In fact, our department responded by setting up the Transportation Security Administration in just 12 months, meeting all 35 congressional mandates on time. At our press event, Secretary Mineta stated, “We’re done with that.” The Transportation Security Administration is now a part of Homeland Security. Now, we can focus on highway safety with the same vigilance that allowed us to set up a 6,000-person agency. Secretary Mineta is very serious about highway safety, and you will see an unprecedented focus from the federal government on this issue. Many of you represent other federal agencies. Whether you represent the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, or the Surgeon General’s Office, we all realize the focus is shifting toward injury as an “epidemic” and must be addressed appropriately.
Not only is there a dreadful human toll here, it is also in our nation’s economic interest to do something about the issue of highway safety. Our analysts ran the numbers again last year and looked at year 2000 data very carefully. Every year, motor vehicle crashes and related injuries cost our nation $230.6 billion. Among the costs are $33 billion per year in medical care. That’s on par with the entire budget appropriation for building roads in this country. Failure to wear safety belts directly accounts for $20 billion; costs related to impaired driving is over $50 billion; and speed-related crashes cost approximately $40 billion.
Seventy-four percent of the entire cost of motor vehicle crashes is not borne by those involved in the crash but by society as a whole. Therefore, it is definitely in our national interest to meet the problem head-on.
I asked our analysts to look at preventable deaths and the countermeasures we already have in place (i.e., seat belts, impaired driving control, child safety, large-truck safety, intersection crashes, and infrastructure development) and to determine which we could focus on to realize the largest reduction in fatalities in the shortest possible time. The answers were actually very simple and not surprising. If safety belt use could be increased to 90%, a third of highway deaths could be avoided. This 90% figure is not wishful thinking. California, Oregon, Washington State, and Hawaii all have belt-use rates over 90%. Other states have belt-use rates in the 80% range. With the exception of one state (two states as of June 2003), states with high belt-use rates are also those with primary safety belt laws. These laws allow officers to cite a motorist or passenger for not wearing a safety belt or for having an unrestrained child in the vehicle. However, 32 states (30 states as of December 2003) still have laws prohibiting police officers from enforcing safety belt laws unless a motorist is committing another traffic violation. This is a travesty. Thus, in the President’s Highway Reauthorization Proposal, the Department of Transportation establishes an annual $100 million incentive program for states to enact primary safety belt laws. As public policy advocates, I hope all of you will consider the importance of primary safety belt laws nationwide.
In this session, the focus is on impaired driving. It causes a third of all deaths on our nation’s highways, and these deaths are preventable. Unfortunately, unlike the safety belt issue that has a very simple cure, impaired driving is a much harder issue to get our arms around, and the work cannot be done by law enforcement only. The problem must be addressed from the point of sale through adjudication and treatment. Thus, the medical community plays a crucial role in reducing these “preventable” highway deaths.
Impaired driving in our country kills approximately 18,000 people per year. This represents a fatality rate of 0.643 per 100 million vehicle miles traveled; 80% of these crashes involve drivers with a blood alcohol concentration (BAC) greater than 0.08. We made great progress on reducing impaired driving during the 1980s to the mid-1990s.
Consequently, alcohol-related crash fatalities dropped from 26,000 in 1982 to a low of around 15,000 to 16,000 fatalities in 1996. However, we have made no progress since. The population of impaired drivers today is different from that population in 1982 when it seemed like everyone drove drunk. People winked at each other about, “how much did you drink last night before you made it home?” There was no societal imperative that impaired driving would not be tolerated. But now there is. Just as the social norms on smoking have changed over the same time period, societal attitudes toward impaired driving have also changed. Some people say this problem is impossible to solve. I disagree.
I was telling a story the other day about my first research paper. As a senior resident in 1983, I presented my paper at a North Carolina Medical Society meeting in Pinehurst. I remember looking back at the slide projector and wondering how the light beams were going to penetrate the waves of smoke coming up from the physicians’ lungs in the audience. Consider how far we have come in 20 years. Today, if you smoke, you go outside. You don’t offend people or put their lives at risk with secondhand smoke.
Perhaps the same will be said 20 years from now on the issue of impaired driving. Unfortunately, impaired drivers are not only different individually, they also vary as a population geographically. Figure 1 compares U.S. states having high numbers of alcohol fatalities, those having high rates of alcohol fatality, and states that have both.
The high-rate states are in black; the high-numbers states are in gray; and states with both high rates and high numbers are denoted by hash marks. As you can see, we have an issue in the South. Alcohol fatalities are fairly low in some less-populated states, yet these states have high rates of alcohol-related fatalities. For example, Montana has a low number of deaths but a very high rate of alcohol fatalities. Interestingly, Montana just failed to pass an open-container law in the most recent legislative session. Unfortunately, it is still part of the culture to drink and drive in many places in our nation, and policy makers are often “enablers.” Attitudinal and cultural differences are obstacles we must overcome if we are going to curb impaired driving across the country.
How has the population of impaired drivers changed? We’ve picked the “low-hanging fruit.” The remainder of impaired drivers appear to have more severe alcohol problems. In 2001, the median and the mode blood alcohol content (BAC) for alcohol-positive drivers involved in fatal crashes was 0.16. Fifty percent of drivers tested had a BAC above 0.16. This is no surprise to those of you who treat trauma patients. In the early 1990s, I conducted a study on all drivers presenting to my emergency department who had a BAC greater than 0.10. These were drivers either identified by emergency medical services or those who admitted to being the driver. The average BAC in this population was 0.204. By definition, this is a sick population. These people were drinking to get drunk. They were not people who committed the social indiscretion of having one glass of wine too many at a 3-hour dinner. These were people with an obvious disease needing medical treatment.
Although driving skills deteriorate after only one drink, the relative risk of a crash increases dramatically when the BAC rises above 0.08. Therefore, to keep drivers with low BACs healthy, we’re going to continue to use general deterrence, such as high-visibility enforcement campaigns. Even though we think it’s better that people drive stone-cold sober, data show it is not people with BACs of 0.04, 0.05, or 0.06 who cause the majority of traffic crash injuries and fatalities in our nation. Trauma patients with high BACs do the most damage to themselves and to others.
Who are these problem drivers and what leads them to believe that they are, somehow, not subject to the laws of physics? Eighty-two percent of drivers in fatal alcohol-related crashes are male drivers. The majority are younger than 35 years old. They wear safety belts much less frequently.
Eighty percent of this group drink beer. Unfortunately, we are a society that consumes our young. The spike on Figure 2 occurs at age 21. Therefore, what has been the effect of changing the legal drinking age to 21? It has pushed the curve to the right, which is a great accomplishment. In fact, we’re saving our teenagers from alcohol-related crashes at unprecedented levels—that’s the good news. The bad news is that ages 19, 20, 21, and 22 are the nexus of inexperienced driving, inexperienced drinking, and high-risk-taking behavior. When we think about screening and intervention, we’re not just talking about the old guy with spider angiomata and the big red nose. We can screen him, perform an intervention, and send him to treatment—and we should. The bigger problem of alcohol-use disorder and driving occurs in a much younger population—young people who drink to get drunk and who didn’t just start doing this yesterday.
What characterizes the fatalities? Over half of alcohol-related fatalities are impaired drivers, but pedestrians are also killed. Some pedestrians are killed by impaired drivers; others are impaired pedestrians who walk into the path of sober drivers. What types of vehicles show an increased involvement in alcohol-related fatal crashes?
Motorcycles present a particular problem for us. In fact, if you look at data over time, alcohol-related fatalities in passenger vehicles increased by only 0.3%. Alcohol-related sport utility vehicle (SUV) fatalities increased by only 7%, although the number of SUVs on the road has increased. In vans, the increase was 9%; for large trucks, there was a 37% increase. I mentioned earlier that the current alcohol-related fatality rate is 0.63 per 100 million vehicle miles traveled. Motorcycle fatality rates are well above this. In fact, the alcohol-related fatality rate for motorcyclists is at least twice that of the rest of the population. If we compare alcohol crash fatality rates for car, van, and SUV drivers, the fatality rates are approximately 0.42, or 0.43 per 100 million vehicle miles traveled. Thus, there is a huge disparity in fatality rates by vehicle type.
Our goal for this year was to reduce the alcohol-related fatality rate to 0.53 per 100 million vehicle miles traveled. We relayed this goal to Congress, but it appears we will not achieve our goal this year unless we begin to directly address the behavior of those who are actually causing the problem. The educable have been educated. Those who are afraid of the social implications of getting a ticket for driving while impaired (DWI) drink less or they don’t drink at all before they get behind the wheel.
We’ve seen a welcome growth in designated-driver programs. As with other high-visibility enforcement, these programs work well for people who are educable and can make rational decisions about their drinking. However, the problem drinker continues to cause problems. Until everyone in the medical community agrees to take some responsibility for detecting this illness, we won’t be able to solve the problem of impaired driving. We need to research behavioral issues that cause people to behave in this way.
What is the federal government doing to combat the problem? The answer lies in both interagency collaboration and funding priorities. NHTSA’s authorization for the money that we are appropriated each year expires in September 2003, as part of the large DOT authorization known as TEA-21. We need another authorization from Congress for funding through the next 6 years to address safety issues affecting our highway system. The Administration has been working on this for about a year and a half now. The president just sent the new bill over to the Hill last week. Secretary Mineta wanted this bill titled the Safety Authorization Act. We call the bill SAFETEA 2004 (the Safe, Accountable, Flexible, and Efficient Transportation Equity Act). Basically, this is how the bill works: when we buy a gallon of gas at the pump, our federal gas tax goes into a separate fund called the Highway Trust Fund. The NHTSA uses these funds for its safety programs and behavioral research. The goal is to distribute money to the states for safety programs that will be aligned with federal goals.
The amount each state receives is based on a particular state’s crash data. States will have to start using those data to determine how they are going to spend their traffic program money. States searching for funds to support worthwhile traffic safety programs should look to the state’s Highway Safety Program and to the state’s Department of Transportation. I would also encourage you, the taxpayer, to hold your state accountable for the way these funds are spent.
At the federal level, we are involved in a high-visibility enforcement campaign using targeted television advertising. How many of you have seen a “Click It or Ticket” ad in the last 2 weeks? That’s very good, because we targeted the male demographic (ages 18–34 years), so congratulations to those of you who saw the commercial. In July, we plan to air a national ad called “You Drink, You Drive, You Lose.” This ad will be repeated during the winter holiday period.
Congress appropriated money to our agency specifically for national advertising so that we could support the work of law enforcement. We have done that. Once again, high-visibility enforcement campaigns help to ensure that people continue to be educated on the dangers of impaired driving and that those who drink responsibly can make it home safely from the restaurant. Meanwhile, we ask you to focus on the sicker part of the population that has not responded to general deterrents.
What can we do as health care providers to make the situation better? There are several things within your power that do not require much extra effort or resources. The first is to improve our data on impaired drivers. All the data that I showed you earlier regarding alcohol-related fatalities are based on known cases, with a mathematical model applied to impute a nationwide number. This modeling is necessary because states still do not require (or in some cases, states discourage) testing people for BAC even after serious or fatal crashes. When a driver dies in a motor vehicle crash, the body is usually taken to the medical examiner’s office, where a BAC sample is obtained from the vitreous humor of the eye. However, if the drunk driver survives, the hospital is a safe place to avoid detection. There are some financial disincentives to BAC testing because of noncoverage by insurance carriers, as well as expenditure of resources in an era of shrinking health care resources. Still, this should not dissuade us from having protocols in place to detect problem drivers or to facilitate their treatment or their prosecution.
The medical community must have uniform systems in place to screen patients at risk for alcohol-use disorders, even if they are sober when presenting for treatment. All of you are leaders in your particular field. Some of you are already choir members and some are skeptics. However, it is my opinion that just as none of you would discharge a patient from your trauma service with a blood glucose level of 280, neither would you discharge a patient with a high BAC test result who may likely leave the emergency room and resume drinking. Alcohol misuse must be dealt with just as we deal with other concurrent medical problems our patients may have.
Many of you are influential in your state medical societies and have other avenues for garnering the attention of your state legislatures. I need your help to change public policy. We need to wake up the legislatures to our data needs and the need to increase postcrash BAC testing. We also need uniform state traffic crash data. We still have many states without basic traffic safety laws, like administrative license revocation, 0.08 laws, and graduated driver’s licensing.
The National Highway Traffic Safety Administration is working toward reforming the adjudication process. In many jurisdictions, the least experienced prosecutors are assigned to DWI cases and routinely go up against experienced defense attorneys who have full-page ads in the phone book advertising, “Got your DWI? Come see me.” We are also working to establish more DWI courts across the country using the drug court model, which allows repeat offenders the option of receiving help or suffering certain legal consequences.
Another issue worthy of discussion is insurance parity. A patient with a blood glucose level of 280 needs follow-up treatment. If that patient has insurance to cover your bill, then there is insurance available for continued treatment of the glucose problem.
Unfortunately, the same is not true for the patient with a high BAC and an obvious alcohol-use disorder. In many states, there is no insurance coverage for psychiatric care or for substance-abuse treatment. This lack of parity certainly needs to be addressed.
To recognize and treat the at-risk group (young risk-taking male drivers under age 35), screening and intervention protocols should be an integral part of every history and physical examination. Before I came to the NHTSA, I conducted a study in which thousands of drivers who had just crashed their cars were screened for alcohol problems. We used the TWEAK (tolerance, worried, eye-opener, amnesia, k/cut down) screening instrument,2 but others also work. Every patient in our study was sober at the time of their crash, yet 14% still tested positive for alcohol use or alcohol dependency. We randomized them either to a control group or to a brief intervention group. The bottom line was this: of those who received intervention, 28% agreed to further evaluation; 49% of those who agreed to further evaluation actually followed up. I found this really interesting. We screened sober people, 14% were positive, and then we randomized them. We used a very brief intervention, which took approximately 2 minutes or less. When family was present, they remained in the room during the intervention. After I had performed the intervention on every patient for a while, I reduced my own anxiety in talking about this sensitive subject. I was amazed at how easy it was and how receptive people were to discussing the issue with their doctor. My intervention experience was very rewarding, because my success was the opposite of what I had expected. I received a lot of positive feedback from patients and their families. Although I used the TWEAK, you can use alcohol screening instruments such as CAGE, or the Michigan Alcoholism Screening Test (MAST), or the brief MAST.3–5 The important thing is to screen.
There are some action items that I would like to ask of you “thought leaders,” people who can get the job done, not only in your hospitals but also at the American College of Surgeons and the American College of Emergency Physicians. First, I encourage you to implement protocols for screening and brief intervention as the standard of care. Second, develop protocols for getting BAC levels on drivers involved in serious and fatal crashes when you suspect alcohol to be a factor, and establish blood alcohol drawing as normal business practice for your hospital. Third, work through your public policy arms to ensure that insurance coverage is provided for people who need it, regardless of their illness.
Thank you very much for your attention. I hope I have convinced you that we are really serious about this problem. Unfortunately, the cycle of change in the political realm can take much longer than it does in the emergency department, where if someone is in pain, you can stop it; or if someone comes in bleeding, you can stop it. The problem of impaired driving in this country is going to take a long time to turn around. The cycle of change will be tremendously long; therefore, we need your help in solving the problem. This and other large-scale problems are not solved in Washington. Rather, they are solved within your communities, within your hospitals—one community and one hospital at a time. Each of you is an agent of change, so I ask each of you to please begin the work today. In your discussions today, I would ask that you reach some consensus on this subject to bring to your peers. You are thought leaders, and your opinions can inform decision makers and bring about desperately needed change. Thank you very much.
Dr. Larry Gentilello: That was a great presentation, Jeff, and I do have a question. You talked about data needs. Currently, there are 36 states that require BAC testing of surviving drivers who are taken to a trauma center. All of these states have insurance provisions that exclude coverage for treatment if patients are alcohol-positive. Thus, if a driver is taken to a hospital and has a positive BAC, the insurance carrier is not required to pay the bill. I don’t know whether the left hand knows what the right hand is doing. Why does a state pass a law requiring testing and then penalize the hospital or set it up to be in a position where it’s in the hospital’s best interest not to know? A lot of the things you spoke about, such as BAC laws of 0.08, and now moving to primary safety belt legislation, have been achieved by tying highway funding to legislative change that is in everyone’s interest. Do you think the NHTSA will bring these insurance practices, along with the BAC testing law, to the attention of the Hill?
Bert Woolard: One light in the tunnel sometimes seems to be the Governor’s Office of Highway Traffic Safety in each state. I’ve always been a little baffled by the process that leads to the priorities of that office, so a comment on this might be helpful for some of us. We may not be aware of federal funding distributed to each state that should help us with these safety problems. We should have some way to tap that and maybe we’d be able to maintain databases or do other work. My understanding is that the priority list comes from Washington for those offices and then somehow that gets translated into local projects. Our Injury Prevention Center has had some help from the Governor’s Office, but how much of that comes from your office in Washington?
Dr. Jeffrey Runge: Dr. Gentilello, that’s a great question. As you can see from the difficulty we are having just in convincing states to pass primary safety belt laws, states do not like it when the federal government tells them what to do, even if ideas are grounded in the best possible data. I’m pessimistic that legislatures will actually pass needed legislation without large monetary incentives. We have provisions in SAFETEA that tie highway funding incentives to legislative action. For example, we have proposed a $600 million incentive program for primary safety belt laws, which is a sizable incentive even for the largest states, so the NHTSA does have a role in promoting science-based legislation, and we are doing so.
Bert, we used to exert a lot more influence over how states spent their money than we do now. Congress told us to “lay off” in the mid-1990s and, as a result, there is a lot less prescriptive advice coming from Washington. A study, commissioned by Senator Dorgan of North Dakota, and recently released with some fanfare, criticized the NTHSA for not giving consistent direction to the states about how to spend federal dollars. They want accountability on the one hand, but also want us to leave the states alone on the other. Thus, SAFETEA consolidates those grant programs and institutes uniform accountability measures. There is a formula grant program, which goes out to every state based on its population and vehicle miles traveled. This will not change.
Everything else is consolidated into one of essentially four pots of money. One is an incentive pot, so if a state meets an alcohol-fatality rate of 0.53 per 100 million vehicles miles driven, it gets money. Second, if a state makes progress in safety belt use, it gets money. Third, if a state passes a primary safety belt law or reaches a 90% belt-use rate, it gets a huge chunk of money. The fourth pot is linked to performance in overall state fatality rate, motorcycles, bicycles, and pedestrian safety.
We also have $50 million allocated for states with high numbers and rates of alcohol-related fatalities. This money will help those states evaluate what is wrong and enable the states to implement safety programs. We have identified best practices, and we know what states should be doing to curb the problem. For instance, New York has a self-sustaining, wonderful alcohol program that has resulted in the third lowest fatality rate for alcohol injury in the nation. We are going to try to get funding tied to results, so if you have a best practice that you can prove is effective, and you go to your governor’s highway safety representative under the new reauthorization, I suspect you’ll have a lot easier time obtaining funds. The chances of people in your state agencies turning a deaf ear will certainly be less likely.
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