Economy, Convenience, and Safety: Can We Have It All?

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COMMENTARIES 785

Economy,

Convenience,

and

Safety:

Can We Have

It All?

Some

Thoughts

on the Occasion

of the

For-tieth Anniversary

of the Committee

on Injury

and

Poison

Prevention

In this issue of Pediatrics, we learn about the dangers of travel in the cargo beds of pick-up

trucks,’ a problem that is both old and new.

Al-though we may have only recently given this hazard the attention it deserves, the issues surrounding

safe travel in pick-up trucks are common to most

other injury control problems. This is but the latest example of the challenge encountered when safety

measures appear to threaten individual freedom,

personal convenience, or economic “reality.”

In the South, the Southwest, and much of rural America, the pick-up truck is, for many families, the only practical vehicle for both work and family transportation. For families of limited means, par-ticularly for those living in nonurban areas, a pick-up truck is both an essential utility vehicle and a family car. Many families can afford no additional vehicle for transportation. Children, beyond the

first, either stay home or ride in the truck bed. It is

not that these families are unconcerned about their

children, it is that they do not perceive a substantial hazard and their options are limited.

But what about the more than 100 annual pedi-atric deaths that result from travel in the cargo

beds of pick-up trucks? Add to those deaths a

disturbing pattern of severe injuries (one injured child in three suffering major head trauma) and it

is clear to pediatricians and other providers of

trauma care that this form of unprotected travel ought not continue-a different view, I suppose, from that of those for whom the pick-up truck is so much a part of daily life. Travel in the back of pick-up trucks is an example of professional opinion at

odds with public perception. If our heritage as

ad-vocates allows us little tolerance for preventable death and disability, it should also leave us sober to the reality that “practical” issues cannot be summarily dismissed. We have encountered such friction before. We should anticipate it and we

should give some thought to a workable approach

to the prevention of such injuries.

The question is not just how to get children out

of the cargo beds of pick-up trucks, but how to

provide our children with a generally safer

environ-ment given that each incremental step may be perceived as costly, restrictive, uncomfortable, and even intolerable. It is really a question in two parts, one of policy and one of practice. First, how should policy makers-those in professional organizations, government agencies, and legislative bodies-translate injury data into sound public policy? Sec-ond, how should physicians translate that same data into patient counseling that is understandable, convincing, practical, and effective.

For pediatricians the problem of economy and convenience vs safety should be quite familiar. An obvious example of the problem is the promotion of car safety seats for children. The cost of seats

has been perceived as a major obstacle to access by

low-income families. And regardless of income, car

seats are not easy for families to use. Any parent

having been through the experience will report that getting an active, snowsuited child into the average car seat takes concentration, persistence, ingenuity, and time.

Bicycle helmets are another example of an injury prevention intervention with a less than

straight-forward application.2 Again, it is a question of cost vs convenience. Although costs

are

becoming more reasonable, many helmets are as expensive as car

seats. Furthermore, cyclists frequently complain that helmets are uncomfortable. And the argument

has been repeatedly raised (though remarkably un-supported) that peer pressure is a major obstacle to the widespread use of helmets by school-aged chil-then.3

A third familiar example of resistance to a safety intervention is that of preventing tap water scald burns. In 1978, Feldman et al4 brought to light the unnecessary trauma suffered by children exposed to scalding tap water. From this data emerged a variety of campaigns to encourage families to set the home water heater thermostat so that the tern-perature at the tap would not exceed 49 to 54#{176}C (120 to 130#{176}F).5 (Given the nonlinear relationship between temperature and scalding capability of hot water, a modest lowering of water temperature can all but eliminate the possibility of unintentional-and even intentional-serious scald burns.) Yet even this safety measure is gaining acceptance only against resistance. Some have asserted that the dishwasher does not adequately clean dishes at the lower temperatures, and that the glassware is spot-ted. Additionally, parents ask whether at lower temperatures there will be sufficient hot water to serve the needs of a busy and active family. Must we install a larger, more expensive water heater to accommodate the family’s needs? Do we need to

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PEDIATRICS

Vol. 86 No. 5 November

1990

carefully stagger showering and doing the laundry?

Not

easy questions.

A final example is the problem of drownings in residential swimming pools, endemic nationally, but now epidemic in California, Arizona, Texas,

and Florida. In 1988, an estimated 800 children younger than 5 years of age drowned in the United States.6 Between a third and a half ofthose children

died in residential swimming pools.7 Although the need for constant supervision has been duly

em-phasized, the most promising, underused strategy

to address this problem is the installation of barrier

fences that provide 360#{176}of protection: fences that

extend not only around the property, but between

the pool and the house.8 Tragedies typically occur

when the child wanders out the back door, onto the pool patio, and into the pooi.

Although there is ample evidence that pool fences

would be effective,9 ordinances to require fencing

have met repeatedly with vigorous opposition.

Again, convenience and expense are the emerging

themes. For a fence to be effective, it ought be at least 120 cm (4 feet) high, optimally 150 cm (5 feet)

high. It should be made of a very fine mesh or

consist of closely spaced vertical pickets. To many, such a fence is both unnecessarily expensive and aesthetically offensive. It is not surprising that

home builders, homeowners, and the model building code associations have been less than enthusiastic about requiring barrier fences? Although we may be dealing with families at opposite ends of the economic spectrum from the majority of those who put their children in the back of a pick-up truck,

the economy and convenience arguments are raised

no less vociferously.

This year marks the 40th anniversary of the

American Academy of Pediatrics Committee on Injury and Poison Prevention.’0 The committee was

founded before seat belts and before child-resistant closures on medicines and poisons. It was a time

before flame-retardant sleepwear and a time when children were suffocating inside abandoned

refrig-erators. Home smoke detectors were unheard of.

Much of the safety incorporated into our current law, custom, culture, and product design we now

take for granted. Pediatricians have witnessed and

have been instrumental in creating dramatic

changes in society’s view of safety in general and

child safety in particular. It has been an

accom-plishment through patience and persistence,

punc-tuated by occasional frustrations, disappointments, and mistakes. After 40 years, what have we learned? I believe that there are three key principles learned

from experience-and worth remembering.

First, public awareness and education form an

essential foundation for all injury prevention efforts

by which we seek to change behaviors. Of course,

education does not in itself prevent injuries, for it

does not necessarily lead either to changes in

be-havior or to changes in products or environment. Yet people will be unlikely to change behaviors and practices unless they recognize adequate reasons to do so. Against the barriers of cost and convenience, people must see these reasons as compelling. Even a law cannot replace awareness and education. Al-though the first child passenger protection law went into effect in 1978, it was not until 1985 that these laws were adopted by all the states. The process was not so much one of promoting legislation as it was one of promoting understanding. Physicians were educators disguised as lobbyists. The rate-limiting process was not even the education of

legislators (although surely many were either

Un-informed of the data or unimpressed by it), but rather the education of their constituents. Even now that we have child passenger protection laws, we recognize a continuing need for public education. Awareness and appreciation of a problem are not only prerequisites for passing a law, but for enforce-ment as well. Whenever legislation is used to change behaviors, it ought to be preceded by public education-and followed up by reinforcing educa-tion. Legislation will do no more than its intended job: legitimizing publicly accepted behaviors in the public interest.

Second, in promoting public awareness of a health or safety problem, physicians in the office can have an effect that works synergistically with the more broadly based (though less personal)

ef-forts to educate the public. Professional

organiza-tions can publish policy statements, launch media campaigns, and endorse legislation, but physicians can talk directly to patients. The pediatrician is particularly well-equipped to translate epidemio-logic data into anticipatory guidance. This can be done quite comfortably alongside nutritional coun-seling, behavioral counseling, and other aspects of health supervision. Fences prevent drowning. A polystyrene-lined helmet can protect your child’s brain. Prevention of drowning and prevention of head injury are certainly public health issues, but they are also personal health issues; each can be addressed by changes in individual behaviors. Con-tinuity of care allows counseling to be customized, with topic and emphasis based on knowledge of a family and assessment of risk. Pick-up truck safety would be a prime example of a topic that ought be discussed selectively.

The third principle of injury prevention is the fact that if a message is persistently delivered-in

its health context, as well as in its political

con-text-extraordinary changes can occur despite

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COMMENTARIES

787

seemingly formidable obstacles of cost, inconven-ience, and cultural inertia. What parents today view

as acceptably safe automobile travel for their

in-fants is very different from the view of the previous generation. In part through our hard work, norms have changed.”

It is gratifying to have witnessed the development of tolerance for what seemed intolerable. People have become quite innovative in finding ways to make safety measures more accessible and accept-able. Car seats are still expensive, but new parents in most parts of the country now have access to loaner programs; and the seats, themselves, have become somewhat easier to use with shields and

straps that are more readily adjustable. Bike hel-mets have become less expensive, lighter in weight,

better ventilated, and more attractive. Several na-tional organizations have launched industry-sup-ported campaigns to make the advantages of these

helmets widely known, and the helmets themselves

widely available. Turning the water heater

ther-mostat down to a safe temperature will soon not be necessary for new units; they will be set to a safe

temperature at the factory. Automatic dishwashers can heat their own water. It is a safe prediction that residential building codes will soon require special temperature-limiting valves built into the plumbing lines serving bathrooms so that scalding water will never reach the tap.

In the case of residential pool drownings as well

as in the case of pick-up truck cargo beds, the

innovation needed to overcome problems of cost, inconvenience, and nonavailability are yet to emerge. We are at an earlier stage with regard to these hazards. One day we will see barriers of some

sort-either physical or electronic-that will be

effective in preventing a toddler from riding a tn-cycle into 2 meters of water. Such innovative

bar-niers will be both aesthetically acceptable and

af-fordable. A safer pick-up truck will also evolve. Either the cab will be large enough to accommodate the whole family safely (some models already have

this feature), or we will find ways to protect those

riding in the bed. Perhaps an entirely redesigned vehicle will succeed today’s pick-up truck, serving both of the pick-up truck’s current functions. Of course, such a vehicle must be economical and convenient as well as safe.

The elimination of many hazards from the child’s environment requires concerted effort by many

per-sons throughout considerable time. We can become

impatient with the pace. If we grow impatient, we

should recall the 7 years separating the passage of

the first state child passenger protection law and

the last. If it was a longer and more frustrating 7 years than we would have liked, the results never-theless made it eminently worthwhile. Among other things, the child passenger protection effort

dem-onstrated that economy and convenience are only relative. Today, rates of car seat usage in some areas exceed 80%, bottles of antifreeze have safety caps, and children’s pajamas will not readily ignite. Ifwe stick to the basics-education and

advocacy-if we promote safety in both the public arena and in the physician’s office, and if we remain

persist-ently intolerant of preventable injury, expense and inconvenience will not overshadow safety, not if the history of the past four decades is any guide.

ACKNOWLEDGMENT

I thank Ronald L. Poland, MD, and Ruth M. Siegel,

JD, for their helpful suggestions.

REFERENCES

MARK D. WIDOME, MD, MPH

Pennsylvania State University College of Medicine

Hershey, PA

1. Woodward GA, Bolte RG. Children riding in the back of pickup trucks: a neglected safety issue. Pediatrics.

1990;86:683-691

2. Thompson RS, Rivara. FP, Thompson DC. A case-control study of the effectiveness of bicycle safety helmets. N EngI

J Med. 1989;320:1362-1367

3. DiGuiseppi CG, Rivara FP, Koepsell TD. Attitudes toward bicycle helmet ownership and use by school-age children. Am J Dis Child.1990;144:83-86

4. Feldman KW, Schaller RT, Feldman JA, McMillon M. Tap

water scald burns in children. Pediatrics. 1978;62:1-7 5. Katcher ML. Prevention oftap water scald burns: evaluation

of a multi-media injury control program. Am J Public

Health. 1987;77:1195-1197

6. Accident Facts. Chicago, IL: National Safety Council; 1989

7. Wintemute GJ, Kraus JF, Teret JD, Wright M. Drowning in childhood and adolescence: a population-based study. Am J Public Health. 1987;77:830-832

8. Orlowski JP. It’s time for pediatricians to ‘rally round the pool fence.’ Pediatrics 1989;83:1065-1066

9. Pearn JH, Wong RYK, Brown J, et al. Drowning and near-drowning involving children: a five-year total population study from the city and county of Honolulu. Am J Public Health. 1979;69:450-453

10. Hughes JG. American Academy ofPediatrics: The First Fifty Years. Chicago, IL: American Academy of Pediatrics; 1980;24-25

11. Foss RD. Sociocultural perspective on child occupant pro-tection. Pediatrics. 1987;80:886-893

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1990;86;785

Pediatrics

MARK D. WIDOME

Prevention

Occasion of the Fortieth Anniversary of the Committee on Injury and Poison

Economy, Convenience, and Safety: Can We Have It All?: Some Thoughts on the

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1990;86;785

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Prevention

Occasion of the Fortieth Anniversary of the Committee on Injury and Poison

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Economy, Convenience, and Safety: Can We Have It All?

COMMENTARIES 785

PEDIATRICS

COMMENTARIES

ACKNOWLEDGMENT

MARK D. WIDOME, MD, MPH

Pediatrics

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