Chapter 3_Hope on the Horizon_pp 42-63

Chapter 3_Hope on the Horizon_pp 42-63 - ~three- Hope on...

Info iconThis preview shows pages 1–22. Sign up to view the full content.

View Full Document Right Arrow Icon
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 2
Background image of page 3

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 4
Background image of page 5

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 6
Background image of page 7

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 8
Background image of page 9

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 10
Background image of page 11

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 12
Background image of page 13

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 14
Background image of page 15

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 16
Background image of page 17

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 18
Background image of page 19

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 20
Background image of page 21

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 22
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: ~three- Hope on the Horizon On the afternoon of June 4, 1996, an ambulance carried a coma— tose young piano teacher from Central Park, where she had been viciously beaten, to the emergency room of New York Hospital- Cornell Medical Center on New York City’s Upper East Side. Her accused attacker, a mentally unbalanced and unemployed former sales clerk, had reportedly smashed her forehead on a concrete side— walk, shattering the bones above her right eye. He was said to have then turned her over and hammered her head against the pave— ment with such intensity that he fractured her skull behind her left ear. Although the neurosurgical resident on duty at the hospital in— serted a shunt to siphon off the excess fluid expected to build inside her skull from her battered and swelling brain, later that night her intracranial pressure rose precipitously anyway, threatening her life. The physician in charge of the victim’s case, Jam Ghajar, the chief of neurosurgery at Jamaica Hospital in Queens, ordered a CT V scan, which showed an extensive clot building in her bruised right frontal cortex. Around midnight he drilled a small hole in her skull, and then, as he told Malcolm Gladwell (to whose thorough account of this case, in the July 8, 1996, New Yorker, I am indebted for the facts related here), “this big brain hemorrhage just came out— plop—like a big piece of black jelly.” Five days later the patient de- veloped a second clot, this time on the left temporal lobe, behind her left ear. This was an especially ominous development, since this area of the brain governs comprehension, and surgery to remove the clot might have inadvertently damaged the young woman’s ability to speak and understand. Again an incision in her skull was made, and again, remarkably, the clot just plopped out on its own. The young piano teacher has made remarkable progress but faces a long, arduous recovery and rehabilitation. But she was extremely lucky to have been taken to one of the few trauma centers in the country that specialize in traumatic brain injury. Five years earlier, when her chief physician and several other researchers had surveyed the nation’s trauma centers, just one—third of them reported that they routinely monitored intracranial pressure. In other words, at most hospitals, the rising pressure inside her skull that twice led physicians to order CT scans, which discovered the blood clots and ultimately prompted life—saving surgery, might well have not been detected. Instead, she likely would have died. In the years to come, many brain—injured victims across the coun— try who formerly would have died may survive because they will receive treatment as good as that administered to the young piano teacher. If this happens, it will be in part because in the summer of 1993, following a professional meeting in Vancouver, Dr. Gha- jar and two other neurosurgeons decided that something needed to be done to dramatically boost the grim odds facing comatose patients with traumatic brain injuries in the United States. About 40 percent of these people now die, while another 40 percent make a satisfactory recovery, which is usually defined as an outcome Hope on the Horizon . 43 . ranging from independent living with some disability to full re— covery; the remaining 20 percent fall into a shadowy netherworld between persistent vegetative state and serious disability. The three physician—researchers enlisted the help of the Brain Trauma Foun— dation, the educational arm of the Aitken Neuroscience Institute, a research group of which Ghajar is president. (The institute was founded by the children of Prince Alfred von Auersperg and Sonny von Bulow, both of whom suffered fatal comas.) The focus of the physicians’ and the foundation’s effort was to allow the thousands of US. hospitals that do not specialize in brain trauma to benefit from the experience of the handful of hospitals that do. At these few institutions, “it is now not unusual for the mortality rates of coma patients to run in the range of 20 percent or less,” or half the deaths experienced at nonspecialist hospitals, Gladwell wrote in the New Yorker. Between winter 1994 and sum- mer 1995, he continued, the foundation hosted eleven meetings featuring some of the world’s leading specialists in brain injuries.‘ At these grueling weekend sessions, the experts reviewed four thou— sand scientific papers relating to fourteen areas of brain-injury management. The product of all this diligent work was a blue three-ring binder setting forth the scientific evidence and treatment guidelines for every phase of traumatic brain injury. Beginning in March 1996, the book was sent to every neurosurgeon in the United States; in addition, the Brain Trauma Foundation mailed it to scientific journals, hospitals, managed care groups, and insurance compa— nies. This was, as Gladwell observed, the first organized effort by neurosurgeons to come up with a standardized set of state—of-the— art treatment recommendations for those with traumatic brain in— juries. He estimated that if the guidelines “are adopted by anywhere close to a majority of the country’s trauma centers, they could save more than 10,000 lives a year.” Hope on the Horizon . 4’4 . THE RESEARCH REVOLUTION Though perhaps it could have happened a few years before it actually did, the fact that the nation’s neurosurgeons only recently developed such a recommended treatment plan—or protocol, in medical jargon—is understandable. As Murray Goldstein, former director of the National Institute of Neurological Disorders and Stroke at the National Institutes of Health (NIH), noted just one year before the blue book was issued, “More has been learned in the past 20 years about how the human brain is organized and functions than in the past 200 years.” He continued, “More has been learned in the past 10 years about nerve cell recovery from in- jury than in the past 10 centuries.” Now medical director for the United Cerebral Palsy Research and Educational Foundation, Goldstein elaborated on the progress in his foreword to the 1995 book Brain Repair, by Donald G. Stein, Simon Brailowsky, and Bruno Will: “Molecular genetics is describ— ing the biological forces that determine the fundamental structures and functioning of the developing brain; behavioral neuroscience is describing the impact of the internal and external environments on the molding of behavior; and the clinical sciences are describ- ing the impact of infection and injury to the brain on total body performance. Brain-imaging technologies are documenting how the living brain functions during the performance of the activities of daily living. The neurochemical processes controlling cognition including language, memory, and problem—solving are also being identified.” When Goldstein’s former agency, the National Institute of Neurological Disorders and Stroke, was established in 1950, the conventional wisdom was that physicians would never be able to do much to help their brain—injured patients. Nerve cells, unlike skin and muscle tissue, were traditionally assumed to be incapable of repair or replication. Until recently, medical science held that Hope on the Horizon . 4’5 . may “wwwwflaanama . .; "-97 wow 1-n—:;1~«: w m: J» once we reached adulthood, we had all the brain cells we would ever have and that any damaged or lost after that were gone forever. Congress, meanwhile, couldn’t be persuaded to fund inquiries that seemed to have no potential for benefit. But in the past few years, as Goldstein emphasizes, our under- standing of the brain has undergone a revolution. New research findings promise hope for those suffering all sorts of neural dam— age, particularly for victims of brain trauma. Neuroscientists have discovered that nerve cells, including brain cells, can regenerate when prompted by certain nerve growth fac— tors. Indeed, traumatic brain injury itself appears to switch on genes that may trigger the release of these healing chemicals. One group of substances, gangliosides, which reside in the outer mem— branes of neurons, appear to cause the cells to sprout new branches that extend into neighboring areas of destruction and replace dead cells. Studies aimed at understanding and identifying such natural repair processes may enable doctors to help the brain reconstruct sections devastated by trauma. Research using fetal cell implants, which have shown promise in mending damaged spinal cords, may also have implications for traumatic brain injury. In either case, the information that had been contained in destroyed cells may have to be relearned, but some patients who now have limited potential for recovery might be able to eventually lead normal lives. Both basic researchers, who unravel the mechanisms and study the chemicals by which the brain operates, and their clinical col— leagues, who apply this knowledge to developing new therapies, have made breakthroughs that offer hope to present and future vic— tims of severe brain trauma. For example, a blow to one part of the brain can trigger a massive release of normally well—controlled brain chemicals which, in turn, can damage sections of the brain not involved in the initial injury. Free radicals, amino acids, and perhaps even nitric oxide play a role in this secondary damage. Hope on the Horizon . 46. Once neuroscientists understand how and why this cascade of bio- chemical events occurs, clinical researchers may be able to develop drugs or other therapies to block this secondary physiological in— suit and prevent the cognitive and behavioral problems that it may cause down the line. Another promising area of inquiry may one day limit the cel— lular devastation that brain injury leaves in its wake. For decades, physicians have used barbiturates to control the secondary dam— age that often follows the initial injury. But putting patients into a drug—induced coma carries its own risks. Moreover, doctors can’t evaluate the recovery potential of a person in an artificial vegeta— tive state. Hypothermia—lowering the temperature of the brain— seems to provide similar benefits without some of the drawbacks. Researchers initially theorized that cooling slowed the metabolic rate, thus slowing brain activity. Now they believe that cooling sta— bilizes the blood vessels and inhibits the massive release of neuro— transmitters that set off a secondary chain of damaging events for brain—injured patients. In 1995, the National Institutes of Health funded a $7.2 mil— lion, flve—hundred—patient study to examine the benefits of hypo— thermia in those with severe traumatic brain injuries that result in coma. By late 1996, about two hundred of these patients had been treated and studied, including a post—treatment evaluation after six months. But because this is a completely blind experiment, no re— sults will be known until the study is complete in 1998. As I write, about three hundred additional patients are yet to be treated and examined at five medical centers nationwide. All patients in the study were to receive standardized, state—of—the-art treatment. But only half were to receive the experimental hypothermia treatment, thus permitting a statistical comparison of the efficacy of the inno— vative treatment versus that of the stande regimen. According to the recipient of the NIH grant, Guy L. Clifton, Hope on the Horizon . 47 . hypothermia treatment should begin as soon as possible after injury and within six hours at the latest. Cooling blankets are wrapped around the patient to lower the body temperature to 90—91 de- grees Fahrenheit (or 32—33 degrees Centigrade). This temperature is maintained for twenty-four hours. Then the patient is gradually warmed over twelve hours to normal body temperature. The NIH grant came to Dr, Clifton, the chairman of neuro— surgery at the UT—Houston Medical School of the University of Texas—Houston Health Science Center, because he and his col— leagues had previously undertaken five years of preliminary clinical trials. These trials had been prompted by their earlier, encourag— ing laboratory studies indicating that decreasing the temperature within the skull by as little as two degrees may be effective in promoting recovery for those with brain trauma. The preliminary trials, which were run concurrently at Hermann Hospital in Hous— ton and at Presbyterian Hospital in Pittsburgh, had suggested that use of hypothermia increased by 20 percent the number of patients achieving a good outcome—“good” being defined as a range of re— sponse, from being able to live independently with some residual disability to full recovery. That impressive numerical percentage, of course, represents an incalculable reduction in the toll of indi— vidual human suffering—by both patients and their families—not to mention significant savings in medical costs and in wages that would otherwise have been lost. Another intriguing and seemingly promising approach to treat— ing brain trauma involves hyperbaric therapy—administering high concentrations of oxygen under pressure. Medical science has long known that lack of oxygen is a major cause of secondary brain damage. Blot clots, for example, wreak only some of their havoc by compressing the tissue around them; they inflict far more harm by squeezing off blood vessels and thus depriving brain cells of oxy- Hope on the Horizon . 48 . gen. But just because too little oxygen harms brain cells, it doesn’t necessarily follow that a large amount heals them. Yet that is pre— cisely what the work done by clinical researcher Paul Harch of theo Ellen Smith Medical Center in New Orleans seems to indicate. Dr. Hatch has had some remarkable results treating brain—trauma patients with hyperbaric therapy. One instance involved a patient who had suffered a severe brain injury after jumping out of a cat traveling forty—five miles per hour. A day after he was admitted to the hospital, the eighteen—year-old registered only seven out of a best possible score of fifteen on the Glasgow Coma Scale. Yet, ten weeks after hyperbaric treatment, he could walk on his own and talk. After one hundred treatments, the young man was transferred to a rehabilitation facility that didn’t practice hyperbaric therapy; his progress plateaued. Four months later, he resumed hyperbaric therapy—and continued his recovery. Throughout the course of the case, Dr. Harch charted the healing of his patient’s brain with SPECT scans, which use single photon emissions (SPEs) to create CT scan images. The scans showed that the area of injury had de— creased in size. Within a year after his accident, the young man was running and riding a bicycle. Dr. Hatch has found hyperbaric therapy effective even when it wasn’t begun until months or even years after the trauma. Although Dr. Harch has discussed his work at professional con— ferences, he has yet to publish a rigorous study with a broad enough patient population to give his work solid scientific underpinnings and thus to promote widespread use of hyperbaric therapy. Even the most impressive anecdotal successes are never enough to show a therapy to be effective, since so many factors-from physiological luck to the researcher’s rapport with the patient—can come into play. But Dr. Harch’s work may well indicate a hopeful new area of treatment, and other clinical scientists are waiting eagerly for the Hope on the Horizon . 49 . publication of his full study. Despite promising new research for treating acute brain injury, our ability to help survivors during re— habilitation hasn’t kept pace with our skill at heroic rescue. THE POLITICAL AWAKENING Encouraging research discoveries, the general expansion of our knowledge about brain function, and good, old-fashioned politi— cal advocacy and lobbying to persuade legislators to deal decisively with the epidemic of brain trauma have finally begun to register in our national political consciousness. Unlike the Brain Trauma Foundation, which funded the brain—trauma protocol book and which sees its mission as mainly educational, the Brain Injury As— sociation (BIA) has fought since its inception in 1980 to influence public policy on behalf of brain—trauma victims. To put itself where policy decisions are made, in 1990 this advocacy group moved its headquarters from Boston to Washington, DC. In response to the BIA’s efforts, in 1992 several US. senators and representatives intro— duced two bills aimed at dealing with traumatic brain injury— the first significant federal legislative action specifically targeted toward the epidemic. For two sessions, these bills worked their way through the tedious process of review and revision in each house of Congress. In 1996, one of them, the Traumatic Brain Injury Act, finally was approved by the Congress, was signed by President Clinton, and became law. It authorized the federal government to spend $24.5 million in the next three years on grants to states that developed model treatment programs as well as to federal agencies that studied the incidence of brain injuries and researched strate— gies for their prevention, treatment, and rehabilitation. Thus far, the act has been more symbolic than substantive, since it authorized expenditures but didn’t fund ongoing programs; funding must ultimately be fixed as a line item in a regular appro— priation bill—something that has yet to happen. While much more Hope on the Horizon o I public money is needed to fund research, the act is a welcome be— ginning. Besides the Traumatic Brain Injury Act, a few other political steps in the right direction have been taken in the past few years. The Americans with Disabilities Act of 1990, for example, pro- hibits discrimination against people with many types of disabilities. By requiring that public buildings and public transportation be ac— cessible to individuals in wheelchairs, this important law is making it easier for brain-injury victims with mobility problems to func- tion independently. THE REHABILITATION REVOLUTION The Americans with Disabilities Act is especially important now, because in the area of traumatic brain injury, we are in the middle of a rehabilitation revolution. The great advances made in reha— bilitative services are fortunate, since many people who formerly would have died of their brain injuries now survive thanks to ad— vances in medicine and trauma care, and they therefore need help relearning skills and readjusting to life. The revolution began fairly quietly—indeed, it was virtually unnoticed by most citizens—in August 1950, when President Harry Truman established the pre— decessor of the National Institute of Neurological Disorders and Stroke. It slowly accelerated throughout the fifties, sixties, and seventies, despite the faCt that treatments for diseases and disorders afflicting far fewer people than brain trauma does (such as muscu— lar dystrophy and juvenile diabetes) received much more public at— tention and public money. And it began to pick up steam in 1989, when Congress and President George Bush declared the 19905 the Decade of the Brain—finally focusing national attention on un— locking the secrets of how the healthy brain develops and works and how the damaged brain might be restored. Since 1980 therapeutic techniques have advanced dramatically, Hope on the Horizon . 51 . and the number of brain—injury inpatient rehabilitation facilities has increased more than a hundredfold. In the past ten years alone, according to the National Conference of State Legislatures (NCSL), the for-profit brain—injury rehabilitation industry has grown expo— nentially to the point where it now generates an estimated $10 billion in fees annually. Still, the NCSL calculates that only one in twenty people with brain injuries receives the rehabilitation ser— vices that he or she needs. What typically stands in a patient’s Way is not the lack of ap— propriate programs but the patient’s inability to pay for them. For those who are not insured, have exhausted their insurance bene— fits, or have left rehabilitation facilities to live with their families or in the community, state services are often grossly inadequate, terribly fragmented, and shamefully inefficient. A number of state bureaucracies have no central headquarters to which people with traumatic brain injuries can turn. State services are spread through- out myriad agencies and departments, from health and education departments to mental health and social services. This forces the already highly stressed victims of brain injury—or, more likely, members of their equally stressed families—t0 go, hat in hand, from office to office in a frustrating and frequently fruitless effort to find the services that they need. This fragmentation also has a debilitating effect on the states themselves by handicapping their policy makers’ efforts to gather the data necessary to develop pro- grams, procedures, and systems that would better meet the needs of victims of brain trauma. Yet in recent years a few bright spots have begun to emerge. Many states are attempting to improve how they serve people with brain injuries by establishing state councils, creating lead agencies, and instituting a system called case management to control costs by ensuring that people get the most appropriate services. These Hope on the Horizon . 52 . services are paid for through traditional sources of financing, such as Medicaid, vocational rehabilitation grants, and state general- revenue funds, and sometimes through more innovative financing approaches. Some States, for example, have established dedicated reserves funded by fines for such motor vehicle violations as speed— ing, drunk driving, or failure to use safety belts. A couple of progressive States have taken the lead in setting up comprehensive model programs that others already have begun to emulate. The case management system mentioned above, for in— stance, was developed in Minnesota and is employed effectively in Florida as well. It holds particular promise because it recognizes that each brain trauma and each brain—trauma victim are different and that both the potential level of recovery and the time required to reach it vary from person to person. Under a case management system, families that are able and willing still provide their brain—injured members with such neces- sities as food and shelter, but they receive help that lets them do so Without necessarily sacrificing some of their members’ lives to full—time caring for the victim. For example, day care for the brain injured can enable a morher, father, or spouse to continue working. And with a job—training program combined with a transportation service, even a moderately disabled brain—injured person may even— tually be able to contribute to his or her living expenses. Case managers are trained to match brain-injured individuals and their families with the services that they need and to make those services accessible to them. Case management not only as— sures more appropriate treatment; it also costs less than the tra— ditional—and haphazard—methods of distributing aid. Thus, by focusing on home- and community—based programs rather than residential treatment institutions, Minnesota estimates that it saves $1 million a year. Hope on the Horizon I o was; fee-w . r l l PREVENTION: THE BEST MEDICINE But as important as life-saving treatment and rehabilitation are for dealing with brain trauma, one thing is even more crucial: preven— tion. There, too, our first small steps already have begun to make a difference. The lion’s share of the 2 million Americans who suf— fer traumatic brain injuries each year sustain them in automobile wrecks. Not only do seat belts and shoulder harnesses save lives; they also have significantly reduced the number of accident victims who suffer brain traumas. Unfortunately, however, only the District of Columbia and eleven states allow police officers to stop vehicles solely for seat—belt violations: California, Connecticut, Georgia, Hawaii, Iowa, Louisiana, New Mexico, New York, North Carolina, Oregon, and Texas. Tougher laws and stepped-up enforcement would certainly boost compliance in the other four states—and lead to an accompanying reduction in brain injuries and deaths. Air bags, which are now standard equipment in most new cars and which federal safety standards require to be installed in all new passengers cars and light trucks by 1999, are estimated to have saved nine hundred lives from the late 19805 to 1994, according to the National Center for Statistics and Analysis of the National Highway Traffic Safety Administration. Air bags have also greatly reduced traumatic brain injuries among front-seat passengers in- volved in head—on crashes and, in the case of vehicles that have side—mounted air bags, among those hit from the side as well. In late 1995, a troubling trend emerged. In November, the US. Centers for Disease Control and Prevention (CDC) noted in the Morbidity and Mortality VVee/eiy Report that eight infants and chil- dren, front—seat passengers all, had sustained traumatic brain and other injuries as a result of the impact from suddenly inflating air bags. By 1997 a national controversy had developed, and it can only be described as curious: whereas air bags could be blamed for sixty-one fatalities (most of them preventable), air bags had saved Hope on the Horizon . 54 . more than sixteen hundred lives. Air bags have clearly been of sig— nificant value in protecting adult and teenage car passengers. But after discovering that some parents were not heeding the warnings printed on many child safety seats and on places like the visors of cars equipped with air bags, the CDC, quite appropriately, under— scored several important recommendations for children: All infants and children should be properly restrained in child safety seats or with lap and shoulder belts. All infants and children should ride only in the back seats of cars, and infants under twenty pounds or one year of age should ride in rear— facing safety seats mounted in the back seats only. The last point is especially important: infants in rear—facing safety seats should never be placed in the front seats of cars or trucks with passenger-side air bags. If a car does not have a rear seat, a child riding in the front seat should be positioned as far away from the air bag as possible. By late 1997 the air bag controversy remained unresolved. Oppo- nents have gained the right to disconnent air bags that might harm small or frail persons; proponents lobby for both front— and side— mounted air bags. At the moment, there is one new and promising passive safety feature that may reduce the number of two—car acci— dents: daytime running lights. The straightforward reasoning for this innovation is that using headlights makes cars more conspicu— ous during daylight hours, making others—drivers and pedestrians alike—more aware of approaching vehicles. Many manufacturers are beginning to make running lights that are activated by igni— tion switches standard equipment on their vehicles. If one doesn’t own a new car with this feature, the same safety advantage can be achieved simply by turning the lights on manually (although of course one must then remember to turn them off while turning off the ignition in order to avoid risking a dead battery). For now, taking advantage of this commonsense expedient seems reason— Hope on the Horizon a o able—as does anything else that improves one’s odds of avoiding a traffic accident, from slowing down on wet roads to leaving ten minutes earlier than necessary to reach your destination. Whether use of daytime running lights actually will pan out as projected—— particularly whether the strategy will remain successful when all cars on the road during the day have their headlights on and people have become accustomed to that sight—is something that only time and further research will tell us. Another life— and brain—saving expedient about which there is little scientific debate involves those who ride on motorcycles. A proven, highly effective way of reducing crash-related head injuries —the main cause of death among unhelmeted motorcyclists—is requiring all motorcycle drivers and passengers of whatever age to wear helmets. Helmets are 67 percent effective at preventing brain injuries, the National Highway Safety Administration estimates, and where they are required by law, the number of motorcyclists using them approaches 100 percent. The good news is that as ofJuly I, 1997, twenty—five states and the District of Columbia had motorcycle helmet laws that applied to all riders, while twenty-two other states had such laws affecting only some riders, usually those under eighteen; Colorado, Illinois, and Iowa had no helmet laws at all. But there is bad news on this subject as well. This is an instance of our nation taking one step forward after we took two steps back, and as I write we are starting to go backward once again. To understand how and why, we need to be aware of a little history. Before 1967, only three states had motorcycle helmet laws. That year the federal government began requiring states to enact such laws in order to qualify for certain highway construction funds and federal safety program grants. By 1975, all but three states had laws requiring motorcyclists of all ages to wear helmets. Then, starting in 1976, the federal Department of Transportation (DOT) began to Hope on the Horizon . 56. financially penalize states without so—called universal helmet laws. State governments promptly began to pressure Congress to revoke the DOT’s authority to assess penalties for noncompliance. Congress caved in to the pressure, with predictable results. Once the federal sanctions were gone, motorcyclists continued to in— tensely lobby state legislators to eliminate or soften the helmet laws, often organizing politically and pressing for antihelmet resolutions at precinct, county, and state Republican and Democratic party conventions. As a consequence, between 1976 and 1978, nineteen states weakened their helmet laws, applying them only to young riders, typically those under age eighteen. Why did so many motorcyclists oppose being forced to protect their heads? Perhaps the aHSWer is the simple truth that motor- cyclists are a n0toriously independent breed, more adventuresome and tolerant of risk than most of the rest of us, and many of them tend to see helmets as both a symbolic and concrete example of a bothersome government interfering with their freedom to let the wind blow through their hair—one of the great sensual pleasures, along with the intense physical “rush” of speed generally, that goes with motorcycle riding. After all, motorcyclists face a risk of death and injury that is twenty times higher per mile traveled than that experienced by people in cars. (This is a statistic that the govern— ment should require be part of all published and broadcast ad- vertising for motorcycles, much like the surgeon general’s health warnings are printed on cigarette packages.) All this is not to say that motorcyclists have not presented some superficially plausible safety arguments against helmets over the years. Some motorcyclists, for instance, have claimed that helmets restrict their hearing and peripheral vision. A 1995 study shows that full—coverage helmets do indeed curtail one’s horizontal peripheral vision, but only to a minor degree—about 3 percent. Riders easily compensated for that, the study found, by rotating their heads Hope on the Horizon - 57- more to look around before changing lanes. The same study found no restriction in the helmeted riders’ ability to hear horn signals or see vehicles in adjacent lanes before changing lanes. Additionally, some motorcyclists critical of helmet laws have cited a study show- ing that helmets cause neck injuries, possibly by adding to the head mass in a crash. But a dozen other studies refute that finding. When motorcyclists’ deaths and injuries began to climb after their success in weakening helmet laws, a more rational View started to prevail in some places. Between 1980 and the early 19905, several of the states that had previously watered down their laws reinstated helmet laws for all riders. In 1991, meanwhile, Congress enacted the bureaucratically titled Intermodal Surface Transportation Effi— ciency Act, which established incentives for states to approve seat- belt and helmet laws covering everyone. Those states that had en— acted both such laws were eligible for special federal safety grants, but those that didn’t have both laws on their books by October 1993 had up to 3 percent of their federal highway funds diverted to highway safety programs. Then in the anti—Washington, antiregulatory fervor after the Re— publicans seized control of both the House and the Senate in 1994, Congress once again flip—flopped. In the fall of 1995, the national legislature lifted the sanctions against states without laws that re- quired motorcyclists to wear helmets. This opened the door for states to once again repeal universal helmet laws. Congress’s zig- ging and lagging underscores how hard it sometimes is for us as a society to apply the measures that many of us already know will work to prevent traumatic brain injury. And it illustrates why every— one who cares about this issue needs to get involved politically— from writing letters to legislators and local newspapers to joining with advocacy groups like the Brain Injury Association. The plain fact is, preventive measures like helmet laws are usefiil in reducing deaths and traumatic brain injuries. Take the experi— Hope on the Horizon n I ence in Texas, where 1 now live. From 1968 to 1977, Texas law man— dated that every motorcyclist and passenger wear a helmet. That law is estimated to have saved 650 lives—and who knows how many brains from being battered. But in 1977 the law was soft- ened and made to apply only to riders younger than eighteen. The weakened statute coincided with a 35 percent rise in motorcyclist deaths. Nonetheless, the news of this increase did not get ade- quately communicated, nor did the rise in carnage and scrambled brains change peoples’ behavior. By August 1989, only 41 percent of Texas’s motorcyclists were said to be using helmets. When Texas reinstated its universal helmet law in September 1989, the num— bers of helmet wearers rose to 90 percent in the first month that the law was in effect. The compliance rate was 98 percent by June 1990. Meanwhile, serious—injury crashes per registered motorcycle dropped by 11 percent. Similar positive results were seen in other states that have likewise reinstituted laws requiring helmets on all motorcycle riders. By 1997 Texas lawmakers decided that only riders under twenty—one would be required to wear helmets. Fatali— ties and injuries will inevitably increase, as will the public cost of motorcycle crashes. The nation also has begun, ever so slowly, to recognize that bi— cycle helmets also prevent brain and other injuries and thus that bike riders should wear helmets, too. In 1995, the Centers for Dis— ease Control and Prevention reported that each year, nearly 1,000 Americans die from injuries caused by bicycle crashes and 550,000 are treated annually in emergency rooms for bike—related injuries. It observed that head injuries account for 62 percent of the bicycle- related deaths and for 33 percent of the bike—related emergency room visits. And it noted that 7 percent of all brain injuries result from bike accidents. Moreover, the CDC cited a 1991 Study from the journal of the American Medical Association, which concluded that universal use of bicycle helmets in the United States could Hope on the Horizon I a spare us an average of 500 fatal and 151,400 nonfatal head injuries every year. Based on these findings and Others—including a case— controlled study in Seattle that found helmet use can cut the risk of bicycle-related head injury by 74 to 85 percent—the CDC rec— ommended that helmets be worn by bicyclists of all ages and at all times whenever they ride. It also urged states and communities to enact laws and implement education campaigns designed to en— courage helmet use. Between ]uly 1991 and March 1997, twelve communities placed on the books comprehensive ordinances requiring all riders to wear helmets. Beginning in 1990, sixteen other jurisdictions passed laws requiring helmets on bike riders under sixteen or eighteen. As of 1997, however, no state had a universal helmet law for bicyclists. But fifteen states have enacted half—a—loaf bike helmet laws, the first of which took effect in July 1992. This patchwork of legislation in- cludes statutes requiring helmets on people below the ages of eigh— teen (California), seventeen (Florida), sixteen (Alabama, Delaware, Georgia, Maryland, and Oregon), fifteen (West Virginia), four— teen (New Jersey and New York), thirteen (Massachusetts), twelve (Connecticut and Pennsylvania), and eight (Rhode Island). At least these laws do affect the largest group of people who ride bicycles— children and teenagers. And thus they represent a hopeful begin— ning—but only a beginning (and usually a lightly enforced one at that)—toward what should be mandatory helmet use by everyone who climbs onto a bicycle. Prevention is not limited to drivers and passengers of cars, bikes, and motorcycles. Other innovative efforts include a model program by Seattle’s Harborview Injury Prevention and Research Center (HIPRC)—a collaboration between the Harborview Medical Cen- ter and the University of Washington Medical School and School of Public Health and Community Medicine—to encourage horse— back riders to wear helmets. HIPRC helped to design an improved Hope on the Horizon . 60 . equestrian helmet that costs only half the price of earlier models; it also aided in a promotion supplying discount coupons for the hel— mets. And it assisted in forming a national coalition of more than a dozen organizations—among them the American Academy of Pediatrics, the US. Combined Training Association, 4—H, the US. Pony Club, and the national SAFE KIDS campaigns—to encourage use of equestrian helmets. Indeed, amongthe most hopeful events of the past decade or so is the creation of injury prevention and research centers like the one in Seattle; there are seven others nationwide. These organiza— tions research the causes and effects of injuries and then attempt to apply what they learn toward developing community programs that can stop injuries before they happen. Take, for instance, the all-too-frequent tragedy of kids being hit by cars, a dispiriting staple of local television’s evening news broad— casts. In most US. cities and in the country as a whole, such car— pedestrian accidents kill more children from ages five to fourteen than do any other type of accident, and they leave many other kids living with the often—debilitating consequences of traumatic brain injury. But it is no longer the top cause of death for such youngsters in Seattle. The reason is the enlightened efForts of HIPRC’s Preven- tion and Health Promotion Section, where researchers develop and evaluate injury—prevention strategies, institute programs, and also spread the word about how often certain injuries occur and how much they cost, both economically and in human suffering. To grapple with the problem of children being hit by cars, the researchers first studied a number of Seattle’s previous fatal car— pedestrian accidents involving children. The aim was to find out exactly who was most at risk and why. The researchers discovered that frequently drivers couldn’t see the children or had an ob- structed view prior to hitting them. And they also learned that about half the preschooler pedestrians killed by cars were struck at Hope on the Horizon . 61 . home—in the garage or driveway. Moreover, when the researchers interviewed parents, they found that the parents usually thought that their kids were much more Streetwise about cars and trafl‘ic than the researchers determined the children actually were. Armed with this evidence, the researchers designed a compre— hensive child-pedestrian safety program. The cornerstone of this venture is an instructional plan used to teach street safety to kids in elementary schools, one which involves parents in the project. The program works. Research shows that it does improve children’s ability to cross Streets safely. The HIPRC researchers also found that children living in apart— ment complexes, housing projects, and similar multifamily dwell— ings were nearly six times more likely to be hit by a car than were kids living in single-family residences. Such multifamily com- plexes, they discovered, often lack sufficient playground space and also tend to be located in areas with busier streets, higher speed limits, and denser on-street parking. Working with the Seattle police and the city engineering depart— ment, the researchers recommended traffic safety measures aimed at improving pedestrian safety at crosswalks, where 30 percent of the pedestrian accidents in Seattle occur. The engineers put up new warning signs. The police strictly enforced laws requiring drivers to stop when pedestrians were in crosswalks and issued a record num— ber of forty-seven—dollar traflic tickets when drivers didn’t stop. Yet the four-year project demonstrated that the hardest thing to change is drivers’ reckless behavior. By the end of the study, many drivers were still whizzing through crosswalks while children were in them. Despite that hitch, which shows the need for more innovative strategies or stiffer fines and tougher policing or both, there is no doubt that, overall, Seattle’s program for teaching kids to be safer pedestrians saves children’s lives and prevents many traumatic brain injuries. For that reason, the program—which is available on Hope on the Horizon . 62 . computer disc from HIPRC—is endorsed by the National Highway Traffic Safety Administration and the federal Bureau of Maternal and Child Health. But the program is also an admirable, working example epitomizing the central mission and message of all eight injury prevention centers around the country, which together are working to explode the myth—and it is a myth—that nothing can be done to prevent accidents. “Simply put,” as the Seattle center tells a public that is still all too indifferent, “the primary cause of accidents is our fatalistic acceptance of them.” Hope on the Horizon I o ...
View Full Document

This note was uploaded on 08/02/2011 for the course UGS 302 taught by Professor Staff during the Spring '08 term at University of Texas at Austin.

Page1 / 22

Chapter 3_Hope on the Horizon_pp 42-63 - ~three- Hope on...

This preview shows document pages 1 - 22. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online