While there is hope, there is life.
|
| L'espoir fait
vivre. While there is hope, there is life. |
It also seems fair to conclude that major reductions in the traffic accident loss per person-hour or person-year, and thus per head of population, have not been achieved by interventions in the form of training, engineering or enforcement. This has been clearly documented in other chapters, notably Chapters 5 through 8. Although some of the interventions of this kind may have been capable of reducing the traffic accident rate per unit distance driven, or the number of accidents at a particular location, these interventions do not seem able to achieve a reduction in the accident rate per time-unit of participation in traffic, or per person-year in the population. Such measures may be useful in allowing people to drive more accident-free kilometres per hour of road use and per year of life, but they fail to add years to their lives. This failure, too, can be understood as being a consequence of the mechanisms postulated by Risk Homeostasis Theory.
The theory says that a nation's accident rate per head of population is the outcome of a closed-loop control process. In this process, fluctuations in the accident rate determine fluctuations in the degree of caution people subsequently apply in their behaviour. And fluctuations in the degree of caution are the cause of the ups and downs in the nation's per capita accident rate. We have also seen that potentially occurring fluctuations in the accident rate are greatly reduced by people's ability to anticipate the potential consequences of health and safety interventions of the technological--read "non-motivating"--kind. Feedback, together with anticipation, leads to adaptive behaviour which has a stabilizing (not a reducing) effect on accident risk. The homeostatic nature of the "accident-production" process implies that a jurisdiction's ability to reduce the accident rate per head of population depends upon that jurisdiction's ability to reduce the amount of risk people choose, accept, prefer, tolerate--their target level of risk, in short.
As we have seen from the previous chapter, incentives for safe performance are able to reduce the accident rate per person-hour of participation in the risky activity. Effective treatment of the problem is directed at its cause, not at its symptoms, while treatment of symptoms provokes symptom substitution. It is not difficult to conceive of effective measures for safety and health insofar as these are dependent on human behaviour, once we have liberated our reasoning from the tyranny of the delta fallacy first mentioned in Chapter 1. By obstructing the channels, one cannot prevent the water that flows through a river delta from reaching the ocean. The solution has to be found upstream. One cannot reduce the accident rate and the lifestyle-dependent damage to health by piecemeal measures that fail to affect the superordinate cause.
Sometimes the delta fallacy is obvious and displayed in simple terms, for instance, in the belief that clearer edge-markings will reduce the highway accident rate in a population. At other times, the fallacy is shrouded in a more complicated argument that has at least the appearance of sophistication.
As an example, consider the type of reasoning that has been put forward to demonstrate the life-saving benefit of seatbelt legislation. Accident analysis in the USA has shown that, in years prior to mandatory seatbelt use, about half as many front-seat passenger-vehicle occupants, who had their seatbelts buckled, were killed in their collisions as compared with front-seat occupants, involved in collisions of similar impact, but who were not wearing their seatbelt. Thus, assume that seatbelts, when worn, are about 50% effective in preventing a fatality. Now compare the numbers of front-seat occupants killed in collisions before and after seatbelt wearing became compulsory. On the basis of the numbers killed who had their seatbelt on, an estimate is made of how many front-seat occupants must have survived their collisions due to using their belts (i.e., about the same number). Finally, show that there has been an increase in seatbelt wearing as a result of the legislation, and the number of people "saved by the seatbelt legislation" can be calculated.[1]
In one study, this type of reasoning led to an estimate of some 7,000 lives saved in the USA during the five-year period between 1983 and 1987.[2] Here, the delta fallacy is reflected in the tacit, but faulty, assumption that seatbelt legislation only influences the seatbelt-wearing rate, while no other aspect of driver behaviour is affected. On the basis of factual data, it may be further noted that the number of fatally injured seatbelt-wearing front-seat occupants in passenger vehicles increased more than six-fold, from 714 in 1983 to 4,709 in 1987. The percentage of fatally injured front-seat occupants of passenger vehicles relative to all traffic fatalities rose slightly, from 63.7 to 65.1%. In the same period, the total number of traffic deaths per annum rose from 41,609 to 45,406, which is equivalent to an increase of about 9%, or about 2% per year (and about twice as fast as the population growth). Note that the data are presented in the very same US government report that claims that thousands of lives were saved!
So, where is the evidence for the thousands of lives that were supposedly saved by the seatbelt legislation? When we rid ourselves of the delta illusion, what we see instead is an increase in lives lost. This increase may be related to the drop in the unemployment rate that occurred in that period (see Section 5.4 and Figure 5.1). Another possible explanation is that we are dealing here with yet another case of seatbelt legislation leading to an increase in accident frequency. This is what seems to have taken place in various other countries. Evidence has been presented in Section 8.2 which also suggests why this may be so.
The traffic safety issue described above has its analogue in the area of health. In discussions of deaths in relation to unhealthy habits and lifestyles, it is not uncommon to read statements to the effect that, in a given country, so many thousands of people per year die as a consequence of being overweight, or sexually contracted disease, or cigarette smoking. Obviously, if we take an estimate that 10,000 people per year die as the result of smoking-related illness, it cannot logically be inferred that the country would count 10,000 more citizens at the end of the year if these 10,000 people had never smoked.
Although risk homeostasis theory is not only concerned with accidents, but lifestyle-dependent disease and death as well, this book has included rather little evidence for its validity in that area. This is because of a dearth of definitive data. The number of people who die in accidents can be assessed with a relatively high degree of accuracy. It is, however, much more difficult to determine with a similar degree of certainty how many people die prematurely as a result of smoking, sunbathing, consuming too much alcohol, being overweight or underweight, being sexually promiscuous, having too little or too much physical exercise, and so on. There are simply too many other factors at work at the same time, factors of unknown degrees of importance and over which the individual has no direct control. These factors include genetic predisposition, environmental conditions (including pollution as well as threats posed by nature itself), and bacteria and viruses.
Offering a person a reward for not having an accident in the future implies offering that person a reason for looking forward to the future with increased expectations. Therefore, it also amounts to motivating that person to be more careful with life and limb and to take the measures necessary to be alive and well when that future comes.
As an alternative to the traditional "Triple E" (Engineering, Education and Enforcement) ideology for increasing safety--an ideology that we have seen to be rather ineffective in reducing the accident rate per head of population--a "Single E" approach is being suggested for the purpose of reducing the accident rate per head of population: "Expectationism".
Expectationism is the name of the preventative strategy for reducing the accident rate and lifestyle-dependent disease and death rate per head of population by enhancing people's perceived value of the future.[3] It comes in two varieties, and these may be called "specific" and "general". A specific expectationist strategy demands that a person fulfill a particular requirement at some future point in time, such as not having been at fault in a road accident or not suffering from alcohol-related cirrhosis of the liver, not suffering from smoking-related respiratory disease, or some other specific criterion of health. The "general" variety sets no detailed criteria; all a person has to do to receive the reward is to be alive at that future date at which the incentive has been promised to materialize.
Consider, as a very simple example of general expectationism, a society in which every citizen is promised that upon reaching the age of retirement, a sum of money that equals five or ten times the average annual wage, in addition to current pensions and old-age benefits. It would seem reasonable to expect that this prize would stimulate people to use and develop their survival skills in such a way that more people than presently is the case will reach that age and be fit enough to enjoy the bonus.
The amount of money to be paid out in this example may appear large, but the benefit may well be found to be larger still, if one considers the amount of money that could be saved. The savings would take the form of reduced costs of medical care, physical damage and disability compensation, as well as a reduction in the current economic loss due to forgone wages and a person's contribution to the gross national product. Consider, too, the savings that would accrue to a nation if governments no longer relied on safety legislation, engineering technology, enforcement practices and educational measures of various kinds. These represent large expenditures, but fail to reduce the accident rate per capita to a significant degree, as we have seen from the available evidence.
Additional benefit would come from a reduction in the social cost of violence. To be violent is to run a major risk to one's life or health, because of the damage that the perpetrator may incur in attacking another person. So, expectationism also holds the promise of reducing violence, not just accidents and lifestyle-dependent diseases.
With respect to accidents and violence, it is interesting to consider the statistics concerning the "violent death" rate in industrialized nations during the first three quarters of this century. The notion of violent death includes three categories: fatal accidents of all kinds (not just in traffic or in industry), homicide and suicide. Data from 31 different countries around the globe--in Europe, the Americas and around the Pacific--have been collected[4] and may be compared. Such comparisons should be made with care because countries' populations differ from one another in their gender and age-group proportions, and these proportions may change over time within any given country. The greater the proportion of young males to the total population, the higher the violent death rate one might expect, other things being equal. Therefore, in order to insure fairness of comparisons between countries at any point in time and within the same country across different time periods, it is necessary to take account of any variations in the gender and age contingents in the populations. This is achieved by "correcting" the mortality statistics for variations in the gender-by-age distributions, and obtaining what are called standardized mortality ratios.
What is remarkable about these standardized mortality ratios due to violence is their pattern from roughly 1900 to 1975 (unfortunately, no comparative tabulations have been published since that time). This pattern shows that, if periods of war are disregarded, the ratios have changed remarkably little--those in the first decade of this century and in 1975 are virtually the same![5] The violent death rate appears to have been remarkably impervious to the improvements in medicine and the modifications in education, engineering and legislation that have been introduced in that period. Note that the human-made environment over this time period has changed dramatically, almost beyond recognition. We can look at old photographs or motion pictures for evidence of this. And note, in particular, that there were very few automobiles around in the first decade of this century while, in the 1970s, traffic deaths were responsible for about one-half of all accidental deaths. The data presented in Section 5.3 suggest that the introduction of the automobile has not even had much influence on the violent death rate as far as traffic is concerned. So, neither the appearance of the automobile, nor the various road and vehicle engineering improvements ever since, seem to have had a major impact on the violent death rate. As far as road fatalities are concerned, Figures 5.2, 5.3 and 5.4 also fail to show a downward trend.
This general pattern of findings may be surprising at first. This is not because the mortality ratios due to accidents and violence were so high in the beginning of this century, although there were very few automobiles around. According to risk homeostasis theory, the presence or absence of these vehicles has little bearing upon the per capita accident rate anyway. The massive advances made since the early 1900s in the design of roads and vehicles, in education, in safety legislation, in medicine and so forth, should not have made a difference either. According to RHT, such interventions may well influence the specific form of risk taking, but would not be expected to influence its overall level. These measures are not motivational in nature and thus fail to influence the target level of risk. In other words, they fail to enhance the desire for health, safety and a longer life.
Instead, there is the remarkable stability of the standardized violent mortality ratios, a stability which is puzzling indeed. It conflicts not only with a general belief in progress (a belief that may be cherished rather than founded in fact), but, more importantly, with a perception that the value of the future has improved over the first 75 years of this century. Pensions have improved; so has housing and health care for the elderly, the poor and the disabled; and many other forms of social legislation have been introduced in both "leftist" and "rightist" countries. These measures should have given citizens in these countries reason to look forward to the future with greater confidence and expectations, with an increased sense of control over their lives, and with more hope.
There is reason to believe that the perceived value of the future has increased. And the puzzle concerning standardized violent mortality ratios may possibly be resolved by considering that another factor has been at work, a factor that favours the taking of accident risk and that has become more prominent during the course of this century. This factor is the perceived value of "present time", time here and now. If present time is highly valued, that is, if every minute counts, people will be likely to speed, to cut corners and take short cuts, to jump lights, to rush to their destination. They will focus on performance and productivity, disregarding safety precautions that would slow them down or otherwise interfere with earning immediate benefit. Higher wages for greater productivity, piecework, generous overtime pay, economic booms (see Section 5.4), and so on, are all reasons for accepting greater accident risk. The target level of accident risk in the population would thus be expected to rise with increases in the value of present time. This century has seen major increases in wages, commissions and salaries. Although the perceived value of the future may have increased, so did the perceived value of the present. If both factors increased by the same degree, no change in the violent death rate would be expected.
Therefore, from the point of view of accident prevention and the provision of health (insofar as this is dependent on lifestyle), it may be more fruitful to consider the perceived value of the future relative to the perceived value of the present. The greater the former in comparison to the latter, the more cautious a person would be expected to be. A study of Québec motorists that used this conceptualization found that individuals who were characterized by a comparatively high valuation of the future had more favourable attitudes to automobile safety, fewer demerit points, and fewer road accidents.[6] American university students with a stronger future orientation have been found to refrain more often from smoking cigarettes.[7]
These studies support the notion that habits beneficial to health and safety are more common among people who hold the future in high regard. It should also be noted, however, that the measurement procedures left something to be desired, and that the findings do not deliver proof that interventions that increase the value of the future relative to the present really do lead to a longer lifespan.[8] All that is supported by firm evidence is that deliberate enhancement of the value of the future, through the implementation of incentives for accident-free task performance, does, in fact, reduce the accident rate per person.
Interestingly, having greater hope for the future does not only appear to stimulate people to adopt a safer and healthier way of life, but it also seems to increase people's resistance to physical diseases that may or may not be dependent on lifestyle. Numerous studies have already established that people with an optimistic view of the future also have a better-functioning immune system.[9] Moreover, there is experimental evidence to suggest that an intervention that is capable of making people more optimistically-minded, can also improve their immune function.[10] This leads to the striking proposition that hope helps people live longer, not just because it motivates them to make decisions that are conducive to health and safety, but also because it stimulates the effectiveness of their physiology in fending off physical disease!
Thus, it would seem worthwhile to consider what modifications could be made to our society so that citizens would have more reason to look forward to their next birthday, their next decade and their later years, than currently is the case. How can helplessness be reduced and a sense of learned hopefulness be instilled in the minds of the nation? What steps might be undertaken towards the establishment of a "safety culture" or, rather, a "health and safety culture"? Here are some simple suggestions. For children and teens increase the weekly allowance at every birthday. Reduce tuition fees for college and university students for subsequent years of study. Increase the legal minimum wage for people as they become older. Provide longer annual holidays as employees become older. Make wages and salaries, as well as job security, more dependent on years on the job. Provide greater tax advantages and insurance discounts for people as they grow older. Offer incentives for saving money and retirement plans, so that people are stimulated to contribute to the monetary value of their future. Take measures that reduce people's fear of becoming a burden upon others, or of being neglected, abused or lonely in their sunset years. Offer older people more opportunity to live in their familiar surroundings. Make euthanasia more widely available to those who want it; for many people, its availability diminishes the dread of a dolorous and undignified death, and thus enhances confidence in the future and the desire to live. So, paradoxically, then, life may be lengthened by the prospect of a hastened yet merciful death.
Expectationism is "green". The focus is on saving, not on exploitation. With respect to life, the focus is on caution, not on daring. With respect to finance, the focus is on saving, not on spending. In short, the recurring theme of expectationism is "saving for later". One factor that contributes to the benefit of saving for later is a livable environment: a clean and green ecology and the availability of natural resources. With a sharpened focus on the future, a society is more likely to protect the environment against misuse for short-term profits.
Expectationism, however, not unlike the ideological "isms" in the political arena that range from "radical socialism" to "savage capitalism", may also bring its own problems. For instance, in an expectationist utopia, the older segments in the population will be more numerous, more prosperous, more powerful, and thus more influential. This entails the dangers of a "gerontocracy", a "rule by seniors", with increased conservatism, a stronger desire to maintain the status quo, and a weaker tendency to explore novel approaches to solving social problems. If there exists a genetic propensity towards risk taking, this will become more widespread throughout the population. This is because people with "risk-taking genes" will be more likely to survive to the age of parenthood, and thus more likely have offspring than currently is the case. The proportion of "risk-taking genes" in the human gene pool would increase as a consequence. Thus, society would become increasingly dependent upon expectationist measures for the maintenance of health and safety, just as the health and fitness of more recent generations have become increasingly dependent upon medical know-how and intervention.
As we have argued, values can be altered through change towards a social order that we have called expectationist, because of its emphasis on giving people reason to look forward to the future with a stronger sense of control, with greater confidence and more hope. Bringing about such a social order engenders benefits, but it also involves costs. The desirability of a human condition that favours cautious health and safety habits depends on human values. The willingness to take action towards the creation of such a condition depends further on the perceived effectiveness of the available means toward that end.
This book has been written in an effort to explain why traditional interventions are not effective and why some innovative ones are. Wider realization that the traditional ways do not work may stimulate willingness to innovate. Wider awareness of the effectiveness of alternative approaches to health and safety may increase willingness to debate the merits of limited or even society-wide implementation of expectationist measures against lifestyle-dependent death and disease, as well as against violence and abuse of the environment. Waiting for Godot will draw to a close. Who knows, Godot may come. And if that does not happen, let it be because we, the nation's people, have decided that Godot is not really all that welcome.
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