Map of life expectancy at birth from Global Education Project.

Wednesday, April 29, 2009

Book Review

While we Were Sleeping: Success stories in injuries and violence prevention

David Hemenway. University of California Press. 2009

(The publisher was kind enough to send me Dr. Hemenway's book to review.)

David Hemenway, of the Harvard Injury Control Research Center, is a great champion of the public health ethos. The title of his new book, based on a Grimm fairy tale about a shoemaker who got unexpected help from elves in the middle of the night, reflects his observation that the huge reductions in our risk of injury over the past century have gone largely unrecognized. Indeed, he makes the broader point that our overall gains in life expectancy and health status are largely attributable to public health measures rather than medical intervention. I am particularly grateful to him for providing the original source of the well-known public health fable about the ambulance at the foot of the cliff, stationed at great expense to catch the people who fall while no-one can be bothered to put up a fence or a warning sign. (It's a poem by one Joseph Malins, dated 1895.)

Hemenway says that the target audience for his book is not his students, but their parents: he wants the world to know how much we have all benefited from the largely unheralded struggles of mostly little-known people. There are exceptions: Ralph Nader is among the heroes he profiles. But most of his subjects are indeed less than famous. The book is organized into chapters on various compartments of daily life -- riding in cars, work, play, hanging out around the house, natural disasters, etc. Each chapter consists of a set of brief histories of some policy, technical, or practice innovation that reduced injuries from one or another cause, followed by two-page professional biographies of three or four people who worked to bring about some of these changes.

Without a doubt, the method is effective at making the case that if we approach injuries as predictable events with ameliorable risk factors and consequences, rather than our folk perception of most injuries as random events, we can adjust the world so as to make them less probable or less harmful; and that doing so often looks, after the fact, like plain common sense. For example, we take guardrails along the highway for granted but somebody had to figure out that they were a good idea and do the engineering research to come up with the most effective models and configurations. In the old days, hockey goalies didn't wear masks. Duhh. And so on.

As you read through example after example, you will have a hard time clinging to a dogmatic belief that government regulation necessarily impairs our liberty or strangles economic productivity. Hemenway has deliberately chosen only examples for which clear evidence of cost-effectiveness is available. Few will retort that we should tolerate having little kids horribly burned for the sake of slightly cheaper pajamas, or blinded or brain damaged for the liberty interest of being allowed to throw lawn darts instead of horseshoes. Ideological libertarianism just ends up collapsing under the weight of a thousand bricks of truth.

I'm sorry to have to say, however, that I don't think Dr. Hemenway's students' parents are going to be able to finish the book, at least not without needing to deglaze their eyeballs afterwards. As a literary experience, it's like a 27 course meal consisting of boiled beets, boiled cabbage, boiled broccoli, boiled carrots, boiled squash, boiled spinach, boiled celery . . . Every course is good for you, not hard to eat, but relentlessly similar and insufficiently seasoned. Every scenario has to conclude with a little Aesop-like moral, e.g. "Roads can be made more or less safe," "Data are crucial both in highlighting the problem and in evaluating the effectiveness of interventions," "Sometimes the crucial step is to recognize that something can be done." These banal morals are chosen largely arbitrarily. Any one of them could apply to many, if not all, of the fables, while each fable could have been the basis for 15 different morals.

The mini-biographies are equally in need of salt. When I read in the preface that I could expect a biography of Ralph Nader, I got interested. I knew Ralph as a youth, and he is a very interesting character, not to mention extremely controversial. Before his flameout in the past decade, he was a major fighter in many a D.C. steel cage match. But Ralph's life story, like all the rest of them, is basically presented as the story of somebody noticing that it would be a good idea to do something (in Ralph's case, make cars more crashworthy), and then eventually talking people into doing it. The existence of politics, and controversy is grudgingly acnkowledged where it is absolutely inescapable, but you can read the entire book without even getting a vague impression that there is a conservative, corporatist politics in this country driven by greed and self-interest.

Hemenway never really grapples head on with the major ideological controversies and political conflicts at the center of public health: the putative tensions between liberty and equality, security and freedom, economic and social values; the struggles of class, diffuse vs. concentrated interests, the powerful and the weak, the idealist and the cynic. There is in fact great drama and real moral interest in these stories, not just the common sense lessons and simple inspiration he draws for us.

I suspect that Dr. Hemenway didn't give his students' parents enough credit for being able to grapple with big issues. He probably thinks that the most effective way to persuade is to avoid confrontation, and that might be true, but you need to get people to read the thing. A little more chili powder, please.

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