longer run, however, the prospect is so appealing that future research and experimentation should be strongly supported. Systematic research into alcohol control policy is only beginning, but its ultimate potential is too great to ignore. However, research on the cause of alcoholism as addictive behavior must also continue. The correlations between per capita consumption and alcoholism deaths due to cirrhosis do not prove the causal factors in addictive behavior in a portion of the exposed population. Before any alternative policies are rejected, it is necessary that we know more about the causes of the behavioral relationships they presuppose.
Bruce C. Vladeck, PhD Assistant Professor of Public Health Robert J. Weiss, MD Director Center for Community Health Systems Columbia University New York REFERENCES 1. Beauchamp, D. E., Public Health: Alien Ethic in a Strange Land? (Commentary). Am. J. Public Health 65:1338-1339, 1975. 2. Beauchamp, D. E. The Alcohol Alibi: Blaming Alcoholics. Transaction 98:12-17, 1975. 3. Ryan, W. Blaming the Victim. Vintage Books, New York, 1971. 4. Friedman, K. M. Cigarette Smoking and Public Policy (Editorial). Am. J. Public Health 65:979-980, 1975. 5. deLint, J. The Prevention of Alcoholism. Prev. Med. 3:24-35, 1974. 6. Schmidt, W., and deLint, J. Estimating the Prevalence of Alcoholism from Alcohol Consumption and Mortality Data. Q. J. Stud. Alcohol. 31:957-964, 1970.
7. Terris, M. Epidemiology of Cirrhosis of the Liver. Am. J. Public Health 58:5-12, 1968. 8. Popham, R. E. Indirect Methods of Alcoholism Prevalence Estimation: A Critical Evaluation. In Alcohol and Alcoholism, edited by Popham, R. E. Addiction Research Foundation, Toronto, Ontario, 1970. 9. Brenner, M. H. Trends in Alcohol Consumption and Associated Illnesses. Am. J. Public Health 65:1279-1292, 1975. 10. Wilkinson, R. The Prevention of Drinking Problems. Oxford University Press, New York, 1970. 11. Niskanen, W. A. Taxation and the Demand for Alcoholic Beverages. The RAND Corporation, Santa Monica, 1960. 12. Efron, V., Keller, M., and Gurioli, C. Statistics on Consumption of Alcohol and on Alcoholism. Rutgers University Press, New Brunswick, New Jersey, 1974. 13. Cahalan, D., Cisin, I. H., and Crossley, H. M. American Drinking Practices. Social Research Group. George Washington University, Washington, DC, 1967. 14. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch.X. U.S. Government Printing Office, Washington, DC, 1974. 15. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. V, Pt. 4. U.S. Government Printing Office, Washington, DC, 1974. 16. Light, D. Costs and Benefits of Alcohol Consumption. Transaction 98:13-24, 1975. 17. U.S. Department of Health, Education, and Welfare, Assistant Secretary for Health. Forward Plan for Health, 1976-1980. 1974. 18. Public Law 93-641, Sec. 1502 (10), 1974. 19. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. VI. U.S. Government Printing Office, Washington, DC, 1974. 20. Chafetz, M. E. Introduction. In Alcohol and Health: New Knowledge. National Institute on Alcohol Abuse and Alcoholism. U.S. Government Printing Office, Washington, DC, 1974.
PERSPECTIVE ON A CURRENT PUBLIC HEALTH CONTROVERSY Numerous controversies have marked the evolution of improvements in the public's health, many major ones having centered on whether individuals must do something themselves to avoid damage from everyday environmental hazards, or whether available actions should be adopted that extend protection to all. The public and professional turbulence about whether smallpox, cholera, typhoid, and childbed fever could and should be controlled are early illustrations. The means of such control have usually been the center of the storm. Examples include quarantines; inoculations; closing down contaminated wells; making obstetrics sanitary; pasteurization of milk; fluoridation of water; and, more recently, controlling some motor vehiclerelated injuries. In public health, as developing scientific knowledge makes possible the control of an environmental source of morbidity and mortality, attempts at control of the damage Dr. Haddon is President of the Insurance Institute for Highway Safety, Washington, DC, and headed, in 1966-1969, what is now the National Highway Traffic Safety Administration. 1342
AJPH DECEMBER, 1975, Vol. 65, No. 12
to people often center initially on modifying or stimulating actions of individuals. Typically, this proves to be a nuisance and insufficiently successful. Later, more effective community-wide measures are often chosen, usually requiring decisions to mandate the necessary environmental changes. These work better because they protect everyone, and because, coming later, they are usually built on more advanced knowledge. Evolution from obstrusive to unobtrusive protective mechanisms is characteristic in our society. And each transition requires technical expertise on the issues. A wide variety of factors complicates this transition. Not the least of these are opposing special interests and the customary presence of misleading folklore concerning the measures involved, especially with respect to the safety, reliability, and efficacy of the proposed measure. Controversies centering on measures for controlling damage from environmental hazards typically go on for decades-until society becomes sufficiently informed to take corrective action. Dr. Leon Robertson's paper, "Safety Belt Use in Automobiles with Starter-Interlock and Buzzer-Light Sys-
tems" (in this issue), contributes facts in a current evolution and controversy of this type. When Hugh DeHaven, working at Cornell Medical College, demonstrated in a landmark paper in 19421 that it was the physical environment impacted rather than the causes or velocities of impacts that determined severity of injury, he started a complex chain of events, and subsequently showed that people could be successfully "packaged" in transit.2 This led to many improvements in passenger "crash-packaging," including the provision of several types of belts. Attempts to get everyone to use them have followed. In the United States, these attempts have included electrical "interlocks"-systems designed to preclude starting of the vehicle unless driver and front seat passenger are belted. But, as Robertson documents, high percentages of such systems are deliberately circumvented. In Victoria, Australia, beginning in December, 1970 and spreading throughout the country, use of seat belts, where present, was required by law with certain exceptions. Urban use reportedly exceeded 70 per cent, rural use 60 per cent, and significant drops in morbidity and mortality followed.3 Many other countries have since adopted such laws; unfortunately, reliable compliance data are not available. At the present time, there is no federal statutory authority in this country requiring the use of belts, although belts have been required by law in all ordinary seating positions in cars sold in the U.S. since 1968. This seeming paradox results from the Constitution's granting authority to the federal government to regulate interstate commerce (such as shipments of new vehicles and hence of their characteristics), and reserving to the states many police matters (commonly interpreted to include possible belt-use laws). Despite years of attempts by belt manufacturers and a variety of others, no state nor other comparable jurisdiction of the United States, except Puerto Rico, has enacted such a law. And, even in Puerto Rico, the law's objective was not achieved. (Compliance with the law, enacted in January, 1974, reached 24 per cent, but dropped to 10 per cent by October, 1974.4) In the wings are "air bags," the automatic crash injury protection devices that the U.S. Department of Transportation (DOT) has been pushing since July, 1968. Analogous to fuses, safety valves, sprinkler systems, and other unobtrusive protective devices that activate in emergencies, air bag systems have had more than one hundred million miles of phenomenally successful performance on U.S. roads.3 Based on decades of sophisticated design evolution and technology, including aerospace approaches (for example, redundant circuitry), air bags respond in a few milliseconds to crash onsets, inflating between vehicle occupants and structures on which they would otherwise impact. Decelerative forces are spread more broadly and gently over the body than with belt systems. Air bags require no technical understanding, no habits, no motivation, no compliance with or fear of legal sanctions, nor any action by vehicle occupants. They deploy only in severe crashes, not in those of minor violence. They are not visible before deployment. Present designs cover the range of the most important kinds of injury-producing crashes-
from head-on to at least 30 degrees to both sides. According to a former senior automobile industry executive in charge
of development, the total "lifetime cost" per vehicle,* when mass produced, is estimated as $171 for full size cars, to protect people in front seats, the principal occupants killed in crashes; the corresponding figure is $140 for small cars.6 Comparable costs for presently required belt restraints are $101.50 and $87.60, respectively.6 DOT concludes that, compared even with 100 per cent belt use, air bags have superior ability to reduce fatal and other injuries, especially in high speed impacts.7 About 65 per cent of U.S. vehicle crash deaths result from impacts in rural areas. Thus, even if the Australian rural belt use rate of 60 per cent could somehow be equaled, the belt approach in the U.S. would be an inadequate solution. Many makers of cars sold in the U.S. have produced or designed cars with air bags to protect front seat occupants. Yet the systems "remain on the shelf." Only one manufacturer sells cars so equipped (as an option); it has only meagerly advertised them, and has not made them routinely easy to purchase. Moreover, these cars are exclusively large and expensive, and this optional equipment will probably be discontinued after the 1976 model year. However, one importer is testing a fleet of air bag cars in the U.S., and they may be available in this country from various sources during the next few years. The controversy has a fascinating and complex mix of pieces. In illustration: after required regulatory steps amounting to administrative due process, DOT issued a standard in 1970 requiring "passive restraints" effective January, 1973. "Passive" refers to automatic systems requiring no user action. Since DOT must by law specify only the "performance" which manufacturers must provide, it could not require air bags, a "design" approach, but merely specified the maximum allowable crash forces on test dummies in crashes of specified severity and type (i.e., 30 miles per hour forward into a solid barrier). Although there are other possible ways of spreading crash forces, this is easily achieved with air bags. Hence, the air bag is commonly the center of the debate. In sharp contrast, the federal belt standard does not deal with the forces produced by belts on test dummies in crashes, merely with belts' minimum strength when pulled on in a static test. Moreover, numerous experts believe that even the best designed belt systems, although offering substantial crash restraint, cannot reduce crash forces sufficiently to compete with air bags in reducing injury. Subsequently, DOT changed its position and, although still allowing passive systems, required that other cars could not be started unless the right and left front seat passengers' belts had been moved in certain ways-which resulted in use of the so-called interlock. DOT was also taken to court. The decision upheld the agency's right ". . .to impel automobile manufacturers to develop and apply new tech* "Lifetime cost" includes manufacturers' and dealers' profits, "cost of replacing expended components on repairable vehicles and incremental fuel costs required to carry . .. related weights."6
EDITORIALS
1343
nology to the task of improving the safety design of automobiles as rapidly as possible."8 The court told the agency, however, that it must revise the test specifications used to determine compliance with its injury reduction criteria. The belt versus bag option was perpetuated; and requirement for a completely passive system was still in regulatory limbo when this Journal went to press. Action up to this point having centered primarily in executive and judicial branches, the controversy next erupted in the House and Senate. The Congressional battle was complex. Opponents of the attempt to repeal the DOT interlock standard alleged that although the standard had been forced on the agency in 1971 to forestall passive restraint requirements, it was far better than nothing until such time as air bags would be required. Interlock opponents also wanted to prohibit DOT from ever mandating air bags.9 After rapid maneuvering, the House voted 337 to 49 in August, 1974 to accomplish both-repeal of the interlock and the banning of mandatory passive restraints. In the Senate, much debate and maneuvering separated the interlock and air bag issues. As a result, the bill which the President signed in November, 1974 banned interlocks but took no position on air bags other than requiring a hearing, and reserving to the Congress for 60 days the right to vote on any passive restraint standard the agency may issue in the future.'° The Wall Street Journal summarized well the two principal issues: first, "while the congressional desire to scrap the interlock is easily understandable, puncturing the air bag at the same time would ill serve the cause of highway safety," and second, "although some of the opposition to the air bag stems from its own peculiar features, much of the dislike derives simply from hatred of the interlock . . there are plenty of differences between the two devices . . . the interlock forces people to do something for their protection, while the air bag doesn't . . . the bag is no more an unwarranted governmental intrusion on individual rights than building codes which require electrical fuses or circuit breakers in homes. Like the bag, these devices work in a crisis, not otherwise, and hassle nobody. Also, like the bag-and unlike belts, with or without the interlock-they protect about everybody, not just those who take some special action."'"
Tragic human wastage has resulted from years of unnecessary delay. An average of more than 10,000 persons a day are injured in all kinds of motor vehicle crashes in the U.S., and tens of thousands die each year. 12 Considering the time required for regulatory steps, administrative and judicial appeals, Congressional review, and minimum production lead time, the regulatory and implementation process and debate will go on for years, at best. Thus, one of the most important health issues in the nation's history hangs in uncertainty and delay. William Haddon, Jr., MD President, Insurance Institute for Highway Safety
REFERENCES 1. DeHaven, H. Mechanical Analysis of Survival in Falls f'rom Fifty to One Hundred and Fifty Feet. War Med. 2:586-596, 1942. 2. DeHaven, H. Accident Survival-Airplane and Passenger Automobile. In Accident Research: Methods and Approaches. Haddon, W., Jr., et al., Harper and Row, New York, 1964. 3. Foldvary, L. A., and Lane, J. C. The Ef'fectiveness of' Compulsory Wearing of' Seat Belts in Casualty Reduction. Accident
Anal. Prev. 6:59-81, 1974. 4. Insurance Institute for Highway Safety. Belt Use in Puerto
Rico. Status Report 10(10):4, 1975. 5. Robertson, L. S. Motor Vehicle Occupant Restraint Use and Eff'ectiveness in Real-World Crashes. Insurance Institute for Highway Safety, Washington, DC, 1975. 6. DeLorean, J. Z. Occupant Restraint System Expenditure/ Benefit Study. Statement before the National Highway Traff'ic Safety Administration, Public Meeting on Federal Motor Vehicle Safety Standard 208-Occupant Crash Protection, Washington, DC, May 19, 1975. 7. National Highway Traffic Safety Administration and Transportation Systems Center. Analysis of Effects of' Proposed Changes to Passenger Car Requirements of' MVSS208. U.S. Department of Transportation, Washington, DC, 1974. 8. Chrysler u. DOT, 472 F.2d 659 (6th Cir. 1972). 9. Motor Vehicle and Schoolbus Safety Amendments of' 1974. Congressional Record, p. H8119ff, August 12, 1974. 10. 15 U.S. Code 1392 (i) (1) (A). 11. Karr, A. R. Will Congress Deflate the Airbag? Wall Street Journal, September 17, 1974. 12. U.S. Department of' Health, Education, and Welfare, Health Resources Administration. Current Estimates from the Health Interview Survey, United States-1973. U.S. Government Printing Office, Washington, DC, 1974.
LETTERS Letters are welcomed and will be published, if found suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words. 1344
AJPH DECEMBER. 1975, Vol. 65. No. 12
'LEGALESE' ON MATERNITY BENEFITS William J. Curran's observations on the implications of Geduldig v. Aiello with regard to the inclusion of
pregnancy- and childbirth-related benefits under future health programs are somewhat misleading. People who have not been trained in the law might well interpret Curran's article to mean that inclusion of pregnancy-related benefits in health
Bruce C. Vladeck, PhD Assistant Professor of Public Health Robert J. Weiss, MD Director Center for Community Health Systems Columbia University New York REFERENCES 1. Beauchamp, D. E., Public Health: Alien Ethic in a Strange Land? (Commentary). Am. J. Public Health 65:1338-1339, 1975. 2. Beauchamp, D. E. The Alcohol Alibi: Blaming Alcoholics. Transaction 98:12-17, 1975. 3. Ryan, W. Blaming the Victim. Vintage Books, New York, 1971. 4. Friedman, K. M. Cigarette Smoking and Public Policy (Editorial). Am. J. Public Health 65:979-980, 1975. 5. deLint, J. The Prevention of Alcoholism. Prev. Med. 3:24-35, 1974. 6. Schmidt, W., and deLint, J. Estimating the Prevalence of Alcoholism from Alcohol Consumption and Mortality Data. Q. J. Stud. Alcohol. 31:957-964, 1970.
7. Terris, M. Epidemiology of Cirrhosis of the Liver. Am. J. Public Health 58:5-12, 1968. 8. Popham, R. E. Indirect Methods of Alcoholism Prevalence Estimation: A Critical Evaluation. In Alcohol and Alcoholism, edited by Popham, R. E. Addiction Research Foundation, Toronto, Ontario, 1970. 9. Brenner, M. H. Trends in Alcohol Consumption and Associated Illnesses. Am. J. Public Health 65:1279-1292, 1975. 10. Wilkinson, R. The Prevention of Drinking Problems. Oxford University Press, New York, 1970. 11. Niskanen, W. A. Taxation and the Demand for Alcoholic Beverages. The RAND Corporation, Santa Monica, 1960. 12. Efron, V., Keller, M., and Gurioli, C. Statistics on Consumption of Alcohol and on Alcoholism. Rutgers University Press, New Brunswick, New Jersey, 1974. 13. Cahalan, D., Cisin, I. H., and Crossley, H. M. American Drinking Practices. Social Research Group. George Washington University, Washington, DC, 1967. 14. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch.X. U.S. Government Printing Office, Washington, DC, 1974. 15. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. V, Pt. 4. U.S. Government Printing Office, Washington, DC, 1974. 16. Light, D. Costs and Benefits of Alcohol Consumption. Transaction 98:13-24, 1975. 17. U.S. Department of Health, Education, and Welfare, Assistant Secretary for Health. Forward Plan for Health, 1976-1980. 1974. 18. Public Law 93-641, Sec. 1502 (10), 1974. 19. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health: New Knowledge. Second Special Report to the U.S. Congress, Ch. VI. U.S. Government Printing Office, Washington, DC, 1974. 20. Chafetz, M. E. Introduction. In Alcohol and Health: New Knowledge. National Institute on Alcohol Abuse and Alcoholism. U.S. Government Printing Office, Washington, DC, 1974.
PERSPECTIVE ON A CURRENT PUBLIC HEALTH CONTROVERSY Numerous controversies have marked the evolution of improvements in the public's health, many major ones having centered on whether individuals must do something themselves to avoid damage from everyday environmental hazards, or whether available actions should be adopted that extend protection to all. The public and professional turbulence about whether smallpox, cholera, typhoid, and childbed fever could and should be controlled are early illustrations. The means of such control have usually been the center of the storm. Examples include quarantines; inoculations; closing down contaminated wells; making obstetrics sanitary; pasteurization of milk; fluoridation of water; and, more recently, controlling some motor vehiclerelated injuries. In public health, as developing scientific knowledge makes possible the control of an environmental source of morbidity and mortality, attempts at control of the damage Dr. Haddon is President of the Insurance Institute for Highway Safety, Washington, DC, and headed, in 1966-1969, what is now the National Highway Traffic Safety Administration. 1342
AJPH DECEMBER, 1975, Vol. 65, No. 12
to people often center initially on modifying or stimulating actions of individuals. Typically, this proves to be a nuisance and insufficiently successful. Later, more effective community-wide measures are often chosen, usually requiring decisions to mandate the necessary environmental changes. These work better because they protect everyone, and because, coming later, they are usually built on more advanced knowledge. Evolution from obstrusive to unobtrusive protective mechanisms is characteristic in our society. And each transition requires technical expertise on the issues. A wide variety of factors complicates this transition. Not the least of these are opposing special interests and the customary presence of misleading folklore concerning the measures involved, especially with respect to the safety, reliability, and efficacy of the proposed measure. Controversies centering on measures for controlling damage from environmental hazards typically go on for decades-until society becomes sufficiently informed to take corrective action. Dr. Leon Robertson's paper, "Safety Belt Use in Automobiles with Starter-Interlock and Buzzer-Light Sys-
tems" (in this issue), contributes facts in a current evolution and controversy of this type. When Hugh DeHaven, working at Cornell Medical College, demonstrated in a landmark paper in 19421 that it was the physical environment impacted rather than the causes or velocities of impacts that determined severity of injury, he started a complex chain of events, and subsequently showed that people could be successfully "packaged" in transit.2 This led to many improvements in passenger "crash-packaging," including the provision of several types of belts. Attempts to get everyone to use them have followed. In the United States, these attempts have included electrical "interlocks"-systems designed to preclude starting of the vehicle unless driver and front seat passenger are belted. But, as Robertson documents, high percentages of such systems are deliberately circumvented. In Victoria, Australia, beginning in December, 1970 and spreading throughout the country, use of seat belts, where present, was required by law with certain exceptions. Urban use reportedly exceeded 70 per cent, rural use 60 per cent, and significant drops in morbidity and mortality followed.3 Many other countries have since adopted such laws; unfortunately, reliable compliance data are not available. At the present time, there is no federal statutory authority in this country requiring the use of belts, although belts have been required by law in all ordinary seating positions in cars sold in the U.S. since 1968. This seeming paradox results from the Constitution's granting authority to the federal government to regulate interstate commerce (such as shipments of new vehicles and hence of their characteristics), and reserving to the states many police matters (commonly interpreted to include possible belt-use laws). Despite years of attempts by belt manufacturers and a variety of others, no state nor other comparable jurisdiction of the United States, except Puerto Rico, has enacted such a law. And, even in Puerto Rico, the law's objective was not achieved. (Compliance with the law, enacted in January, 1974, reached 24 per cent, but dropped to 10 per cent by October, 1974.4) In the wings are "air bags," the automatic crash injury protection devices that the U.S. Department of Transportation (DOT) has been pushing since July, 1968. Analogous to fuses, safety valves, sprinkler systems, and other unobtrusive protective devices that activate in emergencies, air bag systems have had more than one hundred million miles of phenomenally successful performance on U.S. roads.3 Based on decades of sophisticated design evolution and technology, including aerospace approaches (for example, redundant circuitry), air bags respond in a few milliseconds to crash onsets, inflating between vehicle occupants and structures on which they would otherwise impact. Decelerative forces are spread more broadly and gently over the body than with belt systems. Air bags require no technical understanding, no habits, no motivation, no compliance with or fear of legal sanctions, nor any action by vehicle occupants. They deploy only in severe crashes, not in those of minor violence. They are not visible before deployment. Present designs cover the range of the most important kinds of injury-producing crashes-
from head-on to at least 30 degrees to both sides. According to a former senior automobile industry executive in charge
of development, the total "lifetime cost" per vehicle,* when mass produced, is estimated as $171 for full size cars, to protect people in front seats, the principal occupants killed in crashes; the corresponding figure is $140 for small cars.6 Comparable costs for presently required belt restraints are $101.50 and $87.60, respectively.6 DOT concludes that, compared even with 100 per cent belt use, air bags have superior ability to reduce fatal and other injuries, especially in high speed impacts.7 About 65 per cent of U.S. vehicle crash deaths result from impacts in rural areas. Thus, even if the Australian rural belt use rate of 60 per cent could somehow be equaled, the belt approach in the U.S. would be an inadequate solution. Many makers of cars sold in the U.S. have produced or designed cars with air bags to protect front seat occupants. Yet the systems "remain on the shelf." Only one manufacturer sells cars so equipped (as an option); it has only meagerly advertised them, and has not made them routinely easy to purchase. Moreover, these cars are exclusively large and expensive, and this optional equipment will probably be discontinued after the 1976 model year. However, one importer is testing a fleet of air bag cars in the U.S., and they may be available in this country from various sources during the next few years. The controversy has a fascinating and complex mix of pieces. In illustration: after required regulatory steps amounting to administrative due process, DOT issued a standard in 1970 requiring "passive restraints" effective January, 1973. "Passive" refers to automatic systems requiring no user action. Since DOT must by law specify only the "performance" which manufacturers must provide, it could not require air bags, a "design" approach, but merely specified the maximum allowable crash forces on test dummies in crashes of specified severity and type (i.e., 30 miles per hour forward into a solid barrier). Although there are other possible ways of spreading crash forces, this is easily achieved with air bags. Hence, the air bag is commonly the center of the debate. In sharp contrast, the federal belt standard does not deal with the forces produced by belts on test dummies in crashes, merely with belts' minimum strength when pulled on in a static test. Moreover, numerous experts believe that even the best designed belt systems, although offering substantial crash restraint, cannot reduce crash forces sufficiently to compete with air bags in reducing injury. Subsequently, DOT changed its position and, although still allowing passive systems, required that other cars could not be started unless the right and left front seat passengers' belts had been moved in certain ways-which resulted in use of the so-called interlock. DOT was also taken to court. The decision upheld the agency's right ". . .to impel automobile manufacturers to develop and apply new tech* "Lifetime cost" includes manufacturers' and dealers' profits, "cost of replacing expended components on repairable vehicles and incremental fuel costs required to carry . .. related weights."6
EDITORIALS
1343
nology to the task of improving the safety design of automobiles as rapidly as possible."8 The court told the agency, however, that it must revise the test specifications used to determine compliance with its injury reduction criteria. The belt versus bag option was perpetuated; and requirement for a completely passive system was still in regulatory limbo when this Journal went to press. Action up to this point having centered primarily in executive and judicial branches, the controversy next erupted in the House and Senate. The Congressional battle was complex. Opponents of the attempt to repeal the DOT interlock standard alleged that although the standard had been forced on the agency in 1971 to forestall passive restraint requirements, it was far better than nothing until such time as air bags would be required. Interlock opponents also wanted to prohibit DOT from ever mandating air bags.9 After rapid maneuvering, the House voted 337 to 49 in August, 1974 to accomplish both-repeal of the interlock and the banning of mandatory passive restraints. In the Senate, much debate and maneuvering separated the interlock and air bag issues. As a result, the bill which the President signed in November, 1974 banned interlocks but took no position on air bags other than requiring a hearing, and reserving to the Congress for 60 days the right to vote on any passive restraint standard the agency may issue in the future.'° The Wall Street Journal summarized well the two principal issues: first, "while the congressional desire to scrap the interlock is easily understandable, puncturing the air bag at the same time would ill serve the cause of highway safety," and second, "although some of the opposition to the air bag stems from its own peculiar features, much of the dislike derives simply from hatred of the interlock . . there are plenty of differences between the two devices . . . the interlock forces people to do something for their protection, while the air bag doesn't . . . the bag is no more an unwarranted governmental intrusion on individual rights than building codes which require electrical fuses or circuit breakers in homes. Like the bag, these devices work in a crisis, not otherwise, and hassle nobody. Also, like the bag-and unlike belts, with or without the interlock-they protect about everybody, not just those who take some special action."'"
Tragic human wastage has resulted from years of unnecessary delay. An average of more than 10,000 persons a day are injured in all kinds of motor vehicle crashes in the U.S., and tens of thousands die each year. 12 Considering the time required for regulatory steps, administrative and judicial appeals, Congressional review, and minimum production lead time, the regulatory and implementation process and debate will go on for years, at best. Thus, one of the most important health issues in the nation's history hangs in uncertainty and delay. William Haddon, Jr., MD President, Insurance Institute for Highway Safety
REFERENCES 1. DeHaven, H. Mechanical Analysis of Survival in Falls f'rom Fifty to One Hundred and Fifty Feet. War Med. 2:586-596, 1942. 2. DeHaven, H. Accident Survival-Airplane and Passenger Automobile. In Accident Research: Methods and Approaches. Haddon, W., Jr., et al., Harper and Row, New York, 1964. 3. Foldvary, L. A., and Lane, J. C. The Ef'fectiveness of' Compulsory Wearing of' Seat Belts in Casualty Reduction. Accident
Anal. Prev. 6:59-81, 1974. 4. Insurance Institute for Highway Safety. Belt Use in Puerto
Rico. Status Report 10(10):4, 1975. 5. Robertson, L. S. Motor Vehicle Occupant Restraint Use and Eff'ectiveness in Real-World Crashes. Insurance Institute for Highway Safety, Washington, DC, 1975. 6. DeLorean, J. Z. Occupant Restraint System Expenditure/ Benefit Study. Statement before the National Highway Traff'ic Safety Administration, Public Meeting on Federal Motor Vehicle Safety Standard 208-Occupant Crash Protection, Washington, DC, May 19, 1975. 7. National Highway Traffic Safety Administration and Transportation Systems Center. Analysis of Effects of' Proposed Changes to Passenger Car Requirements of' MVSS208. U.S. Department of Transportation, Washington, DC, 1974. 8. Chrysler u. DOT, 472 F.2d 659 (6th Cir. 1972). 9. Motor Vehicle and Schoolbus Safety Amendments of' 1974. Congressional Record, p. H8119ff, August 12, 1974. 10. 15 U.S. Code 1392 (i) (1) (A). 11. Karr, A. R. Will Congress Deflate the Airbag? Wall Street Journal, September 17, 1974. 12. U.S. Department of' Health, Education, and Welfare, Health Resources Administration. Current Estimates from the Health Interview Survey, United States-1973. U.S. Government Printing Office, Washington, DC, 1974.
LETTERS Letters are welcomed and will be published, if found suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words. 1344
AJPH DECEMBER. 1975, Vol. 65. No. 12
'LEGALESE' ON MATERNITY BENEFITS William J. Curran's observations on the implications of Geduldig v. Aiello with regard to the inclusion of
pregnancy- and childbirth-related benefits under future health programs are somewhat misleading. People who have not been trained in the law might well interpret Curran's article to mean that inclusion of pregnancy-related benefits in health
