I believe that I'm a pretty safe driver. I don't use my phone in the car except for calls on my Bluetooth hands-free system, I come to a complete stop at stop signs even when no one else is around, and I never get in the driver's seat after I've been drinking. During the fall of 2020 and spring of 2021, though, I paid more attention than usual to driving safely. Our auto insurance company offered a discount for installing a device in my car that monitored my driving behavior, and my then 15 year-old son (in Utah, the minimum age for a learner's permit is 15) began learning to drive.
There has been a lot of media attention in recent months to the increase in distracted driving and its deadly consequences since the start of the pandemic. After falling for decades thanks to legislation mandating safety features such as airbags to a low of 32,479 in 2011, annual traffic-related deaths (including pedestrians) gradually rose, then spiked during the pandemic from 38,824 in 2020 to 42,795 in 2022. This statistic is similar to the 48,000 firearm homicides and suicides that occur in the U.S. every year.
Why have traffic-related deaths been going in the wrong direction? A New York Times Magazine story highlighted deferred road maintenance, larger and more powerful vehicles, aggressive driving and road rage, and the perennial culprit, intoxicated drivers. A recent analysis of data from the National Highway Traffic Safety Administration found that 1 in 5 deaths of child passengers in motor vehicle crashes involved an alcohol-impaired driver (blood alcohol concentration > 0.08 g/dL), and the more impaired the driver was, the less likely the child was to be wearing a seat belt.
A Vox story pointed the finger at smartphones, noting that a company that sells a more sophisticated version of the device I installed in my car a few years ago - an app that measures phone motion and screen interaction while driving - found that in 2022, drivers interacted with their phones on nearly 58% of trips (an average of 2 minutes, 11 seconds per hour), more than one-third while driving over 50 miles per hour. This is when they knew the app was monitoring their behavior; one wonders if they would have been on their phones even more without it.
The difference between a medical and a public health problem is often merely a matter of perspective. For example, the solution to the medical problem of hypertension is to screen patients for high blood pressure and put the ones whom we diagnose on medications and/or encourage them to be more physically active and eat differently. But treating high blood pressure as a medical problem has been an abysmal failure. According to the National Health and Nutrition Examination Survey, of the one-third of Americans who had hypertension from 2017-2020, more than half had uncontrolled blood pressure (>140/90 mm Hg) and even among patients taking blood pressure medication, nearly one-third had uncontrolled blood pressure. Zoom out from the office setting to communities, counties, and states, and it's easy to see that hypertension is really a public health problem: too much sodium in food, too little access to safe places to exercise without a gym membership, difficulty getting a primary care appointment due to insufficient supply and uneven distribution, and so on.
Is impaired driving a medical or a public health problem? I got a lot of flak from readers when I wrote in a Medscape commentary that I would report to law enforcement a patient who declined to stop driving while high on cannabis. Clinical guidelines recommend counseling parents and guardians about keeping their children in rear-facing car seats until age two, using age and size-appropriate car and booster seats, and having children age 13 and younger ride exclusively in the back seat. With any adolescent approaching the minimum age for a learner's permit (16 years in Pennsylvania), I spend time during the well-child visit discussing the dangers of driving and texting, substance use before or while driving, and getting into a car with an impaired or distracted driver. Perhaps my counseling has saved a few lives over the past 20 years, but it's never been proven that this type of counseling improves health outcomes.
However, the evidence is clear that public health interventions and laws reduce motor vehicle crash injuries and deaths. The Community Preventive Services Task Force has evaluated a long list of interventions that save lives by reducing alcohol-impaired driving and increasing use of child safety seats, seat belts, and motorcycle helmets. The Vox story cited data that associated the passage of "hands free" phone laws with reductions in phone motion and driver distractions, but a lack of enforcement may cause these bad habits to reassert themselves over time.
