76              RECOMMENDATIONS

l-54 Develop interagency plans for prioritizing funding needs and
technical assistance to meet tribal priorities such as:
- Public health planning
- Legal aid

- Media and information services

- Plans for dissemination of knowledge and sharing experience
among local communities.

Strategy
Lead agencies:  BL4, IHS, tribal governments

o  Timeframe: PIans by December 1990
       Implementation:  ongoing as process evolves


Panel J

Treatment

      Chair:
Background Paper:

   Recorder:

Panel Members:

Robert Niven, M.D.
Vernon Ellingstad, Ph.D.
Kathryn Stewart
CAPT Frank Hamilton, M.D.
Loran Archer
Harvey Siegel, Ph.D.
Mark Goldman, Ph.D.
Chauncey Veatch III
James A, Farrow, M.D.
John Allen, Ph.D.
Jeri Shaw

Drinking and driving is a serious social and public health problem. Because
of the enormous human and economic costs of drinking and driving on our
society, the Panel on Treatment unanimously agrees that prevention and
deterrence from drinking and driving are beneficial to all our society.
To improve traffic safety in the United States, the panel advocates the
position that the safest blood alcohol level is 0.0 percent while driving and
strongly recommends that the public service message should clearly state:

"If you are going to drive, don't drink."

The panel further advises that contrary or different messages, including
"Know your limit" messages, should not be used.
From a public health perspective, all of the following recommendations
are important. The panel opts to prioritize and rank order these
recommendations according to which are most pressing and would
enhance an effective response to this problem.

77


78

RECOMMENDATIONS

Prevention

Rehabilitative countermeasures, even if lOO-percent successful, can
have only a limited impact on traffic safety. The main approach to
eliminating alcohol/drug-related injuries or fatalities must be focused on
prevention.

J-l Prevention measures, including both general and specific deterrence
aimed at eliminating the behavior of driving while under the influence, are
essential if major declines in mortality and morbidity are to be achieved.
Prevention measures to be considered include traditional educational
approaches and also public policy, enforcement, legal sanctions, and
treatment measures. All messages, verbal and behavioral, should be clear,
concise, noncontradictory, and focused on eliminating the joint activities of
drinking and driving.

Strategy

7he Surgeon General should immediately begin to promote a single
public health message concerning drinking. This message should be
"Don't drink and drive. "Any contrary messages to this should be
discouraged including "Know your limits " messages.

The Surgeon General should ensure that all Federal Government
promotional materials about drinking and driving be revised to
reflect this position by the National Drunk and Drugged Driving
Awareness Week in 1989 and should ask all voluntary agencies
concerned with drunk driving to adopt an identical message and to
discourage contrary messages.

The Surgeon General should convene a multidisciplinary task force
to develop mechanisms to coordinate and increase prevention efforts
and the reCOF?InleFIdatiOnS frOFn this and other task forces involved in
the Surgeon General's Workshop on Drunk Driving.

E'te Surgeon General, acting through the Public Health Service,
should create a variety of educational materials on drunk driving
which should be widely distributed (including through chemical
dependency and other health care facilities and organizations) and
incorporated in health care training didactic and clinical
cum'culums. IThe creation and dissemination of these materials
should be completed by the National Drunk and Drugged Driving
Awareness Week in 1989, or as soon as possible.


TREATMENT

79

Treatment

J-2 Treatment should not routinely be used as a substitute for legal
sanctions, but rather as an important component of a comprehensive traffic
safety program.

Driving under the influence of alcohol or other drugs is a multifaceted
problem for which there is no single effective treatment of any type
(medical, legal, or punitive).

Treatment programs reduce driving related alcohol/drug incidents in
those alcohol/drug dependent persons successfully treated, both those with
and those without prior DUI offenses. Such programs are also a resource
(as are other components of the health care delivery system) to further the
dissemination of prevention materials.

A systematic approach to offenders using qualified personnel,
appropriate standards, with oversight and quality assurance controls and
without conflict of interest, is necessary to assess those persons who may
benefit from one or a combination of treatment approaches. Such a
systematic approach also needs ongoing evaluation to develop answers to
relevant questions and enhance cost-effectiveness.

The traditional short-term, low-intensity educational programs that are
broadly applied have been of limited effectiveness, and more intensive,
longer term treatment options may be more beneficial (albeit more costly)
and perhaps applicable to a selected population of offenders.

Strategy

Since a significant body of research supports the role of legal
sanctions, in panicular licensing sanctions, in reducing DUI
recidivism, the Surgeon General should encourage Federal, State,
and localgovemments to adopt andpromulgate policies and
practices that offer treatment in combination with licensingpenalties
and other sanctions proven to be effective and to discourage offering
treatment in lieu of other known, effective sanctions.

Because of the wide variations in the structure and quality of
assessment and treatmentprograms from State to State, the Surgeon
General sitouldpromote and encourage States to develop
mechanisms for high-quality diagnostic and referral procedures for
DUI offenders and specifically, should encourage the use of unifomt
diagnostic ctiteria and assessment instmments and treatment
approaches, since this would greatly facilitate reseamh studies on the
eflectiveness and cost-effectiveness of treatment.


80              RECOMMENDATIONS

Research

J-3 Develop a precise data base on the incidence and prevalence of
driving under the influence in different population groups. Since drunk
drivers comprise a heterogeneous population, specific demographic
identifiers among this population need to be defmed. Special populations
(i.e., youth, minorities, and women) should be targeted in obtaining these
data.

J-4 Intensively investigate the neuroscientific basis of high-risk, impulsive
behavior and recidivism in this population.

J-5 Develop a scientific evaluation of treatment modalities and the
combination of various treatment options for the heterogeneous group that
makes up the drunk-driving population.

J-6 Evaluate the effectiveness of new, short-term low-intensity programs
that have an impact on behavior from both an outcome and a process
perspective.

J-7 Develop and evaluate newer treatment modalities in high-risk
populations.

Strategy

The Surgeon General should encourage and foster research and the
coordination of research activities of various U.S. Government
Agencies involved in this field to increase the quantity and quality of
research focused on the drunk dn'ving issues identified by the task
force. A priority in this area, which requires an immediate increase in
research, is the assessment of subpopulations who are already
underrepresented in existing knowledge bases.

The Surgeon General should encourage States and local government
agencies to develop uniform data collection, assessment, and
treatment methodologies, since such information would provide an
invaluable basis for the further development ofpublic policy
initiatives aimed at minimizing the enormous adverse impact of
drunk driving.


TREATMENT

Resources

81

Significant increases in fiscal and personnel resources will be required
for success, but this is not seen as the sole responsibility of the Federal or
State Governments.

J-8 Since DUI has significant economic impact, funds should be used
judiciously at all levels of State, local, and Federal Government. In
allocating resources to address this issue of traffic safety, funds earmarked
for public education should be given the highest priority. Evaluation and
reevaluation of current treatment programs that are most cost effective and
provide the most efficient treatment are encouraged.

J-9 Coordination and leadership, at the highest levels of government and
in the private sector, are also necessary if impaired driving is to be
eliminated. Involvement of health, judicial, law enforcement,
transportation, and education departments, in an intense and truly
cooperative effort, will facilitate the involvement of universities, business,
and private groups in developing, implementing, and testing strategies to
eliminate this national tragedy.

J-10 The cost of treatment should be borne as much as possible by
individuals convicted of DUI, based on their ability to pay. If the individual
is unable to pay, the individual's high-risk group (those convicted of DUI)
should bear the cost.

Resources for supporting this prevention and rehabilitative endeavor
would be derived from revenue from fees, penalties, and other appropriate
sources.

Strategy

In view of scientific data indicating the limited effectiveness of
short-tern, low-intensity educationalprograms, which are the most
common approach to DUI offenders, the Surgeon General should
encourage States and local governments to reassess the use of
resources currently devoted to such programs and to consider
retargeting resources to other treatment orprevention strategies.


Panel K

Citizen Advocacy

       Chair:  Howard F&ton, M.D.
Background Paper:  John McCarthy, Ph.D.
     Recorder:  CAPT Patricia D. Mail
Panel Members:  Mickey Sadoff
           Rebecca Brown
            Ann Esch
         Nancy Ricci
           Ritchie Aanderud
           Marsha Woodward
          Harold Brandt, M.D.
          Wes Roy
           Sue Rusche

Citizen advocacy represents a broad focus of concern that cuts across the
more specifically defined issues associated with driving while intoxicated
(DWI). Having its roots in the towns and communities of the Nation where
the problem of DWI is most omnipresent, the citizen advocate's concerns
encompass all aspects of DWI from advertising and marketing through
enforcement, judicial and administrative issues, and treatment. But the
greatest concentration of effort is in education, for it is through education
of the judiciary, legislature, and citizenry that the dramatic efforts to
reduce and eliminate DWI are concentrated. Only continued community
awareness can bring about the type of behavioral and attitudinal changes
necessary to ensure the safety of the Nation's highways from impaired
operators of motor vehicles.

The Citizen Advocacy Panel was charged with addressing a range of
issues, many of which are being addressed by other panels in the workshop.
After wrestling with these charges, it became apparent that continued
deliberations would only serve to duplicate the recommendations of the
other panels. Each of the charges represented a vital and important issue,

82


CITIZEN ADVOCACY                83

and there was insufficient time to address each in the detail required. The
panel members are concerned that citizen advocates were not empaneled
as members of each of the other panels, for only in that fashion could the
citizen advocates voice their unique concerns.

The citizen advocate is able to represent the perspectives and issues that
cut across jurisdictional lines; represent victim viewpoints; challenge
inaccuracies and inconsistencies in the law, its enforcement, and
disposition; and speak out as a conscience for necessary action.

The panel proceeded to address several issues that were of particular
and continued concern to advocacy groups. The panel also went on record
as supporting and endorsing the recommendations of the Presidential
Commission on Drunk Driving (1983) and the Youth Driving Whout
Impairment Report of the National Commission Against Drunk Driving
(1988). In addition, the panel addressed the special roles and
responsibilities of citizen advocates and supported the mandate provided
by their inclusion in this workshop that citizen advocacy groups continue to
give the issue of DWI the full force of concern in our society which this
grave problem deserves.

The panel makes the following recommendations to the Surgeon
General.

Recommendations for Advocacy Groups

K-l Develop a coalition of national and local advocacy groups for the
purpose of coordination, exchange of information, and strategic planning.

Strategy

An agency should be identified, such as the National Highway
Traffic Safety Administration (NHTSA), under whose sponsorship a
meeting of advocacy groups could be convened to initiate coalition
building. This conference could occur in conjunction with the next
Lifesavers Conference, April 1989.

The NHTSA grant programs should provide finding for regional
workshops on drinking and dnving to facilitate coalition building on
a regional basis. Because of the already established networks of
NHTSA, the Surgeon General should encourage the Congress to
increase appropriations for NHTSA's grant programs. If
coordination with Lifesavers is not feasible, then other sources of
support for a coalition-building conference should be sought and a
preliminary meeting held during 1989,


84             RECOMMENDATIONS

K-2 Establish a national clearinghouse of information about impaired
driving issues and advocacy activities as a resource for advocates and the
general public.

Strategy

73e Surgeon General should provide the leadership to coordinate
appropriate agencies b identi' funding and establish a National
Impaired Driving Prevention Information Clea@house to help
advocacy groups and other interested parties.

o This should be initiated by the end ofjkcalyear 1989.

K-3 Advocacy groups should educate themselves with regard to all
aspects and issues of impaired driving to ensure that they have the most
accurate and up-to-date knowledge about the problems.

Strategy

The National Impaired Driving Prevention Information
Clearinghouse ,vould serve as a major sounze of infonnation and
training materials for advocacy groups and individuals interested in
becoming advocates. Advocates who interact with the press or the
legislators must know current laws and legislative initiatives for
improving them.

K-4 Of all the activities in which advocates are involved, the major efforts
should be directed toward four primary activities that are not emphasized
by any other group:
- Court monitoring
  - Victim assistance

- Influencing public policy and legislation
- Ongoing awareness and public education

Strategy

The National Clearinghouse would be a resource for information to
support these activities, provide training matenbl, serve as a
reposirorv for model legislaCion, and provide assistance with the
development of appropriale materials. However, nothing will be
accomplished withour energetic and vigilant efforts by local
advocates.


RECOMMENDATlONS                 85

K-5 Advocacy groups should continue to expand their volunteer base,
drawing on both victims and potential victims.

K-6 It is important for advocacy groups to keep their volunteers happy
and productive. Volunteers require training in order to be well prepared
and comfortabIe with their tasks. A variety of activities should exist that
challenge and utilize the broad range of volunteer skills and talents that the
individual members bring with their commitment.

Strategy

Advocate participants need to take back to their organizations the
recommendations presented at the workshop and to seek ways to
both implement and encourage support for the recommendations,
giving them wide publicity and assuring the widestpossible
distribution of the subsequent report.
The Proceedings of the Surgeon General's Workshop on Drunk
Driving should be sent to all of the following:
   - State governors
   - State legislators

-  State Attorneys General
-  Members of the U.S. Congress
-  National advocacy groups
-  Federal Judges and members of the U.S.
Supreme Court

-  Members of the Presidential Commission on
Drunk Driving

      -  Advocacy group officers
       -  Members of the citizen advocacy panel.
In addition, copies should be made available to the National
Clearinghouse for Alcohol and Drug Information for distribution to
advocacy group chapters nationally through NCADl's Regional
Alcohol and DrugAwareness Resource (RADAR) Network and the
National Institute of Justice Clearinghouse.

Copies should also be sent to the national officers and all State
presidents of the League of Women Voterx

K-7 Advocacy groups must continually seek a variety of resources within
their communities to support their activities, in&ding help from
corporations, foundations, individuals, and governmental entities.


86             RECOMMENDATIONS

K-8 Advocates should seek opportunities to recognize and reward those
individuals whose behavior and actions are necessary and appropriate to
the task of removing impaired drivers from the streets and streams of
America. Appropriate behavior should be reinforced and recognized,
whether through the services of volunteers or from administrators, law
enforcement officers, judges, probation officers, legislators, or other
professionals.

Strategy

When a national clearinghouse is established one service might be
the development and dissemination of a newsletter that would
feature volunteers and professionals and recognize their important
contributions to getting impaired dn'vers off the Nation's highways.

K-9 Advocates must be on the alert to identify the unaddressed potential
situations in their communities that create a climate for excessive alcohol
consumption. Excessive drinking at sporting events or festivals should be
discouraged. Those individuals responsible for the planning of public
events should be encouraged to seek ways to reduce and control the ready
availability of alcohol and to actively discourage DWI while promoting
alternatives.

Strategy

This activity is a major responsibility of local advocacy groups.
Distribution of the workshop proceedings will help to disseminate
this information.

K-10 Advocates must be constantly on the alert for attempts within their
community or State to revoke and/or weaken established laws and policies
by appending revocation language onto otherwise unrelated bills.

Strategy

A clearinghouse would help make such attempts wide& known, and
tlte tactics in one State would be qposed for all to learn from and
guard against in their own States.

Additional Recommendations

In addition to recommendations specific to citizen advocates, the panel
also wishes to go on record regarding issues that are of great concern to
citizen advocates.


CITIZEN ADVOCACY                87

K-l 1 Emphasize that DWI is a national catastrophe (crisis) representing a
most serious threat to the public health and deserving of extensive and
continuous attention at all levels of government and society.

K-12 State clearly that Driving Under the Influence (DUI) or Driving
While Intoxicated (DWI) is a crime and deserving of criminal sanctions,
even for the first offense. Use a twofold attack consisting of administrative
license revocation per se combined with criminal sanctions. Although some
leniency in punishment and emphasis on education toward behavior
modification are appropriate for first offenders not involved in crashes
resulting in injury or death, the importance of establishing a record of this
first offense as a crime cannot be overstated, for it then becomes the basis
for more punitive sanctions for the multiple offender.

Strategy

This needs to be stated and restated, not only by the Surgeon
General, but by the U.S. Attorney General and Federal and State
attorneys.

To help publicize tJle magnitude of this issue and to give prominence
to thepewasiveness of DWl in the country, reports of DW7 and
related criminal activities, such as hit-and-run, should be regularly
incorporated in the FBI's Uniform Crime Report.

o  Incorporation of such reporting to be initiated by October 1989.

K-13 Increase national attention on DWI and the events leading up to this
act. To accomplish this, use of properiy descriptive language must be
strongly encouraged. This includes the fact that alcohol-related crashes
and injuries are not "accidents."

Strategy

The Surgeon General should encourage all major medical
organizations and the Centers for Disease Control to define
alcohol-related episodes as crashes, with resultant injun'es where
appropriate, and to cease using the word "accident." The CDC
should commence regularly reporting alcohol-related crash injuries
and deaths. These deaths and injuries due to DWl should be
regularly tracked and reported in the Center for Disease Control's
Morbidity and Mortality Weekly Report. The latter will help to raise
health professional awareness about the magnitude of the problem.

o  This should be initiated by October 1, 1989.


88             RECOMMENDATIONS

K-l 4 Increase the use of sobriety checkpoints on the Nation's roads and
highways and reinstate them in those States that have declared them
unconstitutional.

Strategy

The U.S. Attorney General shouldpromulgate the model standards
for setting up such checkpoints. A summary of the issues relating to
this recommendation may be found in the Impaired Driving Issues
Compendium (1989),prepared by Mothers Against Drunk Driving:
  The NationalAssociation of Chiefs of Police, other law enforce-
ment associations, the Justice Department, and NHT&I should all
strong4 urge the use of check@&. NH%4 should encourage State
Attorneys General to review their locai laws and make changes as
needed to implement checkpoints, as well as to provide guidelines to
their members and the various states on the legal implementation of
such checkpoints.

Advocates need to inform themselves about this issue and deter-
mine what their local and State policies are regarding checkpoints.
Wth volunteer legal consultation, conduct a review of local laws to
determine where modification may be needed to implement or
reinstitute checkpoints.

a All of the above with preliminary implementation by December
31, 1990.

K-15 Significantly lower the per se BAC of 0.10 and apply this lowered
standard to the general public consistently throughout the United States.
Standards should be consistent with either the recommendations of the
American Medical Association (.05) or those currently being applied to
commercial transportation operators (.04). The permissible BAC for
drivers under the age of 21 should be established at 0.00 nationally.

Strategy

The U.S. Public Health Service should charge its appropriate
Agencies to begin a review of all relevant research immediately to
determine appropriate BAC levels to safe& operate motor vehicles,
and issue a report on their findings not later than December 30, 1990.

when this determination is made, the infomtation should be
forwarded to NHTSA and the Depattments of Justice, Education,
and Defense for the widest possible promulgation. In addirion, the
PHS should forward a recommendation to the appropriate


CITIZEN ADVOCACY

89

Congressional Committees to consider development of legislation to
establish this level nationally.

Advocacy groups should urge the adoption of the level on a
State-by-State basis.

If all legislative avenues to establish a physiologically relevant
standard fair, then the Congress should consider withholding
Federal highway trust finds from States, as part of a total package of
mandating model standards for the public health and safety.

o Effective legi.sIation and enforcement could be in place by 1992.
The PHS can probably conduct a review of research and make a
recommendation by the end ojFY 1990.

K-16 Adopt uniform graduated penalties for DWI in the States and
territories, with special focus on multiple offenders, especially those
individuals driving with revoked licenses.

Strategy

The Surgeon General should ask NHTSA to work with advocacy
groups, law enforcement officials, and appropriate judiciary
organizations to develop such models and suppoti've educational
material.

The resources of NHTSA should be directed to convening an eqert
working group to establish standard graduated sanctions, with
particular emphasis on multiple offenses, driving under license
revocation, andpenalties for those who knowingly lend a vehicle to
an individual wlto has a revoked license.

K-17 Establish a national computer registry of DWI offenders in which
the recognition of DWI in any State has reciprocity and recognition in all
other States. This should be available to licensing bureaus and all
enforcement officers through a network like the Federal Bureau of
Investigation's National Crime Information Center (NCIC).

Strategy

The Congress is urged to appropriatefunds to implement the I988
Drunk Driving Prevention Act, and advocacy groups nationally
should also urge passage of the provisions of this law in their
individual States.

In addition, the Surgeon General should request participation of the


90

RECOMMENDATIONS

Justice Department and other appropriate law enforcement agencies
and institutions to review and recommend the most qeaYent
manner for creation of this data base.

o Review and recommendations regarding feasibility and cost
could be completed by the end of FY 1990 and the Registry be
bnplemented by the end of FY 1992.

K-18 All States should incorporate into their driver qualification tests
questions on the effects of drinking and driving and the penalties for
violations.

Strategy

Advocacy groups should urge incorporation through their legislators
and licensing bodies.

o  To begin immediately

K-l 9 Testing for BAC should be mandatory as evidence in any crash,
injury, or death in which a motorized vehicle is involved (including boats,
snowmobiles, and other all-terrain and off-road vehicles).

Strategy

The U.S. Attorney General should restate the requirements of the
Uniform Vehicle Code as they pertain to mandatory testing, and
testing should be applied in all trafjic crashes resulting in fatalities or
bodily injury.

o  This emphasis needs to be promulgated immediately and
consistently, certainly as soon as possible after the new Attorney
General takes ofice January 24 1989.

K-20 Require all medical personnel in trauma centers and emergency
rooms to conduct BAC testing and report suspected DWI offenders to the
proper authorities. These laws would be similar to the child abuse laws in
which clinicians are protected against prosecution for compliance, but
compliance is mandatory.

Strategy

The U.S. Attorney General should recommend legislation to provide
protection from prosecution of medical personnel and request that
this requirement be inserted into appropriate legislation.


CITIZEN ADVOCACY                91

Advocates should work with their local medical societies, State
medical associations, and the Attorney General to &aft legislation to
implement and enfome this reporting.

o Mandatory reporting to be passed by at Ieast five States by
December 1992.

K-21 Establish programs of victim assistance for the injured as well as the
dead. These programs should provide help not only with court
proceedings, but with compensation and treatment, both physical and
psychological,

Strategy

Advocacy groups, working with the Department ofJustice and
NHTSA, should establish a Kctims Bill ofRights, to be
incorporated into newly drafted highway safety legislation that is
designed to fill the gaps in the current drunk driving legislation.

The Department of Justice should promote the Etims Bill of
Rights, including the admissibility of Victim Impact Statements for
adoption into law.

o By December 1, 1990.

A model law needs to be developed to address the issue ofnonfatal
injuries incurred in an alcohol-related crash. This must include
restitution/compensation for any degree of injury that occurs. This
model law needs to be incorporated as a statute in new legislation.
Such legislation should be developed during a consensus conference
sponsored by NHTSA.

o By December 31, 1991.

K-22 The Department of Justice and other interested parties should file
amicus briefs before the next session (and, if necessary, in any future
sessions) of the Supreme Court (e.g., South Carolina vs. Gathers 88-305 or
others) in an effort to reverse the high court's decision on Booth vs.
Maryland (107 S.Ct, 2529 [1987]) regarding the admissibility of Victim
Impact Statements.

Strategy

The U.S. Attorney General should submit an amicus brief to the
court in support of the admissibility of victim Impact Statements.

o  By April 1,1989.


92              RECOMMENDATIONS

K-23 Focus increased attention on the issue of alcoholic or codependent
denial and its insidious influence on those who are charged with the public
responsibility of addressing and dealing effectively with impaired driver
issues at all levels. This includes impaired or addicted individuals in
education, the criminal justice system, the medical care system, and private
citizens whose own ilhress may negatively impact their ability to behave in
an appropriate and lawful manner.

Strategy

The U.S. Public Health Service, through appropriate agencies,
should facilitate increased awareness of addiction and the attributes
of an impaired individual, with strong encouragement for the
increased availability of employee assistance programs and other
detection and treatment measures. This education should be
conducted cooperatively with NHTSA and the Departments of
Defense and Education.

o Preliminary information on denial and codependency should be
provided to professional preparation institutions, both law and
medicine, by December 31, 1989.

o  Supervisors in all major Federal Agencies should receive
information on impairment and the availability of employee
assistance programs in theirAgencies by October 1, 1990.

The PHS, through the educational resources of the CDC, should
develop counteradvertising messages for youth to illustrate the
negative consequences of alcohol abuse and to foster a climate of
nonalcoholic sociability.

o Public service announcements should be pilot tested and
available by June 30, 1990.

The panel reiterates that the most important single element in addressing
all the issues of drunk driving is education. Continual community
awareness about the severity and seriousness of DWI must be the
responsibility of all individuals who wish to protect themselves, their
property, and their lives from serious injury or death.

The members of the Citizen Advocacy Panel wish to thank Surgeon
General C. Everett Koop for his concern and his willingness to put the full
weight of his office and the attention of the U.S. Public Health Service on
the issue of drunk driving.

NOTE: The Citizen Advocacy Panel recommends to all concerned
readers the MADD Impaired Drivers Issues Compendium, which provides
detailed information about many of the issues discussed at the workshop.


Closing Remarks

C. Everett Koop, M.D., Sc.D.
Surgeon Genera1 of the U.S. Public Health Service
U.S. Department of Health and Human Services

I'm certain there are no reasonable people who believe that drunk driving
should be tolerated. Yet people shy away from any discussion deeper than
"isn't it terrible." Leadership is hard to come by, because it is a lonely
position. Although this workshop had the enthusiastic representation of five
cabinet departments in planning, only one cabinet secretary-Dr. Otis
Bowen - appeared at this meeting.

It is never an easy assignment to respond to workshop recommendations
because the time is short, the number of recommendations great, and the
Surgeon General has neither budget nor power, save the power of moral
suasion.

It has been my custom to keep the participants and other interested
individuals and organizations apprised of initiatives undertaken and other
activities 6 months and 1 year after publication of the booklet. On selected
subjects in former workshops, annual progress reports have also been
provided to participants.

I am pleased that Jeffrey Miller and Loran Archer have been able to
respond to your deliberations and, believe me, I am grateful to them. They
have indicated a willingness to work with us, and you have heard what a
resource they are for you.

I find myself in the cleanup position, and since the other respondents and
I have already conferred, I will try not to be repetitious. Since the subjects of
many of the panels are crosscutting, generic remarks covering all panels
seem appropriate. Obviously, I will properly refer recommendations with a
narrow focus to appropriate agencies. And when recommendations are sent,
ail will be sent because of the overlaps and crosscutting of some issues and
panels.

The advertising and marketing recommendations remind me of the first,
and at times faltering, steps taken 25 years ago in reference to tobacco
advertising. I'm not being critical; that's a compliment.

93


CLOSING REMARKS

In reference to the research recommendations, you have already heard
from Mr. Archer. I will discuss them with Mr. Archer and Dr. Gordis of
NIAAA, and with Dr. Fred Goodwin, Administrator of ADAMHA, as well
as getting them exposure in appropriate media catering to the academic
community.

I will present the epidemiology panel's recommendations to Dr. James
Mason, Director of the Centers for Disease Control (CDC), for a critique for
feasibility on the part of the Federal Government and request that he report
on current and future plans of the CDC that may address specific
recommendations. I will also ask for the cooperation of the CDC in wide
dissemination of the panel's findings.
Education is probably where I can be most effective, and I pledge myself
to this effort both now as your Surgeon General and later when I leave this
office for the private sector.

I will seek appropriate counsel regarding the broad dissemination of the
judicial and administrative enforcement recommendations to those agencies
most likely to have responsibility and/or the ability to act.
I will undertake to deliver to organized medicine by appropriate
means-personal and by transmittal- concerns and recommendations of the
injury control and treatment panels. I will be contacting these organizations
early on:

  o  American Medical Association-especially the student sector

  o  National Medical Association - for some of the ethnic
   considerations

o  American Academy of Pediatrics

o  American College of Surgeons

o  American College of Preventive Medicine

o  American Academy of Family Physicians

o  American Trauma Society and others that will come to mind or
be suggested by you.

Appropriate contact will also be made with the following groups to
expedite the recommendations on youth and other special populations.
o National PTA

o  National School Board Association

o  The various associations of school principals

o  The National Education Association.


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My work with these groups over the past few years regarding AIDS gives
me easy access and ready credibility.

But also: Boy Scouts, Girl Scouts, Camp Fire Girls, 4-H Clubs, and others.
I note the crosscutting nature of the concerns of the citizen advocacy
panel. I will convene a group (and welcome suggestions from the panel) to
consider the formation of a nonprofit corporation of the 5Ol(c)3 type to act
as an umbrella for a coalition to be supported by dues - to set its own
agenda. I will provide funds to pay legal fees and other expenses to get this
off the ground.

I will seek to put this new organization in touch with possible ongoing
sources of funding. Believe me, this is an effective and productive tool,
judging from our post-workshop experiences with organ procurement for
transplants, child abuse, resource location for handicapped children,
self-help, and so on. I will see that these recommendations reach the widest
possible audience, because we all must be advocates.
And now for some comments that apply to all panels-I will:

Use my relationship with organized medicine to give the final
product of this workshop the broadest applications.
See that a copy of the final document goes to each Senator and
each Congressman with an appropriate covering letter from me.
Do the same for the chiefs of staff of the various congressional
committees that could have a legislative interest in these
recommendations.

Present these findings in detail and with additional comments to
the Association of State and Territorial Health Officers at their
annual meeting in the spring.

Seek an appropriate opportunity to address municipal and
county health officers in the same manner.
Personally sit down with the new Secretary of the Department
of Health and Human Services soon and with the new Surgeon
General eventually and solicit their personal involvement
because of the gravity of the situation and the need for action,
and

Wherever possible, I will lay the burden on government
agencies, private agencies, and academia and seek cooperation
at every level.

When the new administration is underway, I will see that the governors of
each State and territory receive the complete set of documents with a
covering letter from me.


96               CLOSING REMARKS

Now for a final word. Strange as it may seem, there are a few people and
organizations who would have preferred that we not meet on this subject this
week - or maybe ever.

I guess by now everyone knows of my correspondence with Mr. Edward
0. Fritts, President of the National Association of Broadcasters (NAB)
inasmuch as the press had his letter to me when I received my copy. His is a
key organization, I won't deny that. I wanted him and the NAB to be here
with us. I wanted everyone to hear the NAB's point of view not only because
broadcasters are very influential - as we all know-but because they also
have so much at stake in this issue. Hence, they certainly have a right to be
here.

That's why I invited Mr. Edward Fritts. And that's why I also invited Mr.
John O'Toole, the Executive Vice-President of the American Association of
Advertising Agencies (the `Y-A's"), and Mr. Dewitt Helm, the President of
the Association of National Advertisers, the people who are the clients of
the 4-A's.

But all three declined. Mr. O'Toole and Mr. Helm suggested that our
workshop lacked "good balance." They also said they had very little time to
prepare for the discussion that would no doubt take place here. And each
person suggested I cancel the workshop.
I was sorry to get their replies. But, if I may say so, I think their complaints
and suggestions are quite unfair. Now, it is true that one message that might
be heard at this workshop is this one: alcohol contributes to injury and
premature death.

That's a troubling message, to be sure, and one's instincts might well be,
figuratively speaking, to "kill the messenger"- in this case, discredit this
workshop or have it cancelled. If so, then Mr. O'Toole's and Mr. Helm's
strategy didn't work.

However, the letter to me from Mr. Fritts of the NAB was a bit more
unsettling because it contained this observation:
    At best, this workshop is designed to politicize the
    emotional tragedy of drunk driving. At worst, it is a total
    abuse of the policy-setting process.
In addition to being surprised at that unfortunate choice of words, I was
taken aback by that observation, since over the past 7 years I have personally
convened and conducted a dozen workshops, several at the request of
President Reagan, dealing with such difficult issues as -
o Organ transplantation;
o Domestic violence;

o The needs of handicapped children and their families; and


CLOSING REIvfARKS                 97

  . The role of the self-help movement in public health.
And I've conducted workshops on child pornography and public health
and on the care of children who are born with AIDS, and so on. None of
these workshops was called to "politicize an emotional tragedy," and all
these workshops contributed significantly to the policymaking process of this
administration. AS till this one, I am sure.
I don't wish to dwell on the NAB's criticism because it may be nothing
more than an early and predictable phase in the industry's learning process.
That's been the immediate response from the broadcasting and the
advertising industries. We obviously must wait for them to offer something
more helpful. But what are the chances that will happen? If history is any
guide, the chances might be slim.

I hope that's not the case, because the history of smoking and health is not
encouraging. I've reviewed the way the tobacco, broadcasting, and
advertising industries behaved around the time my predecessor, the late Dr.
Luther Terry, released the first Smoking and Health Report 25 years ago.
From that review I can see that, even at this early stage of discussion, there
are already similarities of behavior.

And that's a shame. I think we'd all prefer that these industries-and their
chosen leaders-would heed the oft-quoted wisdom of George Santayana,
who wrote

Those who cannot remember the past are condemned to
repeat it.

I can tell you that I, for one, would rather not repeat the difficult times we
had in the past. I do not think the confrontations were always necessary or
fruitful.

But some aspects of the past are worth noting and worth emulating. For
example, 25 years ago the public health community, with the support of many
citizens' groups and a substantial number of members of Congress,
embarked upon a systematic program of research into the relationship
between smoking and health.

At the same time, and in a responsible way, we also began to look at the
public policy implications of the research results, as they came to light. From
that information we were able to plan ways to help the American people cast
off this high-risk health behavior: smoking. And that meant principally a
long-range and unremitting program of public education and instruction.
That's what happened regarding the issue of smoking and health. And
certainly drinking and driving is high-risk behavior amenable to education
and instruction.

1 respectfully suggest that Mr. Fritts, Mr. O'Toole, and Mr. Helm- and


98                CLOSING REMARKS

their colleagues -review that history as I did, because the American people
may now be - in terms of alcohol-where we were 25 years ago in terms of
tobacco.

The relationship of the National Commission Against Drunk Driving and
this workshop provides a puzzle not easy to solve. That we-the Commission
and this workshop-have the same presumed goal should be obvious. That
we should stand together makes sense.

Yet Mr. Adduci, Chairman of the Commission, cleverly suggested to me
in a letter of November 28,198& that "you may be considering the following
along with other options." One option was to "disregard the views and
position of the National Association of Broadcasters." Another was to
postpone this meeting, and a third was to "notify all panelists that (my) office
had overlooked or was unaware of the fact that DOT had given the National
Commission a $100,000 grant to do a 16-month assessment of its initiatives."

After further correspondence with me and conversations with my staff, it
was agreed that Mr. Adduci and I would let no light be seen between us as
we stood side by side in this effort to reduce the carnage on our highways and
streets. And that either Mr. Aducci or his program director, Dr. Grant,
would speak at the opening plenary session.

This seemed very appropriate in view of the published report of the
commission on "youth driving without impairment," excerpts of which both
Dr. Bowen and I read the day before yesterday at the plenary and
commented upon favorably.

Yet when the confirmatory letter was faxed to me on the 13th-the day
before this workshop opened-there was a quid pro quo. In return for that
speech, we would not release conclusions or recommendations of two of our
panels until the commission had completed its assessment project-a
minimum of 16 months from whenever they start.

I thought that would be unacceptable to you and, therefore, the
Commission refused to speak at the opening plenary session. I thought the
proposed delay - 16 months -was particularly inappropriate in view of the
fact that the National Beer Wholesalers Association and the National
Association of Broadcasters, with participating legal counsel, in the most
intense discussions Wednesday, Thursday, and today, requested only a
45day comment period followed by a 30-day delay before final publication.

As for me, I intend to ignore those who would lynch or execute a first
offender in drunk driving, just as I would ignore those who say that it has not
yet been proven that alcohol is responsible for impaired driving. I intend to
assume what leadership role I may between these two extremes and, as I have
with other issues, transmit what energy, enthusiasm, and credibility I have to
this war against impaired driving.


CLOSING REMARKS                 99

I will think of lots more and keep you posted.
Thanks to Amy Barkin, Steve Moore, and many others who have brought
US this far with the workshop and thank you, Susan Lockhart, for all you will
do with me as we face this problem in the new year.
And thank all of you for coming. Have a blessed holiday season and all
that's good in the new year.