Sleep Medicine, Public Policy, and Public Health

,

Mitler, M.M., Dinges, D.F. and Dement, W.C. Sleep medicine, public policy and public health, In Kryger, M.H., Roth, T. and Dement, W.C. (eds) Principles and Practice of Sleep Medicine, 2nd Edition, Philadelphia: W.B. Saunders, 1994, 453-462.

CHAPTER

41 Sleep Medicine, Public Policy, and Public Health MERRILL M. MITLER, DAVID F. DI NGES, and WILLI A M C. DEMENT

Sleep and sleepiness are amo ng th e most basic of human behaviors. As amply illu stra ted in chapters th1 oughout d11 s text , sleep can be disrupted no t o nl y b) pat holog1 ca l processes but a lso by m ism a 11agc rn c 1it and abuse. 1· ~ When slee p di s rupti o n occ urs, rega rdless of th e reason , the co nseq ue nces for th e indi vidual and , in some circurns tanc 'S, for soc ie t y ca n be serio us. A t present , there is o nl y limit ed r ecognitio n o r thi s f'un darnental fact and o f' th e vast g ulf that still ex ists bet\\'ecn gains in the ~c i e ntifi c ' or i11 o th e r hazardou s situati o n s, c reating a ri s k both to th e intoxicated perso n a nd to innoce n'1 peo pl e who happe n to be in th e \'icinity. ~nforcement is poss ibl e beca u se th ere is o bj ec tive, rapid . c hea p tes tin g for th e prese nce of a lco hol and it s Co n ce ntration in th e S)'Ste m: brea thalvze r and bl ood test s. Sleep 'loss, d e pe ndin g 011 th e degree, a lso lea d s 10 impairm en t. In civil cases, if authorities d e te rmin e th a t impairm e nt rro111 slee p d e pri\'a tion has ca used an accident. th e dri\'c r is co n sid e re d neg li ge nt and is li ab le for civil and criminal p e nalties. Hm1·c ,·er, th e parall e l with alcoho l e nd s th ere beca use acciclem in vestigators have 110 easy, in ex pe nsi\'c, and re li a ble m eas ure m e nt or th e degree or sleep dcpri\'atio11. Thu s. e rrors du e to fo ilin g

ISSUE 3: Should Congress take steps to ensure the well-being of workers engaged in nonstandard hours of work?

Direct. OSHA to d ete rmin e whether issuing standards relating 10 work schedulin g is warra nted. Rev iew curren t regu la tion s to d e te rmin e wh ether th ey ad equately ad cli-ess co nce rns raised by non sta ndard work hours. En co urage labor and managem e nt to include prov ision s regarding the safety and need s of shi ft worke rs in coll ective bargaining agree men ts. Take meas ures to e nsure individual an d publi c safety in se ttin gs where nonstandard work hours a re in e ffec t.

T h e Nationa l Comm iss ion for Slee p Disorders Researc h co mpleted its mission with a co mpreh e nsive report of its findings. 18 Th is docu m e nt ca ll ed for permanent and co n certed government efforts in expand in g basic and cl ini ca l resea rch on slee p disorders as. ~1 e ll as imp rov in g public awareness of th e dange rs of mappropriate slee piness. Th e commission's re port also incorporated , focus ed , and ex panded th e id eas set forth in th e O ffi ce of Tech n o logy Assessment 's report on biologica l rhythms. Senate hearings on th e co mmission 's report led to th e int roduction in February 1993 by Senator Mark H atfi e ld or Se nate Bill I 04 which ca ll ed for the es tablishm e nt of a Nat iona l Center for Slee p Disord e rs Researc h within the Na ti ona l ln stitu tes of H ea lth . Th e genera l purpose o f· this pe rmanent en tity wou ld be to conduct and support re-

Conclusions ln sum mary, there is amp le prece d e nt f01 h ea lth profess iona ls to assum e res pon sibilit >". bo th 1nd1nduall y and co ll ectively through th e ir prokss1onal organizations, to do whatever th ey ca n to improve th e hea lth of th e pub li c. Th is includ es soc ie tal h ea lth 111 ll s broad es t se nse, th e redu ction or ri sk, th e irnprove m e 1ll o f perfor man ce, and th e qualit y or li k . 11 .1d cecl , the special ex pertise of slee p m ed ici 11 c prof c~s 1 0 11 ; ~ Is w n fers a uniqu e and he ig htened se t o f o bl1 ga 110 1.1s to address a nd th e political influ ·nee to shape ra~ 1 0 11al public po li cy . Researc h indi cates that ~lccp , slcep111c s'.'I, a nd inattention re lated to biolog ica l rh yt hill ~ a dvcr~cl } affect workers . This, in turn , lead s to public h ea lth probl e ms and und erscores th e n eed for wiser publi( policy co nce rnin g slee p and slee p cli sordc:rs. It is ax iomatic th a t public policy docs 1101 c ha n ge by itse lf. It is also ax iomatic th at public policy can< h a n gc in a manner tha t is co unterproclucti w· or that po~n a threa t to th e hea lth or th e public (e.g .. wc·;i po11 ~ lll iciam with bo th kn o wlecl ge a nd ex pe ri e nce in di ag n o~ i11 g a nd trea tin g slee p d iso rd e rs, as well as jud g me nt g uid e lin es a bo ut \\' hen 10 ma nage the pa ti e nt a nd \\'h e n to refe r th e pa tie nt to a slee p med icine spct ia list. l 11 its co ng ress iona l re po rt , th e Natio nal C:o 111miss io 11 o n Slee p Di sord e rs Research es t irn atecl th a t O\"Cr 90 per ce nt o r a ll ind ividua ls experie ncin g '>lec p-rc la ted S)'rnp to ms die! 11 0 1 ha ve access to th e be ne fit s o l slee p di so rd e rs med icine. Ig nora nce o r slee p di so rd ers a l t he pri ma ry care leve l co nstituted th e ma in barrie r , bu t cos t a nd ava il a bilit)' o r slee p ~ p e( i a l i s t s co ntr ibutecl as we ll . Boa rd -ce rtif ied slee p s p cc i a li ~ t ~ numbe r less tha n ~ 000 in the Unit ed States . We mu '> t avo id crea tin g a n eve n mo re co mp lex stru ctu re in \\' hi ch th ose slee p specia lists are subspecia lists, ll' ho ma nage o nl y slee p apn ea patie nts, o r o nl y na rrn lcp ~) pa ti e nt s, o r 0 11 1)' psyc hi atr ic slee p d isorde rs , a nd .'> 0 11 . Edu ca ti o n a nd recog nition o f tr ue risk are necessa ry frrst ste ps toward form ula tin g wise pu bli c poli cy . .Ju st as m;tssivc e pid e mi cs in crow ded citi es o r I he 1800s thru st th e 11 o li o11 o r di sease-ca r ryin g microbes into publi t to11.Ki01 1s11 ess. in d ustr ial a 11 ~l L1'.;111 spo rta ti o n catas t ro ph es o f th e 1900s shou ld be fo rcin g worker fa ti g tr c i11 10 the pub li c co nscio usness. In th e late 1800s , new ways o f thi n kin g \\'e re req ui red 10 red uce th e ri sk o f 111i cro bc-IJo rn c di sease. This new thin kin g cha nged th e Oll (l'-lO lll lll Oll pract ice of a doctor's clissecti11 g a co rp~c fo r a na t o m ~ class a nd 1he11 , minut es la1e r, d e li ver in g a \\'Oma n 's ba by wi th o ut eve n washin g hi s h a nd ~. Sirnil a rl ). in th e micl - 1900s, ll' id es preacl awa re11 c~~ o f 1h e hea lth d a nge rs created by che mi ca l tox in s in 1he e m ·iro 11111 c 11 t a 11d the fo od cha in has led to 1 11a~'i\(· < ha 11 gcs i11 1hc 11·ay 11·e th in k a bm 11 0t 1r pcr'0 11 ; rl ,;ifc t1 a nd th e \\'a)' ll'C for m ula ic publi c po li c)' . I .ikcll'i'l'. in th e la te I ~ J O O s. 11c1r ll'a ys of thi11 ki11 g a rc t cquir eel to c 11 s111T tkt t peo ple d o 1101 make ca t a' '' ophi e 111is t;1kn 0 11 1he jo b. 1\ c\1· thi nk ing lllll St

461

cha nge co 111111 o n practi ces such as an a irlin e p il ot's fl yin g a 6- h-lo ng " red eye" a ft e r o n l y~ h o f slee p .

References I. Di ag nos ti c Classif1 ca ti o n Stee rin g C:o m111 i11cc: 1\ 1.J Th or p )'. C ha irn1 a n . Int e rna tio n a l C lass if ica ti o n o l Slee p Diso rd ers: Di ag nos ti c a nd Cod in g !\ la nu al. Roc hcs1c r . !\ I N. A m e ri ca n Slee p Diso rd e rs Assor ia 1io n , 199 0 . '.2. Krygcr i\ 11I , Ro 1h ·r. D cn1e11t V\'C: Pr incipl es and Pract ice of Slee p i\ lcd ir in c. Phil ad e lphi a , WB Sa un de rs Co mpa n y. 1989. '.l. Din ges DF. Crac bc r RC. Cars kad o n l\ l r\ , c t a l: Att e ndin g to in a 11 c 111io n . Scie nce '.2 -l :i: '.-l-12. 1989. '1 . Kr ibbs N B. C c tsy .J . Din ges DF : l n ,·es ti ga ti o n a nd ma n age m e nt o f da r tim e slee p iness in slee p a p nca. In Sa und e rs NA, S u ll iva n C E (eel s): Slee p a nd Brea thi ng. Vo l 2. New Yo rk . Marce l De kk e r . 19 92 . 5. Mi tl c r l\ l l\ 1: Pun c h th e dor k. hit th e h a r . Th e New Yo rk Tim es, .J a n11 a ry I I : I 3Y , 1992 . (i. \\'e bb \\'B . Di nges DF : C ult ura l p e rs p ecti ves o n n a ppin g a nd th e sies ta. / 11 Dinges DF. Bro u g ht on R.J (ed s): S lee p a nd Ale rt ness: C: h ron o bi o lo g ica l. Bc li;11·io ra l a n d 1\ kdi ca l As pec ts o f Napp in g . Ne w Yo rk . Rave n Press . 198 9 , pp 2-l 7- 2(i6. 7. Din ges D F. Bro ug h to n R.J (ed s) : S lee p a nd A le rt ness: C h rnn obio logica l. Be h av io ra l a nd Medi ca l As p ects o f Na p p in g. Ne w \' o rk , Ra ve n Press. 1 98 ~). 8. T e r m an L!\ I, I loc ki ng A: Th e slee p o f sc hoo l c hil dre n : It s di str ibu ti on acco rd in g to age a nd its re lat io n to ph ys ica l a nd lll e n 1a l d ficic nc)' . .J Edn c Ps)•c ho l -1: 1'.\8- 14 7. 19 13. ~ J. O 'Co n no r A L: Q uestio nn a ire res po nses abo u t slee p . !\ laste r 's th esis. Co ra l Ga bles. U n i,·e rsi1 v o r Fl orid a . I 9(i-l. 10. i\ l it lc r l\ l l\ I, Ca rska d o n \I A . ( ;zc islc r C:,\ , c t a l: C:a tas1roph es , slee p a nd publi c po li cy. S lee p I I : I 00- 109. 1988. 11 . T o rfcx is A: D ro wsy ,\m n ica . Ti m e t:\6 :78- 8:i. 199 0 . 12. 1\ litl c r l\ 11\ 1. ll a jcl nkovic R l\ I. S hafor R. c t a l: W he n peo p le d ie. Ca use o f d ea th ve rsus time o f d ea t h . Am .I l\ lcd 82:266 - '.27 4 . 1987. I '. \. ' '01 1.J e nn r E: T agc pe riodi sc h c 1-:in fl [isse a ul c; e bun un d T od . Sc h we iL l\1 cd Wod1 e nsc h r l -l : l :i- 17. Ill '.-\'.\. 1-1 . S mole nsky 1\ 1. I la lbe r g F. Sa r ge m F: C h ro no li io logy o f th e li fe sequ e nce. / 11 110 S , O ga ta K. Yos hi lllura 11 (e d s): Ach ·a nces in C: li ma 1ir Ph ys io logy Tok r o , l gak u S h o in . 1972. pp 28 1-'.\ 18 . 15. l\ l iill e r .J E. Sto ne 1'11. T uri /'. (; . c t a l: C: ir ca cl ia n ,·a r ia tio n in th e o nse t of acu 1c m yoca r dial in fa r ct io n . N En g l .J !\ led '.l 1'.l: I :\ 151322 . l ~l 8:i. 16. Sta mpkr l\ l.J , .J ak u bo wski .J A . lk )·kin D. c l al: Effect o f a lt e rna te- d ay reg ul a r a nd e nt e r ic coa ted as pi r in 011 p la te le t agg regat io n , blee din g tim e a nd thro lll bo xa n e ,\ 2 levels in bl eed u1 gtim c blood . A lll .I l\ k d 8 1:-100-·iO-l . 19 8 6. . . 17. Ridk e r Pl\ 1, l\ la nson .J E. Bu r ing .I E. e t a l: C ircadi a n va n a lH Jll of ac u te nwoca rdia l in l'arc1io n a n d t h e e ffect ol' low-dose as p inn in a r;u1di°1mi Lcd t r ia l o r p h )'s ician s. C irc ul a tion 82:89 7 - ~10 2 , 1 9 ~ )()

18. T o ll e r C l I. Bre1 in s ki D, Sc h afe r A l. c l a l: Co nc u rre nt morn ing in crease in pl a te le t agg rc gab il it)' a nd th e ri s k of m yocardi a l in L11Tt ion a nd sudd e n cardi ac d ea th . N Eng l .J I\ le d '.-\ 16: I :i 14 1:"i 18. I ~ 1 8 7 . 19 . Dawso n /\ . Le h r I'. l\ litl c r l\ I M : Effect o l' c t h a no l o n in s p ira to r)' res ista nce a nd res p irator y d r ive d urin g sle e p . Slee p Re s 20 :63, I !llJ I . 20 . l\ fi tic:r \ l il t . Da\\'so n A. !\kN ;dl )· E: Slee p d iso r d ers a nd rn ron a r )' di sease. l' rog Card io l 4 /'.l:!J/: BIO 111:\. )q HI> (;racber RC: , Lauber JK . C:o1111t'll l.j , ( .. 111dl'1 1'11 : J111 t·1 11.1tHllJ .il a irtrew 'lccp and wakelulnc" .dtt' I 111ult 1pk t111H· """' f11gltt': ,\ «H>pc:rat i' c \tudv. ,\ ' iat Spa< e Ell\ 11 011 \led ,->7. JU ll'l . 1'IHli -1:1. Rosc.:k ind \ ·I R, C:o1111c ll l.J . Di11 ge' IH. et al : l'1l'pla1111l'd 101l.. p1t n :' t : l~ E(; sleep and cl Ice t\ on pin siolog1t.il .tll'1t11t'"· !'>kcp Rt'' 20: 129, 1991 . -! -1. Din gc~ IJF. C:onnell l.J . Ro\cl..ind \IR . c1 .ii : !· lint' o l 1ml..p11 naps and 2-!- hour la1m·e1' 011 ,Jeep debt 111 lo11 g- h.11tl 11.1m111c:ridia11 fli g ht e re11\. Slcc:p Res 20: lllli . I kq> R,., IH:7 1, 198!1. ·17 . US C:o n gre'>S. Ol11(e o f I ce hnol og\ .\'"'"111t ·111 : l\1 olog i( ,il Rh )t hm s: l11 1p licatirn1' fen the \\'01 l..c1 . \\' ,1,Jt111gtt>11 . I)( . l ' '> Co\'e rnm ent Printin g Olfitt'. I !I!) I . pp I 2 l ~l. -1 8. Nat iona l Co111 111 i,sio11 on Slc:ep J)i ,01clc1' J{,·"·. 11.11 : \\' ,11..!' l · p Amc:rita: ,\ :-\atirnrnl Sleep ,\Jc:11 . \ 'ol I . I· '('( 111 1\l' !-.11111111.11\ and Exccu ti\ e Report, Rcpot 1 of till' :\,1t1011 .tl ( 011u111"1011 011 S lee p Di·;orders Re , ea11 11. '.':a1io11 .tl l mti111t1·s ol J k .tlth l.111u aq 199:1. pp I 71i. DllllS 1'11 h . '\o-( i11 P'''"'· \\'; "l1111gtrn1. DC .. Sup. o l Dol'> .. L' S C:mt. !'tint Oil. 11 1!1:1.

Th i.s m a t e r ia l w a.scopie.d a t the- N LM a n.d rm a y t>.e, Sut>.je.i:t USCopyright Law .s