An interview with SAMUEL C. SOUTHARD, M.D.
INTERVIEWER: You have been engaged in accident prevention efforts for many years. Would you tell me your experiences?
DR. S.: After 20 years of work in accident prevention, I believe that the public has to maintain an alert outlook with respect to the products they use and to the activities in which they indulge to recognize the hazards so that they can be eliminated or decreased.
INTERVIEWER: You're really referring to the life style the people are leading, is that right?
DR. S.: Yes, and I'm also referring to the consumer products with which we surround ourselves. For example, some of the frightful bicycle accidents we see are related to product failure, others to operator failure. It is not enough for people to demand safe appliances, safe toys, safe homes and safe cars, but they have to learn to use them safely.
INTERVIEWER: Could you give us some idea of the kinds of accidents you're seeing as a practicing pediatrician and how they have changed over the years?
DR. S.: Well, fortunately, in pediatric practice, we are not seeing a decrease in accidents. Just within the last week I've had several babies fall out of their cribs. A twoand-a-half year old girl was allowed on the porch alone riding a threewheel bicycle and rode it right down the stairs. The latter was a failure of supervision, a failure of an awareness as to what can happen. Another, a teenager, sustained a head injury when he was in a car and didn't have his safety belt fastened; there was a five mile per hour front-end collision. Hopefully, this minimal injury may be a very valuable experience for him which will teach him the value of having proper awareness as to what he should do himself to prevent accidents.
INTERVIEWER: I have a feeling you're saying that with automobiles and bicycles - all the products that are available to a generally affluent society today - there are more opportunities to get into trouble.
DR. S.: Certainly more exposure to hazards, and the most effectual way in the past to diminish these has been by legislation.
INTERVIEWER: Well, by legislation, do you mean that doctors should, in their states and local communities, be working for appropriate legislation?
DR. S.: I'm not so sure if we'll ever come to that fine state of affairs where many doctors will have the amount of time to work for safety legislation.
INTERVIEWER: No, I mean whenever they have a chance to give a talk before the Rotary Club or whatever group it is.
DR. S.: Yes, of course. When we first began our accident prevention efforts back in 1956, that was the first thing that we thought of.
INTERVIEWER: When you say "we began," this sounds like you're part of an organization. Is that right?
DR. S.: To put my work into context, I began to be interested in accidents when I got out of the Army in 1953 and opened up my practice in pediatrics. I saw many injured children and a significant number (1012 per cent) of them were seriously injured. Over the past 20 years, more of my patients over six months of age have been killed by accidents than have died from diseases. Not a year goes by without one of my patients being killed in an accident. The usual fatal accidents are automobile accidents, bicycle-automobile accidents, drownings and falls. So, to get back to the answer to your question, I began my work when the New Jersey chapter of the American Academy of Pediatrics created a Committee on Accident Prevention under the chairmanship of Dr. Walter Stewart. We surveyed the problem, gathered statistics and began to develop a plan. We concluded that since accidents were the prime killer of children from one year throughout childhood physicians should devote more study to this problem. As a side note: Now, in 1972, accidents still are the most common cause of death from one year through 37 years of life. Our initial approach was based on apprising the medical profession of the problem and outlining educational methods that physicians could utilize with their patients. We began with a series of exhibits that we showed in national and state medical meetings around the country (such as AMA, APHA, AAP, etc.). The first was entitled "Home Accident Prevention" and showed the four most common types of home accidents, which are the same today: namely, poisonings, burns, falls and firearm accidents. We listed the national statistics, showed how these accidents occurred and outlined methods of prevention in four scenes portraying the usual circumstances surrounding the accident. The second exhibit was entitled "The Physician's Role in Home Accident Prevention." This depicted what the doctor could do in his office by educating his patients; in his community by giving talks to service clubs and P.T.A.s; in his hospital by establishing a poison control center; and in his leisure time by writing for the newspaper and taking part in various other community efforts. We were still working on the basis that the physician could field this effort. In the meantime, we had established one of the first poison control centers in a community hospital in Atlantic City, N.J. We assisted approximately 100 other hospitals in establishing their own poison control centers.1
A third exhibit was based upon a community-wide accident prevention educational program supervised by Dr. William Farley in Nutley, N.J. entitled, "You Treated 13 Million Injured Children Last Year." This pointed out to the doctor how he could begin a community effort with minimal output of his own time by interesting service clubs and other groups in accident prevention. We prepared kits outlining the various programs and methodologies.
A fourth exhibit, "What's Your Childhood Accident I.Q., Doctor?" was based upon the most common accidents reported during a onemonth survey conducted by Dr. William Farley and myself2 in March, 1962 of all the pediatricians and all the emergency rooms in New Jersey. Believe it or not, we had reported to us 8,700 accidents. However, by this timé we had come to the opinion that the physician should not be the only target of our efforts. Many physicians do not regard accidents as a medical problem. Others have a greater interest in some other medical field as a professional hobby. Many are too busy with current obligations. Some feel that accident prevention is a paramedical activity. Others feel that enough time is being spent on accident prevention. And finally, many physicians have a lack of interest because time and effort spent in accident prevention are not commensurate with the acquisition of greater medical knowledge and skill that can be applied to private practice.3
INTERVIEWER: Well, aren't you saying that the professional, in this case the physician who would get involved in accident work, would really be competing with nonprofessionals who could do the same thing and perhaps do it just as well?
DR. S.: Yes, and we began to realize that more was needed than what we had previously done. Up to now, our work had been mainly evangelistic, and we realized we needed more research and a larger target for our educational efforts. In the early 1960s, I was asked to serve on the National Committee on Accident Prevention of the American Academy of Pediatrics, which was chaired by Dr. Bruce Everist. This group decided to broaden our base by directing an educational program directly to people of the U.S. During the mid1960s, the Academy of Pediatrics, through its public relations office, released many news releases on various types of accidents and their prevention which received nationwide distribution in thousands of newspapers.
INTERVIEWER: But again, this was aimed at the pediatrician.
DR. S.: No, this was aimed at the public of the United States. The newspaper clipping service for the Academy sent us clippings of our releases from every state and most of the major cities of the U.S. These releases concerned toy safety, fire safety, automobile safety, bicycle safety, swimming, poisoning, etc. Concurrently, we were working with our fellow pediatricians through various Academy publications and meetings. Next, we broadened our physician base by inviting representatives of the American Academy of General Practice, which is now called the American Academy of Family Practice, to join our committee. They made valuable contributions to our programs. We distributed hundreds of thousands of leaflets to the offices of family doctors and pediatricians to be used for patient education.
INTERVIEWER: Well, how is all this public relations and publishing financed?
DR. S.: The public relations part and the press releases were all financed by the Academy of Pediatrics, which has spent a lot of money on accident prevention.
INTERVIEWER: That's all from the dues paid by the pediatricians, is that right?
DR. S.: Yes. The financing of the original sets of leaflets was by the Academy. After that, we made arrangements with approximately 40 state boards of health around the nation to reproduce these leaflets and to distribute them free to the physicians in their states. There are two sets of these leaflets by the way. There's a set that grows up with the child, beginning at birth and going up to age 12 years, listing for the mother the most common accidents by age. And the second set is on specific items such as toy safety, drowning, bicycle safety, etc. Furthermore, the Academy sells at cost quantities of these leaflets to physicians or to the public. Sample copies are free.
INTERVIEWER: So, these are being widely distributed now you feel?
DR. S.: Very widely distributed. We estimate that over 100 million of these leaflets have been distributed to physicians and the public, and it's still going on. In fact, in 1968, the New Jersey state department of health printed five million copies of one leaflet entitled "Safe Driving A Parental Responsibility" and distributed these to motorists through the toll booth collectors on the various toll roads in New Jersey. These public information campaigns were rather extensive and were free to the public and to the doctors. I believe that this public educational campaign helped to create a favorable political climate for much of the recent safety legislation.
By the early 1960s, we concluded that motivating and educating the physicians plus public education was not enough and that we had to go further and begin to influence safety legislation. Our committee took an active interest in legislation. We already had a working relationship with various federal agencies. Members of the Committee on Accident Prevention of the American Academy of Pediatrics and members of our Subcommittee on Accidental Poisoning have appeared before House and Senate committees on most of the major pieces of safety legislation in the past 10 years. Our Academy now has a Washington office, staffed by Mr. George Degnon and Miss Sally Stemple.
INTERVIEWER: He's a lobbyist on child safety?
DR. S.: Well, he's not only involved in child safety, and he's not truly a lobbyist. What he does is to offer the services of the Academy and its members to the Congress and various federal agencies, and he keeps the Academy abreast of current legislation. For instance, I was called upon recently to testify before the Senate Subcommittee on Appropriations in support of the appropriation for the Bureau of Product Safety of the FDA.
INTERVIEWER: Is anything happening legislatively?
DR. S.: Absolutely, a tremendous amount has been happening legislatively. The Academy has had an input into the legislation relating to poisoning, packaging, flammability of fabrics, consumer product safety, toy safety, safety glazing and some excellent legislation in the area of studying accidents - for instance, the creation of the National Commission on Product Safety.
INTERVIEWER: What were the objectives of this commission?
DR. S.: The duties of the commission were defined by Congress as 1) to identify the categories of household products which may present an unreasonable hazard to the health and safety of the consuming public; 2) to identify the extent to which self-regulation by industry affords such protection; 3) to ascertain the protection against such hazardous products afforded to the public by common law and 4) to review federal, state and local laws pertaining to protection of consumers against hazardous products. The commissioners were appointed by President Johnson. The commission was funded with $2,000,000 and given two years to conduct its studies. The commissioners sought out one of the most knowledgeable men in the country on accident prevention, Mr. William White, to be the executive director of this National Commission on Product Safety. Mr. White asked me to head the task force to study the first question that the Congress gave us, number one above.
INTERVIEWER: Did you take on this task?
DR. S.: Yes, it was too rare an opportunity to miss. I took a sabbatical leave from my practice and went to Washington and worked with this commission in 1969.
INTERVIEWER: What did you achieve then, just in summary?
DR. S.: Well, actually, I've gotten a little ahead of my story on legislation. A lot legislatively was achieved before that. For instance.
Public Law 90-189 in December of 1967, which was an act to amend the flammable fabrics act to increase the protection afforded consumers against injurious inflammable products. We played a role in that. In fact, we published an article in Pediatrics on the number of children that are burned by thin flimsy cotton garments, especially nightgowns.4 Another was Public Law 890756, in November of 1966, an act to amend the Federal Hazardous Substances Labeling Act and many others. Three members of our committee sat on the special advisory group convened by the FDA in 1966 which resulted in the limitation of candy flavored "baby aspirin" to 36 tablets per bottle and other agreements.
INTERVIEWER: Well, can you tell me what was your year in Washington like and what effectiveness did you have?
DR. S.: We stimulated and started some of the most definitive research that's ever been done on the subject of preventing accidents related to household consumer products.
INTERVIEWER: Who is we?
DR. S.: The National Commission on Product Safety. The first thing our task force did was to test whether or not direct reporting by physicians was feasible in order to develop a statistically valid image of the accidents that occur in the U.S. This concept had never been tested on a national basis. We did a mail survey of 87,000 physicians and had more accidents reported in a one-month period than had ever previously been recorded. But we concluded that due to the pressures that exist on the practicing physician we would not be able to set this up on a continuing regular basis, and therefore we dropped the concept of direct reporting by physicians.
We then attacked the problem from another viewpoint, and that was to see if we could devise a fully computerized electronic surveillance system utilizing paramedical personnel. We set up the working model at Prince Georges Hospital in Maryland. The way it worked then and the way it works now are very much the same. Only today, it's much more sophisticated. We developed a computer program, an injury code, a body part code and an index of severity. This had never been done before. We wished to be able to reduce to numbers the type of the injury, the body part injured, the severity, the product involved and the disposition of the patient. This was developed in early 1969. Another task force developed a consumer product code. We trained people at the hospital, and every accident patient treated in the accident room was asked how the accident happened and if any consumer product was involved. At the end of the night shift, the hospital employee that we trained would dial a telephone number which would connect him with our recorder. And then, using the touchtone telephone and our codes, he would tap out the patient identification, the product involved, the body part injured, the type of injury and the disposition of the patient. We fed this data into our computer which enabled us to correlate and retrieve this information.
Today's system is called the National Electronic Injury Survey and Surveillance System, in brief, NEISS. This consists of 121 hospitals around the country, selected on a statistical and demographic basis so that the results from the survey are now projectable to the national population. This gives us a valid method of determining on a national basis what types of accidents are being caused by specific products.
Previous to this system, we ran into lethargy on the part of many manufacturers to engineer safety into their products. They gave many excuses such as: "We've had no experience with anybody reporting these products as being unsafe to us." "It's not our product that's unsafe, it's our competitor's." Or, "It's the small fly-by-night companies who jump into the market, make an unsafe product and jump out of the market, but it's not our product." At one meeting a crib manufacturer disclaimed any knowledge of death produced by strangulation in one of his cribs. Yet we had evidence that he had testified in such a case where the parents had sued his company because their child had been strangled in one of his cribs. The parents won the suit and were awarded a cash settlement. A sad story and a sad performance!
We knew that many of their answers were invalid, but we could not prove it statistically on a national basis.
Now we have a system where we can identify unsafe products rapidly and validly. What we need next is a system that will take over from this point and rapidly get those unsafe products off the market. As part of our work in Washington, our task force group outlined such a system. The report has been given to the Congress and to the President. The future depends on all of us encouraging Congress and the President to act. Another thing which had never been done before was to conduct an extensive bibliographic research through world literature on accidents utilizing the computerized facilities of Med-Lars (Medical Library and Retrieval Service). This bibliography on accidents may be found in the final report of the National Commission on Product Safety. We also established the guidelines for a study which we were unable to fund in 1970, but which has been funded in 1972 by the Bureau of Product Safety of the FDA. This was a study to do anthropometry on infants and to relate their measurements and other anthropometric data to the construction of infant furniture. This has been done for airline passengers and astronauts, but not done for our nation's most precious heritage, our children. We're building unsafe high chairs, playpens and changing tables that are built to sell by their appeal to the mother as a piece of furniture. We accumulated a number of instances of falls from high chairs, changing tables and cribs. We met with the manufacturers of infant furniture and found out that they had no established standards whatsoever and that the only federal requirement was that they would not use paint which contained lead. We found products on the market that were unsafe. And when we brought this to the attention of manufacturers, we felt that we were handed short answers. We suggested that they develop a committee on standards. After six months, they hadn't even appointed the committee; and frankly, when the committee was appointed, it took them almost a year and a half to hold a meeting which adjourned without any realistic action. So, we decided that to wait for the manufacturers to come up with standards was unreasonable.
We decided to relate infant anthropometry to the construction of infant furniture. I discussed this with Dr. Ashley-Montague, and he referred me to several anthropologists capable of conducting this study. We contacted and received a study proposal from Dr. Richard Snyder. We asked him to conduct a study on infant anthropometrics to result in a report of critical body dimensions and characteristics which might be utilized as a basis for standards for proper design of juvenile furniture; to formulate a human factors safety evaluation of such current juvenile furniture that could be provided by the National Commission on Product Safety; and from the above tests, to recommend changes necessary for safety design and protection of infants utilizing juvenile furniture.
An example that I use frequently in testifying before various committees is that of a ten-month old infant. The heaviest part of that child's body inch for inch is the head. When he is sitting in a highchair and rests his head on his arms on the tray, how does that change his center of gravity, and how does that increase the tipability factor of that highchair? These factors have never been considered in the building of highchairs, cribs, etc. Do you have children?
INTERVIEWER: Yes, and grandchildren. I know what you're talking about.
DR. S.: Well, that's great. When you were raising your children, you probably had a bathinette, which had a canvas top supported by a metal or wooden rim. The top was used for changing, and beneath it was the tub for bathing. It was not a beautiful piece of furniture, but it was much safer than what's in current use today. Your grandchildren are probably using these new style changing tables. The top of your wife's bathinette had a depression in the middle so for the baby to get to the edge, he had to roll uphill; also, when he got to the top he would hit against the wooden or metal rim and that was unpleasant and frequently would encourage him to stay in the middle where it was safe. Now, the current changing table is a piece of furniture with a foam rubber pad at the top which, instead of having a declivity in the middle, may actually have a convexity. When the child gets near the edge, it is less resistant than the middle. It tends to diminish in thickness so that it increases the downhill slant and enhances the possibility of a fall. Instead of inhibiting a fall, it facilitates a fall.
This is another example of a consumer product that does not have safety engineered into it. We expect that Dr. Snyder's study will establish the criteria that are needed.
In our interim report to the President and to the Congress, we recommended an amendment to the Child Protection Act of 1969. I am happy to say that this amendment was adopted by the Congress and signed by President Nixon. This amendment for the first time legislated that items intended for use by and for children had to be free from mechanical, electrical and thermal hazards. For instance, we tested one child's play stove which developed an external temperature of 600 degrees. Your wife's kitchen stove probably only goes up to 550 degrees, and that's inside and not outside.
A final recommendation of the National Commission on Product Safety was the establishment of a permanent agency empowered to investigate and control consumer product safety. This legislation is now being considered by Congress. In summary, my Odyssey in dystichematology (dystichema is the Greek word for accidents) has added a thrill to my life's work in pediatrics. It has afforded me the opportunity to extend my ministrations beyond my practice to all the children of the U.S. If this 20 years of work has saved one child's life, it was worth it.
1 Southard. S.. Stewart. W and Matthews. W The mechanics of establishing a poison control center in a community hospital J Ped 52:6 (1958). 718-722
2 Farley. W and Southard. S Childhood accidents J Med Soc NJ 65 3 (1968). 96-100
3 Southard S The role of the family physician in accident prevention J Med Soc N.J. 60 6 (1963). 232
4 Southard. S investigation of fabrics involved in wearing apparel fires The Committee on Accident Prevention of Amer Acad, of Ped (Samuel C Southard. M D . Chairman) Pediatrics 34 5 (1964)