Tuesday, August 17, 2010

Engineering our way to Serious Aviation Safety--lessons for Serious Medicine Strategy

How many of the 131 aboard this airplane survived this crash on a Caribbean island yesterday morning?   Amazingly, everyone survived, even as the plane broke into three pieces.  (One man did die of a heart attack shortly after impact.)   “It was a miracle and we have to give thanks to God,” said San Andres Gov. Pedro Gallardo.  That's a perfectly good answer, of course, but here on this earth, there were other factors, too.  Such as better planning and engineering.

And that point is full of implications for improving healthcare and for saving money.  But let's start with transportation safety.

"ABC World News" took up the topic of the air crash last night.  The segment headline featured the chyron, “A Miracle?”   Then reporter Sharyn Alfonsi intro'd her piece, noting that this crash-miracle was “the latest in a series of unbelievable crashes, with unbelievable results,” citing two recent airliner crashes, in Denver and Jamaica, in which everyone survived.

Next up, anchor George Stephanopoulos, spoke with ABC's aviation consultant John Nance.

Stephanopoulos:  John, you see those pictures, you wonder how anyone could survive.  Yet as Sharon points out, these other dramatic survivor stories.  Is this a significant pattern, or just coincidence?

Nance: George, I think it is significant.  I think it’s 20 or 30 years of very hard work in the aviation manufacturing arena, and safety.  In looking at what’s happened in the past and saying, how do we keep seats from collapsing on people, how do we put fireblocking materials in.  I think we’re seeing the fruits of all those labors.

Exactly.  It's a lot safer to fly on an airplane these, days, thanks to better engineering--and yes, maybe some mandates.  And the same holds true for autos: seatbelts, padded dashboards, and airbags, better highway design and signage, among other innovations--all have made driving safer.  Ninety-five percent safer, in fact, over the last nine decades.

The group Advocates for Highway and Auto Safety has computed the death rate per million vehicular miles traveled, going all the way back to 1921, and found something interesting: the death rate has gone steadily downward.  In 1921, the first year for which Advocates tabulated statistics, the US suffered 13,253 motor vehicle fatalities; that was a rate of 24 per hundred million miles traveled.  Interestingly, that death rate fell steadily for most of the following decades, exactly four decades later, in 1961--before anyone had ever heard of Ralph Nader--the death rate had fallen by almost 80 percent, to 4.9 fatalities per hundred million miles.   Which is to say, the general trend of systems is to improve efficiency--and safety is a function of efficiency.   And since the early 60s, thanks in part to Nader’s efforts, the death rate has fallen drastically yet again, by roughly three-quarters, down to a minuscule 1.27 in 2008.  That is, the total drop in fatalities per vehicle mile is 95 percent.

Did such efforts cost money?   Sure.  But we were worth it.  And there's a larger savings to the economy if people aren't getting killed as much--a 95 percent drop in fatalities can be calculated as an increase in GDP; just as those 130 survivors of the San Andres Island aircrash will go on to live productive lives.

The commonality between aviation safety and auto safety is this: Accidents will happen.   The challenge, therefore, is to see the problem whole and clear in advance, and to take appropriate action, in advance.   To get on the left side of the experience curve.

Thus the parallel to a Serious Medicine Strategy.   Aviation safety, and auto safety, can be thought of as a pre-emptive cure for accidents.  Accidents will happen.  The issue is how bad they are.   And so we should think ahead, realizing that a certain percentage of us will suffer an accident every year.   We should realize that it's cheaper to pay for accident-mitigation in advance--cheaper than paying the costs of people in the hospital, or suffering the opportunity cost of people in the morgue.  Such anticipatory cost-accounting might seem like a chilly way of thinking about safety issues, but the results--people living longer and better--are plenty warm.

And so the same lesson applies to the inevitable health-occurrences in our lives.  As we grow older, starting from birth, we will get the common cold, the flu, cancer, Alzheimer's--or a thousand other diseases.   It's completely predictable that we will get at least one killer disease, and many of them will cut us down in the midst of our productive lives.  In the past, in our wisdom, we chose to eliminate some of those inevitable diseases through a vaccine, notably measles and polio.  And we have fought the good fight against other diseases, including TB, smallpox, and AIDS.   Unfortunately, we seem to have lost interest in such anticipatory health-creation in recent decades.    These days, in Washington, all the discussion seems to be about health insurance, as distinct from medicine.

Our pre-emptive health efforts can be considered the medical equivalent of pre-emptive efforts to promote aviation and auto safety.    Thus the question: Should we have more such pre-emptive health efforts, or should we content ourselves with picking up the damage--and, of course, paying for the damage?

As Nance might have said, aviation safety is not a vaccine, but it edging closer to a cure.   The aviation equivalent of a vaccine, we might observe, would be some sort of mechanism that prevents planes from crashing; who doubts that we could develop such a mechanism if we wanted to.  Once again: Are we worth it?

And if we are worthy of a Serious Aviation Strategy, then we are also worthy of a Serious Medicine Strategy.


  1. Yes, but if airlines cut corners on maintenance (high quality parts, hiring skilled personnel) or on personnel (over-tired, underpaid pilots working back-to-back transcontinental trips) then all the advances in R&D are for naught. See:

    How Is Airline Safety Like Healthcare?

    How Is Airline Safety Like Healthcare? II(second item)

    How Is Airline Safety Like Healthcare? III (ninth item)

  2. Stiletto: That's why we need a proper balance between corner cutting to save money, R&D to discover dramatic new treatments, polishing the details to gain efficiencies. Too much or not enough of any of these will either result in wasted money or wasted lives. The question is how to reach such a level of balance. The free market is a well proven approach to make sure that you get what you pay for. The current trend seeks to break this iron law of economics by pursuing the idea of getting what you didn't pay for as a way of life. Of course it can never work but somehow people keep believing that if we all just pretend hard enough that somehow it can be different this time.

    The solution to all of this misallocation of resources is to connect the expenses with the benefits through a free market, not to promote the idea that more spending or more consumption without the spending, or more regulations, or more rationing, or more research, or more micromanagement.

    In other words, I'm sympathetic to the general idea that all politicians can do is slather big doses of money onto wounds and that they don't know anything about curing people and they have no business running our medical system even if they did. That applies to Jim too though. Even if he's better qualified to make basic judgments than some Washington Czar, he's still not going to make as much sense out of all of the bits of input out there as millions of people making their own choices for themselves in a free market.


  3. Brian: Quality control and cost control are diametrically opposite goals, and my fear is that ObamaCare will end up being penny wise and pound foolish. For instance, paying highly trained doctors a pittance to treat Medicaid patients - while pushing more people into this government coverage - which will result in reduced numbers of doctors available to treat increased numbers of patients, which drives down both access to care and the quality of care delivered.

  4. "Fate Is The Hunter" by Ernest K. Gann is a great read and details why technology can never conquer the dangers of flight.

    Pilots need great tools to help them (like a good pair of aviator sun glasses) and lots of training, but in the end the sky will still claim its fair share of those who venture into it.