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New research, published this Tuesday in Lancet Psychiatry, suggests that a fairly cheap and simple policy change could save enough lives — specifically among women — to more than reverse the ugly uptrends in American mortality rates, and could do so over a period of months rather than years.
South Dakota runs a program called 24/7 Sobriety as a non-jail alternative offered to people arrested for alcohol-involved crimes, primarily repeat drunk driving. As a condition of pretrial release or probation, they are required to stop drinking. Compliance is monitored by taking a breath test twice a day, seven days a week, for an average of about four months, and skipped or positive tests (anything but a reading of zero) are punished with a night or two in jail.
The program costs less than $2 per participant per day; offenders are required to bear that cost, presumably out of the money they would otherwise spend on alcohol.
The initial program evaluation showed big effects on future drunk driving by program participants (down 50 percent over the following two years). Subsequent studies by the RAND Drug Policy Research Center showed that for the entire population — not just participants — 24/7 Sobriety reduces drunk driving arrests by 12 percent. It also reduces arrests for domestic violence by 9 percent, even though domestic violence charges are rarely the reason an offender is put on the program.
The new study by RAND’s Nancy Nicosia, Beau Kilmer, and Paul Heaton examines total-population, all-cause mortality — it drops an average of 4 percent after a county adopts the program. Even though most of the offenders are men, the lives saved seem to concentrate among women.
Deaths from injury (accident, suicide, and homicide) and cardiovascular events (heart attack and stroke) go down more than deaths from other conditions. That number is so astonishing as to be hard to believe, and in fact the study team held up publication for a year to check the math and wait for another round of data to come in. But so far, the result seems to be solid.
If that figure is right, and if the South Dakota results could be matched nationwide, a 4 percent reduction in mortality would mean slightly more than 100,000 avoided deaths per year. Those are big "ifs," and there is still research to be done to nail down both the numbers of lives saved and the causal mechanisms that save them. (Perhaps reduced drinking by male heavy drinkers leads to reduced stress among — or less heavy drinking by — their female partners.)
But the drunk driving results alone, which are amply demonstrated and easy to understand, more than justify the very modest costs of the program. And surely if the state is justified in telling drunk drivers that they have to stop driving, it’s justified in telling them they have to stop drinking: No one needs a bottle to get to work.
Saving 100,000 lives a year would be a great achievement under any circumstances. But right now there’s additional reason to look hard for programs to reduce mortality rates, especially among women.
Over the past 15 years, death rates have risen for white non-Hispanic American adults who do not attend college. The rise in mortality shows up in two recent studies: one by Anne Case and Angus Deaton of Princeton, the other by Gina Kolata and Sara Cohen of the New York Times. The Case and Deaton study focused on the age range 45 to 54, while the Times analysis found rising death tolls among all age groups up to 65, with the rate among younger adults rising fastest. Both studies show those without college educations hit the hardest. Reanalysis of the Case and Deaton results by Andrew Gelman of Columbia shows a smaller rise in mortality among the middle-aged, concentrated among women.
This should not be happening. With rising incomes, improved medical care, and safer homes, roads, and workplaces, mortality rates trend down, not up, except when disturbed by war, pestilence, or major economic dislocations such as the collapse of the Soviet Union after 1989. We don’t expect to see figures like these in the United States.
And white non-Hispanic Americans stand out not only from the residents of other advanced countries, but also from African Americans and Latinos, whose mortality has continued to fall steadily. Figuring out what has gone wrong and what to do about it ought to be a major political issue, though so far only Hillary Clinton seems to have mentioned it.
In that context, the power of 24/7 Sobriety to save lives, and especially women’s lives, meets an urgent need. Even a fraction of the estimated effect, if extended to the whole county, would more than reverse the trends found by Case and Deaton, and by Kolata and Cohen.
It’s time — long past time — to get the sobriety show on the road.
Mark Kleiman is a professor of public policy at the NYU Marron Institute for Urban Management, a member of the Committee on Law and Justice of the National Research Council, and an editor of the Journal of Drug Policy Analysis.
