TIME: Almanac 1993/TIME Almanac 1993.iso/time/121790/1217130.000

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                                                                                HEALTH, Page 78

COVER STORY

Drowsy America


For millions of people caught in the nation's 24-hour whirl,
sleep is the last thing on their mind. It shouldn't be. Lack
of rest is leading to everything from poor grades to industrial
accidents.

By ANASTASIA TOUFEXIS -- With reporting by Barbara
Dolan/Chicago, Janice M. Horowitz/New York and James
Willwerth/Los Angeles


    At 7 a.m. or 6 or maybe even 5, the blare of the alarm
breaks the night, and another workday dawns. As an arm gropes
to stop the noise and the whole body rebels against the harsh
call of morning, the thought is almost always the same: I have
to get more sleep. That night, after 17 or 18 hours of fighting
traffic, facing deadlines and racing the clock, the weary soul
collapses into bed once again for an all-too-brief respite. And
just before the slide into slumber, the nagging thought
returns: I have to get more sleep.

    Millions of Americans make this complaint, but how many do
anything about it? Sleep is a biological imperative, but do
people consider it as vital as food or drink? Not in today's
rock-around-the-clock world. Not in a society in which mothers
work, stores don't close, assembly lines never stop, TV beckons
all the time, and stock traders have to keep up with the action
in Tokyo. For too many Americans, sleep has become a luxury
that can be sacrificed or a nuisance that must be endured.

    To some night owls, the very idea of spending more than 20
years of one's life in idle snoozing is appalling. Listen to
Harvey Bass. Between a job as a computer-systems manager in New
York City and free-lance consulting, he gets no more than five
hours of sleep a night and sometimes only two. He admits that
the schedule occasionally leaves him with a "tingling around
my head." Even so, he says, "if I live a normal life span, I
will have lived 20% more than the average person because I'm
awake."

    That may sound like an attractive exchange, but scientists
are increasingly making the case that forgoing rest is a
foolish and often perilous bargain. In fact, evidence is
mounting that sleep deprivation has become one of the most
pervasive health problems facing the U.S. Researchers have not
proved conclusively that losing sleep night after night
directly causes physical illness, but studies show that mental
alertness and performance can suffer badly. "Sleepiness is one
of the least recognized sources of disability in our society,"
declares Dr. Charles Pollak, head of the sleep-disorder center
at Cornell University's New York Hospital in Westchester
County. "It doesn't make it difficult to walk, see or hear. But
people who don't get enough sleep can't think, they can't make
appropriate judgments, they can't maintain long attention
spans."

    Such mental fatigue can be as threatening as a heart attack.
Recent evidence indicates that drowsiness is a leading cause
of traffic fatalities and industrial mishaps. "Human error
causes between 60% and 90% of all workplace accidents,
depending on the type of job," observes biological psychologist
David Dinges of the University of Pennsylvania. "And inadequate
sleep is a major factor in human error, at least as important
as drugs, alcohol and equipment failure." Other research
suggests that sleep loss contributes to everything from drug
abuse to poor grades in school.

    A typical adult needs about eight hours of shut-eye a night
to function effectively. By that standard, millions of
Americans are chronically sleep deprived, trying to get by on
six hours or even less. In many households, cheating on sleep
has become an unconscious and pernicious habit. "In its mild
form, it's watching Ted Koppel and going to bed late and then
getting up early to get to the gym," says Cornell's Pollak. In
extreme cases people stay up most of the night, seeing how
little sleep will keep them going. They try to compensate by
snoozing late on weekends, but that makes up for only part of
the shortfall. Over the months and years, some researchers
believe, the deficit builds up and the effects accumulate.
"Most Americans no longer know what it feels like to be fully
alert," contends Dr. William Dement, director of Stanford
University's sleep center. They go through the day in a sort
of twilight zone; the eyes may be wide open, but the brain is
partly shut down.

    Single parent Dianna Bennett, 43, works as a nurse at a
correctional facility in Gardner, Mass. To be able to spend
time with her three children during the day, she works the
night shift, a schedule that usually allows her no more than
four hours of sleep. "My kids tell me I'm always tired," she
says. Amy Schwartzman, 35, a law student at Tulane University,
gets up at 9 a.m. and, what with classes, moot court and work
as a research assistant, often does not get home until 10 p.m.
That's when she studies or unwinds. Nights of tumbling into bed
at 3 a.m. make her feel "as if my brain isn't moving as quickly
as it should," says Schwartzman, noting that the circles under
her eyes keep getting darker. "My mother told me I look like
a raccoon."

    One sign of sleep deprivation is requiring an alarm clock
to wake up. Another is falling asleep within five minutes after
your head hits the pillow. Well-rested people drop off in 10
to 15 minutes. A third clue is napping at will. "People like
to boast about their ability to catch 40 winks whenever they
want," explains Dement, "but what it means is that they're
excessively sleepy." On the other hand, when people get enough
rest, they remain awake no matter what the provocation: droning
teachers, boring books, endless roads, heavy meals, glasses of
wine -- even articles about sleep.

    Perhaps the most insidious consequence of skimping on sleep
is the irritability that increasingly pervades society.
Weariness corrodes civility and erases humor, traits that ease
the myriad daily frustrations, from standing in supermarket
lines to refereeing the kids' squabbles. Without sufficient
sleep, tempers flare faster and hotter at the slightest
offense.

    But there are far grimmer effects. Harrowing tales are told
by interns and residents, many of whom routinely work 120-hour
weeks, including 36 hours at a stretch. Some admit that
mistakes are frighteningly common. A California resident fell
asleep while sewing up a woman's uterus -- and toppled onto the
patient. In another California case, a sleepy resident forgot
to order a diabetic patient's nightly insulin shot and instead
prescribed another medication. The man went into a coma.
Compassion can also be a casualty. One young doctor admitted to
abruptly cutting off the questions of a man who had just been
told he had AIDS: "All I could think of was going home to
bed."

    The U.S. Department of Transportation reports that up to
200,000 traffic accidents each year may be sleep related and
that 20% of all drivers have dozed off at least once while
behind the wheel. Truckers are particularly vulnerable. A
long-haul driver covering up to 4,000 miles in seven to 10 days
often averages only two to four hours of sleep a night. "I've
followed trucks that were weaving all over the road," says
Corky Woodward, a driver out of Wausau, Wis. "You yell, blow
your air horn and try to raise them on the CB radio. But
sometimes they go in the ditch. You ask what happened, and they
can't remember because they're so tired."

    No one knows how large a role fatigue has played in train
and air disasters over the years, but the danger is undisputed.
A drowsy engineer and crew were deemed the probable cause of
the 1988 head-on collision of two Conrail freight trains near
Thompsontown, Pa., a crash that cost four lives and $6 million.
Long plane flights that cross through many time zones are more
common than ever, and they often leave pilots suffering from
jet lag. Yet today's highly automated cockpits require pilots
to be especially vigilant in monitoring dials and digital
displays. Says one pilot for an international air courier:
"There have been times I've been so sleepy I was nodding off as
we were taxiing to get into takeoff position." As the workplace
becomes ever more technologically sophisticated, the price of
disaster is higher. "So many more people can be hurt when a
train engineer or a nuclear technician falls asleep in 1990
than when a stagecoach driver fell asleep in 1890," notes
psychologist Merrill Mitler, director of sleep research at the
Scripps Clinic in La Jolla, Calif.

    Sleep-deprived workers may resort to alcohol and drugs as
a way to compensate for fatigue. But the solution only
compounds the distress. Many people wind up on a hurtling
roller coaster, popping stimulants to keep awake, tossing down
alcohol or sleeping pills to put themselves out, then
swallowing more pills to get up again.

    Putting in long hours and getting little rest are bad
enough. But people who work unusual shifts face a double
whammy. About 20% of U.S. employees toil during the evening or
night hours, or rotate through day, evening and night duty.
Such workers are both sleep starved and out of synch with their
natural sleep-wake cycle. For most people, biological alertness
peaks in the morning and early evening. It dips mildly in the
afternoon (hence the tendency toward midday naps) and plummets
between midnight and dawn. Night workers are butting against
those rhythms, forcing themselves to stay awake just when their
bodies are nudging them to tap out.

    Researchers have documented an alarming increase in the
frequency of mishaps during the graveyard shift of 11 p.m. to
7 a.m. For instance, between 4 a.m. and 6 a.m., the rate of
fatigue-related accidents for single trucks is 10 times as high
as the rate during the day. Experts say it is no surprise that
the Exxon Valdez oil spill as well as the disasters at the
Union Carbide plant in Bhopal, India, and the nuclear reactor
at Three Mile Island occurred after midnight, when distractions
are few and operators are liable to be at their drowsiest.

    Off-duty shift workers trying to get to sleep are still
battling their bodies' natural inclinations, this time to get
up. When they do manage to doze off, their rest tends to be
fitful, since other bodily functions keep to their usual
rhythms. "Nightworkers are often up at noon because their brain
and bladder wake them up," explains Dr. Charles Czeisler,
director of the sleep laboratory at Boston's Brigham and
Women's Hospital. "The average nightworker sleeps less than the
typical dayworker does."

    Even one night of shortened sleep can produce adverse
effects. People will briefly rise to an occasion, such as
playing tennis or giving a speech, but mental concentration,
flexibility and creativity suffer. Two nights of skimpy sleep,
and rote functioning is affected. In laboratory tests,
sleep-deprived subjects have trouble adding columns of figures
or doing simple repetitive tasks like hitting buttons in a
prescribed pattern. By the end of a week, people can be
seriously impaired. "Driving home on Friday is a greater risk
than on Monday, when you haven't been deprived of sleep all
week," says Mary Carskadon, director of chronobiology at E.P.
Bradley Hospital in Providence. And stopping at a bar with
colleagues for a postwork drink can make the situation worse;
studies show that it takes less alcohol to make people drunk
when they are tired.

    One of the most surprising recent discoveries concerns the
sleep needs of adolescents. For years they were urged to get
eight hours, the same as adults. No longer. Teenagers appear
to require more than 9 1/2 hours. Carskadon found that to be
the case when she studied a group of children every summer for
seven years, from the time they were ages 10 to 12 until they
turned 17 to 19. During the experiments, the youngsters got 9
1/2 hours of sleep each night. In the beginning years of the
study, they experienced no problems during the day, but after
they reached puberty there was an increase in daytime
sleepiness.

    Teenagers who are struggling to juggle demanding academic
schedules, friendships and dating, and sometimes after school
jobs, are horrified by the idea of nine-plus hours of sleep.
"My God, how would I have time to do anything?" protests
Kimberly Erlich, 15, of Van Nuys, Calif. "That would mean going
to sleep at 8 p.m. I can't imagine that." Kimberly tries to get
at least seven hours.

    Others appear to be getting even less. And that is
interfering with their ability to learn, contend teachers, who
say they are confronting more and more draggy pupils, even in
elementary school. Sleepy youngsters are arriving late to
class, forgetting assignments, moving at a snail's pace from
task to task, and sometimes dropping their head on their desk
to catch a few winks.

    College students are notorious for nodding off in class and
hibernating on weekends. Phil Simon, a 20-year-old junior at
the University of Oregon in Eugene, is not unusual. During the
week, he rises anytime between 7:30 a.m. and 11, depending on
his classes, and retires sometime between 1 a.m. and 2:30. He
naps whenever he gets a chance, but that does not always work
well. "A few weeks ago," he recalls, "I had a break between two
morning classes, so I slept. But when I woke up, the morning
class I had attended felt like it never happened. It seemed
more like a dream." On weekends he heads for bed at 3 a.m. and
doesn't get up until 1 p.m.

    It was civilization that created the dilemma of sleep loss.
The sun presumably dictated the habits of ancient people: when
it was up they were awake, and when it went down they slept.
Maybe when the moon was full they stayed up a bit later. The
discovery of fire probably allowed the first change in that
pattern. As flames lit the dark, surely some adventurous souls
delayed bedtime. But sweeping change came only a century ago
with the introduction of the light bulb. Thomas Edison's
glowing invention permitted cheap, safe and efficient
illumination throughout the darkest nights. By the end of World
War II, people were sleeping about eight hours.

    Today new cultural and economic forces are combining to turn
the U.S. into a 24-hour society. Many TV stations, restaurants
and supermarkets operate through the day and night. Business
is increasingly plugged into international markets that require
around-the-clock monitoring and frequent travel across time
zones. As CEO of Intellicorp, a software company, Tom Kehler,
43, regularly works 12-hour days in his Mountain View, Calif.,
office and hop scotches the globe. This fall he spent 13 days
in Europe, followed by a few days back in California and 10
days in the Orient. Then he flew home and went directly from
plane to office. He subsists on four to five hours of sleep a
night and occasional 15-minute catnaps during the day -- and
unlike most people, he likes it. "Sleep always felt like an
interference with life," he says.

    Changing family patterns are adding to the national sleep
deficit. Working single mothers and two-career families are
hard pressed to find time for the children or the household
chores. To fit everything in, parents are extending their
waking hours. Financial advisor Ben Sax, 34, commutes to New
York City each day from his home in a suburb to the north,
where he lives with his wife Holly, a lobbyist, and their two
children, ages 4 and 6. The parents get by on four to five
hours of sleep. "We're shocked when we call people at 9:30 or
10 at night and they're asleep," says Ben. "Our kids are still
up at that time." In fact, many working couples are keeping
their youngsters up late simply to see them.

    Not all sleeplessness is by choice. Clinical sleep disorders
are a major contributor to the national drowsiness. Many
Americans suffer from nocturnal myoclonus, a condition in which
their legs twitch throughout the night and break up their
sleep. About 3 million adults, mostly overweight men, are
afflicted with sleep apnea. In this disorder, muscles in the
upper airway regularly sag open. The struggle to take in air
can result in snoring that rivals a jackhammer, though
sufferers are often oblivious. "A person with apnea might not
even be aware that he woke up to 500 to 1,000 time last night,
because the arousals are so brief," says psychologist Thomas
Roth, chief of Henry Ford Hospital's sleep-disorder center in
Detroit. The consequences can be deadly: people with severe
apnea have two to five times as many automobile accidents as
the general population. An overlooked side effect: people with
apnea or leg spasms frequently disrupt the sleep of their bed
partner. Both apnea and myoclonus can be treated, once
diagnosed.

    The most common sleep complaint is insomnia. About a third
of Americans have trouble falling asleep or staying asleep,
problems that result in listlessness and loss of alertness
during the day. Most of the time the distress is temporary,
brought on by anxiety about a problem at work or a sudden
family crisis. But sometimes sleep difficulties extend for
months and years. Faced with a chronic situation, insomniacs
frequently medicate themselves with alcohol or drugs. Doctors
warn that in most cases sleeping pills should not be taken for
longer than two or three weeks. Such drugs can lose their
effectiveness with time, and it takes higher and higher dosages
to achieve a result. People run the risk of becoming dependent
on pills.

    Because so few studies have been done, scientists cannot
make definitive comparisons between American sleep patterns and
those of other countries. But many researchers believe that all
industrialized nations are experiencing sleep-deprivation
problems, though usually not as serious as in the U.S. "The
Europeans don't have 24-hour societies like we do," say Henry
Ford Hospital's Roth. "If you're in Paris and you are looking
for a restaurant at 2 in the morning, you're not going to find
one so easily." In Germany most stores close by 6:30 p.m., TV
networks usually sign off by 1 a.m., and Sunday remains largely
a day of rest.

    If any nation can be said to be suffering greater sleep loss
that the U.S., it may be Japan. Officeworkers in Tokyo often
commute for an hour or more, arriving at their desks by 9 a.m.
and staying until 8 p.m. or later. Then they go out and eat
and drink with collegues, an essential part of the job, and
catch the last train home at midnight. Workers get only 113
days off a year, compared with the Americans' 134 and Germans'
145. Exhausted Japanese can be seen sleeping everywhere: on
subways and trains, in elevators, at concerts and baseball
games, and during business meetings. The usual apology: "Well,
it's not exactly polite, but it can't be helped."

    Many Americans concede nothing to the Japanese in the
tireless department. "People love to boast about how little
sleep they've had," says Dr. Neil Kavey, director of Columbia
University's sleep center in New York City. "It's macho and
dynamic." Those who run themselves ragged are often hailed as
ambitious comers, while those who insist on getting their rest
are dismissed as lazy plodders.

    As long as that attitude persists, the national sleep
deficit will not be easy to close. Government and businesses
can help by formulating more enlightened work rules and
schedules. What is needed most of all, though, is a fundamental
change in Americans' thinking about the necessity of sleep. A
difficult task, yes. But not impossible. Millions of citizens
have already shown themselves capable of making far harder
decisions once they realize that their health is at stake.
Americans have stubbed out cigarettes, laced up exercise shoes
and pushed away plates laden with high-cholesterol, high-fat
foods. By comparison, choosing to spend more time abed in
blissful oblivion should be attractive. It is a message that
is becoming unmistakable: Wake up, America -- by getting more
sleep.


____________________________________________________________
WHAT CAN BE DONE


    1. SET LIMITS ON WORK HOURS. New York State regulations
place caps on the time interns and residents are on duty: 80
hours a week and 24 hours a shift.

    2. TAKE NAPS. The Federal Aviation Administration probably
will soon permit pilots to take scheduled naps in cockpits on
long-haul flights (while a copilot commands the aircraft). A
two-year study showed that pilots allowed to snooze for 40
minutes did better in vigilance tests than pilots who did not
take sleep breaks.

    3. ADJUST WORK SCHEDULES. To accommodate the natural
sleep-wake cycle, workers who serve on various shifts should
rotate forward, moving from day to evening to night. The period
on any one shift should be at least three weeks.

    4. RESET THE BIOLOGICAL CLOCK. Experiments at Boston's
Brigham and Women's Hospital show that carefully time exposure
to bright artifical light and darkness over two to three days
can help people adapt to the night shift and avoid jet lag.

    5. CONSIDER THE COSTS. The pay can be great for overtime  or
unpopular shifts, and some people prefer working miserable
hours because they can then get a longer stretch of time off.
But is the stress to body and mind really worth it?