How asleep should truck drivers be on the job?

Many people say, “not asleep at all. Wait, why is that even a question?”

Over the past several years, this has become a question of health policy that has morphed into a question about the role of government. A string of high-profile incidents involving somnolent truck drivers and railroad engineers have called attention to an emerging sleep disorder. For one, a conductor crashed a train into a crowded station in Hoboken, New Jersey, injuring more than 100 people. He was found to have the condition, called obstructive sleep apnea, which affects alertness and can cause people to spontaneously fall asleep even during the most stimulating tasks.

In March of last year, the Obama administration proposed that this sort of incident should be prevented when possible. One proactive approach was to begin requiring screening train engineers and truck drivers for sleep apnea.

This turned out to be a politically divisive idea. On Friday, the Trump administration announced that it had withdrawn that proposed requirement, as part of a comprehensive effort to eliminate regulations that could ostensibly limit economic growth.

This was met with consternation from consumer- and health-advocacy organizations. A spokesperson for the National Transportation Safety Board, for one, which has advocated for screening truckers for the sleep disorder for years, told Bloomberg the agency is “disappointed” that the Department of Transportation withdrew the “much-needed” rule.

The sleep-inducing condition, which affects at least one in 10 people to some degree, is increasingly common. In serious cases, obstructive sleep apnea can render a person with symptoms that sound like classic narcolepsy, falling asleep with little to no warning. In this way it is similar to narcolepsy, only the primary problem is respiratory. People with the condition do not breathe well while sleeping at night, which degrades the quality of the sleep, and leaves people impaired and exhausted during the day.

The condition is present among many people who report sleeping well and for seven or eight hours each night, unaware that the breathing interruptions are precluding deep, restorative cycles. Hence the demand for screening—at least among people whose jobs involve commanding enormous machines at high velocities in close proximity to other humans.

The aftermath of a commuter-train crash at a New Jersey station in September 2016 (National Transportation Safety Board / AP)

The sleep disorder has become more common and better-known in recent years as the average human body size has increased. People snore because their airways are slightly compressed, leading air to be forced through a narrow space and create a trumpet-like effect. This is partly due to the collapse that occurs when lying on one’s back, and partly due simply to anatomical differences among people.

As people gain weight, they become more likely to snore—the additional mass only adding weight to further compress the airways. Gaining weight also disposes people to obstructive apnea, which amounts to temporary total obstruction of the airway.

So how do doctors decide who to screen for this condition? Earlier this year, the U.S. Preventive Services Task Force reviewed all available studies and issued guidelines for health-care providers. Published in the Journal of the American Medical Association, the guidelines say that current evidence does not support screening all people. But, they add, it may be the case that “persons who work in safety-sensitive transportation occupations (e.g., truck drivers or rail operators) have unique testing needs.”

If you’re a doctor who has turned to this definitive text for definitive word, this is unhelpful. And even if the guidelines were unequivocal about screening all truckers for obstructive sleep apnea, many would be unable or unwilling to pay for the testing if it were optional, as some employers and insurers leave the costs to the individual truckers.

In the pages of Overdrive, a trucking-industry trade publication, reporter Todd Dills has been following the apnea-testing debate for years. He has profiled multiple truckers who have been set back less by apnea than by the cost of apnea testing, among them a 450-pound trucker named William Stewart. Even though insurance covered much of the costs of his treatment and the forced-air breathing machine Stewart was prescribed to wear while sleeping, he ended up paying around $1,500 out of pocket.

Truck driver Charlie Resch adjusts the positive-pressure mask he keeps in the cab of his truck to wear while he is asleep. The pressure keeps his airways from collapsing. Sleeping in this mask is the standard treatment for sleep apnea. (AP)

It’s possible that sometimes policies implemented by elected officials are an effective approach to keeping people safe and well. A comprehensive approach could include covering the costs of apnea screening and treatment, which could save money by preventing crashes. Yet Trump has promised to be against regulations in the broadest sense of the term, vilifying an entire class of tools to address public-health problems. The administration also last month sidelined a looming requirement for the use of speed limiters in the trucking industry, among other health-related measures like revoking an Obama-era regulation that allowed residents of nursing homes to take them to court over claims of abuse.

Trump’s premise across the board is that regulations are “major job killers.” The corollary is that a “free market” will prevent such problems. This sort of solution to public-health problems is rarely straightforward. In the case of truckers with a sleep-inducing condition, consumers could, for example, insist on buying only products from companies would work with shippers who screen their drivers for obstructive sleep apnea. For example, a label on a broom might read, “Our brooms are shipped by drivers who have been screened for obstructive sleep apnea.” (As though people don’t already have enough to consider when buying brooms.)

I’m skeptical that this will happen. I’m also skeptical that removing this sort of regulation will actually save or create jobs.

In industries like trucking, which stand precarious in the face of challenge by emerging driver-less technology, it may seem obvious to decrease regulations that limit jobs, but if more drivers are asleep or impaired on the job, and more errors and harm are the result, this could instead precipitate the decline of the human-driven truck industry in favor of safer, more reliable self-driving options. The attempt to create jobs by eliminating rules could itself be the killer.