Forcing events in public health

Hearing is a complex, always-on metabolic system that suffers from lack of maintenance when under oxidative stress, yet hearing preventive care is virtually unknown today, while hearing impairment is among the largest incurable chronic disabilities worldwide. From the public health perspective, something is wrong.

The argument in short is that public health innovations do not spread on the strength of the evidence behind them. They spread when they become forcing events, when the cost of inaction becomes legible to an actor, someone who has the authority, the responsibility, and the accountability to act on it.

Hearing has enormous costs and, so far, no actor. That is the real reason routine hearing care barely exists, and it is why the usual appeal, that the problem is large and the science is sound, has not been enough.

My last post reported real-world data demonstrating that the auditory micronutrition formula ACEMg is associated with the maintenance of normal auditory function. ACEMg is not a hearing loss antidote. Data is directional, not definitive, certainly not causal. However, even within that careful framing, the real-world data so far suggests that routine maintenance for hearing is possible.

My last post closed by answering the rhetorical question, "What would happen if we became hearing maintainers?" saying I believe public health would improve along with measurable decreases in hearing loss and its consequences. Further, I believe clinical care can expand to preventive care, collecting real-world evidence of benefit from routine health monitoring of auditory micronutrition supplementation.

It often takes decades for public health innovations to become widely accepted, and hearing preventive care is unlikely to be an exception. However, forcing events have been proven to accelerate adoption. This post summarizes seven examples of the forcing-event pattern, beginning with dentistry, and then lists three potential forcing-event conditions for hearing. Dentistry maps onto hearing most precisely and establishes the template, so I take it first, then show the same pattern across a century of public health before turning to hearing.

Toothbrushing and military recruitment

Toothpaste and toothbrushes were introduced in the late 1800s but remained niche items for decades. The Gies Report, named for its lead author and published by the Carnegie Foundation for the Advancement of Teaching a century ago this year, is widely recognized for revolutionizing dental education in the United States and Canada from primarily a trade or craft into a medical profession.

Preventive care had been available for about half a century, but was not generally adopted until a military crisis in 1941 forced mass institutional reaction and a mandated shift to preventive hygiene. The military faced a recruiting crisis in the run-up to WWII. Army Selective Service regulations specified a minimum of six opposing teeth; failure to meet that standard became a leading cause of rejection from military service. In June 1941, about six months before the U.S. entered the war, 17 percent, or about 64,000 of the roughly 380,000 men who failed their physicals flunked on the basis of their teeth. The military was forced to reduce its standard, and started accepting men with "remediable defects" in August 1942. The Army Dental Corps ballooned from 316 active-duty dentists in 1941 to over 15,000 by 1944, performing more than 16 million extractions and nearly 70 million restorations (filling cavities and fitting dentures) from January 1942 to August 1945. ^[1]

Daily brushing became mandatory military discipline. Toiletry kits for active-duty soldiers included toothbrushes and toothpowder. (Tooth powder was cheap to make and easy to massively distribute. The metal required for toothpaste tubes was strictly rationed.) Returning soldiers continued their habit as consumers, accelerating widespread adoption in the 1950s.

Dental disease had been common and disabling for decades; its scale was not the trigger. The forcing event was triggered in 1941 when the U.S. military needed to raise an army and discovered it couldn't. The cost became legible to an actor with the authority, the responsibility, and the accountability to act. A draft board examiner looking into a recruit's mouth was that actor. The following examples illustrate variations on the pattern.

Forcing events follow a pattern

The forcing-event pattern in public health is not unique to dentistry; it has recurred for the last century and a half: adoption stalls for years, the cost becomes undeniable to someone who can act, and the change that could not happen suddenly does.

1. Cholera: The Broad Street pump (1854). When a cholera outbreak killed over 600 people in Soho, England, within days, John Snow mapped the deaths back to a single contaminated water pump. Local officials, deeply skeptical of germ theory, removed the pump handle anyway simply because the death toll was mounting close to their own homes. New cases fell off almost immediately afterward, though historians note the outbreak was likely already waning as residents fled the area, so the handle's removal may have sealed the argument more than it stopped the disease. Either way, it worked where it mattered most: Snow's theory now had a visible, dramatic result behind it, and that credibility fed directly into Parliament's later decision to fund Joseph Bazalgette's citywide sewer system, the infrastructure that finally ended London's cholera epidemics for good ^[2].

2. The 1918 flu pandemic. Influenza wasn't even a reportable disease in most states going into 1918, so outbreaks were often confirmed only after they'd spread widely. The pandemic's deadlier second wave forced states to amend their sanitary codes and make influenza reportable, while cities imposed mask and quarantine orders almost overnight, creating the surveillance infrastructure still used in public health. ^[3]

3. Penicillin: World War II (WWII). Penicillin sat as a lab curiosity for over a decade because peacetime drug companies had no incentive to solve its brutal manufacturing problems. The war made every infected wound a military liability, and Roosevelt's War Production Board forced competing firms to share proprietary fermentation techniques, scaling output from single-patient batches to 2.3 million doses in time for D-Day ^[4].

4. Oral rehydration therapy (1971). ORT had been tested in small trials through the 1960s but stayed a medical curiosity, distrusted by clinicians wedded to IV treatment. When war in East Pakistan pushed millions into refugee camps and a cholera outbreak exhausted the supply of IV saline, Dr. Dilip Mahalanabis had no choice but to distribute salt-and-sugar solution at scale, cutting cholera mortality from roughly 30% to under 4% ^[5].

5. AIDS and the FDA (1980s to 1990s). Before AIDS, new drugs moved through the FDA on a fixed, years-long timeline regardless of urgency. Confronted by a visible, organized, and dying patient population staging sit-ins at its own headquarters, the FDA created the Accelerated Approval pathway in 1992, letting drugs for serious conditions reach patients based on surrogate markers rather than full survival data, a mechanism now used well beyond HIV, in cancer and other diseases ^[6].

6. COVID-19 vaccines (2020). Vaccine development normally runs safety trials, efficacy trials, and manufacturing scale-up sequentially over many years, commonly known as Phase II and III. Operation Warp Speed didn't skip steps; it forced them to run in parallel, funding manufacturing before trials even finished, compressing a process that typically takes a decade or more into under twelve months for the first authorized doses ^[7].

Hearing is searching for its forcing event

Three candidates:

1. Military. Military non-deployability is an ongoing crisis. Army audiologists have spent years studying how hearing loss affects soldier performance, and for over 30 years, service members have undergone annual audiometric testing, with a hearing-loss threshold that triggers a mandatory medical review board. Many soldiers have been formally labeled non-deployable as a result. Military service induces a disability that compromises quality of life, diminishes deployable manpower, and incurs enormous ongoing costs on taxpayers.

I attended a military medical conference several years ago and asked a senior medical officer about the problem. "There's nothing we can do." he said. "The military hurts them and the VA gets them ["VA" is the U.S. Department of Veterans Affairs]".

The military feels the cost as directly as any actor in these examples. What it has lacked is a preventive tool. Absent one, it can only test, label, and discharge, which is why the most cost-aware institution in hearing still produces measurement, not maintenance.

Today, the VA compensates more than 1.6 million veterans for hearing loss and more than 3.5 million for tinnitus. Tinnitus is the #1 most prevalent service-connected disability across all VA compensation, hearing loss is #2, per VA's FY2025 Annual Benefits Report. ^[8].

In fact, the VA has proposed to stop rating tinnitus as a standalone condition, folding it into the hearing-loss rating and ending the automatic 10 percent award that is most veterans' first claim. The change is proposed as of mid-2026, not final, and existing ratings are protected ^[9]. Faced with the single most-claimed disability in its entire schedule, a powerful institution that could trigger a forcing event for hearing is narrowing what counts, instead of acting to prevent the injury.

2. Civilian workforce. If the military shows what a forcing event looks like, occupational hearing loss shows what one looks like when it doesn't quite happen. The example involves two federal agencies, NIOSH, the National Institute for Occupational Safety and Health, a research agency in the Centers for Disease Control and Prevention (CDC), and OSHA, the Occupational Safety and Health Administration, in the Department of Labor.

In 1972, NIOSH called on OSHA to lower its permissible noise exposure for factory workers. It took nine years to develop the scientific consensus resulting in the 1981 OSHA Hearing Conservation Amendment that required employers to run a hearing conservation program above the 85 dBA action level. Then, policy ran into politics. Ronald Reagan's OMB, the Office of Management and Budget, the largest office within the Executive Office of the President, stayed the rule for review. The final version that took effect in 1983 was, in the words of one longtime hearing-conservation historian, "stripped down." It never touched the actual exposure limit, which remains 90 dBA to this day, more than 40 years later. ^[10]

Today, occupational noise-induced hearing loss is the most prevalent injury of its kind in American industry, affecting more than 10 million workers, costing employers roughly a quarter-billion dollars a year in workers' compensation. Real damage and real money.

The different institutional response to military and civilian populations is noteworthy. For civilians, the cost is spread across millions of employers, the injury shows up 10 to 30 years after the exposure that caused it, and the costs land in the insurance systems, not on a commanding officer or the national healthcare system for veterans. So instead of a forcing event, we got a slow bureaucratic grind that produced a diluted mandate, a hearing conservation program, rather than the harder institutional response of actually lowering the exposure limit.

3. General population recreational noise. Here, the forcing event response pattern becomes even more diffuse. The World Health Organization (WHO) estimates that more than a billion young people are at risk of hearing loss from personal audio devices and unsafe listening habits ^[11]. That's a bigger number than the combined military and workplace categories by orders of magnitude. Yet despite widespread agreement and alarm among researchers and public health advocates, that risk has so far produced only weak, largely voluntary mandates.

France has had a 100 dB device cap since 1998, and an EU mandate followed in 2009. A 2013 European standard added an 85 dB default setting, but users can override it back up to 100 dB, and the limits have not been meaningfully strengthened since. A push to make the lower cap mandatory rather than optional did not advance, because member states could not agree on a hard 85 dB limit ^[12].

In 2019, the WHO-ITU, a partnership between the World Health Organization (WHO) and the International Telecommunication Union (ITU), issued a standard covering personal audio devices ^[13]. In 2025 the WHO-ITU issued a voluntary standard for safe listening for video gameplay and esports that manufacturers can choose to adopt ^[14].

We're on our own. Unless data changes that.

The candidate examples illustrate that the scale of harm is not likely to produce an actor to initiate a forcing event for hearing preventive care in the foreseeable future. Not the commanding officer watching a medical review board declare a soldier non-deployable. Not the safety inspector filing a claim ten years after the exposure that caused it. Not even a motivated policymaker or huge institution in the case of the VA. And certainly not the child with earbuds, one of billions, who is not an actor at all, which helps explain why recreational noise damage, currently the largest population of my three candidates, has moved policy the least. Billions of individuals are absorbing the costs of hearing disability personally today, so hearing maintenance will very likely continue to be personal choice.

That is precisely why data matters. It does not wait for a single actor. Distributed evidence lets many small actors, each provider, insurer, and patient, act on the same cost at once, substituting a thousand small decisions for the one forcing event that is not coming.

Perhaps hearing health care providers and their professional organizations, insurers, public institutions and policymakers can consolidate power to respond. Every forcing event in this history needed a catastrophe to make the cost legible. Data can make hearing's cost legible without one. That is where we go next.

References

1. American Dental Association, "Serving Those Who Serve: Military Dentistry and the ADA — Dentistry at the Front Line." Link
2. Tulchinsky TH. John Snow, Cholera, the Broad Street Pump; Waterborne Diseases Then and Now. Case Studies in Public Health. 2018;77-99. doi:10.1016/B978-0-12-804571-8.00017-2 Link
3. Smithsonian Magazine, "How the 1918 Flu Pandemic Revolutionized Public Health." Link
4. Society for History Education, "How the Mass Production of Penicillin Became Possible." Link
5. Our World in Data, "Oral rehydration therapy: a low-tech solution that has saved millions of lives." Link
6. Cato Institute, "Challenging the Moral Authority of the FDA." Link
7. U.S. Government Accountability Office, "Operation Warp Speed." Link
8. Veterans Benefits Administration, 2025 Annual Benefits Report. Link
9. U.S. Department of Veterans Affairs, Schedule for Rating Disabilities: Ear, Nose, Throat, and Audiology Disabilities, 87 FR 8474 (proposed Feb. 15, 2022).
10. 29 CFR 1910.95(b)(1) (OSHA Occupational Noise Exposure standard). Link
11. Dillard LK, Arunda MO, Lopez-Perez L, et al. Prevalence and global estimates of unsafe listening practices in adolescents and young adults: a systematic review and meta-analysis. BMJ Global Health. 2022;7(11):e010501. Link
12. European Commission, Directorate-General for Health and Consumers (SCENIHR), 2019. Link
13. World Health Organization and International Telecommunication Union. Safe Listening Devices and Systems: A WHO-ITU Standard. 2019. Link
14. World Health Organization and International Telecommunication Union. Global standard for safe listening video gameplay and esports. 2025. Link