Drowsy America
By Anastasia Toufexis
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 afterschool 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 hopscotches 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 adviser 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 and fail to keep the passage 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 500 to 1,000 times 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 the 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 those in the U.S. "The Europeans don't have 24-hour societies like we do," says Henry Ford Hospital's Roth. "If you're in Paris and you're 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 than the U.S., it may be Japan. Officeworkers in Tokyo often commute for an hour or more, arriving at their desks at 9 a.m. and staying until 8 p.m. or later. Then they go out to eat and drink with colleagues, an essential part of the job, and catch the last train home at midnight. Workers get only 113 days off a year, compared with 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 tirelessness 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 theirhealth 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 some more time abed in blissful oblivion should be attractive. It is a message that is becoming unmistakable: Wake up, America -- by getting more sleep.
With reporting by Barbara Dolan/Chicago, Janice M. Horowitz/New York and James Willwerth/Los Angeles