Road injury and its prevention emerge as an international health issue
Low-income and middle-income countries record more than 85 percent of all road fatalities, vastly out of proportion to the number of motorized road users and miles they travel. These countries’ traffic disease burden includes 96 percent of children killed in traffic crashes worldwide. According to the most recent international studies, in 2002, road crashes were the ninth leading contributor to the global burden of disease, accounting for 2.6 percent of worldwide death and disability as measured by disability-adjusted life years (DALYs). More striking, by 2020, road crashes will rise to third place, ahead of cerebrovascular disease (strokes) and just behind ischaemic heart disease and unipolar major depression and will account for the vast share of the 77 percent increase in deaths from causes other than communicable disease. (Read the full story, “Measuring the Burden,” in this issue of the newsletter).
The single factor most responsible for the rise in road crash death and injury in low- and middle-income countries is their extremely rapid rate of motorization. Although that in itself is an indicator of rising prosperity, the threat from road crashes does not follow the typical "diseases of affluence" pattern, where chronic diseases associated with more sedentary habits and excessive caloric intake supplant "developing world" diseases associated with poor sanitation and malnutrition. There is a correlation, but only to a point. Interestingly, when prosperity rises to a yet higher plateau, traffic crashes tend to recede as a cause of death and injury per vehicle while rising in absolute terms because the number of vehicles is increasing. The reduction in deaths per vehicle is reflected to some extent by wealthier countries’ success in establishing enforcement programs to increase seat belt use and reduce the frequency of driving under the influence. However, as Australia demonstrates, while wealth generally fosters the development of such programs, it does not guarantee high levels of traffic safety. A concerted policy is needed, and it must be tailored to reach various risk groups
The correlation between socio-economic status and risk from traffic crashes is further complicated when considered in the context of wealthy countries. People in high-income countries who live below the socio-economic norm experience higher rates of death and injury from road crashes. So there is excessive risk for populations on the downside of a wealthy economy as well as those in a poor economy with rising wealth and mobility. These are new phenomena that researchers are just starting to analyze. (Read the full article on the epidemiology of traffic injury, “Risk Patterns Old and New” in this issue of the newsletter).
In addition, because crash victims in low-income countries tend to be of lower socio-economic status, and because a disproportionate number are males in the prime of their earning years, the economic consequences of deaths and injuries from traffic crashes can be catastrophic for family networks. A single crash-related injury can have ripple effects on many households. For instance, in India, many of the forced sales of land are made to pay for treating injured family members, many of whom have suffered their injuries in traffic crashes. Also in India, the price of an average car represents 12 years' wages, so that its loss or damage is an acute financial setback. By comparison, in the U.S., a typical worker can pay for a working car with three months' wages. Also, people who live at lower socio-economic levels tend to not have a strong voice in the political dialog that could lead to greater government attention to road safety in general and policies relevant to their situation in particular.
While certain traffic safety interventions, such as better enforcement of speeding, DUI, and seat belt laws and safer infrastructures, including protected crossings for pedestrians and separate lanes for non-motorized vehicles, have been effective in high-income countries, there are often barriers to their successful implementation in low-income countries. The risks posed to road users in these countries may require new, creative interventions beyond what has been done in wealthy countries. Additionally, what has worked in these countries will not necessarily enjoy the same success in low-income countries.
Interventions should take into account the critical differences in these countries, where circumstances of crashes and the nature of crash victims are so different. For example the percentage of drivers among people killed in crashes is much lower in poorer countries (driver deaths being a more commonly used measure than occupant deaths). Drivers make up 10 percent of crash deaths. In the motorized world, that figure is six times higher. That difference is partly explained by the fact that many more victims in low-income countries are not riding in a vehicle.
There are other notable differences. Roughly 40 percent of all road deaths in wealthy countries occur in urban areas. In low-income countries, urban areas have a much greater share of road deaths, with urban pedestrian deaths alone accounting for 55 to 70 percent of all road deaths. Additionally, large numbers of victims in poor countries are riding in vehicles that are sub-standard in terms of safety features—motorized rickshaws, scooters, and the like—as opposed to the more protective double-axle, four-wheel vehicles that are the standard in the wealthy world.
These phenomena contribute to a core dilemma for the new road safety campaigns: much of the death and injury burden stems from increasing competition for road space by a wide range of users who travel at different speeds and with lesser degrees of the protective "armor" afforded by fully enclosed, four-wheel vehicles. This is no accident. According to the WHO World Report on Road Traffic Injury Prevention, government policies in these countries favor "integration of all transport modes to the disadvantage of the most vulnerable road users, pedestrians and cyclists.”
"The conflict is most severe on streets passing through crowded low-income urban residential areas and in settlements along major roads passing through rural areas,” notes Reich Nantulya, in the 2003 article "Equity dimensions of road traffic injuries in low- and middle-income countries."
In highly motorized, high-income countries, the governments can afford to build a parallel infrastructure to serve the more vulnerable road users, notes Dinesh Mohan, director of the Transportation Research and Injury Prevention Programme at the Indian Institute of Technology in Delhi, in his April 2004 article, "The Road Ahead: Traffic Injuries and Fatalities in India." But such duplication is beyond the budgets of lower-income countries. "[T]here are no standards for providing services needed by non-motorised transport. These services mushroom along urban or intercity highways to fulfill the demands of road users; however, their existence is viewed as an 'illegal encroachment' on the designed road space."
This marks a stark difference from trends in the motorized world, where planners are striving to encourage mixed-use boulevards and other alternatives to high-speed freeways in order to promote physical activity and re-animate urban spaces.
Land use policies could play a crucial role in effecting improvements in road safety, as these nations rush to build new transportation systems to satisfy the mobility demands of their populations. However, strong, accountable planning strategies have not received the same priority as other policies seen as more directly related to economic growth.
A project in India saw a major thoroughfare being planned through rural settlements. Planners did seek out ways for local residents to have protected pedestrian crossings, but they found it difficult to design crossings that were convenient and were placed in such a manner that people would use them.
In addition, some of the fastest-growing regions are located beyond the sphere of historic governmental influence. That is the case in Guadalajara, Mexico, for example, where economic growth is so rapid that major trucking routes are coming into the region, but most government and institutional expertise is located far away, in Mexico City, the country's capital and traditional seat of power.
A critical element is the lack of guidance from the top due to an absence of governmental expertise and authority to enact and enforce road safety measures. This is closely linked to a core shortcoming: the lack of data defining the problem and the absence of a way to measure the effectiveness of any interventions that are undertaken. And part of that lack would seem to be explained by the reduced political stature of the victims. Mohan has written extensively on this aspect, as well as the debate over "blaming the victim," that is, investing in education and awareness campaigns aimed at drivers and other road users, versus using governmental influence to force vehicles and roads to be built with safety more in mind. One lesson that could be taken from high-income countries is that educational campaigns rarely have any lasting effect without being linked to consistent, highly visible enforcement.
"You also see the people's anger… What people are saying … is that it’s not acceptable to have your kids killed on the street."—Dinesh Mohan
"The government keeps talking about road safety and what they should do and they translate that concern into television campaigns or ads or articles in papers and posters and so on. In every Indian city you see billboards on the roads telling people how to be safe, to drive safely. But we know from experience here that that doesn’t really change things much.
"You also see the people's anger," Mohan said. "For example, in India it’s true; in Egypt it’s true; in Malaysia, Indonesia, sometimes China. When a truck or a bus hits a pedestrian or bicyclist, and if the driver doesn’t run away from the scene of the accident, he gets lynched, and every second day some bus or truck gets burnt because it has run over a pedestrian, or especially a child. If a child is hit by a bus or truck, it gets burnt by the crowd. So to me this is ample evidence that the people do not take the existence of accidents as something acceptable. What people are saying by indulging in this violence on the streets is that it’s not acceptable. It’s not acceptable to have your kids killed on the street.
"The second evidence we have is that road humps are coming all over the place, even on the intercity roads, so that if a child gets killed on an intercity highway—and these are not limited access highways, these are open highways—if a child gets killed on a highway in a village, the villagers go to the local politician, force the politician to get the engineer to get a road hump on the highway. Now there are very few villages left in India where you don’t have a road hump when the road goes through a village. And similarly in a lot of residential neighborhoods in cities people are putting up road humps all over the place, and as far as the government is concerned, these humps are all illegal, but they can’t do anything to stop them. So there’s, I would say, a people’s movement for safety without realizing it." (To read the entire interview, click here)
And, finally, there is a large gap in post-crash trauma care. "In a 5-year study in Malaysia in the 1990s, none of a series of 120 patients with acute traumatic spinal or spinal cord injuries had spinal immobilization during transport from the injury site to the hospital," reports TSC researcher Ted Brown in his 2003 master's thesis study of EMS services in the low-income world, focusing on Thailand. He also described a patchwork response system, with few emergency vehicles staffed and equipped at even the most rudimentary levels. Efforts to establish standards and procedures were just getting underway, he noted at the time, but pre-hospital care was still rarely available to traffic crash victims. (Read the full story in our Fall 2003 Newsletter)
One of the more wide-ranging responses to Road Safety Day is a series of reports and programs by the Australian government, which at one time suffered rates of traffic-related death and injury on a level with many low-income countries today. It also tuned policies to address the fact that within its boundaries it has road users characteristic of low-income countries. It also has managed to meld policies that address both sets of situations and thus might be of use for countries as they continue to become more prosperous and, concomitantly, more motorized. (Read the article "Learning from Australia" in this issue)