Editorials
War on the roads
The public health community must intervene
The last thing the world needs is another war. Nevertheless, this week the BMJ exposes one more - the war on the world's roads <http://bmj.com/cgi/ijlink?linkType=FULL&journalCode=bmj&resid=324/7346/1139>. But to what extent can the global road trauma epidemic be likened to war?
War is often waged by the powerful on the weak. In this case, the interests of pedestrians, cyclists, and other vulnerable road users are pitted against the powers that stand to profit from increasing global motorisation. And there are many millions of casualties. Every day about 3000 people die and 30 000 people are seriously injured on the world's roads.1 In this issue Nantulya and Reich point out that over 85% of the deaths and 90% of disability adjusted life years lost from road traffic injuries are in low and middle income countries, with pedestrians, cyclists, and bus passengers bearing most of the burden.2 Most of the victims will never own a car, and many are children. Even in the high income countries, poor children are at greatest risk. The existence of a steep social class gradient in mortality in child pedestrians is well documented, but the evidence about socioeconomic gradients in morbidity due to injury has been conflicting.3 This week Hippisley-Cox and colleagues report a study of over 56 000 admissions of injured children to hospitals in Trent that provides clear evidence of a social class gradient in morbidity from injury, and which is steepest for injuries in pedestrians.4 Nevertheless, the prevention of traffic crashes is low on the list of public health priorities both in the United Kingdom and internationally, with record low levels of funding in research and development.5
As in other wars, propaganda is an important weapon. It is not in the interests of those who sell road transport to allow the private trouble of road death and injury to become a public issue. The idea that governments and the motor manufacturing industry have a major responsibility is not for public consumption. It is much more acceptable that the victims are held responsible. In this issue, Roger Browning, a trustee of the victims' charity RoadPeace, writes about the loss of his daughter in a road crash and his frustration at the absence of an appropriate response from the relevant authorities, including the medical profession.6 According to Marcel Haegi, the president of the European Federation of Road Traffic Victims, the failure of governments to properly enforce road safety laws, and to investigate road deaths as they would other situations involving the taking of life, is commonplace.7
The current preoccupation with educational programmes for pedestrians and road safety awareness campaigns might be another example of road safety propaganda. For example, writing on injuries in child pedestrians in low income countries, the Global Road Safety Partnership (led by the World Bank) argues that one reason why these accidents happen is that children do not have the necessary knowledge and skills that allow them to deal with the hostile traffic environment.8 On the basis of their systematic review of controlled trials of pedestrian education programmes, however, Duperrex and colleagues point out that there is no evidence that education programmes for pedestrians reduce the risk of motor vehicle collisions involving child pedestrians, and no trials have been conducted in low and middle income countries.9 But research in biomechanics has shown that changes in the design of vehicles could greatly reduce the frequency and severity of pedestrian injuries.10 Indeed, if vehicles complied with the recommendations of the European Enhanced Vehicle Safety Committee (EEVC), the estimated reductions in deaths among pedestrians could exceed 20%. The motor manufacturing industry vigorously opposes the introduction of this committee's recommendations for safety tests to benefit pedestrians. Trucks and buses hit a large number of pedestrians and bicyclists around the world, and it is possible to make the fronts of these vehicles safer.1 At present this issue is not on the agenda of any manufacturer or official safety agency.
How can we end the war on the roads? Contributors in this theme issue offer a range of strategies. Firstly, health practitioners must join forces with victims' organisations to build broad based coalitions advocating improved prevention and better care for road victims.7 In particular, Coates and Davies highlight the need for more research and better training of doctors in prehospital trauma care.11 Secondly, we must counter propaganda by insisting on research based countermeasures, including those specifically tailored to local traffic conditions in low and middle income countries.12 O'Neill and Mohan call for national or regional road safety agencies staffed with trained professionals.12
By 2020 road traffic crashes will have moved from ninth to third place in the world ranking of the burden of disease and will be second place in developing countries. Connor and colleagues in New Zealand show that sleepiness among drivers may account for nearly a fifth of road traffic crashes.13 Similarly, if the international public health community continues to sleep through the global road trauma pandemic it will be accountable for many millions of avoidable deaths and injuries.
Ian Roberts, professor of epidemiology and public health. London School of Hygiene and Tropical Medicine, London WC1E 7HT (ian.roberts at lshtm.ac.uk)
Dinesh Mohan, Henry Ford professor for transportation safety. Indian Institute of Technology, New Delhi 110 016, India
Kamran Abbasi, assistant editor.
BMJ
------------------------------------------------------------------------
1. Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Boston: Harvard University Press, 1996. 2. Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ 2002; 324: 1139-1141[Full Text]. 3. Roberts I, Power C. Does the decline in child injury death rates vary by social class? BMJ 1996; 313: 784-786[Abstract/Full Text]. 4. Hippisley-Cox J, Groom L, Kendrick D, Coupland C, Webber E, Savelyich B. Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992-7. BMJ 2002; 324: 1132-1134[Abstract/Full Text]. 5. Ad Hoc Committee on Health Research Relating to Future Intervention Options. Investing in Health Research and Development. Geneva: World Health Organization, 1996. 6. Browning R. Where are the protests? BMJ 2002; 324: 1165[Full Text]. 7. Haegi M. A new deal for road crash victims. BMJ 2002; 324: 1110[Full Text]. 8. Global Road Safety Partnership. www.grsproadsafety.org (accessed 3 May 2002). 9. Duperrex O, Bunn F, Roberts I. Safety education of pedestrians for injury prevention: a systematic review of randomised controlled trials. BMJ 2002; 324:1129-1131[Abstract/Full Text]. 10. Crandall JR, Bhalla KS, Madely NJ. Designing road vehicles for pedestrian protection. BMJ 2002; 324: 1145-1148[Full Text]. 11. Coates TJ, Davies G. Pre-hospital care for road traffic crashes. BMJ 2002; 324: 1135-1138[Full Text]. 12. O'Neill B, Mohan D. Reducing motor vehicle crash deaths and injuries in newly motorising countries. BMJ 2002; 324: 1142-1145[Full Text]. 13. Connor J, Norton R, Ameratunga S, Robinson E, Civil I, Dunn R, et al. Driver sleepiness and risk of serious car occupant injury: population based case-control study. BMJ 2002; 324: 1125-1128[Abstract/Full Text].