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  • Road Traffic Injuries: Hidden Epidemic in LessDeveloped CountriesAlyson Hazen, BS and John E. Ehiri, PhD, MPHBirmingham, Alabama

    Road traffic injuries (RTIs) are a leading cause of morbidity,disability and mortality in less developed countries. Globallyin 2002, 1.2 million deaths resulted from RTIs, and about 10times that were injured. RTIs are often preventable, and thetechnology and knowledge to achieve success in this areaexist. In spite of this, it is projected that given the currenttrend and without adequate intervention, RTIs will rank thirdof all major causes of morbidity and mortality globally by2G20. Although >85% of the global deaths and injuries fromroad traffic crashes occur in less developed countries, trafficsafety attracts little public health attention in these nations,due in part to a plethora of other equally important prob-lems, including infectious diseases. Unfortunately, the publichealth and economic impact of traffic-related injuries anddisabilities can be incalculable in these countries, owing totheir poorly developed trauma care systems and nonexist-ent social welfare infrastructures to accommodate theneeds of the injured and the disabled. In this paper, we high-light the problem posed to public health in less developedcountries by RTIs and examine contributing factors. Toengender debate and action to address the problem, wereviewed interventions that have proven effective in indus-trialized nations and discussed potential barriers to theirreplication in less developed countries.Key words: road traffic injuries * traffic safety, accidents aunintentional injuries U developing countres U disabilities

    K 2006. From the Department of Health Behavior (Hazen) and Departmentof Maternal & Child Health (Ehiri), School of Public Health, University ofAlabama at Birmingham, Birmingham, AL. Send correspondence andreprint requests for J Natl Med Assoc. 2006;98:73-82 to: John E. Ehiri, PhD,MPH, Department of Maternal & Child Health, School of Public Health,University of Alabama at Birmingham, 1665 University Blvd., Ryals Building320, Birmingham, AL 35294; phone: 205-975-7641; fax: 205-934-8248; e-mail:[email protected]

    INTRODUCTIONThe World Health Organization (WHO) produced

    its first authoritative report on the problem ofroad traf-fic injuries (RTIs) more than 40 years ago.' In 1974,Resolution WHA27.59 was passed by the WorldHealth Assembly, declaring RTIs "a major publichealth issue" and calling on member states to addressit.' Nevertheless, implementation ofprograms has beenslow or nonexistent, and RTIs continue to exact anenormous social and economic toll on many poorcountries around the world.2 In contrast to the consis-tent declines seen in high-income countries (HICs),many developing nations have witnessed dramaticincreases in the number of road traffic deaths.3 As aresult, there has been renewed interest in the interna-tional health community to more strongly emphasizethe public health importance of road safety. For exam-ple, the WHO recently formed the Department ofInjuries and Violence Prevention, and the World Bankformed an interdisciplinary taskforce to ensure roadsafety issues are jointly addressed by transport andpublic health departments and professionals. In addi-tion, the 2004 World Health Day was dedicated to roadsafety to reflect the huge importance ofthis problem.'

    William Haddon, Jr. pioneered road safetyresearch when he combined the host-agent-environ-ment triad with the concepts of primary, secondaryand tertiary prevention to create the Haddon Matrix(Table 1 ).4 This matrix provides a framework forunderstanding the etiology of injuries and allows forthe identification of potential interventions at eachstep in the injury process.4 The resulting systemsapproach taken by developed countries has resultedin decreased rates of motor vehicle injuries andfatalities by dispelling the notion that road trafficcrashes are random and unpredictable events and byinvolving professionals from multiple sectors (Table2)." 5 However, this approach has been a challengefor less developed countries to adopt as it requiresconsiderable resources and infrastructure to imple-ment.' Nonetheless, there are available measuresthat can be taken to reduce the concomitant human

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  • ROAD TRAFFIC INJURIES IN LESS DEVELOPED COUNTRIES

    suffering and economic impact caused by RTIs.This paper discusses the current state of RTIs in

    less developed countries, including the magnitudeand key determinants of the problem, contributingfactors and selected prevention interventions thathave proven effective in HICs and are potentiallytransferable to other settings. Data presented are pri-marily from observational and descriptive studies asrandomized controlled trials or controlled before-after studies conducted in less developed countrieson this subject are rare. When possible, evidence forintervention effectiveness is presented from system-atic reviews of studies performed in HICs. WHOAfrican and southeast Asia regions are emphasizedsince these are among the worst affected.'2 Lessdeveloped countries encompass those of both low-and middle-income levels, as defined by the WorldBank. Low-income countries have a gross nationalincome (GNI) per capita of $765 or less, while mid-dle-income countries are between $766 and $9,385.6MAGNITUDE OF THE PROBLEM

    RTIs are a cause of public health concern in virtu-ally every country of the world.7 However, the distri-bution of mortality and morbidity is highly uneven,with developing countries incurring 85% of all deathsdue to traffic crashes, 90% of lost disability-adjustedlife years (DALYs) and 96% of all child deaths due toRTIs.8 Estimates of deaths resulting from RTIs varyas a result of underreporting and a lack of reliabledata due to incomplete records.9 According to WHOestimates, approximately 1.2 million people werekilled in traffic crashes in 2002.' An additional 20-50million persons are injured or disabled each year.8Most ofthese statistics are accounted for by "vulnera-ble road users," including pedestrians, bicyclists,motorcyclists and riders of scooters or mopeds, most-ly in less developed countries.9

    Table 1. The Haddon matrix applied to a road traffic crashFactors

    EnvironmentPhases Human Vehicle Physical SocialPreevent

    Attitudes Roadway designKnowledge Vehicle condition Traffic calming Traffic laws

    Use of alcohol Speed Pedestrian facilities Cultural normsDriver experience

    Event Use of seat belts Seat belts Shoulders, medians Helmet andWearing fastened helmet Helmets Guardrails seat belt laws

    Postevent First aid Fire risk Availability of trauma Standards of traumaMedical treatment care equipment care in hospitals

    Traffic congestion

    In 1998, RTIs ranked ninth for DALYs lost glob-ally.8 In 2002, they were the second leading cause ofdeath for children aged 5-14 years and young adultsaged 15-29 years, and the third leading cause ofdeath for adults aged 30-44 years.' It is projectedthat if current trends continue and new initiatives arenot instituted, by 2020, RTIs will rank third forDALYs lost globally, and road traffic deaths indeveloping countries could increase by up to 80%.'I8

    RTIs place enormous economic strain at thenational, local and individual levels. Those most oftenaffected by RTIs are young adults aged 15-44, whoaccount for 48-78% of all traffic-related fatalities.9Males are consistently more likely to be injured orkilled, thus increasing the number of economicallydisadvantaged widows and orphans.8'9 Indeed,removal of the breadwinner, funeral costs, hospital-ization fees or extended medical care for severeinjuries can push a family into poverty.9 Direct eco-nomic costs of global traffic crashes are estimated at$518 billion.' For developing countries, the costs areestimated at $65 billion, more than the total amountof all foreign aid donated.9 In reality, these costs arelikely to be considerably higher, especially when indi-rect and social costs are factored into the estimates.Direct costs include hospitalization fees, long-termmedical care for the injured and loss of productivity.The average annual cost to the society of road trafficcrashes ranges from 0.3% of the GNP in Vietnam tonearly 5% in Malawi and South Africa.8KEY DETERMINANTS OF RTIS INDEVELOPING COUNTRIES

    Numerous factors play a significant role in trafficcrashes and resulting injuries.8 Some involve humanbehavior while others are system-related. Risk factorsfor the majority ofRTIs around the world are the same,although they may differ in magnitude depending on

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    the region. Some of the major factors are the increasednumber of motor vehicles, speed, alcohol and mix ofroad users. These are discussed in detail below.Increased Number of Motor VehiclesA primary reason for the increase in fatalities and

    injuries from traffic crashes in poor countries is simplythe rising number ofmotor vehicles.2 Economic growthis associated with expanded mobility and demand fortransportation services.' India, China and Vietnam,whose economies grew during the past 10-15 years,have seen rapid increases in their number of motorvehicles.' In India, four-wheeled motor vehicles haveincreased by 23% in only three years and could number267 million by 2050.1,2 China has seen a fourfoldincrease in vehicles since 1990 to >55 million.' In Viet-nam, from 1992 to 2001, the number of motorcyclesincreased from less than 2 million to >8 million.'0 Inaddition, in just one year, the number ofmotor vehiclesin Vietnam increased by 14%, while deaths and injuriesrose by 31% and 16%, respectively.2Speed

    Speed is a crucial factor in many road traffic crash-es and influences both crash probability and severity ofinjury." As a general rule, the greater the speed, themore likely a crash will occur and the more likelysevere injuries will be sustained." In Ghana, speedalone was responsible for half of all traffic crashesbetween 1998 and 2000 and contributed to 44% of allpolice-reported crashes in Kenya."" 2 A study in Kuwaitattributed speed to be the primary cause for almost92% of traffic crashes in the sample.'3

    Commercial vehicles-taxis, trucks, buses andminibuses-are disproportionately involved in trafficcrashes in many low-income countries and inflict sub-stantial morbidity and mortality.'2"4"5 Pressure toadhere to strict timetables often causes commercialdrivers to exceed posted speed limits.' Speed regulatorson commercial vehicles are often nonfunctional, non-existent or intentionally disabled.' There is frequentlyan increased reliance on public transport in less devel-oped countries. Ideally, this would be a positive phe-nomenon given the need to reduce traffic congestionand emissions. However, public transportation systemsare not well developed in many resource-poor coun-tries, thus allowing informal and unregulated fare-based systems to proliferate.9" 4 These systems, such asthe matatus in Kenya, often consist of hazardouslydecrepit vehicles that are overloaded with passengers.9Intense competition for fares results in aggressive driv-ing and over-speeding.9Alcohol

    Although alcohol is a known risk factor for traf-fic crashes, reliable data on the prevalence of driving

    under the influence of alcohol in developing coun-tries are sparse. In Kenya, a survey of hospitalizedpatients revealed that of those being treated for traf-fic-related injuries, 40% of drivers and 20% ofpedestrians reported being under the influence ofalcohol at the time of the crash.'2 A study in NewDelhi revealed that one-third of hospitalized motor-ized-two-wheeler riders admitted to drinking alco-hol and driving.' Alcohol poses a huge threat to roadusers in South Africa.'6 Data from the NationalInjury Mortality Surveillance System shows that ofall fatal transport-related cases tested in 2001, >50%had elevated blood alcohol content (BAC) and out ofthose, 91% exceeded the legal limit of 0.05 g/dl.'6Over 62% of pedestrian fatalities had an elevatedBAC and almost 25% had BAC of >0.25 g/dl, morethan five times the legal limit.'6 In addition, >46% ofdrivers killed had BAC of >0.05g/dl.'6Mix of Road Users

    Most developing countries have a blend of roadusers that is very different from that of industrializednations. This mix varies depending on the region buttypically consists of pedestrians, push carts, bicy-cles, mopeds/scooters/motorcycles, trucks, minibus-es, buses and cars.' Danger arises from this mixtureof slow-moving, nonmotorized users and fast-mov-ing, motorized users sharing the same road space.9Urban Versus Rural Differentials

    The group ofroad users most often injured variesby region and geographic locale. In Asia, riders oftwo-wheeled vehicles and pedestrians are most com-monly injured.8 Motorcycles and bicycles had thehighest rates of injuries in 2001 for both urban andrural regions in Vietnam.10 Data from the Viet-namese Ministry ofTransportation also indicate thaturban traffic crashes are more frequent but that ruralcrashes are generally more severe.'0 In India, thesesame road users account for 70-80% of all deathsdue to RTIs, while occupants of cars account foronly 5%*.7 Africa sees most injuries and deaths beingsustained by pedestrians in urban crashes and usersofpublic transportation systems in rural crashes.'2 Incontrast to Vietnam, 60% of all injury-producingcrashes in Kenya occur on rural intercity highways,but only 40% occur in urban regions.'2 Due tocrowded public transport vehicles being involved inrural crashes, the number of casualties per motorvehicle collision is greater on rural than urbanroads.'2 Studies in Kenya show that pedestrians as awhole are the most vulnerable of all road users, andthis group experiences the greatest number ofinjuries and deaths from traffic crashes.'2 Pedestri-ans in urban areas accounted for >70% of the totalannual deaths due to road traffic crashes in 1998.12

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    In addition, a recent survey at Kenyatta NationalHospital in Nairobi reported that pedestriansaccounted for 65% of patients admitted for traffic-related injuries.'2 Pedestrians in urban areas are alsothe most likely to be injured in Latin America andthe Caribbean.8 In Colombia, traffic crashes arealmost entirely an urban phenomenon, with only10% of crashes occurring on rural highways.'8 As aresult, pedestrians made up nearly 68% of victimsfrom traffic crashes in Bogota' in 2000.18CONTRIBUTING FACTORSPoverty

    There are a number of indirect factors, includingsocioeconomic factors, that contribute to and worsenRTIs in developing countries. Whereas walking anduse of public transportation systems provide benefitsto health and the environment in industrializednations, these modes of transport place the poor atrisk of RTIs in developing countries owing to the lackof safe pedestrian lanes and inadequately regulatedmass transit systems. Using level of education as anindicator of socioeconomic status in Kenya, it wasfound that 27% ofpeople with no schooling relied onwalking and 55% used public transportation, mostlymatatus.9 In contrast, 81% of those educated beyondsecondary school rode in private cars, none walked,and only 19% used public transportation.9 The poorare also less able to pay for medical treatment afterbeing injured because the introduction of user fees atpublic health facilities has eliminated the free health-care that was formerly available.2Inadequate Surveillance Systems

    Many countries have some sort of system to col-lect data on road traffic crashes, usually from hospi-tal records or police reports.'0"'2 However, underre-porting is a major problem, even in developedcountries with good reporting systems."9"9 Minorinjuries are most likely to be underreported.'9 Peoplemay not seek medical treatment for such injuries ormay be unable to pay for services and so are not cap-tured by hospital records.9'20 This is more likely to betrue for rural than urban areas. In rural areas ofGhana, for example, patients that sustained severeTable 2. The systems approach to road safety* A science-based approach to injury pioneered by William Haddon, Jr* Haddon Matrix combines injury event time sequence and epidemiologic triad* Allows for identification of primary factors that contribute to traffic crashes and possible interventions

    to prevent crashes or mitigate severity of crash outcomes* Can be used to identify problems, formulate strategies, set targets and monitor performance* Requires multisector cooperation and institutional capacity* Is crucial for reducing road traffic injuries and fatalities

    injuries were less likely to seek hospital treatmentthan patients in urban areas due to an inability to payfor care.2 Police and/or hospitals might not recordinjuries or fail to share information, resulting in dis-crepancies between sources.'20 Road traffic crashesthat occur in rural areas frequently go unreporteddue to the lack of police presence.20 Furthermore, thequality of the data is often questionable and makesinternational comparisons difficult.' Data may beincomplete or interpreted differently, reporting sys-tems differ, and definitions of an RTI or death arenot standardized."9 Even when data are collected,they are rarely used as a basis for developing andevaluating policy or interventions?' Reliable andaccurate data on the magnitude, characteristics andconsequences of road traffic crashes are desperatelyneeded in order to firmly establish RTIs as a publichealth priority and to create policy guidelines andinterventions.' Without this data, policy makers willcontinue to fail to design appropriate policyresponses to this public health challenge.9Inadequate Trauma Care Systems

    Inadequate public health infrastructure meansmany victims of traffic-related injuries die or are dis-abled from not receiving prompt trauma care.22' Inmany developing countries, formal emergency med-ical services are nonexistent or are inaccessible to amajority ofthe population where they exist.2' Much ofsub-Saharan Africa and southern Asia do not haveeven rudimentary ambulance services in rural andmost urban areas.2' Surviving traffic crash victims areoften transported to a hospital by bystanders, rela-tives, commercial vehicles or the police.2' In Kenya,only 2.9% of crash victims are transported to a hospi-tal by an ambulance.' Likewise, hospitals themselvesare largely unprepared to treat trauma victims, whorequire special equipment and specialized medicalcare. A study of 11 rural hospitals located along busyroads that received high numbers of RTI victims inGhana revealed that they were staffed by generalpractitioners with no training in trauma care.2' Inthese same hospitals, none had chest tubes, which areinexpensive and vital for the treatment of life-threat-ening chest injuries, and only four had the necessaryequipment to maintain an open, breathing airway.2' In

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    Kenya, only 40% of public, private and mission hos-pitals were well prepared to treat trauma patients, andalmost none of the standard treatment items for man-aging severe injuries were found in governmenthealth facilities.2 While lack of supplies is problemat-ic, so too is poor utilization of such equipment when itis available. A review of >2,000 trauma admissions inan urban hospital in Ghana showed low utilization ofblood transfusion and chest tubes.2' Thus, inadequatetrauma care is not unique to rural environments thatlack ambulance services, as even well-stocked urbanhospitals have much room for improvement in treat-ing trauma victims.INTERVENTIONS

    In this section, we discuss interventions that havebeen proven effective in reducing RTI morbidity andmortality in HICs (Table 3) and examine their poten-tial applicability to developing countries. Currentinterventions, barriers to implementation, interven-tion effectiveness and good practice examples insome developing countries are also highlighted todemonstrate what can be achieved even in situationsof limited resources.Motor Vehicle Occupant Protection

    It is well established that seat belts decrease deathand severe injury for motor vehicle occupants.'7"1322-25Studies conducted in the 1980s estimated that theyreduce motor vehicle fatalities by 50% and severeinjuries by 55%.22,23 More recent studies have showneven greater reductions.24'25 Seat belt use is mandatedin many industrialized nations, but usage is low inmost developing countries as many vehicles may nothave functional belts.23 It is estimated that less thanhalf of automobiles in developing countries are out-fitted with functional seat belts.23 In addition, thelack of enforcement of existing seat belt laws con-tributes to the low usage.22 However, seat belts are afeasible intervention for developing countries toadopt, providing several strategies accompany theimplementation. Given that only half the vehicles indeveloping countries have functional belts, it isunrealistic to mandate usage.

    One measure that governments could take is toban the importation of vehicles without functionalbelts.22 This would prevent from entering the countryunsafe vehicles that would subsequently place occu-pants at risk. Another measure could be to requirepublic transport vehicles to have seat belts installed,as is currently done with matatus in Kenya.26 Suchmeasures have the potential to improve public trans-portation safety by requiring each passenger to havetheir own seat, thus reducing passenger overloading.

    Two-Wheeler RidersHelmets are a primary intervention with proven

    effectiveness in reducing the risk of head injury. ACochrane systematic review revealed that motorcy-cle helmets reduced the risk ofhead injury by 72%.27Helmets also appeared to reduce the risk of mortali-ty, although an overall estimate of effect was not cal-culated.27 Studies in Taiwan, Indonesia and Malaysiahave attributed reductions in deaths to theiruse." 22'28'29 Taiwan saw a decrease in motorcycle fatal-ities and nonfatal injuries of 14% and 31%, respec-tively, following the passage of a mandatory motor-cycle helmet law in 1997.28 Nonfatal head injuriesalso fell by 44%.28 Helmet legislation passed since1973 in Malaysia is estimated to have contributed toa reduction in motorcycle fatalities by 30%.' Man-dating helmet use by motorcycle riders is a highlytransferable and feasible intervention for poor coun-tries to adopt, since people who are able to buy amotorcycle should be able to afford a helmet.22

    Standard helmets provide full head coverage andhave a thick energy-absorbing lining, while nonstan-dard helmets cover a small amount of the head andhave a thinner lining made from less absorbentmaterial.30 Few studies have investigated the differ-ences between helmet types and injury outcomes.One study found that 33% of motorcycle riderswearing nonstandard helmets were killed and 75%sustained head injuries, while 13.6% of riders wear-ing standard helmets were killed and 30.7% hadhead injuries.30 It is crucial that helmets be approvedand worn properly for them to be effective. Anobservational study in Indonesia revealed that 45%of motorcycle drivers and 87% of passengers worethem with the chin strap unfastened, providing littleprotection in the event of a crash.29

    Strategies to increase motorcycle helmet usewould be to encourage or even require the purchaseof an approved helmet when purchasing the motor-cycle.'9 The importation of standard helmets thatmeet safety requirements, education campaigns onthe importance of proper use and the enforcement ofusage laws have the potential to reduce injuries anddeaths from motorcycle crashes.2223

    Likewise, bicycle helmets have been shown toreduce the risk of head and brain injuries by63-88%, but current usage is extremely low world-wide.31 A study in Wuhan, China showed that noneof the patients admitted for bicycle-related crasheshad been wearing a helmet.22 However, mandatorypurchase and use of an approved helmet is unrealis-tic in many developing countries because bicyclesare the cheapest form oftransportation used primari-ly by the poor.23 Strategies to promote their use couldinclude government subsidy on helmet purchase,resources permitting and bicycle safety campaigns

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    to raise awareness of the importance of helmet useand foster safe riding habits.23Pedestrians

    The physical separation of pedestrians from traffichas been shown to reduce pedestrian injuries anddeaths.23 Despite this, sidewalks are primarily limitedto urban areas, even in developed countries, leavingsemiurban and rural inhabitants to walk along road-ways.22 Urban sidewalks may be crowded with ven-

    Table 3. Interventions with proven effectiveness in reducing road traffic injuries and fatalities in HICsAuthor/Year Count Objectives Study DesignRivara et al, 2000 To determine the effectiveness of * Descriptive(United States)24 automatic shoulder belt systems in * Data collected from 1993-1996,

    reducing risk of injury and death National Highway Traffic Safetyamong front-seat passenger vehicle Administration Crashworthinessoccupants Data System

    Cummings et al, To estimate the relative risk of death * Matched-pair cohort2003 (United among belted and unbelted front-seat * Data collected from 1986-1998,States)25 occupants Fatality Analysis Reporting System

    Norvell et al, 2002 To estimate the association between * Matched-pair cohort(United States)32 death and helmet use * Data collected from 1980-1998,

    Fatality Analysis Reporting System

    Rowland et al, To compare incidence, type, severity * Retrospective cohort1996 (United and costs of crash-related injuries * Data collected from WashingtonStates)33 resulting in hospitalization or death for State patrol records

    helmeted and unhelmeted motorcycleriders

    Thompson et al, To examine the effectiveness of bicycle * Prospective case-control1996 (United helmets in four age groups, in crashes * Data collected from emergencyStates)34 involving motor vehicles and by helmet departments of seven Seattle

    type hospitalsOssenbruggen To use logistic regression models to * Logistic regression analysiset al, 2001 identify factors that predict the * Data collected from police(United States)38 probabilities of crashes and injury accident reports

    Bunn et al, To assess whether area-wide traffic Systematic review and meta-analysis2003 (United calming schemes can reduce road of randomized controlled trials andKingdom)39 crash-related deaths and injuries controlled before-after studies

    dors, in disrepair or simply not used.35 In Karachi,Pakistan, it was observed that encroachments on side-walks were a prime cause of pedestrians steppingonto the road.35 Predictive models based on trafficdata gathered in Addis Ababa, Ethiopia, indicate thatwider sidewalks result in increased pedestrian safety.36Furthermore, a raised curb on the road edge reducedpedestrian accidents by 46% on undivided roads.36Sidewalks are feasible for developing countriesbecause they are inexpensive but must be accompa-

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    nied by educational campaigns to increase publicawareness.22 Also, a review of evidence-based trafficengineering measures revealed that physical barriers,such as fences or dividers, are effective in reducingpedestrian-motor vehicle crashes.37 These act to pre-vent midblock crossing and channel pedestrians tosafe crossing areas.37 During this period of increasedtraffic, governments must understand the need to allo-cate resources for creating sidewalks or barricades toprotect this most vulnerable group.22

    Study Population Intervention Outcomes Measured Key Study, ResultsFront-seat motor Seat belts Risk of death for Manual shoulder plus lap beltvehicle occupants shoulder plus lap belt reduced risk of death by 73%

    (OR, 0.27; 95% Cl, 0.16-0.46)and automatic shoulder pluslap belt reduced risk of deathby 86% (OR, 0.14; 95% Cl,0.07-0.26)

    Front-seat Seat belts Death within 30 days Seat belts reduced relativepassenger car of crash risk of death by 61% (RR=0.39;occupants 95% Cl, 0.37-0.41)

    Motorcycle crash Motorcycle Death within 30 days Motorcycle helmets reduceddriver/passenger helmets of crash relative risk of death by 39%pairs (RR=0.61; 95% Cl, 0.54-0.7)

    Motorcycle crash Motorcycle Head injury Unhelmeted riders werevictims helmets almost three times more likely

    to be hospitalized with headinjury (RR=2.9; 95% Cl, 2.0-4.4)and nearly four times morelikely to have severe headinjury than helmeted riders(RR=3.7; 95% Cl, 1.9-7.3)

    Bicycle crash Bicycle helmets Head and brain injury Helmets reduced head injury byvictims 69% (OR, 0.31; 95% Cl, 0.26-0.37)

    and brain injury by 65% (OR,0.35; 95% Cl, 0.25-0.48)

    1. Sidewalks Pedestrian-motor 1. Crash probability is twice as2. Efficient land vehicle crashes likely at a site without a

    use sidewalk than a site with one2. Multipurpose land-use

    zones had fewer crashesthan single-purpose land-use zones

    Studies were Area-wide traffic Road traffic injuries Sixteen studies found an 1 1%conducted in calming schemes reduction in road trafficGermany, injuries (pooled rate ratio 0.89;Netherlands, 95% Cl, 0.8-1.0)Australia and theUnited Kingdom

    Cross-Cuffing InterventionsCross-cutting interventions aim to protect all road

    users. Some interventions limit vehicle speed throughvarious traffic calming measures. Speed can be restrict-ed by placing speed bumps or rumble strips at high-fre-quency crash sites or by enforcing posted speed lim-its.23 In industrialized nations, speed limits are enforcedby police, but in low-income countries, this is difficultdue to resource constraints. For example, the policeforce in Ghana is comprised of nearly 16,500 officers

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    who are assigned only 145 vehicles for a country withover 18 million inhabitants.22 This number of vehiclesis totally inadequate to properly enforce almost anypolicy, be it seat belt use or drunk driving. Speedbumps or rumble strips are therefore a viable option forpoor countries because they are highly cost-effectiveand simple to install." These are also particularly wellsuited for protecting residents who live near rural inter-city highways." A systematic review of controlledbefore-after studies has shown an 1 1% reduction inRTIs due to traffic calming techniques, such as speedbumps, mini-roundabouts and road narrowing.39 Theseinterventions have the potential to reduce RTIs andfatalities in less developed countries.39

    Cross-cutting interventions also include measuresto reduce the effects of alcohol on road users. Sobri-ety checkpoints, lower BAC and minimum drinkingage laws in HICs have reduced alcohol-related crash-es, injuries/fatalities and extent of impaired driving.22However, the transferability of these interventions toless developed nations-particularly those that arevery poor is unknown.22 As alcohol is a primary riskfactor for RTIs, developing nations could begin byestablishing the prevalence of drinking and driving.5This could be done through random roadside surveysusing breathalyzers and testing for blood alcoholamong fatally injured drivers.5 Once prevalence hasbeen established, targeted interventions and rationalpolicies could be developed.40Additional Options

    Interventions that limit exposure to risk, such asbuilding regulated mass transit systems, improvingefficient land use, restricting motor vehicles andproviding shorter routes for cyclists and pedestrians,should also be explored.' The latter measure isextremely important for reducing risk to pedestrianswho typically cross through traffic rather than usepedestrian bridges that have long stairways and areinconveniently located.4"42 These interventions havebeen effective in developed countries, and their usein developing nations should be encouraged when-ever possible.' A combination of these measures hasthe potential to allow for increased safe mobility,promote the health benefits of walking and cycling,and decrease levels of air pollution.'Barriers to Implementation andEffectiveness

    Intervention plans can fail to be effective due to ahost of potential obstacles. Barriers can be social,such as helmets not being "cool" or being too hot oruncomfortable.22 Reasons frequently cited fornonuse in Indonesia were laziness, physical discom-fort and lack of police to enforce use.29 Token com-pliance with laws is also a barrier to effectiveness.

    Helmet use in Indonesia was seen primarily as a lawenforcement issue and not one of safety, hence thehigh rates of riders wearing their helmets unfas-tened.29 Low literacy also hinders education efforts,such as those to promote safe bicycle or motorcycleriding, using seat belts or safer crossing behaviors.22

    Barriers can also be due to cultural beliefs. Inmany countries, injuries are still thought to be actsof God, and victims can be blamed for their injury,which is summed up by the Ghanaian saying: "Thedead is always guilty".23 The fact that road trafficcrashes are still referred to as "accidents" gives theimpression that these are random and unpredictableevents.3 The worldviews of various cultures canimpede efforts to promote a rational systemsapproach to road safety. The western worldview isbased on the belief that events are preventable andone is in control of one's life.43 This perspective is atodds with religions and cultures that have a strongsense of predestiny and fate.43 Traditional health-promotion efforts may not be effective if factorsleading to traffic crashes are thought to be outside ofone's locus of control.43

    Poverty, in all countries, represents a major barri-er to intervention implementation. National eco-nomic situations prevent many countries from ade-quately addressing any health problem, with trafficsafety being no exception.22 More obvious and press-ing health issues, such as HIV/AIDS and otherinfectious diseases, consume large portions ofhealthbudgets in developing countries so that RTIs are notconsidered a priority.22 Lack of resources for properlaw enforcement is a considerable barrier to improv-ing road safety in less developed nations. In additionto education and engineering strategies, developedcountries have relied upon enforcement of laws toreduce RTIs and fatalities."'36 Corruption alsoseverely undermines the effectiveness of lawenforcement by allowing infractions to go unpun-ished, thus leading to the perception that traffic lawsare "toothless".44 According to Nantulya and Muli-Musiime, pervasive corruption is a social determi-nant of road traffic crashes in Kenya, where briberyis said to be "regrettable but widespread".44 Riskcompensation may limit overall effectiveness ofinterventions. It has been argued that safety meas-ures can increase risky behavior because individualsfeel more protected.45 This is especially applicable tohelmet and seat belt laws, which can improve thesafety of the compliant individual but raise the riskfor others due to increased unsafe drivingbehaviors.45 Lastly, lack of political will may be themost important barrier. Without the commitment ofgovernments, little action will be taken.3

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  • ROAD TRAFFIC INJURIES IN LESS DEVELOPED COUNTRIES

    CURRENT INTERVENTIONS:SUCCESS STORIESDespite the bleak outlook, there are examples of

    effective measures being taken to reduce mortalityand morbidity from RTIs in less developed countries.A low-income country that has implemented an effec-tive intervention to decrease speeding and resultingcrashes is Ghana. Rumble strips were installed atintervals at the Suhum Junction, a frequent crash siteon the Accra-Kumasi highway. This simple interven-tion contributed to a decrease in crashes of 35% andfatalities by 55% in a 16-month period. The total costof the installation was less than $21,000, a bargainwhen compared to estimates of $104,610 to redesignthe junction or $184,600 to construct a walkway andguardrails to separate pedestrians."I

    Another successful program has been conductedin Colombia, a middle-income country, which saw a50% drop in traffic fatalities from 1995 to 2002 as aresult of a series of interventions implemented atnational and local levels.' In 1995, the Traffic Acci-dent Mandatory Insurance Law was introduced,requiring all vehicles to have insurance policies. Alevy on insurance generates revenue to fund massmedia prevention campaigns, road safety educationand support of other activities carried out by stateroad safety entities. This law also guarantees that theinsurer pays for any hospital care received by victimsof traffic crashes and has led to improvements in therecording of information on road traffic crashes. TheMinistry of Transportation (MoT) also has severalinitiatives, including a national road safety plan,which will be used to provide policy frameworks andissue general guidelines to local authorities. Anotheris a national monitoring system, which would allowauthorities to track vehicle locations via geographicsensing devices installed in public transport vehicles.

    In Bogota', several policies have been implement-ed to mandate that all drinking establishments closeby 1:00 a.m., to restrict driving in the city duringcertain hours two days each week and to restrict pri-vate vehicles in the city. Last has been the introduc-tion of Bogota's mass transit system, which trans-ports an average of 800,000 people per day. It hasimproved mobility in the city in addition to reducingthe number of injuries along its routes by buildinginfrastructure that ensures the safety of pedestriansand other road users. The drivers are under contract,and their salaries are established by law. This differsfrom most public transportation systems where driv-ers are paid based on the fares they collect-a situa-tion that leads to vehicles being massively over-loaded with passengers and driven at high speeds toreach new passengers before the competition."'8

    Conclusion and the Way ForwardMuch remains to be done to reduce mortality and

    morbidity associated with road traffic crashes in devel-oping countries. Many are just beginning to take actionand programs are in their infancy. Others have still notrecognized the true extent of the problem; deaths andinjuries will continue to rise in those countries. Theadoption ofa systems approach to road safety is crucialto stemming the loss of life. However, it is presumptu-ous to assume an intervention designed in the west willbe effective in a less developed country without firstunderstanding the local context and unique social deter-minants. Research is needed to further uncover factorsthat distinguish road traffic crashes from those occur-ring in developed countries. Information gathered canbe used to develop novel interventions as well as identi-fy ways to adapt western interventions to meet localneeds. Indigenous solutions should be sought andencouraged to promote sustainability and decreasereliance upon international "experts". These actionswill also increase community participation and can fos-ter a sense of ownership, thus improving the likelihoodof success and compliance. In addition, rigorous evalu-ation is desperately needed to determine effectivenessofprograms and transferability of interventions to lessdeveloped countries as well as prevent the wasteful useof scarce resources. Regulating informal public trans-portation systems and enforcing safety legislationcould go a long way in reducing the burden of RTIs. Itis imperative that governments of developing countriesmake this issue a top priority alongside HIV/AIDS andother pressing public health problems. Public invest-ment and funding for road safety must be increasedboth by governments and donors-to curb the substan-tial loss ofhuman capital. The time for action has come.REFERENCES1. Peden M, Scurfield R, Sleet D, et al, eds. World report on road traffic injuryprevention. Geneva: WHO; 2004.2. Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries indeveloping countries. BMJ. 2002;324:1139-1141.3. Rosenberg ML, Mcintyre MH, Sloan R. Global road safety. lnj Control SafPromot. 2004;11 (2):141-143.4. Runyan CW. Using the Haddon matrix: introducing the third dimension.lnj Prev. 1998;4:302-307.5. Mock C, Kobusingye 0, Vu Anh L, et al. Human resources for the controlof road traffic safety. Bull World Health Organ. 2005;83(4):294-300.6. The World Bank. Country classification. www.worldbank.org/data/coun-tryclass/countryclass.html. Accessed May 12, 2005.7. Mohan D. Road traffic injuries-a neglected pandemic. Bull WorldHealth Organ. 2003;81(9):684-685.8. Nantulya VM, Sleet DA, Reich MR, et al. The global challenge of roadtraffic injuries: can we achieve equity in safety? Inj Control Saf Promot.2003;1 0(1 -2):3-7.9. Nantulya VM, Reich MR. Equity dimensions of road traffic injuries in low-and middle-income countries. lnj Control Saf Promot. 2003;10(1 -2):13-20.10. Le LC, Pham CV, Linnan MJ, et al. Vietnam profile on traffic-relatedinjury: facts and figures from recent studies and their implications for roadtraffic injury policy. Presented at Road Traffic Injuries and Health EquityConference; April 10-12, 2002; Cambridge, MA.

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  • ROAD TRAFFIC INJURIES IN LESS DEVELOPED COUNTRIES

    11. Afukaar FK. Speed control in developing countries: issues, challengesand opportunities in reducing road traffic injuries. Inj Control Saf Promot.2003:10(1-2):77-8 1.12. Odero W, Meleckidzedeck K, Heda PM. Road traffic injuries in Kenya:magnitude, causes and status of intervention. In] Control Saf Promot.2003;1 0( -2):53-6 1.13. Koushki PA, Bustan MA, Kartom N. Impact of sofety belt use on roadaccident injury and injury type in Kuwait. Accid Anal Prev. 2003;35:237-241.14. Mock C, Amegashie J, Darteh K. Role of commercial drivers in motorvehicle related injuries in Ghana. In] Prev. 1999;5:268-271.15. Hyder AA, Ghaffar A, Masood TI. Motor vehicle crashes in Pakistan: theemerging epidemic. Inj Prev. 2000;6:199-202.16. Matzopoulos R. A profile of fatal injuries in S. Africa. Third Annual Reportof the National Injury Mortality Surveillance System. www.sahealthinfo.org/violence/2001 chapter6.pdf. Accessed May 23, 2005.17. Mohan D. Rood traffic deaths and injuries in India: time for action. NotIMed J India. 2004;1 7(2):63-66.18. Rodriguez DY, Fernandez FJ, Velasquez HA. Rood traffic injuries inColombia. Inj Control Saf Promot. 2003;1 0(1-2) :29-35.19. Nakohara S, Wakai S. Underreporting of traffic injuries involving childrenin Japan. Inj Prev. 2001;7:242-244.20. Romao F, Nizamo H, Mapasse D, et al. Road traffic injuries in Mozam-bique. Inj Control Saf Promot. 2003;1 0(1 -2):63-67.21. Mock C, Arreola-Risa C, Quansah R. Strengthening care for injured per-sons in less developed countries: a case study of Ghana and Mexico. InjControl Saf Promot. 2003;10(1 -2):45-5 1.22. Forjuoh SN. Traffic-related injury prevention interventions for low-incomecountries. Inj Control Saf Promot. 2003;10(1 -2):109-118.23. Forjuoh SN, Li G. A review of successful transport and home injury inter-ventions to guide developing countries. Soc Sci Med. 1996;43(1 1):1551-1560.24. Rivara FP, Koepsell TD, Grossman DC, et al. Effectiveness of automaticshoulder belt systems in motor vehicle crashes. JAMA. 2000;283(21):2826-2828.25. Cummings P, Wells JD, Rivara FP. Estimating seat belt effectiveness usingmatched-pair cohort methods. Accid Anal Prev. 2003;35:143-149.26. Mulama J. Kenya: Government stands firm on minibus strike. Inter PressService. February 7, 2004. www.afrika.no/Detailed/4802.html. AccessedMay 24, 2005.27. Liu B, Ivers R, Norton R, et al. Helmets for preventing injury in motorcycleriders. The Cochrane Database Syst Rev. 2003;(4):CD004333. Review.28. Tsai MC, Hemenway D. Effect of the mandatory helmet law in Taiwan.Inj Prev. 1999;5:290-291.29. Conrad P, Bradshaw YS, Lamsudin R, et al. Helmets, injuries and culturaldefinitions: motorcycle injury in urban Indonesia. Accid Anal Prev. 1996;28(2):1 93-200.30. Peek-Asa C, McArthur DL, Kraus JF. The prevalence of non-standardhelmet use and head injuries among motorcycle riders. Accid Anal Prev.1999;31:229-233.31. Thompson DC, Rivara FP, Thompson R. Helmets for preventing headand facial injuries in bicyclists. The Cochrane Database Syst Rev. 1999;(4):CDOO 1855. Review.32. Norvell DC, Cummings P. Association of helmet use with death in motor-cycle crashes: a matched-pair cohort study. Am J Epidemiol. 2002;156(5):483-487.33. Rowland J, Rivara F, Salzberg P, et al. Motorcycle helmet use and injuryoutcome and hospitalization costs from crashes in Washington state. Am JPublic Health. 1996;86(1):41-45.34. Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicycle safetyhelmets in preventing head injuries. A case-control study. JAMA. 1996:276(24): 168-73.35. Khan FM, Jawaid M, Chotani H, et al. Pedestrian environment andbehavior in Karachi, Pakistan. Accid Anal Prev. 1 999;31:335-339.36. Berhanu G. Models relating traffic safety with road environment and traf-fic flows on arterial roads in Addis Ababa. Accid Anal Prev. 2004;36:697-704.37. Retting RA, Ferguson SA, McCartt AT. A review of evidence-based traf-fic engineering measures designed to reduce pedestrian-motor vehiclecrashes. Am J Public Health. 2003:93(9):1456-1463.

    38. Ossenbruggen PJ, Pendharkar J, Ivan J. Roadway safety in rural andsmall urbanized areas. Accid Anal Prev. 2001;33:485-498.39. Bunn F, Collier T, Frost C, et al. Traffic calming for the prevention of roadtraffic injuries: systematic review and meta-analysis. Inj Prev. 2003;9:200-204.40. Gururaj G. Alcohol and road traffic injuries in South Asia: challenges forprevention. J Coll Physicians Surg Pak. 2004;14(12):713-718.41. Mutto M, Kobusingye OC, Lett RR. The effect of an overpass on pedes-trian injuries on a major highway in Kampala-Uganda. Afr Health Sci.2002;2(3):89-93.42. Hijar M, Trostle J, Bronfman M. Pedestrian injuries in Mexico: a multi-method approach. Soc Sci Med. 2003;57:2149-2159.43. Dixey RA. 'Fatalism', accident causation and prevention: issues forhealth promotion from an exploratory study in a Yoruba town, Nigeria.Health Educ Res. 1999;14(2):197-208.44. Nantulya VM, Muli-Musiime F. Kenya: Uncovering the Social Determi-nants of Road Traffic Accidents. In: Evans T, Whitehead M, Diderichsen F,Bhuiya A, Wirth M, eds. Challenging Inequities: From Ethics to Action. NewYork: Oxford University Press; 2001:211-225. A

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    welcomes your Letters to the Editor aboutarticles that appear in the JNMA or issuesrelevant to minority healthcare. Addresscorrespondence to [email protected].

    The University of Maryland's Institute of Human Virology is seekinga non-tenure track, full-time Instructor or Assistant Professorfaculty member in the School of Medicine's Department ofMedicine. Faculty rank commensurate to experience.Applicants must demonstrate a strong interest and experiencein the clinical management of HIV infection and associateddiseases and complications, must be board-certified in internalmedicine, and preferably board eligible or board certified ininfectious diseases. The qualified candidate will be based inAfrica, and will fully participate in PEPFAR (President's EmergencyPlan for AIDS Relief) Program to bring antiretroviral therapyassessment, treatment, training and monitorng to resource-poorcountres. Position will provide expert technical assistance andsupervision of programmatic activities to the medical fieldteams, including site assessment training and QA/QI activities.Position will also be responsible for planning and executingoperational research efforts conducted by the clinical researchdivision in the context of its international efforts. Please directinquires with CV, four references and a brief description ofcareer plans and goals to Robert R. Redfield, M.D, c/o JoAnnGibbs, Academic Programs Office, Department of Medicine,University of Maryland Medical Center, Room N3E10, 22 S.Greene St., Baltimore, MD 21201. The University of Maryland,Baltimore is an AA/EEO/ADA Employer. Applicants from diverseracial, ethnic and cultural backgrounds are encouraged toapply. Please reference Position 03-309-443.

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