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CARS, trucks and bikes are essential to our daily lives, our productivity and our independence. Yet they are inextricably linked to one of the major health challenges of our time.
The WHO reveals some staggering statistics. At least 1.2 million people worldwide will die on roads this year. A further 50 million people will be severely disabled. About half will be “vulnerable road users” — pedestrians, cyclists and motorcyclists.
Most of those killed or injured will be young adults and the majority will be men. Unsurprisingly, low- and middle-income countries will shoulder most of the burden — 91% to be precise, despite having only 50% of the world’s motor vehicles.
Five major risk factors for road traffic injury have been identified — speed, drink-driving, and not using helmets, seat belts and child restraints — yet only 7% of countries have adequate laws to address them.
Road traffic crashes (RTCs) aren’t like other public health problems, such as cancer or cardiovascular disease, as they happen suddenly with no prolonged exposure.
A motor vehicle is the vector and the disease is major trauma.
No other vector is so interwoven in our daily lives. Cigarettes aren’t essential for people to get to work, and fatty foods aren’t indispensible for doing the shopping. The other key difference is that RTCs are almost entirely preventable — no one is genetically predisposed to a car crash.
And therein lies the rub. How do you make safer something as ubiquitous as driving or being a passenger in a motor vehicle? More so, how do you promote interest in a problem as banal as a car crash?
You can’t contain road traffic injury like you can an infectious outbreak, nor does it conjure the same newsworthy terror as a village overcome by some new haemorrhagic virus.
That’s not to say that significant efforts are not being made. The UN decade of action for road safety is framed by five pillars — road safety management, infrastructure, safe vehicles, road user behaviour and post-crash care.
As part of this decade of action, 33 900: The Australian Road Safety Collaboration has been formed to facilitate greater industry collaboration and promote improved road safety.
As clinicians, we naturally focus on the clinical problem. But those of us who treat car crash victims know that it’s impossible to ignore the public health aspects, including the way services are organised.
Australia’s response to road trauma is world-leading. In Victoria, the state with the densest road network in Australia, actual road deaths have reduced by 70% since 1970 and, when road trauma results in serious injury, the likelihood of death has halved since 2001.
Both of these tremendous achievements have not happened in isolation or by chance. This goal has only been realised through collaborative and aggressive legislation around safer road behaviours and the introduction of an integrated trauma system.
Yet the burden remains enormous.
As with many things, Australia is lucky when it comes to road traffic crashes. This is not to take away from the cost of road trauma to individuals affected by it, but to contrast the robustness of our clinical and sociopolitical response with the reality in the rest of the world.
People injured on the road in Australia will by-and-large receive world-class care. From the publicly funded retrieval services delivering intensive care at the roadside to the therapists assisting injured people to rehabilitate, the system is impressive — including safer roads to begin with.
Globally, RTCs cost US$518 billion or 1%–3% of gross national product per country. In low- and middle-income countries the cost is US$65 billion, which is greater than the total amount received in development assistance. That’s a lot of money, especially when road use is ever increasing
RTCs aren’t like other public health problems. They are largely preventable and rarely just bad luck.
However, there is one similarity — ignoring the problem won’t help to solve it.
Dr Simon Hendel is an anaesthesia fellow, an associate of the Centre for International Health at the Burnet Institute and completing a fellowship in aeromedical retrieval in remote North Queensland. Professor Russell Gruen is a general and trauma surgeon at The Alfred in Melbourne, professor of surgery and public health at Monash University and director of the National Trauma Research Institute.
The Royal Australasian College of Surgeons has a Road Safety Advisory Committee and was instrumental in gaining seatbelt legislation in Victoria in 1970. Many other advances over the years. I suggest every Surgical Body in the world develop such a Committee. We have the backing of about 6,000 Surgeons in Australia and New Zealand. The advocacy of the World’s Surgeons through WHO would be powerful.
By the way the closing speed on Australian roads can be 220kph. In Germany they are going the same way on autobahns, so different non-comparable circumstances.
Interestingly reviews in the UK and Victoria showed that 30% of serious trauma patients entering the hospital system die from human error. Subsequently, introducing guidelines for treatment has reduced that to 3%. Many countries could well take a look at the post crash care guidelines for serious trauma, in order to reduce fatalities and improve outcomes. See http://www.ncepod.org.uk/2007report2/Downloads/SIP_summary.pdf and http://docs.health.vic.gov.au/docs/doc/Review-of-Trauma-and-Emergency-Services-%E2%80%93-Victoria-1999-report-(RoTES-review)
What I always find lacking in all these studies is statistics regarding age of vehicles, quality of road infrastructure and driver experience. Instead the focus is always on speed, drink driving and enforcement, which I believe show misleading correlations with the number of fatalities and injuries on roads.
For example, Germany has a lower death toll than Australia, despite having less enforcement and no speed limits on freeways. Random breath testing in Germany is unheard of and only done once an accident happens. Clearly focusing solely on speed, drink driving and enforcement is not the only answer. Australia already has some of the lowest speed limits in the world and some of the strictest enforcement. Pushing further in these areas is not helping and only turning the country into a police state. Investing in a dual-carriageway motorway from Brisbane through Sydney to Melbourne would save more lives than an policy or enforcement ever will.
Considering law enforcement as the solution to the death toll in lower income countries is clearly short-sighted. A complete lack of road infrastructure and 20 year old vehicles which lack basic safety features are the primary and sole reasons the death toll is so high lower income countries. The countries with the lowest death tolls are not surprisingly the ones with the best road infrastructure and highest purchasing power which leads to the ownership of the latest cars.
The drop in fatalities in higher income countries worldwide and not just in Australia, since the 1970s has far more to do with the technological advancement in the automotive industry than any other factor.
“A number of jurisdictions including Canada and UK now require physicians to report ADHD drivers thought to be at risk of problem driving to the Ministry of Transportation. However, no standardised well validated tool currently exists to help guide clinicians in evaluating patient driving risk as well as response to treatment. The development of such a reliable metric would encourage clinicians to identify and manage their patients with problem driving more reliably. The question of medico-legal liability is in its infancy with no established case law for physicians found negligent of failing to adequately treat ADHD patients with the appropriate medications to reduce driving risk. Whilst the available literature does not yet provide clear evidence that stimulant medication should be the standard of care for problem drivers long term, it is probably only a matter of time before this question will be debated in a legal arena. Meanwhile it behooves the prudent physician to keep abreast of the emerging literature in this area and to provide clinical management targeted at improving the driving safety for patients.”:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2277254/
The motor car has been described as a rural technology inappropriately applied to cities. Much of the discourse on road safety has focussed on making it safer per Km but has ignored the number of Km driven. There are great health benefits available through the extra physical activity of active transport, but we cannot expect people to adopt walking, or cycling unless it is safe and convenient.
One of the sure ways to reduce the road toll is to make roads narrower and more congested, make parking more difficult to find and more expensive, and to ensure that alternative forms of transport are fast and convenient. The usual idea of a safe road, with many lanes, dual carriage way and restricted access only induces more people to drive greater distances so defeats its original purpose.
“The powers (vehicle) the passenger (driver) and the pathway (road).
May I address the power: many cars are too powerful and too fast and are so advertised by the salesmen. They encourage road hoons whose only pleasure is speed. They are usually young, inexperienced and are overrepresented in road accident statistics. Motor manufacturers need to be persuaded to play their part in correcting the road horror – but will they be too powerful? One way would be through the large amount of money they receive in subsidies from the government.
The passengter (driver): alcohol and drugs and too many distractive hoons in the car. There are an enormous number of alcohol outlets which are responsible for the alcohol binges that lead to violence and death not just on the roads. This needs to be addressed.
The pathway: I believe that much of the improvement in road accident figures overall is due to changes in the roads, particularly right-hand turning lanes and stop-signs.
There is a lot more but I believe these are some of the most important matters that need to be addressed urgently.