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Rapid Responses: Rapid Responses published:
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Another reason for high accidents rate
- Vasiliy V. Vlassov (14 May 2002)
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Primary Trauma Care
- Stephen M Drage, Douglas Wilkinson, PTC Chairman & Consultant in Intensive Care, Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU (15 May 2002)
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Persons at risk get hit
- Nicholas Moore (17 May 2002)
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Pathology in Kampala
- Ciaran J O'Brien (20 May 2002)
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A call for evidence based prevention of road traffic injuries in the developing world
- Adnan A Hyder (23 May 2002)
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Road Traffic Safety and Health Equity: A Call To Action
- Vinand M. Nantulya, Michael R. Reich, et al (30 May 2002)
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Road deaths in low income countries - need for careful analysis
- Dinesh Mohan (10 June 2002)
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International comparisons needed to identify contextual factors in road traffic injuries
- Tsung-Hsueh Lu, Li-Li Ping, Associate Prefessor, Department of Public Health, Shantou University Medical College, Guangdong, China; Ragnar Andersson, Professor Division of Public Health Sciences, Department of Social Sciences, Karlstad University, Karlstad, Sweden (14 June 2002)
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General speed limit proposal
- Colin F Clarke (17 June 2002)
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The neglected epidemics-A tip of the Iceberg
- Abd Hamid Mat Sain (25 June 2002)
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Road traffic injury research in developing countries: the neglected literature
- Ronald Lett, Wilson Odero, Associate Professor of Public Health, Moi Unvesity, PO Box 4606, Eldoret, Kenya (29 June 2002)
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Re:Trauma Care: several alternative courses available in Africa
- Ronald R Lett, Olive Kobusingye, Secretary General, Injury Prevention Initiative for Africa (15 September 2002)
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Vasiliy V. Vlassov, Director, Russian branch The Cochrane Collaboration
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There is another reason for less-than-blessed countries to have high accident rate and road accident rate. It is the unsafe life practices in developing countries. Russia do not feel itself developing country, but death due to accidents is the major cause of increased mortality in Russia. If some one go across Moscow by nice Metropolitane (Moscow official name for Tube) he or she will find no one announcement 'care you head' or 'beware step ahead', no one red/black/yellow strip marking the dangerous place, no one non-slippery step. At railroad no one car is equipped by strips for passengers sleepind on the upper bed place. And such examples are endless. The same is true for many developing countries, as I know. The reduction of mortality from accidents is not just installation of sophisticated vehicles, but a whole life style, which depends from many things, such as pressure of poverty, first. When I ran from one of my three jobs to another across Moscow, sometimes I think about my colleagues in Duke or Oxford who just bike to their campuses for whole day. |
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Stephen M Drage, PTC Instructor Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Bucks HP21 8AL, Douglas Wilkinson, PTC Chairman & Consultant in Intensive Care, Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU
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We would like to congratulate Nantulya and Reich (1) for highlighting the 'neglected epidemic' of road traffic injuries in developing countries. Their article and that by O'Neill & Mohan (2) rightly concentrates on the primary prevention of motor vehicle crashes. However, they make little comment on the need for improved early resuscitation of trauma victims in less affluent countries. It is common for the victims of motor vehicle crashes to present at a district hospital or medical centre which may not have medically qualified staff. Even if a doctor is available, their training in trauma resuscitation may be limited. To address this problem the Primary Trauma Care Foundation runs 2 day courses in less affluent countries to train surgeons, anaesthetists and other health professionals in the prevention and early management of severe trauma using the basics of primary and secondary survey but tailored to the confines of their experience and resources. Primary Trauma Care (PTC) differs from other trauma management programmes in that it is geared to doctors and other health workers working in rural environments with limited resources. The PTC Foundation devolves responsibility and ownership of the courses early and encourages locally trained PTC doctors to continue the work of training and structuring trauma courses in their local area. The manual, slides and acetates and other resources are translated into the local language, and the initial courses are free to the countries that request the course. The first course was run in Fiji in 1997 at the request of the Fiji School of Medicine and has since been run in Africa, India, the South Pacific and South America. The World Health Organization has recognised PTC, and is including the whole course manual in the WHO learning materials for district surgical services. The PTC Foundation is based in Oxford with its primary sponsor being the World Federation of Societies of Anaesthetists (WFSA). The PTC Foundation also receives funding from the Royal College of Anaesthetists, AusAid and the Dutch Society of Anaesthetists. For more information or to request a course, the PTC foundation can be contacted at ptc@nda.ox.ac.uk or PTC head office, Outeniqua House, 313 Woodstock Road, Oxford OX2 7NY. 1 Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ 2002; 324: 1139-41. 2 O’Neill B, Mohan D. Reducing motor vehicle crash deaths and injuries in newly motorising countries. BMJ 2002; 324: 1142-5. |
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Nicholas Moore, Prof Clinical pharmacology University Bordeaux 33076, France
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The paper was fascinating, in that it does give a very clear view of the traffic conditions in different countries. The people involved in accidents are those at risk ie on the streets. This could have been illustrated by photographs of the typical traffic conditions in the various countries cited: In the US, one would see vast numbers of single-user cars, where the only occupant of a car is its driver. In Los Angeles, walking down a street I was approached by a passing police car to enquire whether my car had broken down and if I needed help. The pedestrian is an anomaly. It is not surprising that very few pedestrians are involved in accidents, and that most victims are drivers. There is really nothing much else to hit. On the other hand, in Saigon (Ho-chi-minh city), there are 3 million mopeds for 9 million inhabitants, and most are on the mopeds. There are very few individual cars. finding 62% of motorcycles involved in crashes is not surprising: a typical street photograph would show a mass of mopeds (usually with severral passengers) and bicycles, with one or two cars, and a few very full minibuses. It is hard to hit anything else than a moped. Though I have never been to Kenya or Africa, or India, the pictures and films I have seen of these places tend to show large crowds of pedestrians and overflowing buses or automobiles: the proportion of drivers to non-drivers is very low. The probability of hitting another driver is much lower than that of hitting a pedestrian or a passenger. So that the profile of the victims is really a reflection on the traffic conditions in a given country, all other factors being equal. Is the solution to developing countries' victim profiles to develop an US-style road scene, with the ensuing pollution, energy waste, etc? |
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Ciaran J O'Brien, Consultant Pathologist Dept. of Pathology, Swansea NHS Trust, Morriston Hospital, Swansea SA6 6NL
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Editor- Problems providing medical services in developing countries are frequently discussed in the BMJ, most recently the epidemic of road traffic injuries (1). The developement of laboratory services receives less attention. On a recent trip to Uganda, I visited St. Francis' Hospital, Nsambya, Kampala.This is a 361-bed mission hospital with departments of medicine, surgery, obs/gyn and paediatrics, labour wards, operating theatres, OPD/casualty, radiology and pathology. Hospital staff are keen to develop the pathology service, especially histopathology/cytology, which is very limited at present. They are looking for an experienced pathologist, perhaps recently retired, to work there on a voluntary basis, for a year or two. This is an opportunity to develop the diagnostic service, to provide leadership to the laboratory and to teach. There are also tremendous opportunities for research in collaboration with staff in Mulago teaching hospital and Makerere University. Uganda has suffered much over the last fifty years, most recently from the impact of HIV/AIDS (2). The country is however looking to a more hopeful future after a period of sustained economic growth and political stability and, in many ways, is regarded as a beacon for other African nations (3). Someone taking up this challenge would be assured a very warm welcome while making a very positive contribution towards the developement of medical services. The opportunity to enjoy a very interesting and beautiful country and a lovely climate are also worth consideration! Please contact the auithor for further details. Ciaran O'Brien 1. Nantulya VM, Reich MR, The neglected epidemic:road traffic injuries in developing countries. BMJ 2002; 324: 1139-1141. 2 Morgan D, Mahe C, Mayanga B, Whitworth A G. Progression to symptomatic disease in people infected with HIV-1 in rural Uganda: prospective cohort study. BMJ 2002; 324:193-196. 3. Leggett I. Uganda. An Oxfam Country Profile. Fountain publishers, 2001. 2. Nantulya |
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Adnan A Hyder, Assistant Professor Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
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Sir- I welcome the paper on road traffic injuries in developing countries by Nantulya and Reich and the attention given to this issue by the BMJ. As we develop the case for focusing attention and resources on road traffic injuries, it is critical to understand the evidence base on which we stand. The following are important points to add to the stand taken in the paper and to clarify some of the issues raised in it. 1. It is clear that on an aggregate global and regional level, road traffic injuries are affecting the developing world. However, these global data are based on a dearth of nationally representative information on road traffic injury mortality and morbidity from developing countries. Our current knowledge base rests on small studies and special surveillance systems; with a few examples of national data on road traffic injuries.(1) As each country recognizes the importance of this problem, there will have to be better national data available to assess the true magnitude and distribution of the problem. 2. National resources are limited in developing countries and programs compete for resources. It is important to recognize that the proportion of death and disability attributable to injuries overall, and road traffic injuries in particular, has been increasing over time.(2) Combined with the potential preventability of this loss of life and health, it makes for a powerful rationale for seeking policy attention and resource investments. 3. Despite the increasing knowledge of the burden of road traffic injuries in the developing world, there is little action for prevention or control. This is the most important feature as it represents not only a policy, but also a research gap. There are interventions available in the developed world and yet their effectiveness has not been tested in the developing world. How will effective single interventions work in the form of a "package" of interventions in the South? What is the cost effectiveness of interventions for road traffic injuries in the developing world? Which interventions are likely to be more acceptable by the community in these countries? These and other issues need to be answered as we plan, develop and implement programs for prevention and control in the developing world. 4. I disagree with Nantulya and Reich on the role of corruption. Neither is this phenomenon specific to road traffic injuries nor the main cause of the high burden. It is an important issues that we need to consider but neither the means nor the chances of decreasing corruption will offer any hope. It has also been argued that in the case of road traffic injuries, corruption may also serve as an inhibitory factor since drivers end up being stopped and paying the police directly rather than paying the fines. I think it is critical to define those factors which are amenable to change and responsible for the largest share of the burden. 5. A large share of the burden of road traffic injuries in the developing world is due to mortality. With crash fatality rates of 50% or higher and with the public transport system being involved in a high percentage of crashes (rsulting in several deaths per crash) it is most important to prevent the occurance of crashes.(3) Although primary prevention of road traffic injuries would be most effective, post-event interventions clearly also have to be considered. There are no structured assessments of national emegency medical systems available in the literature. Most of the reports are from single or selected facilities and provide some sense of the inadequacies of acute care in the developing world but lack the ability to generalize.(4) It is therefore important to use systematic methods to assess prehospital and hospital care and plan appropriate interventions. We are witnessing a different form of epidemiological transition than that experienced by the developed world. Infectious diseases have not been conquered; at the same time chronic conditions are common place; and the burden of injuries and violence is in on the rise in the developing world. The 'triple burden' on poor countries is a risk not only to their health, but also their overall development. It is time for us to confront the third of these triple burdens - especially road traffic injuries - before we lose more lives. References: 1. Ghaffar A, Siddiqui S, Shahab S, Hyder A. National Injury Survey of Pakistan. Islamabad: Health Services Academy, Pakistan, 2001 2. Hyder AA, Morrow RH. Applying burden of disease methods in developing countries: a case study of Pakistan. Am J Public Health 2000;90:1235 3. Hyder AA, Ghaffar A, Masud T. Motor vehicle crashes in Pakistan: the emerging epidemic. Injury Prevention 2000;6:199 4. London JA, Mock CN, Quansah RE, Abantanga FA, Jurkovich GJ. Priorities for improving hospital-based trauma care in an African city. J Trauma. 2001 Oct;51(4):747-53. |
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Vinand M. Nantulya, Conference Co-Director Harvard Center for Population and Development Studies, 9 Bow Street, Cambridge, MA 02138 USA, Michael R. Reich, et al
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As part of the response to the epidemic of road traffic injuries in developing countries [1], the Harvard Center for Population and Development Studies organized an international conference on road traffic injuries and health equity on April 10-12, 2002, in Cambridge, Massachusetts, in collaboration with WHO/HQ/Department of Injuries and Violence Prevention/Geneva, the University of Washington's Harborview Injury Prevention Research Center, the Centers for Disease Control's National Center for Injury Prevention and Control, and the Task Force for Child Survival [2]. Attended by 32 participants from eleven low-and middle-income countries and 28 resource participants representing academia, donor agencies, civil society, and collaborating institutions, the conference reviewed the current status of road traffic injuries in the developing world, assessed interventions that could significantly reduce the burden of road traffic injuries in these countries, and developed a multi-country intervention plan for research and action. Conference participants proposed the following areas for future research and action on road traffic injuries in developing countries: injury surveillance systems; systems for protecting vulnerable population groups; mechanisms for national road safety enforcement; minimum essential trauma care packages; and capacity development. The participants issued a conference resolution, given below, calling for greater attention to road traffic injuries to be placed on development agendas at community, national, and international levels, and for concerted efforts by governments, donor agencies, and civil society. PREAMBLE Road traffic injuries are a major public health problem globally. With over 1 million people killed each year, it is the 10th leading cause of death worldwide. With 20 million more injured or disabled each year, it is the 9th leading cause of disability-adjusted life years lost worldwide and projected to become third by 2020. Yet few governments or organizations recognize the magnitude of the problem, the potential for prevention, or the need for effective road safety policies. Road traffic injuries have a strong association with health inequities both globally and within countries. According to the World Health Organization, low- and middle-income countries account for about 85% of all traffic deaths and 90% of the disability-adjusted life years lost worldwide each year. Within these countries, road traffic injuries place the greatest toll on the poorest and most vulnerable members of society. The victims are not usually the drivers of automobiles (as in high-income countries), but are pedestrians, motorized two and three- wheelers and cyclists, and passengers in buses, minibuses, and trucks. Globally, road traffic injuries strike hardest at children and the working -age group (as the 2nd leading cause of death), with enormous social and economic consequences especially for poor households, making their poverty worse. There are many proven and effective measures that can be applied now to promote road traffic safety in low and middle-income countries. These include speed control, reducing drunk and drug-impaired driving, vehicle occupant protection, helmet use, high visibility, safety standards for vehicles and replacement parts, improved trauma care, roadway design, and city planning. To be effective, these interventions should be adapted to the local context of each country and community. NEED FOR SUSTAINABLE ACTION An International Conference on Road Traffic Injuries and Health Equity was held on April 10-12, 2002, with teams from eleven low- and middle-income countries and people from the private sector, academia, police, insurance agencies, research institutions, civil society, international organizations, donor agencies, private foundations, and the media. We, the participants at this conference, are convinced that road traffic injuries, like other health and safety problems, can be understood, predicted, and prevented. By coming together in a global alliance, we can reduce the burden of road traffic injuries, especially in resource-poor settings. We believe the following actions can help save millions of lives: A. Governments should make the prevention of road traffic injuries a high priority for public policy, and establish a national road safety commission with regulatory authority and adequate personnel and resources to assure implementation of road safety measures. B. All participating organizations-governmental and private, national and international, not-for-profit and for-profit?should collaborate with local communities in establishing systems for collecting reliable data, assessing the dimensions of the problem, understanding what works, promoting safety interventions, and mobilizing resources and political commitment. C. Effective alliances are needed for multiple policies at the local and national levels, including public-private partnerships, to link the fields of public health, health care, transportation, law enforcement, engineering, and education. D. Alliances are also required at the global level, to create an inclusive international partnership of organizations committed to road traffic safety in low- and middle-income countries, to raise the priority given to road traffic injuries on international agendas. For all these actions, special efforts should be made to protect the poor and the most vulnerable members of society, because they bear the largest burden from road traffic injuries in low- and middle-income countries. We, the participants at this conference, are committed to work together to pursue these goals. We urge other individuals and organizations to join us in these efforts. 1 Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ 2002; 324: 1139-41. 2 Road traffic injuries and health equity conference, Cambridge, Massachusetts, USA, April 10-12, 2002. http://www.hsph.harvard.edu/traffic (Last accessed May 29, 2002). |
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Dinesh Mohan, Professor, Indian Institute of Technology, Delhi New Delhi 110016, India
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Vinand M Nantulya and Michael R Reich are to be complimented for focussing our attention on road traffic fatalities and injuries in less motorised countries. However, some of their conclusions are based on anecdotal information or a limited number of studies from two or three countries. They state that among children aged 0-4 and 5-14 years, the number of fatalities per 100 000 population in low income countries was about six times greater than in high income countries in 1998. It is not clear whether these statistics refer to age-specific rates.This is not true for many low income countries if age specific rates are used. As a matter of fact, age specific death rates for children in many low income countries are lower than those in high income countries. The reason given for rising toll of fatalities and injuries from road traffic crashes in poor countries is growth in numbers of motor vehicles as a major contributing factor. This needs to be qualified. Highly motorised countries have much higher numbers of cars per capita, yet have lower death rates per vehicle. Indeed, deaths due to road traffic crashes per capita in less motorised countries are generally lower than those in high income countries. Growth in cars per capita in low income countries will continue unless high income countries show by example that they can do with fewer cars. The authors also state that higher number of people killed or injured per crash in countries with low income is a second reason for the high number of road traffic injuries in developing countries. They say that the high rates in Vietnam and Kenya (and elsewhere) are due to frequent crashes involving multi-passenger vehicles, including buses, trucks, and minibuses. This explanation misses the difference in modal share of those killed. Since a vast majority of those killed in less motorised countries are vulnerable road users, it stands to reason that there would be more deaths per crash even if everything else was the same. If two cars travelling at 60 km/h hit each other, the occupants would escape death if belted. However, if a car hits a pedestrian at 60 km/h it is unlikely that the victim would survive. Just this difference can explain the higher rates. In vehicle to vehicle crashes they would not find much differences in average death rates for most countries, if restraint use is accounted for. The authors also blame corruption as a huge problem in some countries leading to high death rates. I would not jump to such conclusions. If the police officers were efficient in being corrupt, they would maximise their incomes by apprehending as many violators as possible, thus reducing traffic death rates! Death rates in low income countries will only be reduced if the work done on their problems follows similar levels of scientific rigour as that in high income countries. |
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Tsung-Hsueh Lu, Associate Professor Department of Public Health, Chung Shan Medical University, Taichung 402, Taiwan, Li-Li Ping, Associate Prefessor, Department of Public Health, Shantou University Medical College, Guangdong, China; Ragnar Andersson, Professor Division of Public Health Sciences, Department of Social Sciences, Karlstad University, Karlstad, Sweden
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EDITOR----Two recent articles published in BMJ highlight the importance of identifying contextual factors (factors that are invariant within a population but variable between populations) in road traffic injuries. Nantulya and Reich reported different patterns of road use among road crash fatalities in developed and developing countries,[1] while O'Neill and Mohan illustrated that countermeasures that are effective in highly motorized countries might not be effective in less motorized ones.[2] These reports underscore the argument that international comparisons are needed to reveal important contextual factors in injury prevention research.[3] Traditional individual-based epidemiological studies of injury patterns within a country can identify only the causes that distinguish risks among individuals within the population. This approach will fail to detect causes that are either widespread or relatively invariant within a country, whether these are inherent group characteristics or derive from interactions among individuals. Indeed, this may be one of the reasons that modifying risk factors identified by traditional case-control and cohort studies is often ineffective in intervention studies.[4] Some contextual factors, including economic development, level of motorization, congestion of traffic flows, population density and religions are not readily modified. Others, such as road planning and construction, legislation, and enforcement of traffic laws are more amenable to modification and might play an important role in injury prevention if identified. Study also showed that the pattern for traffic fatalities among different European countries was strongly related to different structural factors.[5] International comparisons are critical to revealing such factors. Tsung-Hsueh Lu, Associate Professor, Department of Public Health,
Chung Shan Medical University, Taichung 402, Taiwan
Li-Li Ping, Associate Prefessor, Department of Public Health, Shantou
University Medical College, Guangdong, China Ragnar Andersson, Professor, Division of Public Health Sciences,
Department of Social Sciences, Karlstad University, Karlstad, Sweden
1.Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ 2002; 324; 1139-1141. 2.O'Neill B, Mohan D. Reducing motor vehicle crash deaths and injuries in newly motorizing countries. BMJ 2002; 324; 1142-1145. 3.Lu TH. International comparisons do help and are essential for avoiding type III error in injury prevention research. Inj Prev 2001; 7: 270-71. 4.Roberts I. Research priorities for injury prevention. Inj Prev 2001;7:2- 3. 5.Melinder KA, Andersson R. The impact of structural factors on the injury rate in different European countries. Euro J Public Health 2001;11:301-8. |
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Colin F Clarke, CTCnational Councillor Retired
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Many countries may benefit by reducing road deaths and helping in reducing vehicle pollutants by introducing a basic four-speed zone system: maximum speed of 30 mph in built up areas, 50 mph on roads outside built up areas, 60 mph on A roads and 70 mph on motorways. As an example, the benefits for the UK are listed below. The need for change 1. In 2000, there were 189 deaths on the motorways in Britain compared to 1,806 deaths on rural, non built-up roads. 2. By length and amount of traffic 'B' roads have the highest rates of fatalities. 3. Countries with the metric equivalent of 50mph – 80km/hr, the Netherlands and Denmark, already show cyclists safety to be much higher than in the UK. Benefits of proposal 4. Improved safety nation-wide, without highway authorities having to approve individual roads for lower speed limits. 10,000 injuries could be prevented. 5. Assist in protecting the character of the countryside and rural life from high traffic speeds. 6. A legal message to slow down when leaving 'A' roads would be given. 7. The proposal applies to over 80% of rural roads. 8. Traffic calming, humps, squeeze points and other measures would not be required. 9. The proposal could be implemented without extensive use of signs. 10. The general limits of 70mph motorways, 60mph 'A' roads single carriageway, and the 50mph for other rural roads, if not signed lower, is easy to publicise. 11. Other countries could use a similar system to lower their limits for non-major rural roads, improving safety in many countries. 12. If required exemptions could be catered for in some circumstances, for example, a 'B' road dual carriageway may be given a 60mph limit if suitable. 13. Motor vehicle emissions reduce by about 25%, at driving speeds of 50mph compared to 60mph. 14. Promote cycling, walking, horse riding and the enjoyment of the countryside. Proposal from Colin Clarke, |
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Abd Hamid Mat Sain, Associate Professor Dept of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kelantan16150,Malaysia
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Dear Sir, To regard the menace of road traffic accidents as an epidemic in the developing world is epidemiologically very appropriate indeed as expressed by Nantulya et al in their recent paper. It is interesting and relevant to appreciate the apparent irony highlighted in the paper with regard to the relationship between the numbers of motorvehicles in a community and the number of deaths of people involved in the accidents. More pedestrians, passengers, and cyclists deaths as compared to motorists in the developing countries reflect a fundamental undercurrent of those communities in a more complex ways than the attempted reasons given by the authors. Although the paper has painstakingly provided the readers with large amount of quantitative data to explain the issue at hand, it is inescapable to view the issue in a broader political, economic, social and educational perspectives of those communities. Most if not all of the developing countries have a low or primitive standards of these social processes. Despite the clamour for globalization and increase in communications, many happenings in those countries are reminiscent of the feudal worlds. The strong and powerful have the upper hand whilst the weak and downtrodden are constantly vulnerable to all the forces operating in the communities. Social civility is a scarce commodity in these communities. The vulnerability of the "weak" road-users is only one example of the manifestations of those social processes. In fact, all "weak" passengers in any forms of transportations, land or sea are susceptible to fatality due to errors committed by the drivers or the owners of those enterprises. As such, additional to the concluding assertions by the authors for specific appraisals to the current perceived causes of the epidemic, in my opinion, those communities have to also seriously consider a wider changes in the social, education and organizational processes in order to effect a significant and lasting impact on health and general wellbeing. The role of physicians and scientists from developed countries is perhaps limited to engaging with the respective colleagues from the developing countries in looking at this epidemic from a larger perspective of societal health. |
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Ronald Lett, Adjunct Professor of Surgery McGill University, 205 1035 West Broadway, Vancouver BC V6H 1E3, Wilson Odero, Associate Professor of Public Health, Moi Unvesity, PO Box 4606, Eldoret, Kenya
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We thank the BMJ for devoting this special issue to road traffic crashes. Nantulya and Reich highlight the growing burden of road traffic injuries (RTIs) in developing countries and advance several reasons for this increase1. We are disappointed that this article has disregarded published studies and relied heavily on web-based data, institutional reports, and media report: only 2 out of the 17 citations are articles in refereed journals. Throughout the article there is no reference to published reviews or original research papers on RTIs originating from developing countries. This omission may mislead readers to believe that published material on the subject in the developing world is scant. Published research on RTIs in developing countries is readily available; for example, a recent study in Uganda2, provides valuable epidemiological data. Another point we wish to raise is that whereas the authors acknowledge that this article was based largely on one study from Kenya, they have inappropriately generalized the findings to all developing countries. It is worth to recognize the diversity of developing countries. Though grouped together based on a specific cut-off annual GNP per capita, they are heterogeneous in numerous aspects including geography, size, population, culture, economy, political orientation, transport systems, infrastructure, and level of motorization. Even within the same region or country there is marked contrast in rates, risk factors and patterns of road traffic injury3. The argument that the growth of numbers of motor vehicles is the major contributing factor for the increasing road deaths and injuries is simplistic and fails to recognize other fundamental road safety issues, and the multifactorial nature of motor vehicle crashes. Soderlund and Zwi, for instance, have shown the importance of a country’s wealth in road safety: fatality rates per 10,000 vehicles are inversely related to per capita annual GNP, and decrease exponentially with the increase in level of vehicle ownership5. High-income countries have more resources available for development of safer transport systems, effective road safety interventions, and trauma care services. This partly explains why industrialized nations with 60% of the world’s motor vehicles contribute only 15% of the global road fatality. Addressing road safety should be based on evidence of risk factors and effectiveness of interventions. The growing body of literature on injury in developing countries therefore needs to be accessed, and what is available should be used. We concur that good road safety policy is urgently needed to address this epidemic but it should be based on good science. Ronald Lett, Adjunct Professor of Surgery McGill University; Scientific Associate Injury Control Center - Uganda Kampala Uganda Wilson Odero, Associate Professor of Public Health Moi University, P.O Box 4606, Eldoret, Kenya 1. Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ, 2002;324:1139-1141. 2. Kobusingye O, Guwatudde D, Lett R. Injury Patterns in Rural and Urban Uganda. Injury Prevention 2001 Mar 7 (1):46-50 3. Odero W, Garner P, Zwi AB. Road traffic injuries in developing countries: a comprehensive review of epidemiological studies. Tropical Medicine and International Health, 1997; 2:445-460. 4. Soderlund N, Zwi AB. Traffic-related mortality in industrialized and less developed countries. Bulletin of the World Health Organization, 1995; 73: 175-182. |
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Ronald R Lett, Scientfic Associate Injury Control Center Uganda #205 1037 West Broadway Vancouver Canada V6H 1E3, Olive Kobusingye, Secretary General, Injury Prevention Initiative for Africa
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We concur with Drage and Wilkinson who in response to the article by Nantulya and Reich emphasize the importance of trauma training in low income countries. We would like to make two clarifications. The ascertain that the Primary Trauma course differs from other trauma management programs, as it is geared for rural environments with limited resources is an over statement. There are several other courses that have this mandate including the Trauma Team Training (TTTTM)course developed under the auspices of the Injury Prevention Initiative for Africa and a similar course developed at Kumasi University in Ghana. Both these courses are active programs in West and East Africa. One of us (RRL) who is a co-author of the upcoming WHO publication Surgical Care at the District Hospital can confirm that PTC is included as Part 7 of this publication but also notes that the editorial committee for this WHO publication did not endorse any specific courses. Moreover in a specific WHO consultation meeting held in Geneva June 25 and 26th which was attended by OCK, it was decided that no specific trauma course was to be recognized.. The magnitude of trauma in low income countries is unacceptable and all who are trying to reduce the burden of injury death and disability should be commended. We wish the PTC foundation well in their endeavours but also congratulate many others for similar laudable contributions. We concur with the findings at this WHO meeting that regional differences make uniform recommendations untenable. We look forward to the guidelines, the product of this meeting which will be collated by Dr. Charles Mock, Chair of the International Surgical Societies Working Group for Essential Trauma Care.5 Ronald Lett
Olive Kobusingye
1.Drage Stephen and Wilkonson Douglas, Primary Trauma Care, May 29th 2002 http://www.responses@bmj.com/cgi/eletters/324/7346/1139#2346 2Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ 2002; 324: 1139-41 3.Lett R, Kobusingye O. The Injury Prevention Initiative for Africa: Achievements and Challenges; African Journal of Injury and Safety Promotion ,September 2002 4.Mock CN, Quansah RE, Addae-Mensah L. Kwame Nkrumah University of Science and Technology continuing medical education course in trauma management, in International Approaches to Trauma Care. Trauma Quarterly, Vol. 14, No. 3, pp. 345 - 348, 1999. 5.Mock C, Peden M, Joshipura M, Goosen J. Report on the Consultation Meeting to Develop an Essential Trauma Care Programme. Geneva: World Health Organization, Ref: WHO/NMH/VIP/02.09.Also available at:http://www.who.int/violence_injury_prevention/ |
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