A call for evidence based prevention of road traffic injuries in the developing world
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
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
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.
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.
Competing interests: No competing interests