Author: ctedeschi

An Epidemic of Trauma on the Road

This week on PLOS TGH, Christopher Tedeschi, Assistant Professor of Medicine at Columbia University and a practicing emergency physician, explores the global and local epidemic of road traffic accidents. From personal close-call, to big-picture epidemiology…

 

Last month, Graco Children’s Products recalled 3.8 million infant car seats amid concerns that their buckles could become jammed with spilled food or liquid, making it impossible to remove a child in an emergency.  My ten-month old daughter has been using one of those seats—and out of an abundance of caution and maybe some paranoia, my wife and I upgraded to a new model.

Flickr / Cars10s PhoToesJust before the recall we traveled in India for several weeks.  In Bangalore and Mumbai, we hopped in the back of taxis and rickshaws with no better restraint than a white-knuckled grip.  And now I’m supposed to worry about the tiny chance that some apple juice will gunk up the car seat buckle when I get home?

On our first day in Mumbai we had a near miss.  During a poorly executed U-turn, the front end of our taxi came within inches of a speeding city bus.  The driver slammed on the brakes.  We stopped short.  I grabbed our daughter.  The bus sped by, we took a deep breath and moved on.  It seemed like one of those all-too-common close calls on the roads in India (and lots of other places) — close calls that generally seem to work out without any real bodily harm.

But there is real injury.  Each year in India, road accidents claim thousands of lives, and injure many more.  India reported more than 130,000 road traffic deaths in 2010, likely an underestimate since statistics are based on police records.  The financial cost totals approximately three percent of the country’s GDP.

2861747022_82260c0bd1_bRegulation may help, but only partly.  National seat-belt and helmet laws are on the books, but WHO data suggest that less than 50 percent of motorcycle drivers (and less than ten percent of passengers) actually wear a helmet.  The numbers for seat belts are similar.  Enforcement is anemic.  A quick spin around any major city reveals that the law is followed only intermittently, although  more motorcyclists seem to be wearing helmets than even a few years ago.  But it’s still gut wrenching to watch un-helmeted drivers, carrying two or even three passengers, including small children, hurtle through traffic unprotected.

The impact of traumatic injuries, many which do not present to medical care in time and many more which are preventable, can be measured in thousands of lives and millions of dollars.  Worldwide, 92 percent of road traffic deaths happen in low or middle income nations.  In recent years, we have trained our sights in this setting on the prevention of non-communicable diseases—diabetes, heart disease, cancer.  But remember that trauma is a disease too, with predictable incidence and injury patterns amenable to primary and secondary prevention.  And while it is not now practical to mandate rear-facing car seats for infants in most of the world, we can be aggressive in promoting strategies to minimize trauma morbidity by means of helmet and seatbelt use, safe driving, and coordinated pre-hospital and emergency care.

Flickr / Peter RichmondSecondary prevention means adequate EMS systems to respond to accidents, including ambulances that function as more than souped-up taxis.  It also means development of standardized, location-specific protocols with pre-hospital providers trained in basic first aid and advanced trauma care.  Legal protections should permit good samaritans to assist the victims of road accidents without the fear of getting caught in lengthy official investigations or police cases.

In some places, US or European-style systems might not be the answer.  While working on EMS and disaster preparedness projects in India over the past several years, many people have told me that calling an ambulance wouldn’t even enter their mind in the event of a road accident.  Traffic is congested, transport times are long, and many ambulances arrive with little more than a stretcher and a few helpers to lift a patient.  Accident victims are often transported to the hospital in private cars or rickshaws.  A few years ago, public health officials in Colombo, Sri Lanka, implemented the brilliant idea of simply training rickshaw drivers as first responders.  More recently, innovative ideas such as developing a system of motorcycle ambulances have been proposed which may mold a pre-hospital system more appropriate for congested mega-cities.

Back in New York, I work in an emergency department which serves a high volume of patients from the Dominican Republic.  We often see patients who have arrived in the US seeking care for everything from heart disease and stroke to recent trauma.  And most of those traumas, not surprisingly, are young healthy people who were involved in road accidents.

The DR ranks second (only behind the Pacific island of Niue, where a tiny population leads to skewed statistics) on WHO’s list of death rates due to road traffic deaths.  Although Dominican law prescribes that motorcycle riders (but not passengers) wear helmets, few comply.  A proposed points system and stricter enforcement may help, but only real a cultural shift that enables drivers to assess risk and make safe choices will effect change.  Studies by Dominican and American researchers show that drivers feel that helmets are unnecessary for short distances, in rural areas, or for passengers, and are perceived as costly and unattractive.

Flickr / Satish KrishnamurthySure, I’ll bring my daughter to India again, and hopefully to plenty of other places.  We won’t necessarily use the same precautions that we use at home in New York.  As I buckle her into her government-approved, rear-facing, upgraded car seat, I think of the difference between the risk I am taking, and the risk to which all those families riding two-wheelers are exposed every day.  The gap is too big, and there are too many young, healthy lives at stake.  A technological fix only represents a small part of the problem—after all, helmets and seat belts are generally available and reasonably affordable.

The real challenge is to promote a culture that emphasizes the idea that road accidents happen, that their terrible consequences can be mitigated, and that home-grown systems can be developed to care for trauma patients.

Any ideas?

 

Christopher Tedeschi, MD, MA, is Assistant Professor of Medicine at Columbia University and a practicing emergency physician.  He is past-chair of the disaster and humanitarian medicine committee of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine.  He has worked in disaster preparedness in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during emergencies.  He is visiting faculty at the Global Emergency Medicine program at Weill Cornell Medical College.  Prior to medical school, he received his master’s from the writing seminars at Johns Hopkins and worked for HBO Documentaries.  He lives in NYC.

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Are Disaster News Stories a Catastrophe? Why Aid Agencies Should Partner with the Press

Since typhoon Haiyan ravaged the Philippines last month, some predictable patterns of disaster news coverage have begun to emerge – including evidence of a sometimes contentious relationship between the press and aid organizations. This week on PLOS TGH, Columbia University’s Chris Tedeschi explores. 

Flickr / DFID - UK Department for International DevelopmentStories about the acute phase of the disaster—sudden chaos and unprecedented destruction—have given way to a secondary wave of intermittent criticism, stories of corruption, and even debate about why we still can’t get it right when the international aid machine groans into action.

On time.com, John Crowley argued that a disproportionate number of stories ask why disaster responders have not yet repaired a system rife with inefficiency.  He notes that reports from the field indicate that the problems are not as pronounced as news reports make them out to be.

Crowley argues that some of the overblown coverage reflects the moment when journalists witness the inevitable chaos before roads are cleared and medicines are delivered.  He blames the media for exaggerating this disparity of supply and demand in the early phase of a crisis, and for “scaremongering” security issues, ultimately delaying aid.

But even the scaremongering is part of an awkward symbiotic relationship between aid groups and the press.  Reporters depend on NGOs for access, and in turn, aid organizations survive on dollars donated by individuals and groups moved by dramatic news reports.

The secondary wave of  reporting usually focuses on something gone awry—fuel line brawls after Sandy, cholera in Haiti, everything in Katrina—and helps to maintain viewership while postponing crisis fatigue, thus generating more support for agencies on the ground.  Oftentimes, financial contributions from this phase can pad the budget of NGOs for months to come.

In Linda Polman’s The Crisis Caravan:  What’s Wrong with Humanitarian Aid, journalist Richard Dowden describes the relationship between NGOs and the media in Goma following the 1994 Rwandan genocide:  “Each [NGO representative] would give a higher death toll, because each one would know that the man with the highest death toll would get on the nine o’clock news that night.   And being on the nine o’clock news meant you got money….”

Flickr / Official U.S. Navy ImageryTo some degree, the media does focus disproportionately on what’s gone wrong, partly because journalists fall into a trap of propagating classic disaster myths:  all aid comes from far away, countless people and resources are required, and locals often can’t help themselves.

Few reporters cover humanitarian crisis full time.  A 2004 study by the Fritz Institute and Reuters Foundation found that of 265 reporters surveyed, only 27 said that crisis stories were more than half their output.  Reporters who do specialize in humanitarian emergencies often lack resources or the specialist knowledge to understand complex issues, and make poor use of available resources such as the UN OCHA website and reliefweb.

Ultimately, Crowley’s conclusion is on target.  Information is aid.  Stories should focus on building capacity and empowering responders, and describing the experiences of those impacted by the disaster.  Less congratulatory stories should focus not on the unalterable realities of disaster response, but on the need for organizations to operate efficiently and transparently.

“It is time to look at how effectively international organizations are supporting a normally well-oiled (but now struggling) domestic response capacity,” Crowley argues, “not how international aid shipments are arriving late.”  Sadly, it’s not that simple.  Stories about how everything is going well would fail to paint the real picture, and would deny a critical role of the press:  to expose injustice, highlight inefficiency, and serve the public.

Flickr / DVIDSHUBHistorically, NGOs and humanitarian organizations have been largely immune from critical coverage, despite an enormous diversity in the quality of the services they provide. In a rare exception after the 2010 Haiti earthquake, a Lancet editorial described the aid machine as “polluted by the internal power politics and unsavoury characteristics seen in many big corporations.”

So maybe the press should be even more critical of what’s going on in the field.  What about missed benchmarks and overspending?  And why are those aid shipments arriving late after all?  We should encourage coverage – for the benefit of donors, readers and affected populations – of poorly coordinated efforts, of groups who cannot provide their own volunteers with basic necessities, of money and resources spent on aid which never reaches its goal, of disaster tourists who take more than they give.

NGOs and reporters alike ought to avoid the trap of addressing inputs rather than outputs, describing how many dollars have been donated or tons of medicine have been shipped, rather than what those dollars purchased or who received the medications.

Flickr / Are Disaster News Stories a Catastrophe?  Why Aid Agencies Should Partner with the Press

Several authors have argued for standardization in the practice of humanitarian assistance, but a formal system has yet to emerge.  In any emergency, most NGOs and aid groups will demonstrate excellence.  But sometimes, there will be confusion, wastefulness, and corruption.  And when the dollars at stake have come from governments, private donors, church groups and bake sales, the folks spending the money deserve to know what happens on the ground.

NGOs should take the lead in understanding their role in preventing disaster “catastrophization.”  In the Fritz/Reuters study, when journalists were asked, “what do you consider the most difficult barrier to crisis reporting?” the most common answers included “lack of response from groups at the scene,” and “lack of coordination between groups at the scene and their own parent organizations.”

So how can NGOs avoid coverage that makes their skin crawl?  Offer press training to field workers.  Develop strategies for press relations.  Share (don’t hide) information regarding peer organizations, and avoid duplicated effort.  Understand that reporters are under pressure to tell dramatic stories that include conflict.  And most of all, prepare for greater scrutiny:  humanitarian aid workers are professionals spending millions of dollars of other people’s money, and ought to be accountable for it.

 

Christopher Tedeschi, MD, MA, is Assistant Professor of Medicine at Columbia University and a practicing emergency physician.  He is past-chair of the disaster and humanitarian medicine committee of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine.  He has worked in disaster preparedness in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during emergencies.  He is visiting faculty at the Global Emergency Medicine program at Weill Cornell Medical College.  Prior to medical school, he received his master’s from the writing seminars at Johns Hopkins and worked for HBO Documentaries.  He lives in NYC.

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