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.
Just 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.
Regulation 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.
Secondary 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.
Sure, 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.
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.