April 2004 Bulletin

Road traffic injuries epidemic in developing nations

What orthopaedic surgeons can do to help

By Bruce D. Browner, MD

Beginning in the 1970s, road safety improvements in North America, Europe, Japan, Australia and New Zealand resulted in significant reductions in rates of motor vehicle fatalities. Control of drunk driving, mandatory use of child-restraint devices and seat belts were the greatest contributors to this trend. Improvements in passive protection, such as airbags, and vehicle design have further reduced the number of deaths and the severity of injuries. The situation is quite different, though, in the developing world where the growing number of crashes has caused the road safety problem to reach epidemic proportions.

Road traffic in India brings its own challenges.
In highly motorized countries, occupants of cars are the primary victims of traffic crashes. In developing, newly motorizing countries, the majority of deaths and injuries are sustained by vulnerable road users such as pedestrians, bicyclists, motorcycle and scooter riders, and by passengers on public transportation. They travel together on the same roads with buses, trucks and cars in a chaotic traffic stream. Collisions between unprotected humans and heavy vehicles frequently result in death and serious injury, even at lower speeds.

In established market economies, cars are the predominant mode of private transportation, but in the newly motorizing countries, more affordable motorcycles and scooters are being purchased and are joining the unregulated traffic stream in large numbers. The vehicle growth rate of 16 percent to 18 percent per year in many Asian countries will lead to a doubling of the number of vehicles in five years and a trebling in eight years, causing even more severe problems.

Not separating the various road users, sparse traffic safety laws, inadequate police enforcement, absence of pre-hospital emergency care, and limited resources for acute hospital and rehabilitative care are additive factors explaining the frequency of accidents and their devastating consequences.

The burden of the problem
Annually, 1.2 million people die and up to 50 million people are injured or permanently disabled from accidents on the world's roads. Underreporting of injuries is common in the developing world and these estimates may represent only half the true number. Eighty-nine percent of all road traffic fatalities and injuries occur in the developing world and the problem is growing.
A five-year study titled The Global Burden of Diseases and Injury, published in 1996 by researchers from the Harvard School of Public Health and the World Health Organization (WHO), examined the relative significance in terms of death and disability of the major health conditions and projected changes between 1990 and 2020. A WHO report predicted that road traffic crashes would move from ninth place to third place on the list of causes of worldwide death and disability. In this position, it would be exceeded only by heart disease and uni-polar major depression. By comparison, war will rank eighth and HIV tenth.

In its 1998 annual report, the International Federation of Red Cross and Red Crescent Societies (IFRC) recognized road traffic accidents as a major global health problem, equal in magnitude and seriousness to wars and natural disasters. They recommended that urgent attention be given to this global epidemic. Unless something is done, we could see 10 million to 15 million more deaths and 340 million to 400 million more injuries during this decade.

Economic impact
The World Bank estimates that the annual cost of traffic crashes in developing countries is $100 billion. In comparison, the combination of foreign loans and aid totals $60 billion, making clear that road traffic accidents are seriously undermining economic and social development in these countries.

Trauma victims are often young males who are workers and wage earners in their families. When they are killed or disabled, there is a profound effect on their families. In some countries, unfavorable customs and laws do not provide for the widows of those killed, and the accident also leads to the break-up of the family.

To lessen the human suffering and decrease the negative economic influence of road traffic accidents, in 1999 the World Bank Group and IFRC formed the Global Road Safety Partnership. Under the framework of the World Bank —Business Partners for Development, this collaborative initiative brings together business, government and civilian societies to conduct focused projects and safety campaigns.

A role for orthopaedic surgeons
Severe musculoskeletal injuries are common in vulnerable road users such as pedestrians and cyclists. Sequelae of these injuries are often the principal determinant of disability and economic losses for the survivors of road traffic accidents. Common injuries, such as broken legs, may receive little or no care, leaving victims permanently and unnecessarily disabled. As primary care givers for these devastating injuries, orthopaedic and trauma surgeons can have a pivotal role in the control of the global road safety problem.

Because its membership represents 103 countries, and improving education and patient care in the developing countries have always been part of its mission, the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT) has established a Trauma Committee to work on the problem of road traffic injury reduction. The committee will develop initiatives in both prevention and treatment. Improvement of surveillance systems to allow collection of accurate, standardized information on accidents, fatalities and injuries is a priority.

The number of education programs that transfer useable knowledge on prevention and treatment of traffic injuries from the developed to the developing countries must be increased. Surgeons also must be recruited to volunteer through the International Center for Orthopaedic Education in programs such as Orthopaedics Overseas and to donate books and equipment for use in emerging nations. There are no organized emergency medical systems in place so those individuals who do render aid to victims of traffic injuries should receive training to improve the effectiveness of their efforts:

In addition, the world orthopaedic community must support colleagues in developing countries in efforts to advocate for the priority of road safety and support events such as WHO World Health Day (April 7th), which this year focused on the theme, “Road safety is no accident.”

BJD support
The Bone and Joint Decade (BJD), in a international effort to raise awareness about the significance and cost of musculoskeletal disorders, helped place road safety on the United Nations (UN) agenda. In my role as chair of the AAOS International Committee, I came to know Wahid Al-Kharusi, MD, of Oman, the deputy secretary general of the Pan Arab Orthopaedic Association. He is the orthopaedic surgeon to the Sultan of Oman, who is very interested in improving road safety in Oman.

Dr. Al-Kharusi's interest was instrumental in bringing the issue to the attention of Oman's U.N. Ambassador Fuad Mubarak Al-Hinai, who became a passionate advocate for road safety within the U.N. It was through his support and drive that resolutions were passed which placed road safety on the U.N. agenda and called for a dedicated half-day session of the U.N. General Assembly on April 14, 2004 and a U.N. Stakeholder's forum, “Global Road Safety — A Shared Responsibility.” U.N. Secretary General Kofi Annan; WHO Director General Dr. Jong-wook Lee, MD; high level officials from the World Bank, UNICEF and UNDP; and U.S. Transportation Secretary Norman Y. Mineta, were invited speakers at the General Assembly session. The Stakeholder's forum brought together leaders from safety and health organizations around the world to discuss the problem and consider collaborative actions.

Until now, road safety has been treated as a transportation issue rather than a public health problem. That mind-set needs to change. American orthopaedic surgeons should lobby the U.S. government to increase the priority of international road safety in foreign policy. Enabling legislation is needed to expand the international role of Centers for Disease Control and National Highway Transportation Safety Administration. In addition, the U.S. Agency for International Development needs to be convinced that road safety projects are a worthy cause, so funding will be made available.

As witnesses to the carnage, orthopaedic surgeons can attest to the unnecessary pain and suffering endured by patients following road traffic crashes. Their moral authority and prominence as influential members of society will allow them to be powerful advocates for change.

After more than 20 years working on the front line in some of America's busiest trauma centers, I thought I knew all there was to know about road traffic injuries. But the last six years working in international affairs has opened my eyes to a larger reality. What I had seen previously was only the tip of the iceberg. Although we still have more than 40,000 deaths on the roads annually in the U.S., the numbers of fatalities and injuries in the developing countries are far worse. If I did not know this as a veteran orthopaedic trauma surgeon, how could the public, media and government officials know the truth about the road traffic injury epidemic?

Some may feel that the word epidemic should not be applied to this problem. As road traffic crashes kill almost 3,000 people a day and more than one million a year currently and the numbers are growing, the term seems justified to me. Although hard to measure uniformly with current methods, the number of injures could be anywhere from 25 to 50 times as large.

Prevention is certainly the most cost effective way to avoid serious harm from vehicular crashes but even with substantial improvements, serious injuries will continue to occur at home and abroad. Orthopaedic surgeons must assist their colleagues in other countries in developing better systems and methods of trauma care. To accomplish this, we must leave the operating room and clinic and become involved by participating in international education programs and volunteer efforts.

Bruce D. Browner, MD, is a member of the International Steering Committee of the Bone and Joint Decade, founding chair of the SICOT Trauma Committee and past chair of the AAOS International Committee.

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