Road Transport in Urban India: Its Implications on Health

Abstract

Urban population in India has increased from 17-31.16% between 1951 and 2011. Transport sector in India is an extensive system comprising different modes of transport, but road transport is the dominant mode playing an important role in conveyance of goods and passengers and linking the centers of production, consumption and distribution. Road transport accounted for 4.7% of India's gross domestic product (GDP) in 2010-11. Although essential for mobility, trade, economic development and growth, integration and social inclusion, there are negative impacts of transportation as well especially that of energy intensive transport. The objective of this paper is to review the multiple impacts on health as a result of road transport in urban areas. A review of literature was done for publications related to the topic focusing on the last 10 years. Sources included Pubmed, Google scholar, WHO website, Ministry of Home Affairs, Government of India, Transport Research Wing, Ministry of Road Transport and Highways. Government of India, National Crime Record Bureau, Central Pollution Control Board Government of India etc. We used a health and environment cause-effect framework [Figure 1], the DPSEEA framework (Driving forces, Pressures, State, Exposures, health Effects and Actions) which is a descriptive representation of the way in which various driving forces generate pressures that affect the state of the environment and ultimately human health, through the various exposure pathways by which people come into contact with the environment. The framework takes account of the fact that various factors responsible for health and environment problems may be associated with such driving forces as population growth, urbanization, economic development, technological change, and to the policies underlying them. "Pressure" may be exerted on the environment which cause development sectors to generate various types of outputs (for example in the form of pollutant emissions), causing the "state" (quality) of the environment to be degraded through the dispersal and accumulation of pollutants in the environment such as air, soil, water and food. People may become "exposed" to potential hazards in the environment when they come into direct contact with these pollutants through breathing, drinking or eating. A variety of health effects may subsequently occur, ranging from minor, subclinical effects to illness and death depending on the intrinsic harmfulness of the pollutant, the severity and intensity of exposure and the susceptibility of the individuals exposed. Various actions can be implemented at different points of the framework and may take a variety of forms, including policy development, standard setting, technical control measures, health education or treatment of people with diseases. Language: en

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Indian Journal of
Community Medicine
Official Publication of Indian Association of Preventive and Social Medicine
www.ijcm.org.in
Jan-Mar 2016 / Vol 41 / Issue 1
ISSN 0970-0218
Indian Journal of Community Medicine • Volume 41 • Issue 1 • January-March 2016 • Pages 1-****

Indian Journal of Community Medicine/Vol 41/Issue 1/January 2016 16
Introduction
Urban population in India has increased from 17-31.16%
between 1951 and 2011.(1) Transport sector in India is
an extensive system comprising different modes of
transport, but road transport is the dominant mode
playing an important role in conveyance of goods
and passengers and linking the centers of production,
consumption and distribution. Road transport accounted
for 4.7% of India’s gross domestic product (GDP) in 2010-
11.(2) Although essential for mobility, trade, economic
development and growth, integration and social
inclusion, there are negative impacts of transportation
as well especially that of energy intensive transport.
The objective of this paper is to review the multiple impacts
on health as a result of road transport in urban areas. A
review of literature was done for publications related to
the topic focusing on the last 10 years. Sources included
Pubmed, Google scholar, WHO website, Ministry of Home
Affairs, Government of India, Transport Research Wing,
Ministry of Road Transport and Highways. Government
of India, National Crime Record Bureau, Central Pollution
Control Board Government of India etc. We used a
health and environment cause-effect framework [Figure
1], the DPSEEA framework (Driving forces, Pressures,
State, Exposures, health Effects and Actions)(3) which is
a descriptive representation of the way in which various
driving forces generate pressures that affect the state of
the environment and ultimately human health, through
the various exposure pathways by which people come
into contact with the environment.(3) The framework takes
account of the fact that various factors responsible for
health and environment problems may be associated with
such driving forces as population growth, urbanization,
economic development, technological change, and to the
policies underlying them. “Pressure” may be exerted on
the environment which cause development sectors to
generate various types of outputs (for example in the form
of pollutant emissions), causing the “state” (quality) of the
environment to be degraded through the dispersal and
accumulation of pollutants in the environment such as
air, soil, water and food. People may become “exposed”
to potential hazards in the environment when they
come into direct contact with these pollutants through
breathing, drinking or eating. A variety of health effects
may subsequently occur, ranging from minor, subclinical
effects to illness and death depending on the intrinsic
harmfulness of the pollutant, the severity and intensity
of exposure and the susceptibility of the individuals
exposed. Various actions can be implemented at different
points of the framework and may take a variety of forms,
including policy development, standard setting, technical
control measures, health education or treatment of people
with diseases.
Health effects
Transport access is critical for inclusive growth, economic
development leading to rising demand for road
transport. In 2009-10, road network in the country carried
85.2% of the total passenger movement by roads and
railways put together, and 62.9% for freight transport.(4)
There has been a gradual change in the environment
and an increase in the number of cars, emission of
pollutants and noise emission have been documented
over the years leading to numerous health consequences
described below.
Road Transport in Urban India: Its Implications
on Health
Hariom Kumar Solanki, Farhad Ahamed, Sanjeev Kumar Gupta, Baridalyne Nongkynrih
Centre for Community Medicine, Old O.T. Block, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence:
Dr. Baridalyne Nongkynrih, Additional Professor of Community Medicine, Centre for Community Medicine, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi - 110 029, India. E-mail: baridalyne@gmail.com
Received: 30-11-13, Accepted: 24-02-14
Access this article online
Quick Response Code:
Website:
www.ijcm.org.in
DOI:
10.4103/0970-0218.170959
CME

Solanki, et al.: Road transport urban health
17 Indian Journal of Community Medicine/Vol 41/Issue 1/January 2016
Road trafc accidents
The total number of registered motor vehicles in India
increased from about 0.3 million in 1951 and 21.4 million
in 1991 to about 142 million in 2011.(2) Registered vehicles
grew at a Compound Annual Growth Rate (CAGR)
of 9.9% between 2001 and 2011. At this growth rate,
the number of vehicles double every 6-7 years. The
53 million-plus cities as on 31st March 2011 accounted
for 39.7 million registered vehicles. Among these,
Delhi with 72.3 lakh vehicles, had the largest number,
followed by Bengaluru (37.9 lakh), Chennai (34.6 lakh),
Hyderabad (30.3 lakh) and Pune (20.9 lakh).(2) These
ve cities accounted for half (49.3%) of the total vehicles
in the 53 million-plus cities. The eet size in nearly all
public transport undertakings has actually declined
rather than increase to meet the increasing demands
of transportation; and the use of personalized modes
especially two wheelers has increased at the rate of 12%
per annum in last two decades.(4) All these factors exert
a tremendous pressure on the environment. To make the
situation worse, most major roads and junctions in Indian
cities are heavily encroached upon by parked vehicles,
roadside hawkers and pavement dwellers.
The increase in car density in urban areas gives rise to
a state of volatile environment, conicts between cars
and pedestrians. Exposure to such hazardous situations
leads to disastrous and sometimes fatal effects on the
population due to road trafc accidents, road rage, etc.
Lack of footpaths, service lanes, cycle tracks and trafc
calming measures to reduce speed, where non-motorized
mode of transport blend with motorized trafc, increase
the risk of accidents and their severity.(5) The number of
people injured in accidents increased threefold from 13-42
per lakh population between 1970 and 2011. Reported
accidents and injuries in government reports are likely
to be underestimates because mild injuries are more
common and don’t get reported. A population-based
study from Hyderabad estimated an annual incidence
of road trafc crash as a pedestrian or motorized two
vehicle user using three month recall period at 2288
per 100,000 population and that of non-fatal road trafc
injury (RTI) at 1931 per 100,000 population.(6) In India,
it was estimated that the ratios between deaths, injuries
requiring hospital treatment and minor injuries was
1:15:70.(7) RTAs affected mainly the people of productive
age group, predominantly male(8) In India, the largest
share (37%) of ‘accidental deaths’ due to unnatural causes
is accounted for by road accidents in age group 30 to
44 years, 47.2% of deaths are due to trafc accidents.(9)
Air pollution
Air pollution is a well-known environmental risk to
health. Vehicular emissions depend on age of vehicle,
emission rate of different vehicle categories. With
deteriorating mass transport services and increasing
personalized motor vehicle use, vehicular emission
is assuming serious dimensions in most Indian cities.
Nearly 20% of passenger transport emission is by private
automobiles although they only contribute 4% total
passenger transport activity in Indian cities.(10)
Urban residents exposed to traffic pollution are at
potentially higher risk of health effects from exposure
to carcinogenic poly-aromatic hydrocarbon (PAH)
compounds.(11) Studies show that PAH ratio decreases
signicantly as a function of distance from the road.(12)
The new (2005) guidelines by World Health Organization
(WHO)(13) recommend revised limits for the concentration
of selected air pollutants — particulate matter, ozone,
nitrogen dioxide and sulphur dioxide. These guidelines
are much lower than the standards set by the National
Ambient Air Standard prescribed by Central Pollution
Control Board, India.(14) However, measured levels of
Figure 1: Effects of road transport on health: DPSEEA framework

Solanki, et al.: Road transport urban health
Indian Journal of Community Medicine/Vol 41/Issue 1/January 2016 18
these in Indian cities were found to be unsatisfactory,
largely because of high levels respirable suspended
PM. Their levels were as high as 10 times in some cities
like Delhi, Kolkata and Chennai.(15) Contribution of
automobiles in total air pollution is reported between
40–80%. For Delhi’s ambient air quality, contribution of
transport sector was estimated as high as 72%.(16)
Noise pollution
Community noise includes road, rail and air trafc,
industries, construction and public works. It is caused
mainly by traffic and alongside densely travelled
roads equivalent sound pressure levels for 24 hour can
reach 75-80dB. Prevalence of hearing loss is more in
workers exposed to higher road trafc noise compared
to those less exposed.(17) Indian studies have shown
that vehicular trafc contributes signicantly to noise
pollution and annoyance in urban areas.(18-20) High
noise levels interfere with speech and communication,
decrease learning ability and scholastic performance.
In the rst half of night, exposure to road trafc noise
chronically impaired cortisol regulation which correlated
with disturbance of sleep, impaired concentration and
memory.(21) Road traffic noise exposure was found
associated with disturbed sleep, headache, hypertension,
other cardiovascular diseases, especially in elderly
persons.(22-25) Individuals exposed to road trafc noise
had poor perception of their health; while another study
of residents of quieter areas had higher health related
quality of life scores compared to those living in noisy
areas.(26,27)
Guidelines by the Central Pollution Control Board
(CPCB), New Delhi, India suggest that noise levels
should not exceed 75 dB in daytime and 70 dB during
night in industrial areas, while the corresponding
levels for commercial area are 65 dB in day and 55 dB
in night. In residential areas noise levels should not
exceed 55 dB in day and 45 dB at night; corresponding
values for silence zones in day time is 50 dB and 40 dB
at night.(28) However in a study undertaken by National
Environmental Engineering Research Institute, Nagpur
revealed that noise levels in residential, commercial and
industrial areas, and silent zones of Delhi and other cities
far exceeded the standards prescribed by CPCB. The
average noise level in Delhi was 80 dB, which is more
than the recommended value, that is 55 dB. Another
Indian study in Asanasol found that at all locations
of data collection ambient noise levels were above the
prescribed guideline values.(29)
Physical inactivity
Poor availability of footpaths and cycle lanes acts as
disincentive to active transport, also pedestrian and
people on two wheelers are most vulnerable to injuries
in case of road trafc accident. This increases the number
of motorized vehicles usage. A study estimated that
lack of physical activity can be held responsible for
3.3% deaths and 19 million Disability Adjusted Life
years (DALYs) worldwide, through diseases including
ischaemic heart disease, diabetes, colon cancer, stroke,
and breast cancer.(30)
Other health effects
Air pollution due to vehicular trafc in urban dwellings
can sensitize residents to pollens and is also associated
with eczema in children.(31) Self-reported nasal discharge,
blocked nose, sneezing and itching were strongly
associated with living close to heavy trafc or living
in cities. Proximity of residence of women during
pregnancy to main road also increased the association
of diagnosis of asthma and atopic eczema in the
infants born to these women.(32) Some of the studies are
summarized in Table 1.
Action
Tackling these problems require multifaceted actions,
targeting various points in D-P-S-E-E-A framework.
It would obviously be impossible to reduce all
environmental exposures to a level at which the risk to
human health is zero. Measures which address the higher
end of the framework that is driving force, pressure and
state of the environment are the most effective; but they
are the ones which are most difcult to achieve.
There are numerous examples of interventions the world
over which have been successful in reducing health
effects, some of which are mentioned below.
Traditionally, road safety has been assumed to be the
responsibility of the transport sector. However road
trafc injuries are a major public health issue, which
needs to be tackled by the health department too. In
USA about 30 years ago, William Haddon Jr described
road transport as an ill designed “man-machine”
system needing comprehensive systemic treatment. He
produced what is now known as the Haddon Matrix,
illustrating the interaction of three factors — human,
vehicle and environment during three phases of a crash
event: Pre-crash, crash and post-crash. The resulting
nine-cell Haddon matrix models the dynamic system,
with each cell of the matrix allowing opportunities for
intervention to reduce road crash injury [Table 2].(38) This
work led to substantial advances in the understanding
of the behavioural, road-related and vehicle-related
factors that affect the number and severity of causalities
in road trafc accidents. Evidence from some highly-
motorized countries shows that this integrated approach
to road safety produces a marked decline in road deaths
and serious injuries.(39) Studies in Denmark have shown
that providing segregated bicycle tracks or lanes alongside
urban roads reduced deaths among cyclists by 35%.(40) In

Solanki, et al.: Road transport urban health
19 Indian Journal of Community Medicine/Vol 41/Issue 1/January 2016
Ghana, the use of rumble strips reduced crashes by 35%
and deaths by 55% in certain locations.(41) In Ahmedabad,
Bus Rapid Transit (BRT) was started since 2009, and
now carries about 400,000 passengers a day. Since then,
transport has shifted away from private vehicles to the
BRT system, and there has been more than 50% decrease
in road trafc fatalities in the BRT corridor.(42)
Research is also necessary to discover new technologies
and opportunities for road safety from time to time.
The Transportation Research and Injury Prevention
Programme at the Institute of Technology in New Delhi,
India is one such institute.
Besides road traffic accidents, other health benefits
have been reported by efforts to reduce pollution due
to road transport. Recent research in Canada indicated
that adults who moved away from residences in close
proximity to trafc (<150 m from a highway or <50 m
from a major road) had a lower risk of coronary heart
disease (CHD) mortality than did those remaining in
locations close to trafc.(43) Additionally, children who
moved away from residences with high background
PM10 experienced an increased rate of lung function
growth compared with children who moved to areas
with high PM10.(44) In London, positive health impacts
have resulted from the implementation of the congestion
charge scheme, which included an increase in active
transport (cycling and walking), a decrease in noise
pollution and related stress.(45)
Steps underway in Indian cities
The Government has taken steps in Indian cities for
providing cleaner, more efcient and alternate mode
Table 1: Indian studies showing effects of urban transportation on health
Author, year
of publication
Study setting Study ndings
Road trafc injuries
Bhuyan PJ et al., 2013 Assam India RTAs affected mainly the people of productive age group which were
predominantly male
Reddy G et al., 2012 Chandigarh, India Overall incidence of injury was 48.7/1000 population. Maximum cases (35%)
were of Road Trafc Injury (RTI). For each case of fatal injury there were 14
cases of severe injuries and 33 cases of mild injuries. 75% RTI victims in
study were in the age group of 15-44 years
Dandona R et al., 2006 Hyderabad, India Annual incidence per 100,000 population of road trafc crash as a pedestrian
or motorised two wheeled vehicle user was 2,288; of non-fatal RTI was 1,931
and that of fatal RTI was 17.3
Mohan D et al., 2004 India Ratio of deaths to injuries requiring hospital treatment and to minor injuries in
road trafc accidents was 1:15:70
Sathiyasekaran BW,1996 Urban slum, Madras The incidence for road trafc injury was 16 per 1000 persons. The relative risk
of males to females for trafc injuries was 3.04
Pollution related effects
Ingle ST et al., 2005 Jalgaon, Maharashtra Trafc policemen had impaired pulmonary function test due to exposure to
vehicular exhaust: FEV1 was 73% of the expected value while PEFR was only
66% of the expected value
Davis H et al., 2012 Global Both air pollution and noise are likely independent risk factors for CVD
Agarwal S et al., 2011 Jaipur, Rajasthan, India 60-85% people judged vehicular road trafc as major source of noise pollution
and being annoyed by it. 52% reported frequent irritation and 67% had
common noise-related problem like headache or loss of sleep
Banerjee D et al., 2009 Residents of Asansol,
West Bengal, India
Percent of population highly annoyed due to road trafc noise was 26.50
+/− 3.37 (19.44-33.2) Mean dissatisfaction score was 2.96 +/− 0.90 (1.04-4.45)
Prakash A et al., 2006 Residents of Delhi,
India
Rural transport vehicles (RTVs) most annoying, followed by buses, auto-
rickshaws and taxis
Siddique et al., 2011 Delhi, India ADHD was found in 11.0% of urban children in contrast to 2.7% of the control
group (P<0.001). PM10 level was positively correlated with ADHD (OR=2.07;
95% CI, 1.08-3.99)
Table 2: The Haddon Matrix
Phase Factors
Human Vehicle & equipment Environment
Pre-crash Crash prevention Information attitudes Police
enforcement
Road worthiness, lighting, braking,
handling, speed management
Road design and road layout
speed limits, pedestrian facilities
Crash Injury prevention during
the crash
Use of restraints impairment Occupant restraints other safety
devices, crash-protective design
Crash-protective road side
objects
Post-crash Life sustaining First-aid skills
Access to medics
Ease of access re risk Rescue facilities

Solanki, et al.: Road transport urban health
Indian Journal of Community Medicine/Vol 41/Issue 1/January 2016 20
of transportation. Metro Rail Projects were started in
India beginning with commissioning of rst phase of
Delhi Metro in 2004. Presently Metro trains are running
in Delhi, Haryana (Gurgaon), Uttar Pradesh (NOIDA,
Ghaziabad), Karnataka (Bangalore) and Mumbai
(Maharashtra). Approval for new metro network
development has been granted in Kolkata, Chennai and
Hyderabad. Moreover, Delhi has adopted Compressed
Natural Gas (CNG) for public transportation.
In 2006, National Urban Transport Policy was approved
to ensure safe, affordable, quick, comfortable, reliable
and sustainable transportation systems in the cities
for mobility needs of the residents. It emphasises on
incorporation of urban transport at the urban planning
stage with focus on more equitable road space allocation.
Unied Metropolitan Transport Authorities in all million
plus cities has been recommended. Under Jawaharlal
Nehru National Urban Renewal Mission, 63 cities
were identied to provide cash assistance in grants by
Central Government for infrastructure developments
projects including urban transportation sector as roads,
highways, expressways, Mass Rapid Transport System
and metro projects. Bus based public transport systems
are to be incentivised under this scheme. It is estimated
that an investment of Rs 4,35,380 crores is required
between 2008 and 2027 to improve urban transportation
in 87 identied cities.(46) The National Safety Council
of India launched a campaign “The National Safety
Day/Safety Week Campaign” for nearly three decades
to mark its Foundation Day (4th March). These activities
have signicantly contributed to reduction in the rate
of accidents and created wide spread safety awareness.
Road Safety Week is observed every year from 1st–7th
January.
In recognition that road accidents are a major public
health problem. National Road Safety Policy was
approved in India in 2010 based on Sunder committee
recommendations. Under this policy Government
of India has committed to increase awareness about
road safety issues, establish a road safety information
database, ensure safer road infrastructure, vehicles,
drivers and safety of vulnerable road users.
Recommendations
There is sufficient evidence to show that effective
measures can reduce morbidity and mortality due to
road transport, which could take the form of a policy or
comprehensive plan of action. Exposure to air pollutants
is largely beyond the control of individuals, and requires
action by public authorities at all levels. Enforcement of
speed and alcohol limits, child restraints, safety belts and
helmet use; pedestrian friendly front ends of vehicles
and collision warning systems and design changes in
vehicles like low oor buses with automatic closing
doors, better and functional headlights and reectors
etc. to increase visibility of vehicles will help prevent or
decrease accidents and injuries. Measures like regulating
vehicle entry to city centers at busy hours, hike in parking
charges and taxes will decrease congestion, commuting
time, stress, risk of accidents and pollution. On the other
hand, health services should be strengthened especially
access to emergency trauma services, enhance capacity at
all levels from primary to tertiary level of care in health
promotion and patient management; this would go a
long way in reducing morbidity and mortality due to
health effects either from accidents or other pollution
related ill-health effects.
Conclusion
This paper highlights some of the adverse health
impacts of urban transportation in India where
planning and management of transportation activities
has not kept pace with increasing demands due to
rapid urbanization. A combination of approaches
will be required to address the problems in all levels
according to D-P-S-E-E-A framework. The role of
the government is crucial in planning and strict
implementation of safety measures; there is therefore
urgent need for capacity building and research,
strengthening and enabling legal, institutional, and
nancial environment for road safety. Health system
strengthening should be given priority to achieve
signicant reduction of health effects of road transport.
Although policies, rules and intent are in place, results
will only be visible if implementation, enforcement
and monitoring are done effectively.
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How to cite this article: Solanki HK, Ahamed F, Gupta SK, Nongkynrih
B. Road transport in Urban India: Its implications on health. Indian J
Community Med 2016;41:16-22.
Source of Support: Nil, Conicts of Interest: None declared.