Road traffic injuries: Hidden epidemic in less developed countries

Abstract

Road traffic injuries (RTIs) are a leading cause of morbidity, disability and mortality in less developed countries. Globally in 2002, 1.2 million deaths resulted from RTIs, and about 10 times that were injured. RTIs are often preventable, and the technology and knowledge to achieve success in this area exist. In spite of this, it is projected that given the current trend and without adequate intervention, RTIs will rank third of all major causes of morbidity and mortality globally by 2020. Although > 85% of the global deaths and injuries from road traffic crashes occur in less developed countries, traffic safety attracts little public health attention in these nations, due in part to a plethora of other equally important problems, including infectious diseases. Unfortunately, the public health and economic impact of traffic-related injuries and disabilities can be incalculable in these countries, owing to their poorly developed trauma care systems and nonexistent social welfare infrastructures to accommodate the needs of the injured and the disabled. In this paper, we highlight the problem posed to public health in less developed countries by RTIs and examine contributing factors. To engender debate and action to address the problem, we reviewed interventions that have proven effective in industrialized nations and discussed potential barriers to their replication in less developed countries.

Full text

Road
Traffic
Injuries:
Hidden
Epidemic
in
Less
Developed
Countries
Alyson
Hazen,
BS
and
John
E.
Ehiri,
PhD,
MPH
Birmingham,
Alabama
Road
traffic
injuries
(RTIs)
are
a
leading
cause
of
morbidity,
disability
and
mortality
in
less
developed
countries.
Globally
in
2002,
1.2
million
deaths
resulted
from
RTIs,
and
about
10
times
that
were
injured.
RTIs
are
often
preventable,
and
the
technology
and
knowledge
to
achieve
success
in
this
area
exist.
In
spite
of
this,
it
is
projected
that
given
the
current
trend
and
without
adequate
intervention,
RTIs
will
rank
third
of
all
major
causes
of
morbidity
and
mortality
globally
by
2G20.
Although
>85%
of
the
global
deaths
and
injuries
from
road
traffic
crashes
occur
in
less
developed
countries,
traffic
safety
attracts
little
public
health
attention
in
these
nations,
due
in
part
to
a
plethora
of
other
equally
important
prob-
lems,
including
infectious
diseases.
Unfortunately,
the
public
health
and
economic
impact
of
traffic-related
injuries
and
disabilities
can
be
incalculable
in
these
countries,
owing
to
their
poorly
developed
trauma
care
systems
and
nonexist-
ent
social
welfare
infrastructures
to
accommodate
the
needs
of
the
injured
and
the
disabled.
In
this
paper,
we
high-
light
the
problem
posed
to
public
health
in
less
developed
countries
by
RTIs
and
examine
contributing
factors.
To
engender
debate
and
action
to
address
the
problem,
we
reviewed
interventions
that
have
proven
effective
in
indus-
trialized
nations
and
discussed
potential
barriers
to
their
replication
in
less
developed
countries.
Key
words:
road
traffic
injuries
*
traffic
safety,
accidents
a
unintentional
injuries
U
developing
countres
U
disabilities
K
2006.
From
the
Department
of
Health
Behavior
(Hazen)
and
Department
of
Maternal
&
Child
Health
(Ehiri),
School
of
Public
Health,
University
of
Alabama
at
Birmingham, Birmingham,
AL.
Send
correspondence
and
reprint
requests
for
J
Natl
Med
Assoc.
2006;98:73-82
to:
John
E.
Ehiri,
PhD,
MPH,
Department
of
Maternal
&
Child
Health,
School
of
Public
Health,
University
of
Alabama
at
Birmingham,
1665
University
Blvd.,
Ryals
Building
320,
Birmingham,
AL
35294;
phone:
205-975-7641;
fax:
205-934-8248;
e-mail:
jehiri@uab.edu
INTRODUCTION
The
World
Health
Organization
(WHO)
produced
its
first
authoritative
report
on
the
problem
of
road
traf-
fic
injuries
(RTIs)
more
than
40
years
ago.'
In
1974,
Resolution
WHA27.59
was
passed
by
the
World
Health
Assembly,
declaring
RTIs
"a
major
public
health
issue"
and
calling
on
member
states
to
address
it.'
Nevertheless,
implementation
of
programs
has
been
slow
or
nonexistent,
and RTIs
continue
to
exact
an
enormous
social
and
economic
toll
on
many
poor
countries
around
the
world.2
In
contrast
to
the
consis-
tent
declines
seen
in
high-income
countries
(HICs),
many
developing
nations
have
witnessed
dramatic
increases
in
the
number
of
road
traffic
deaths.3
As
a
result,
there
has
been
renewed
interest
in
the
interna-
tional
health
community
to
more
strongly
emphasize
the
public
health
importance
of
road
safety.
For
exam-
ple,
the
WHO
recently
formed
the
Department
of
Injuries
and
Violence
Prevention,
and
the
World
Bank
formed
an
interdisciplinary
taskforce
to
ensure
road
safety
issues
are
jointly
addressed
by
transport
and
public
health
departments
and
professionals.
In
addi-
tion,
the
2004
World
Health
Day
was
dedicated
to
road
safety
to
reflect
the
huge
importance
of
this
problem.'
William
Haddon,
Jr.
pioneered
road
safety
research
when
he
combined
the
host-agent-environ-
ment
triad
with
the
concepts
of
primary,
secondary
and
tertiary
prevention
to
create
the
Haddon
Matrix
(Table
1
).4
This
matrix
provides
a
framework
for
understanding
the
etiology
of
injuries
and
allows
for
the
identification
of
potential
interventions
at
each
step
in
the
injury
process.4
The
resulting
systems
approach
taken
by
developed
countries
has
resulted
in
decreased
rates
of
motor
vehicle
injuries
and
fatalities
by
dispelling
the
notion
that
road
traffic
crashes
are
random
and
unpredictable
events
and
by
involving
professionals
from
multiple
sectors
(Table
2)."
5
However,
this
approach
has
been
a
challenge
for
less
developed
countries
to
adopt
as
it
requires
considerable
resources
and
infrastructure
to
imple-
ment.'
Nonetheless,
there
are
available
measures
that
can
be
taken
to
reduce
the
concomitant
human
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006
73

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
suffering
and
economic
impact
caused
by
RTIs.
This
paper
discusses
the
current
state
of
RTIs
in
less
developed
countries,
including
the
magnitude
and
key
determinants
of
the
problem,
contributing
factors
and
selected
prevention
interventions
that
have
proven
effective
in
HICs
and
are
potentially
transferable
to
other
settings.
Data
presented
are
pri-
marily
from
observational
and
descriptive
studies
as
randomized
controlled
trials
or
controlled
before-
after
studies
conducted
in
less
developed
countries
on
this
subject
are
rare.
When
possible,
evidence
for
intervention
effectiveness
is
presented
from
system-
atic
reviews
of
studies
performed
in
HICs.
WHO
African
and
southeast
Asia
regions
are
emphasized
since
these
are
among
the
worst
affected.'2
Less
developed
countries
encompass
those
of
both
low-
and
middle-income
levels,
as
defined
by
the
World
Bank.
Low-income
countries
have
a
gross
national
income
(GNI)
per
capita
of
$765
or
less,
while
mid-
dle-income
countries
are
between
$766
and
$9,385.6
MAGNITUDE
OF
THE
PROBLEM
RTIs
are
a
cause
of
public
health
concern
in
virtu-
ally
every
country
of
the
world.7
However,
the
distri-
bution
of
mortality
and
morbidity
is
highly
uneven,
with
developing
countries
incurring
85%
of
all
deaths
due
to
traffic
crashes,
90%
of
lost
disability-adjusted
life
years
(DALYs)
and
96%
of
all
child
deaths
due
to
RTIs.8
Estimates
of
deaths
resulting
from
RTIs
vary
as
a
result
of
underreporting
and
a
lack
of
reliable
data
due
to
incomplete
records.9
According
to
WHO
estimates,
approximately
1.2
million
people
were
killed
in
traffic
crashes
in
2002.'
An
additional
20-50
million
persons
are
injured
or
disabled
each
year.8
Most
of
these
statistics
are
accounted
for
by
"vulnera-
ble
road
users,"
including
pedestrians,
bicyclists,
motorcyclists
and
riders
of
scooters
or
mopeds,
most-
ly
in
less
developed
countries.9
Table
1.
The
Haddon
matrix
applied
to
a
road
traffic
crash
Factors
Environment
Phases
Human
Vehicle
Physical
Social
Preevent
Attitudes
Roadway
design
Knowledge
Vehicle
condition
Traffic
calming
Traffic
laws
Use
of
alcohol
Speed
Pedestrian
facilities
Cultural
norms
Driver
experience
Event
Use
of
seat
belts
Seat
belts
Shoulders,
medians
Helmet
and
Wearing
fastened
helmet
Helmets
Guardrails
seat
belt
laws
Postevent
First
aid
Fire
risk
Availability
of
trauma
Standards
of
trauma
Medical
treatment
care
equipment
care
in
hospitals
Traffic
congestion
In
1998,
RTIs
ranked
ninth
for
DALYs
lost
glob-
ally.8
In
2002,
they
were
the
second
leading
cause
of
death
for
children
aged
5-14
years
and
young
adults
aged
15-29
years,
and
the
third
leading
cause
of
death
for
adults
aged
30-44
years.'
It
is
projected
that
if
current
trends
continue
and
new
initiatives
are
not
instituted,
by
2020,
RTIs
will
rank
third
for
DALYs
lost
globally,
and
road
traffic
deaths
in
developing
countries
could
increase
by
up
to
80%.'I8
RTIs
place
enormous
economic
strain
at
the
national,
local
and
individual
levels.
Those
most
often
affected
by
RTIs
are
young
adults
aged
15-44,
who
account
for
48-78%
of
all
traffic-related
fatalities.9
Males
are
consistently
more
likely
to
be
injured
or
killed,
thus
increasing
the
number
of
economically
disadvantaged
widows
and
orphans.8'9
Indeed,
removal
of
the
breadwinner,
funeral
costs,
hospital-
ization
fees
or
extended
medical
care
for
severe
injuries
can
push
a
family
into
poverty.9
Direct
eco-
nomic
costs
of
global
traffic
crashes
are
estimated
at
$518
billion.'
For
developing
countries,
the
costs
are
estimated
at
$65
billion,
more
than
the
total
amount
of
all
foreign
aid
donated.9
In
reality,
these
costs
are
likely
to
be
considerably
higher,
especially
when
indi-
rect
and
social
costs
are
factored
into
the
estimates.
Direct
costs
include
hospitalization
fees,
long-term
medical
care
for
the
injured
and
loss
of
productivity.
The
average
annual
cost
to
the
society
of
road
traffic
crashes
ranges
from
0.3%
of
the
GNP
in
Vietnam
to
nearly
5%
in
Malawi
and
South
Africa.8
KEY
DETERMINANTS
OF
RTIS
IN
DEVELOPING
COUNTRIES
Numerous
factors
play
a
significant
role
in
traffic
crashes
and
resulting
injuries.8
Some
involve
human
behavior
while
others
are
system-related.
Risk
factors
for
the
majority
of
RTIs
around
the
world
are
the
same,
although
they
may
differ
in
magnitude
depending
on
74
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
the
region.
Some
of
the
major
factors
are
the
increased
number
of
motor
vehicles,
speed,
alcohol
and
mix
of
road
users.
These
are
discussed
in
detail
below.
Increased
Number
of
Motor
Vehicles
A
primary
reason
for
the
increase
in
fatalities
and
injuries
from
traffic
crashes
in
poor
countries
is
simply
the
rising
number
of
motor
vehicles.2
Economic
growth
is
associated
with
expanded
mobility
and
demand
for
transportation
services.'
India,
China
and
Vietnam,
whose
economies
grew
during
the
past
10-15
years,
have
seen
rapid
increases
in
their
number
of
motor
vehicles.'
In
India,
four-wheeled
motor
vehicles
have
increased
by
23%
in
only
three
years
and
could
number
267
million
by
2050.1,2
China
has
seen
a
fourfold
increase
in
vehicles
since
1990
to
>55
million.'
In
Viet-
nam,
from
1992
to
2001,
the
number
of
motorcycles
increased
from
less
than
2
million
to
>8
million.'0
In
addition,
in
just
one
year,
the
number
of
motor
vehicles
in
Vietnam
increased
by
14%,
while
deaths
and
injuries
rose
by
31%
and
16%,
respectively.2
Speed
Speed
is
a
crucial
factor
in
many
road
traffic
crash-
es
and
influences
both
crash
probability
and
severity
of
injury."
As
a
general
rule,
the
greater
the
speed,
the
more
likely
a
crash
will
occur
and
the
more
likely
severe
injuries
will
be
sustained."
In
Ghana,
speed
alone
was
responsible
for
half
of
all
traffic
crashes
between
1998
and
2000
and
contributed
to
44%
of
all
police-reported
crashes
in
Kenya.""
2
A
study
in
Kuwait
attributed
speed
to
be
the
primary
cause
for
almost
92%
of
traffic
crashes
in
the
sample.'3
Commercial
vehicles-taxis,
trucks,
buses
and
minibuses-are
disproportionately
involved
in
traffic
crashes
in
many
low-income
countries
and
inflict
sub-
stantial
morbidity
and
mortality.'2"4"5
Pressure
to
adhere
to
strict
timetables
often
causes
commercial
drivers
to
exceed
posted
speed
limits.'
Speed
regulators
on
commercial
vehicles
are
often
nonfunctional,
non-
existent
or
intentionally
disabled.'
There
is
frequently
an
increased
reliance
on
public
transport
in
less
devel-
oped
countries.
Ideally,
this
would
be
a
positive
phe-
nomenon
given
the
need
to
reduce
traffic
congestion
and
emissions.
However,
public
transportation
systems
are
not
well
developed
in
many
resource-poor
coun-
tries,
thus
allowing
informal
and
unregulated
fare-
based
systems
to
proliferate.9"
4
These
systems,
such
as
the
matatus
in
Kenya,
often
consist
of
hazardously
decrepit
vehicles
that
are
overloaded
with
passengers.9
Intense
competition
for
fares
results
in
aggressive
driv-
ing
and
over-speeding.9
Alcohol
Although
alcohol
is
a
known
risk
factor
for
traf-
fic
crashes,
reliable
data
on
the
prevalence
of
driving
under
the
influence
of
alcohol
in
developing
coun-
tries
are
sparse.
In
Kenya,
a
survey
of
hospitalized
patients
revealed
that
of
those
being
treated
for
traf-
fic-related
injuries,
40%
of
drivers
and
20%
of
pedestrians
reported
being
under
the
influence
of
alcohol
at
the
time
of
the
crash.'2
A
study
in
New
Delhi
revealed
that
one-third
of
hospitalized
motor-
ized-two-wheeler
riders
admitted
to
drinking
alco-
hol
and
driving.'
Alcohol
poses
a
huge
threat
to
road
users
in
South
Africa.'6
Data
from
the
National
Injury
Mortality
Surveillance
System
shows
that
of
all
fatal
transport-related
cases
tested
in
2001,
>50%
had
elevated
blood
alcohol
content
(BAC)
and
out
of
those,
91%
exceeded
the
legal
limit
of
0.05
g/dl.'6
Over
62%
of
pedestrian
fatalities
had
an
elevated
BAC
and
almost
25%
had
BAC
of
>0.25
g/dl,
more
than
five
times
the
legal
limit.'6
In
addition,
>46%
of
drivers
killed
had
BAC
of
>0.05g/dl.'6
Mix
of
Road
Users
Most
developing
countries
have
a
blend
of
road
users
that
is
very
different
from
that
of
industrialized
nations.
This
mix
varies
depending
on
the
region
but
typically
consists
of
pedestrians,
push
carts,
bicy-
cles,
mopeds/scooters/motorcycles,
trucks,
minibus-
es,
buses
and
cars.'
Danger
arises
from
this
mixture
of
slow-moving,
nonmotorized
users
and
fast-mov-
ing,
motorized
users
sharing
the
same
road
space.9
Urban
Versus
Rural
Differentials
The
group
of
road
users
most
often
injured
varies
by
region
and
geographic
locale.
In
Asia,
riders
of
two-wheeled
vehicles
and
pedestrians
are
most
com-
monly
injured.8
Motorcycles
and
bicycles
had
the
highest
rates
of
injuries
in
2001
for
both
urban
and
rural
regions
in
Vietnam.10
Data
from
the
Viet-
namese
Ministry
of
Transportation
also
indicate
that
urban
traffic
crashes
are
more
frequent
but
that
rural
crashes
are
generally
more
severe.'0
In
India,
these
same
road
users
account
for
70-80%
of
all
deaths
due
to
RTIs,
while
occupants
of
cars
account
for
only
5%*.7
Africa
sees
most
injuries
and
deaths
being
sustained
by
pedestrians
in
urban
crashes
and
users
of
public
transportation
systems
in
rural
crashes.'2
In
contrast
to
Vietnam,
60%
of
all
injury-producing
crashes
in
Kenya
occur
on
rural
intercity
highways,
but
only
40%
occur
in
urban
regions.'2
Due
to
crowded
public
transport
vehicles
being
involved
in
rural
crashes,
the
number
of
casualties
per
motor
vehicle
collision
is
greater
on
rural
than
urban
roads.'2
Studies
in
Kenya
show
that
pedestrians
as
a
whole
are the
most
vulnerable
of
all
road
users,
and
this
group
experiences
the
greatest
number
of
injuries
and
deaths
from
traffic
crashes.'2
Pedestri-
ans
in
urban
areas
accounted
for
>70%
of
the
total
annual
deaths
due
to
road
traffic
crashes
in
1998.12
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006
75

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
In
addition,
a
recent
survey
at
Kenyatta
National
Hospital
in
Nairobi
reported
that
pedestrians
accounted
for
65%
of
patients
admitted
for
traffic-
related
injuries.'2
Pedestrians
in
urban
areas
are
also
the
most
likely
to
be
injured
in
Latin
America
and
the
Caribbean.8
In
Colombia,
traffic
crashes
are
almost
entirely
an
urban
phenomenon,
with
only
10%
of
crashes
occurring
on
rural
highways.'8
As
a
result,
pedestrians
made
up
nearly
68%
of
victims
from
traffic
crashes
in
Bogota'
in
2000.18
CONTRIBUTING
FACTORS
Poverty
There
are
a
number
of
indirect
factors,
including
socioeconomic
factors,
that
contribute
to
and worsen
RTIs
in
developing
countries.
Whereas
walking
and
use
of
public
transportation
systems
provide
benefits
to
health
and
the
environment
in
industrialized
nations,
these
modes
of
transport
place
the
poor
at
risk
of
RTIs
in
developing
countries
owing
to
the
lack
of
safe
pedestrian
lanes
and
inadequately
regulated
mass
transit
systems.
Using
level
of
education
as
an
indicator
of socioeconomic
status
in
Kenya,
it
was
found
that
27%
of
people
with
no
schooling
relied
on
walking
and
55%
used
public
transportation,
mostly
matatus.9
In
contrast,
81%
of
those
educated
beyond
secondary
school
rode
in
private
cars,
none
walked,
and
only
19%
used
public
transportation.9
The
poor
are
also
less
able
to
pay
for
medical
treatment
after
being
injured
because
the
introduction
of
user
fees
at
public
health
facilities
has
eliminated
the
free
health-
care
that
was
formerly
available.2
Inadequate
Surveillance
Systems
Many
countries
have
some
sort
of
system
to
col-
lect
data
on
road
traffic
crashes,
usually
from
hospi-
tal
records
or
police
reports.'0"'2
However,
underre-
porting
is
a
major
problem,
even
in
developed
countries
with
good
reporting
systems."9"9
Minor
injuries
are
most
likely
to
be
underreported.'9
People
may
not
seek
medical
treatment
for
such
injuries
or
may
be
unable
to
pay
for
services
and
so
are
not
cap-
tured
by
hospital
records.9'20
This
is
more
likely
to
be
true
for
rural
than
urban
areas.
In
rural
areas
of
Ghana,
for
example,
patients
that
sustained
severe
Table
2.
The
systems
approach
to
road
safety
*
A
science-based
approach
to
injury
pioneered
by
William
Haddon,
Jr
*
Haddon
Matrix
combines
injury
event
time
sequence
and
epidemiologic
triad
*
Allows
for
identification
of
primary
factors
that
contribute
to
traffic
crashes
and
possible
interventions
to
prevent
crashes
or
mitigate
severity
of
crash
outcomes
*
Can
be
used
to
identify
problems,
formulate
strategies,
set
targets
and
monitor
performance
*
Requires
multisector
cooperation
and
institutional
capacity
*
Is
crucial
for
reducing
road
traffic
injuries
and
fatalities
injuries
were
less
likely
to
seek
hospital
treatment
than
patients
in
urban
areas
due
to
an
inability
to
pay
for
care.2
Police
and/or
hospitals
might
not
record
injuries
or
fail
to
share
information,
resulting
in
dis-
crepancies
between
sources.'20
Road
traffic
crashes
that
occur
in
rural
areas
frequently
go
unreported
due
to
the
lack
of
police
presence.20
Furthermore,
the
quality
of
the
data
is
often
questionable
and
makes
international
comparisons
difficult.'
Data
may
be
incomplete
or
interpreted
differently,
reporting
sys-
tems
differ,
and
definitions
of
an
RTI
or
death
are
not
standardized."9
Even
when
data
are
collected,
they
are
rarely
used
as
a
basis
for
developing
and
evaluating
policy
or
interventions?'
Reliable
and
accurate
data
on
the
magnitude,
characteristics
and
consequences
of
road
traffic
crashes
are
desperately
needed
in
order
to
firmly
establish
RTIs
as
a
public
health
priority
and
to
create
policy
guidelines
and
interventions.'
Without
this
data,
policy
makers
will
continue
to
fail
to
design
appropriate
policy
responses
to
this
public
health
challenge.9
Inadequate
Trauma
Care
Systems
Inadequate
public
health
infrastructure
means
many
victims
of
traffic-related
injuries
die
or
are
dis-
abled
from
not
receiving
prompt
trauma
care.22'
In
many
developing
countries,
formal
emergency
med-
ical
services
are
nonexistent
or
are
inaccessible
to
a
majority
of
the
population
where
they
exist.2'
Much
of
sub-Saharan
Africa
and
southern
Asia
do
not
have
even
rudimentary
ambulance
services
in
rural
and
most
urban
areas.2'
Surviving
traffic
crash
victims
are
often
transported
to
a
hospital
by
bystanders,
rela-
tives,
commercial
vehicles
or
the
police.2'
In
Kenya,
only
2.9%
of
crash
victims
are
transported
to
a
hospi-
tal
by
an
ambulance.'
Likewise,
hospitals
themselves
are
largely
unprepared
to
treat
trauma
victims,
who
require
special
equipment
and
specialized
medical
care.
A
study
of
11
rural
hospitals
located
along
busy
roads
that
received
high
numbers
of
RTI
victims
in
Ghana
revealed
that
they
were
staffed
by
general
practitioners
with
no
training
in
trauma
care.2'
In
these
same
hospitals,
none
had
chest
tubes,
which
are
inexpensive
and
vital
for
the
treatment
of
life-threat-
ening
chest
injuries,
and
only
four
had
the
necessary
equipment
to
maintain
an
open,
breathing
airway.2'
In
76
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
Kenya,
only
40%
of
public,
private
and
mission
hos-
pitals
were
well
prepared
to
treat
trauma
patients,
and
almost
none
of
the
standard
treatment
items
for
man-
aging
severe
injuries
were
found
in
government
health
facilities.2
While
lack
of
supplies
is
problemat-
ic,
so
too
is
poor
utilization
of
such
equipment
when
it
is
available.
A
review
of
>2,000
trauma
admissions
in
an
urban
hospital
in
Ghana
showed
low
utilization
of
blood
transfusion
and
chest
tubes.2'
Thus,
inadequate
trauma
care
is
not
unique
to
rural
environments
that
lack
ambulance
services,
as
even
well-stocked
urban
hospitals
have
much
room
for
improvement
in
treat-
ing
trauma
victims.
INTERVENTIONS
In
this
section,
we
discuss
interventions
that
have
been
proven
effective
in
reducing
RTI
morbidity
and
mortality
in
HICs
(Table
3)
and
examine
their
poten-
tial
applicability
to
developing
countries.
Current
interventions,
barriers
to
implementation,
interven-
tion
effectiveness
and
good
practice
examples
in
some
developing
countries
are
also
highlighted
to
demonstrate
what
can
be
achieved
even
in
situations
of
limited
resources.
Motor
Vehicle
Occupant
Protection
It
is
well
established
that
seat
belts
decrease
death
and
severe
injury
for
motor
vehicle
occupants.'
7"1322-25
Studies
conducted
in
the
1980s
estimated
that
they
reduce
motor
vehicle
fatalities
by
50%
and
severe
injuries
by
55%.22,23
More
recent
studies
have
shown
even
greater
reductions.24'25
Seat
belt
use
is
mandated
in
many
industrialized
nations,
but
usage
is
low
in
most
developing
countries
as
many
vehicles
may
not
have
functional
belts.23
It
is
estimated
that
less
than
half
of
automobiles
in
developing
countries
are
out-
fitted
with
functional
seat
belts.23
In
addition,
the
lack
of
enforcement
of
existing
seat
belt
laws
con-
tributes
to
the
low
usage.22
However,
seat
belts
are
a
feasible
intervention
for
developing
countries
to
adopt,
providing
several
strategies
accompany
the
implementation.
Given
that
only
half
the
vehicles
in
developing
countries
have
functional
belts,
it
is
unrealistic
to
mandate
usage.
One
measure
that
governments
could
take
is
to
ban
the
importation
of
vehicles
without
functional
belts.22
This
would
prevent
from
entering
the
country
unsafe
vehicles
that
would
subsequently
place
occu-
pants
at
risk.
Another
measure
could
be
to
require
public
transport
vehicles
to
have
seat
belts
installed,
as
is
currently
done
with
matatus
in
Kenya.26
Such
measures
have
the
potential
to
improve
public
trans-
portation
safety
by
requiring
each
passenger
to
have
their
own
seat,
thus
reducing
passenger
overloading.
Two-Wheeler
Riders
Helmets
are
a
primary
intervention
with
proven
effectiveness
in
reducing
the
risk
of
head
injury.
A
Cochrane
systematic
review
revealed
that
motorcy-
cle
helmets
reduced
the
risk
of
head
injury
by
72%.27
Helmets
also
appeared
to
reduce
the
risk
of
mortali-
ty,
although
an
overall
estimate
of
effect
was
not
cal-
culated.27
Studies
in
Taiwan,
Indonesia
and
Malaysia
have
attributed
reductions
in
deaths
to
their
use."
22'28'29
Taiwan
saw
a
decrease
in
motorcycle
fatal-
ities
and
nonfatal
injuries
of
14%
and
31%,
respec-
tively,
following
the
passage
of
a
mandatory
motor-
cycle
helmet
law
in
1997.28
Nonfatal
head
injuries
also
fell
by
44%.28
Helmet
legislation
passed
since
1973
in
Malaysia
is
estimated
to
have
contributed
to
a
reduction
in
motorcycle
fatalities
by
30%.'
Man-
dating
helmet
use
by
motorcycle
riders
is
a
highly
transferable
and
feasible
intervention
for
poor
coun-
tries
to
adopt,
since
people
who
are
able
to
buy
a
motorcycle
should
be
able
to
afford
a
helmet.22
Standard
helmets
provide
full
head
coverage
and
have
a
thick
energy-absorbing
lining,
while
nonstan-
dard
helmets
cover
a
small
amount
of
the
head
and
have
a
thinner
lining
made
from
less
absorbent
material.30
Few
studies
have
investigated
the
differ-
ences
between
helmet
types
and
injury
outcomes.
One
study
found
that
33%
of
motorcycle
riders
wearing
nonstandard
helmets
were
killed
and
75%
sustained
head
injuries,
while
13.6%
of
riders
wear-
ing
standard
helmets
were
killed
and
30.7%
had
head
injuries.30
It
is
crucial
that
helmets
be
approved
and
worn
properly
for
them
to
be
effective.
An
observational
study
in
Indonesia
revealed
that
45%
of
motorcycle
drivers
and
87%
of
passengers
wore
them
with
the
chin
strap
unfastened,
providing
little
protection
in
the
event
of
a
crash.29
Strategies
to
increase
motorcycle
helmet
use
would
be
to
encourage
or
even
require
the
purchase
of
an
approved
helmet
when
purchasing
the
motor-
cycle.'9
The
importation
of
standard
helmets
that
meet
safety
requirements,
education
campaigns
on
the
importance
of
proper
use
and
the
enforcement
of
usage
laws
have
the
potential
to
reduce
injuries
and
deaths
from
motorcycle
crashes.2223
Likewise,
bicycle
helmets
have
been
shown
to
reduce
the
risk
of
head
and
brain
injuries
by
63-88%,
but
current
usage
is
extremely
low
world-
wide.31
A
study
in
Wuhan,
China
showed
that
none
of
the
patients
admitted
for
bicycle-related
crashes
had
been
wearing
a
helmet.22
However,
mandatory
purchase
and
use
of
an
approved
helmet
is
unrealis-
tic
in
many
developing
countries
because
bicycles
are
the
cheapest
form
of
transportation
used
primari-
ly
by
the
poor.23
Strategies
to
promote
their
use
could
include
government
subsidy
on
helmet
purchase,
resources
permitting
and
bicycle
safety
campaigns
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006
77

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
to
raise
awareness
of
the
importance
of
helmet
use
and
foster
safe
riding
habits.23
Pedestrians
The
physical
separation
of
pedestrians
from
traffic
has
been
shown
to
reduce
pedestrian
injuries
and
deaths.23
Despite
this,
sidewalks
are
primarily
limited
to
urban
areas,
even
in
developed
countries,
leaving
semiurban
and
rural
inhabitants
to
walk
along
road-
ways.22
Urban
sidewalks
may
be
crowded
with
ven-
Table
3.
Interventions
with
proven
effectiveness
in
reducing
road
traffic
injuries
and
fatalities
in
HICs
Author/Year
Count
Objectives
Study
Design
Rivara
et
al,
2000
To
determine
the
effectiveness
of
*
Descriptive
(United
States)24
automatic
shoulder
belt
systems
in
*
Data
collected
from
1993-1996,
reducing
risk
of
injury
and
death
National
Highway
Traffic
Safety
among
front-seat
passenger
vehicle
Administration
Crashworthiness
occupants
Data
System
Cummings
et
al,
To
estimate
the
relative
risk
of
death
*
Matched-pair
cohort
2003
(United
among
belted
and
unbelted
front-seat
*
Data
collected
from
1986-1998,
States)25
occupants
Fatality
Analysis
Reporting
System
Norvell
et
al,
2002
To estimate
the
association
between
*
Matched-pair
cohort
(United
States)32
death
and
helmet
use
*
Data
collected
from
1980-1998,
Fatality
Analysis
Reporting
System
Rowland
et
al,
To
compare
incidence,
type,
severity
*
Retrospective
cohort
1996
(United
and
costs
of
crash-related
injuries
*
Data
collected
from
Washington
States)33
resulting
in
hospitalization
or
death
for
State
patrol
records
helmeted
and
unhelmeted
motorcycle
riders
Thompson
et
al,
To
examine
the
effectiveness
of
bicycle
*
Prospective
case-control
1996
(United
helmets
in
four
age
groups,
in
crashes
*
Data
collected
from
emergency
States)34
involving
motor
vehicles
and
by
helmet
departments
of
seven
Seattle
type
hospitals
Ossenbruggen
To
use
logistic
regression
models
to
*
Logistic
regression
analysis
et
al,
2001
identify
factors
that
predict
the
*
Data
collected
from
police
(United
States)38
probabilities
of
crashes
and
injury
accident
reports
Bunn
et
al,
To
assess
whether
area-wide
traffic
Systematic
review
and
meta-analysis
2003
(United
calming
schemes
can
reduce
road
of
randomized
controlled
trials
and
Kingdom)39
crash-related
deaths
and
injuries
controlled
before-after
studies
dors,
in
disrepair
or
simply
not
used.35
In
Karachi,
Pakistan,
it
was
observed
that
encroachments
on
side-
walks
were
a
prime
cause
of
pedestrians
stepping
onto
the
road.35
Predictive
models
based
on
traffic
data
gathered
in
Addis
Ababa,
Ethiopia,
indicate
that
wider
sidewalks
result
in
increased
pedestrian
safety.36
Furthermore,
a
raised
curb
on
the
road
edge
reduced
pedestrian
accidents
by
46%
on
undivided
roads.36
Sidewalks
are
feasible
for
developing
countries
because
they
are
inexpensive
but
must
be
accompa-
78
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
nied
by
educational
campaigns
to
increase
public
awareness.22
Also,
a
review
of
evidence-based
traffic
engineering
measures
revealed
that
physical
barriers,
such
as
fences
or
dividers,
are
effective
in
reducing
pedestrian-motor
vehicle
crashes.37
These
act
to
pre-
vent
midblock
crossing
and
channel
pedestrians
to
safe
crossing
areas.37
During
this
period
of
increased
traffic,
governments
must
understand
the
need
to
allo-
cate
resources
for
creating
sidewalks
or
barricades
to
protect
this
most
vulnerable
group.22
Study
Population
Intervention
Outcomes
Measured
Key
Study,
Results
Front-seat
motor
Seat
belts
Risk
of
death
for
Manual
shoulder
plus
lap
belt
vehicle
occupants
shoulder
plus
lap
belt
reduced
risk
of
death
by
73%
(OR,
0.27;
95%
Cl,
0.16-0.46)
and
automatic
shoulder
plus
lap
belt
reduced
risk
of
death
by
86%
(OR,
0.14;
95%
Cl,
0.07-0.26)
Front-seat
Seat
belts
Death
within
30
days
Seat
belts
reduced
relative
passenger
car
of
crash
risk
of
death
by
61%
(RR=0.39;
occupants
95%
Cl,
0.37-0.41)
Motorcycle
crash
Motorcycle
Death
within
30
days
Motorcycle
helmets
reduced
driver/passenger
helmets
of
crash
relative
risk
of
death by
39%
pairs
(RR=0.61;
95%
Cl,
0.54-0.7)
Motorcycle
crash
Motorcycle
Head
injury
Unhelmeted
riders
were
victims
helmets
almost
three
times
more
likely
to
be
hospitalized
with
head
injury
(RR=2.9;
95%
Cl,
2.0-4.4)
and
nearly
four
times
more
likely
to
have
severe
head
injury
than
helmeted
riders
(RR=3.7;
95%
Cl,
1.9-7.3)
Bicycle
crash
Bicycle
helmets
Head
and
brain
injury
Helmets
reduced
head
injury
by
victims
69%
(OR,
0.31;
95%
Cl,
0.26-0.37)
and
brain
injury
by
65%
(OR,
0.35;
95%
Cl,
0.25-0.48)
1.
Sidewalks
Pedestrian-motor
1.
Crash
probability
is
twice
as
2.
Efficient
land
vehicle
crashes
likely
at
a
site
without
a
use
sidewalk
than
a
site
with
one
2.
Multipurpose
land-use
zones
had
fewer
crashes
than
single-purpose
land-
use
zones
Studies
were
Area-wide
traffic
Road
traffic
injuries
Sixteen
studies
found
an
1
1%
conducted
in
calming
schemes
reduction
in
road
traffic
Germany,
injuries
(pooled
rate
ratio
0.89;
Netherlands,
95%
Cl,
0.8-1.0)
Australia
and
the
United
Kingdom
Cross-Cuffing
Interventions
Cross-cutting
interventions
aim
to
protect
all
road
users.
Some
interventions
limit
vehicle
speed
through
various
traffic
calming
measures.
Speed
can
be
restrict-
ed
by
placing
speed
bumps
or
rumble
strips
at
high-fre-
quency
crash
sites
or
by
enforcing
posted
speed
lim-
its.23
In
industrialized
nations,
speed
limits
are
enforced
by
police,
but
in
low-income
countries,
this
is
difficult
due
to
resource
constraints.
For
example,
the
police
force
in
Ghana
is
comprised
of
nearly
16,500
officers
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006
79

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
who
are
assigned
only
145
vehicles
for
a
country
with
over
18
million
inhabitants.22
This
number
of
vehicles
is
totally
inadequate
to
properly
enforce
almost
any
policy,
be
it
seat
belt
use
or
drunk
driving.
Speed
bumps
or
rumble
strips
are
therefore
a
viable
option
for
poor
countries
because
they
are
highly
cost-effective
and
simple
to
install."
These
are
also
particularly
well
suited
for
protecting
residents
who
live
near
rural
inter-
city
highways."
A
systematic
review
of
controlled
before-after
studies
has
shown
an
1
1%
reduction
in
RTIs
due
to
traffic
calming
techniques,
such
as
speed
bumps,
mini-roundabouts
and
road
narrowing.39
These
interventions
have
the
potential
to
reduce
RTIs
and
fatalities
in
less
developed
countries.39
Cross-cutting
interventions
also
include
measures
to
reduce
the
effects
of
alcohol
on
road
users.
Sobri-
ety
checkpoints,
lower
BAC
and
minimum
drinking
age
laws
in
HICs
have
reduced
alcohol-related
crash-
es,
injuries/fatalities
and
extent
of
impaired
driving.22
However,
the
transferability
of
these
interventions
to
less
developed
nations-particularly
those
that
are
very
poor
is
unknown.22
As
alcohol
is
a
primary
risk
factor
for
RTIs,
developing
nations
could
begin
by
establishing
the
prevalence
of
drinking
and
driving.5
This
could
be
done
through
random
roadside
surveys
using
breathalyzers
and
testing
for
blood
alcohol
among
fatally
injured
drivers.5
Once
prevalence
has
been
established,
targeted
interventions
and
rational
policies
could
be
developed.40
Additional
Options
Interventions
that
limit
exposure
to
risk,
such
as
building
regulated
mass
transit
systems,
improving
efficient
land
use,
restricting
motor
vehicles
and
providing
shorter
routes
for
cyclists
and
pedestrians,
should
also
be
explored.'
The
latter
measure
is
extremely
important
for
reducing
risk
to
pedestrians
who
typically
cross
through
traffic
rather
than
use
pedestrian
bridges
that
have
long
stairways
and
are
inconveniently
located.4"42
These
interventions
have
been
effective
in
developed
countries,
and
their
use
in
developing
nations
should
be
encouraged
when-
ever
possible.'
A
combination
of
these
measures
has
the
potential
to
allow
for
increased
safe
mobility,
promote
the
health
benefits
of
walking
and
cycling,
and
decrease
levels
of
air
pollution.'
Barriers
to
Implementation
and
Effectiveness
Intervention
plans
can
fail
to
be
effective
due
to
a
host
of
potential
obstacles.
Barriers
can
be
social,
such
as
helmets
not
being
"cool"
or
being
too
hot
or
uncomfortable.22
Reasons
frequently
cited
for
nonuse
in
Indonesia
were
laziness,
physical
discom-
fort
and
lack
of
police
to
enforce
use.29
Token
com-
pliance
with
laws
is
also
a
barrier
to
effectiveness.
Helmet
use
in
Indonesia
was
seen
primarily
as
a
law
enforcement
issue
and
not
one
of
safety,
hence
the
high
rates
of
riders
wearing
their
helmets
unfas-
tened.29
Low
literacy
also
hinders
education
efforts,
such
as
those
to
promote
safe
bicycle
or
motorcycle
riding,
using
seat
belts
or
safer
crossing
behaviors.22
Barriers
can
also
be
due
to
cultural
beliefs.
In
many
countries,
injuries
are
still
thought
to
be
acts
of
God,
and
victims
can
be
blamed
for
their
injury,
which
is
summed
up
by
the
Ghanaian
saying:
"The
dead
is
always
guilty".23
The
fact
that
road
traffic
crashes
are
still
referred
to
as
"accidents"
gives
the
impression
that
these
are
random
and
unpredictable
events.3
The
worldviews
of
various
cultures
can
impede
efforts
to
promote
a
rational
systems
approach
to
road
safety.
The
western
worldview
is
based
on
the
belief
that
events
are
preventable
and
one
is
in
control
of
one's
life.43
This
perspective
is
at
odds
with
religions
and
cultures
that
have
a
strong
sense
of
predestiny
and
fate.43
Traditional
health-
promotion
efforts
may
not
be
effective
if
factors
leading
to
traffic
crashes
are
thought
to
be
outside
of
one's
locus
of
control.43
Poverty,
in
all
countries,
represents
a
major
barri-
er
to
intervention
implementation.
National
eco-
nomic
situations
prevent
many
countries
from
ade-
quately
addressing
any
health
problem,
with
traffic
safety
being
no
exception.22
More
obvious
and
press-
ing
health
issues,
such
as
HIV/AIDS
and
other
infectious
diseases,
consume
large
portions
of
health
budgets
in
developing
countries
so
that
RTIs
are
not
considered
a
priority.22
Lack
of
resources
for
proper
law
enforcement
is
a
considerable
barrier
to
improv-
ing
road
safety
in
less
developed
nations.
In
addition
to
education
and
engineering
strategies,
developed
countries
have
relied
upon
enforcement
of
laws
to
reduce
RTIs
and
fatalities.
"'36
Corruption
also
severely
undermines
the
effectiveness
of
law
enforcement
by
allowing
infractions
to
go
unpun-
ished,
thus
leading
to
the
perception
that
traffic
laws
are
"toothless".44
According
to
Nantulya
and
Muli-
Musiime,
pervasive
corruption
is
a
social
determi-
nant
of
road
traffic
crashes
in
Kenya,
where
bribery
is
said
to
be
"regrettable
but
widespread".44
Risk
compensation
may
limit
overall
effectiveness
of
interventions.
It
has
been
argued
that
safety
meas-
ures
can
increase
risky
behavior
because
individuals
feel
more
protected.45
This
is
especially
applicable
to
helmet
and
seat
belt
laws,
which
can
improve
the
safety
of
the
compliant
individual
but
raise
the
risk
for
others
due
to
increased
unsafe
driving
behaviors.45
Lastly,
lack
of
political
will
may
be
the
most
important
barrier.
Without
the
commitment
of
governments,
little
action
will
be
taken.3
80
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
CURRENT
INTERVENTIONS:
SUCCESS
STORIES
Despite
the
bleak
outlook,
there
are
examples
of
effective
measures
being
taken
to
reduce
mortality
and
morbidity
from
RTIs
in
less
developed
countries.
A
low-income
country
that
has
implemented
an
effec-
tive
intervention
to
decrease
speeding
and
resulting
crashes
is
Ghana.
Rumble
strips
were
installed
at
intervals
at
the
Suhum
Junction,
a
frequent
crash
site
on
the
Accra-Kumasi
highway.
This simple
interven-
tion
contributed
to
a
decrease
in
crashes
of
35%
and
fatalities
by
55%
in
a
16-month
period.
The
total
cost
of
the
installation
was
less
than
$21,000,
a
bargain
when
compared
to
estimates
of
$104,610
to
redesign
the
junction
or
$184,600
to
construct
a
walkway
and
guardrails
to
separate
pedestrians."I
Another
successful
program
has
been
conducted
in
Colombia,
a
middle-income
country,
which
saw
a
50%
drop
in
traffic
fatalities
from
1995
to
2002
as
a
result
of
a
series
of
interventions
implemented
at
national
and
local
levels.'
In
1995,
the
Traffic
Acci-
dent
Mandatory
Insurance
Law
was
introduced,
requiring
all
vehicles
to
have
insurance
policies.
A
levy
on
insurance
generates
revenue
to
fund
mass
media
prevention
campaigns,
road
safety
education
and
support
of
other
activities
carried
out
by
state
road
safety
entities.
This
law
also
guarantees
that
the
insurer
pays
for
any
hospital
care
received
by
victims
of
traffic
crashes
and
has
led
to
improvements
in
the
recording
of
information
on
road
traffic
crashes.
The
Ministry
of
Transportation
(MoT)
also
has
several
initiatives,
including
a
national
road
safety
plan,
which
will
be
used
to
provide
policy
frameworks
and
issue
general
guidelines
to
local
authorities.
Another
is
a
national
monitoring
system,
which
would
allow
authorities
to
track
vehicle
locations
via
geographic
sensing
devices
installed
in
public
transport
vehicles.
In
Bogota',
several
policies
have
been
implement-
ed
to
mandate
that
all
drinking
establishments
close
by
1:00
a.m.,
to
restrict
driving
in
the
city
during
certain
hours
two
days
each
week
and
to
restrict
pri-
vate
vehicles
in
the
city.
Last
has
been
the
introduc-
tion
of
Bogota's
mass
transit
system,
which
trans-
ports
an
average
of 800,000
people
per
day.
It
has
improved
mobility
in
the
city
in
addition
to
reducing
the
number
of
injuries
along
its
routes
by
building
infrastructure
that
ensures
the
safety
of
pedestrians
and
other
road
users.
The
drivers
are
under
contract,
and
their
salaries
are
established
by
law.
This
differs
from
most
public
transportation
systems
where
driv-
ers
are
paid
based
on
the
fares
they
collect-a
situa-
tion
that
leads
to
vehicles
being
massively
over-
loaded
with passengers
and
driven
at
high
speeds
to
reach
new
passengers
before
the
competition."'8
Conclusion
and
the
Way
Forward
Much
remains
to
be
done
to
reduce
mortality
and
morbidity
associated
with
road
traffic
crashes
in
devel-
oping
countries.
Many
are
just
beginning
to
take
action
and
programs
are
in
their
infancy.
Others
have
still
not
recognized
the
true
extent
of
the
problem;
deaths
and
injuries
will
continue
to
rise
in
those
countries.
The
adoption
of
a
systems
approach
to
road
safety
is
crucial
to
stemming
the
loss
of
life.
However,
it
is
presumptu-
ous
to
assume
an
intervention
designed
in
the
west
will
be
effective
in
a
less
developed
country
without
first
understanding
the
local
context
and
unique
social
deter-
minants.
Research
is
needed
to
further
uncover
factors
that
distinguish
road
traffic
crashes
from
those
occur-
ring
in
developed
countries.
Information
gathered
can
be
used
to
develop
novel
interventions
as
well
as
identi-
fy
ways
to
adapt
western
interventions
to
meet
local
needs.
Indigenous
solutions
should
be
sought
and
encouraged
to
promote
sustainability
and
decrease
reliance
upon
international
"experts".
These
actions
will
also
increase
community
participation
and
can
fos-
ter
a
sense
of
ownership,
thus
improving
the
likelihood
of
success
and
compliance.
In
addition,
rigorous
evalu-
ation
is
desperately
needed
to
determine
effectiveness
of
programs
and
transferability
of
interventions
to
less
developed
countries
as
well
as
prevent
the
wasteful
use
of
scarce
resources.
Regulating
informal
public
trans-
portation
systems
and
enforcing
safety
legislation
could
go
a
long
way
in
reducing
the
burden of
RTIs.
It
is
imperative
that
governments
of
developing
countries
make
this
issue
a
top
priority
alongside
HIV/AIDS
and
other
pressing
public
health
problems.
Public
invest-
ment
and
funding
for
road
safety
must
be
increased
both
by
governments
and
donors-to
curb
the
substan-
tial
loss
of
human
capital.
The
time
for
action
has
come.
REFERENCES
1.
Peden
M,
Scurfield
R,
Sleet
D,
et
al,
eds.
World
report
on
road
traffic
injury
prevention.
Geneva:
WHO;
2004.
2.
Nantulya
VM,
Reich
MR.
The
neglected
epidemic:
road
traffic
injuries
in
developing
countries.
BMJ.
2002;324:1139-1141.
3.
Rosenberg
ML,
Mcintyre
MH,
Sloan
R.
Global
road
safety.
lnj
Control
Saf
Promot.
2004;11
(2):141-143.
4.
Runyan
CW.
Using
the
Haddon
matrix:
introducing
the
third
dimension.
lnj
Prev.
1998;4:302-307.
5.
Mock
C,
Kobusingye
0,
Vu
Anh
L,
et
al.
Human
resources
for
the
control
of
road
traffic
safety.
Bull
World
Health
Organ.
2005;83(4):294-300.
6.
The
World
Bank.
Country
classification.
www.worldbank.org/data/coun-
tryclass/countryclass.html.
Accessed
May
12,
2005.
7.
Mohan
D.
Road
traffic
injuries-a
neglected
pandemic.
Bull
World
Health
Organ.
2003;81(9):684-685.
8.
Nantulya
VM,
Sleet
DA,
Reich
MR,
et
al.
The
global
challenge
of
road
traffic
injuries:
can
we
achieve
equity
in
safety?
Inj
Control
Saf
Promot.
2003;1
0(1
-2):3-7.
9.
Nantulya
VM,
Reich
MR.
Equity
dimensions
of
road
traffic
injuries
in
low-
and
middle-income
countries.
lnj
Control
Saf
Promot.
2003;10(1
-2):13-20.
10.
Le
LC,
Pham
CV,
Linnan
MJ,
et
al.
Vietnam
profile
on
traffic-related
injury:
facts
and
figures
from
recent
studies
and
their
implications
for
road
traffic
injury
policy.
Presented
at
Road
Traffic
Injuries
and
Health
Equity
Conference;
April
10-12,
2002;
Cambridge,
MA.
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006
81

ROAD
TRAFFIC
INJURIES
IN
LESS
DEVELOPED
COUNTRIES
11.
Afukaar
FK.
Speed
control
in
developing
countries:
issues,
challenges
and
opportunities
in
reducing
road
traffic
injuries.
Inj
Control
Saf
Promot.
2003:10(1-2):77-8
1.
12.
Odero
W,
Meleckidzedeck
K,
Heda
PM.
Road
traffic
injuries
in
Kenya:
magnitude,
causes
and
status
of
intervention.
In]
Control
Saf
Promot.
2003;1
0(
-2):53-6
1.
13.
Koushki
PA,
Bustan
MA,
Kartom
N.
Impact
of
sofety
belt
use
on
road
accident
injury
and
injury
type
in
Kuwait.
Accid
Anal
Prev. 2003;35:237-241.
14.
Mock
C,
Amegashie
J,
Darteh
K.
Role
of
commercial
drivers
in
motor
vehicle
related
injuries
in
Ghana.
In]
Prev. 1999;5:268-271.
15.
Hyder
AA,
Ghaffar
A,
Masood
TI.
Motor
vehicle
crashes
in
Pakistan:
the
emerging
epidemic.
Inj
Prev.
2000;6:199-202.
16.
Matzopoulos
R.
A
profile
of
fatal
injuries
in
S.
Africa.
Third
Annual
Report
of
the
National
Injury
Mortality
Surveillance
System.
www.sahealthinfo.org/
violence/2001
chapter6.pdf.
Accessed
May
23,
2005.
17.
Mohan
D.
Rood
traffic
deaths
and
injuries
in
India:
time
for
action.
NotI
Med
J
India.
2004;1
7(2):63-66.
18.
Rodriguez
DY,
Fernandez
FJ,
Velasquez
HA.
Rood
traffic
injuries
in
Colombia.
Inj
Control
Saf
Promot.
2003;1
0(1-2)
:29-35.
19.
Nakohara
S,
Wakai
S.
Underreporting
of
traffic
injuries
involving
children
in
Japan.
Inj
Prev.
2001;7:242-244.
20.
Romao
F,
Nizamo
H,
Mapasse
D,
et
al.
Road
traffic
injuries
in
Mozam-
bique.
Inj
Control
Saf
Promot.
2003;1
0(1
-2):63-67.
21.
Mock
C,
Arreola-Risa
C,
Quansah
R.
Strengthening
care
for
injured
per-
sons
in
less
developed
countries:
a
case
study
of
Ghana
and
Mexico.
Inj
Control
Saf
Promot.
2003;10(1
-2):45-5
1.
22.
Forjuoh
SN.
Traffic-related
injury
prevention
interventions
for
low-income
countries.
Inj
Control
Saf
Promot.
2003;10(1
-2):109-118.
23.
Forjuoh
SN,
Li
G.
A
review
of
successful
transport
and
home
injury
inter-
ventions
to
guide
developing
countries.
Soc
Sci
Med.
1996;43(1
1):1551-1560.
24.
Rivara
FP,
Koepsell
TD,
Grossman
DC,
et
al.
Effectiveness
of
automatic
shoulder
belt
systems
in
motor
vehicle
crashes.
JAMA.
2000;283(21):2826-2828.
25.
Cummings
P,
Wells
JD,
Rivara
FP.
Estimating
seat
belt
effectiveness
using
matched-pair
cohort
methods.
Accid
Anal
Prev.
2003;35:143-149.
26.
Mulama
J.
Kenya:
Government
stands
firm
on
minibus
strike.
Inter
Press
Service.
February
7,
2004.
www.afrika.no/Detailed/4802.html.
Accessed
May
24,
2005.
27.
Liu
B,
Ivers
R,
Norton
R,
et
al.
Helmets
for
preventing
injury
in
motorcycle
riders.
The
Cochrane
Database
Syst
Rev.
2003;(4):CD004333.
Review.
28.
Tsai
MC,
Hemenway
D.
Effect
of
the
mandatory
helmet
law
in
Taiwan.
Inj
Prev.
1999;5:290-291.
29.
Conrad
P,
Bradshaw
YS,
Lamsudin
R,
et
al.
Helmets,
injuries
and
cultural
definitions:
motorcycle
injury
in
urban
Indonesia.
Accid
Anal
Prev.
1996;
28(2):1
93-200.
30.
Peek-Asa
C,
McArthur
DL,
Kraus
JF.
The
prevalence
of
non-standard
helmet
use
and
head
injuries
among
motorcycle
riders.
Accid
Anal
Prev.
1999;31:229-233.
31.
Thompson
DC,
Rivara
FP,
Thompson
R.
Helmets
for
preventing
head
and
facial
injuries
in
bicyclists.
The
Cochrane
Database
Syst
Rev.
1999;(4):
CDOO
1855.
Review.
32.
Norvell
DC,
Cummings
P.
Association
of
helmet
use
with
death
in
motor-
cycle
crashes:
a
matched-pair
cohort
study.
Am
J
Epidemiol.
2002;156(5):
483-487.
33.
Rowland
J,
Rivara
F,
Salzberg
P,
et
al.
Motorcycle
helmet
use
and
injury
outcome
and
hospitalization
costs
from
crashes
in
Washington
state.
Am
J
Public
Health.
1996;86(1):41-45.
34.
Thompson
DC,
Rivara
FP,
Thompson
RS.
Effectiveness
of
bicycle
safety
helmets
in
preventing
head
injuries.
A
case-control
study.
JAMA.
1996:276
(24):
168-73.
35.
Khan
FM,
Jawaid
M,
Chotani
H,
et
al.
Pedestrian
environment
and
behavior
in
Karachi,
Pakistan.
Accid
Anal
Prev.
1
999;31:335-339.
36.
Berhanu
G.
Models
relating
traffic
safety
with
road
environment
and
traf-
fic
flows
on
arterial
roads
in
Addis
Ababa.
Accid
Anal
Prev.
2004;36:697-704.
37.
Retting
RA,
Ferguson
SA,
McCartt
AT.
A
review
of
evidence-based
traf-
fic
engineering
measures
designed
to
reduce
pedestrian-motor
vehicle
crashes.
Am
J
Public
Health.
2003:93(9):1456-1463.
38.
Ossenbruggen
PJ,
Pendharkar
J,
Ivan
J.
Roadway
safety
in
rural
and
small
urbanized
areas.
Accid
Anal
Prev.
2001;33:485-498.
39.
Bunn
F,
Collier
T,
Frost
C,
et
al.
Traffic
calming
for
the
prevention
of
road
traffic
injuries:
systematic
review
and
meta-analysis.
Inj
Prev.
2003;9:200-204.
40.
Gururaj
G.
Alcohol
and
road
traffic
injuries
in
South
Asia:
challenges
for
prevention.
J
Coll
Physicians
Surg
Pak.
2004;14(12):713-718.
41.
Mutto
M,
Kobusingye
OC,
Lett
RR.
The
effect
of
an
overpass
on
pedes-
trian
injuries
on
a
major
highway
in
Kampala-Uganda.
Afr
Health
Sci.
2002;2(3):89-93.
42.
Hijar
M,
Trostle
J,
Bronfman
M.
Pedestrian
injuries
in
Mexico:
a
multi-
method
approach.
Soc
Sci
Med.
2003;57:2149-2159.
43.
Dixey
RA.
'Fatalism',
accident
causation
and
prevention:
issues
for
health
promotion
from
an
exploratory
study
in
a
Yoruba
town,
Nigeria.
Health
Educ
Res.
1999;14(2):197-208.
44.
Nantulya
VM,
Muli-Musiime
F.
Kenya:
Uncovering
the
Social
Determi-
nants
of
Road
Traffic
Accidents.
In:
Evans
T,
Whitehead
M,
Diderichsen
F,
Bhuiya
A,
Wirth
M,
eds.
Challenging
Inequities:
From
Ethics
to
Action.
New
York:
Oxford
University
Press;
2001:211-225.
A
We
Welcome
Your
Comments
The
Journal
of
the
National
Medical
Association
welcomes
your
Letters
to
the
Editor
about
articles
that
appear
in
the
JNMA
or
issues
relevant
to
minority
healthcare.
Address
correspondence
to
ktaylor@nmanet.org.
The
University
of
Maryland's
Institute
of
Human
Virology
is
seeking
a
non-tenure
track,
full-time
Instructor
or
Assistant
Professor
faculty
member
in
the
School
of
Medicine's
Department
of
Medicine.
Faculty
rank
commensurate
to
experience.
Applicants
must
demonstrate
a
strong
interest
and
experience
in
the
clinical
management
of
HIV
infection
and
associated
diseases
and
complications,
must
be
board-certified
in
internal
medicine,
and
preferably
board
eligible
or
board
certified
in
infectious
diseases.
The
qualified
candidate
will
be
based
in
Africa,
and
will
fully
participate
in
PEPFAR
(President's
Emergency
Plan
for
AIDS
Relief)
Program
to
bring
antiretroviral
therapy
assessment,
treatment,
training
and
monitorng
to
resource-poor
countres.
Position
will
provide
expert
technical
assistance
and
supervision
of
programmatic
activities
to
the
medical
field
teams,
including
site
assessment
training
and
QA/QI
activities.
Position
will
also
be
responsible
for
planning
and
executing
operational
research
efforts
conducted
by
the
clinical
research
division
in
the
context
of
its
international
efforts.
Please
direct
inquires
with
CV,
four
references
and
a
brief
description
of
career
plans
and
goals
to
Robert
R.
Redfield,
M.D,
c/o
JoAnn
Gibbs,
Academic
Programs
Office,
Department
of
Medicine,
University
of
Maryland
Medical
Center,
Room
N3E10,
22
S.
Greene
St.,
Baltimore,
MD
21201.
The
University
of
Maryland,
Baltimore
is
an
AA/EEO/ADA
Employer.
Applicants
from
diverse
racial,
ethnic
and
cultural
backgrounds
are
encouraged
to
apply.
Please
reference
Position
03-309-443.
82
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION
VOL.
98,
NO.
1,
JANUARY
2006