Road traffic deaths and injuries in India: Time for action

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Editorials
VOLUME 17 NUMBER 2 MARCH/APRIL 2004
Road Traffic Deaths and Injuries in India: Time for action
Every day as many as 140 000 people are injured on the world’s roads. More than 3000 die and some 15
000 are disabled for life… Current figures are alarming enough. Even more alarming are trends. If they
continue, by 2020, the numbers of people killed and disabled every day on the world’s roads will have
grown by more than 60%, making road traffic injuries a leading contributor to the global burden of disease
and injury.
— Dr Lee Jong-wook1
Once we accept that road traffic injury control is a public health problem and that we have an ethical
responsibility to arrange for the safety of individuals, then it follows that healthcare professionals have to
assume responsibility for participating in efforts to control this pandemic. In India, over 80 000 persons
die in traffic crashes annually, over 1.2 million are injured seriously and about 300 000 disabled
permanently. In India, for individuals more than 4 years of age, more life-years are lost due to traffic
crashes than due to cardiovascular diseases or neoplasms.2 Road traffic injuries are among the second to
sixth leading cause of death in the age group 15–60 years in all countries of the Southeast Asia region.
This is why World Health Day 2004 focuses on road traffic injuries and measures to prevent them. The
slogan for the day is ‘Road Safety Is No Accident’. Road safety does not happen accidentally, but requires
deliberate effort by the government and its many partners.
In the past three decades the incidence of traffic crash fatalities and injuries has reduced significantly in
the rich, highly motorized countries; on the other hand, the total number of casualties in India has
continued to increase for the past 50 years. One cannot attribute this failure to the forms of government,
culture or religious practices existing in India or in more than 100 low-income countries. Among these
countries, there is great variation in size (populations can vary from less than a million to more than one
billion), religions, cultural practices and forms of government. If these factors had a determining
influence then there should have been a few countries where road safety policies were successful. The
fact that this has not happened means that there must be other reasons why the road safety situation in
India is less than desirable.
One reason is that health and technical professionals in India have not taken a scientific approach to this
problem. In Australia, Europe and North America, many of the pioneers in road safety research came from
the health profession: William Haddon Jr, a public health professional, was the first head of the National
Highway Traffic Safety Administration of the USA when it was established in the late 1960s; Dr Gordon
Trinca, a surgeon in Melbourne, has been the National Chairman, Road Trauma Committee, Royal
Australasian College of Surgeons; in Sweden, Bertil Aldman, MD designed the rear-facing child seat in 1963
and established the injury prevention centre at Chalmers University. There are many others. However, in
India, we do not have many surgeons or physicians who have taken up the cause of road safety in a
scientific and consistent manner. Some have even gone against the implementation of the compulsory
helmet law on frivolous grounds, unlike the official statement issued by the American College of Surgeons
which concludes ‘the American College of Surgeons supports efforts to enact and sustain universal helmet
laws for motorcycle riders’.3
This must change. Considering the enormity of the problem, health professionals in India must get
involved in the following ways:1
• Include road safety in health promotion and disease prevention efforts;
• Systematically collect health-related data on the magnitude, characteristics and consequences of
road traffic crashes;
• Support research to increase knowledge about risk factors and the development, implementation,
monitoring and evaluation of effective counter measures;
• Promote capacity-building in all areas of road safety and the management of survivors of road
traffic crashes;
• Translate effective science-based information into policies and practices that protect vehicle
occupants and vulnerable road users;

• Strengthen prehospital and hospital care as well as rehabilitation services for all trauma victims;
• Develop trauma care skills of medical personnel at the primary, district and tertiary healthcare
levels;
• Promote the development of policies aiming at greater integration of health and safety concerns
into transport policies, and facilitate this by further developing methods and tools to this effect
(e.g. for integrated assessments);
• Invest in medical research to improve the care of trauma survivors;
• Advocate for greater attention to road safety in view of the health impact and costs;
For a start, it would be ideal if we acquaint ourselves with some of the facts. Systematic reviews
of the scientific literature provide the following insights.4
• Educational programmes by themselves are usually insufficient to change overall behaviour: they
may increase knowledge, but rarely result in appropriate behaviour change among road users at
the societal level.
• A few individuals may change their behaviour, but individuals also behave differently on the
same day under different circumstances.
• Driver education may be necessary for beginners to learn the elementary skills required to obtain
a driving licence, but compulsory training in schools leads to early licensing. There is no evidence
that such schemes result in reductions in crash rates.
• Most attempts at enforcing road traffic legislation do not have any lasting effects, either on road
user behaviour or on crash rates, unless the effort is sustained. Stricter penalties (in the form of
higher fines or longer prison sentences) do not affect road user behaviour; imposing stricter
penalties often reduces the level of enforcement.
• Enforcement of laws against driving under the influence of alcohol, a minimum age for the
consumption of alcohol, and sobriety checkpoints are measures that do reduce the incidence of
road traffic injuries.
• Placing cameras at intersections reduces red light violations and crashes by 25%–40%.
• Helmet use reduces head and facial injuries in cycle and motorcycle users of all ages involved in
all types of crashes, including those with motor vehicles.
• Use of seat-belts and airbags can reduce fatalities among car occupants by over 30%.
• The only effective way to get most motorists to use safety belts is by introducing appropriate
legislation. When laws exist, advertising can inform the public about them and their enforcement.
• Rear brake lights mounted high on a vehicle reduce the incidence of rear-end crashes.
• Daytime use of headlights reduces the number of multiparty daytime accidents by about 10%–15%
for cars and motorcycles. In urban areas, traffic-calming techniques, roundabouts and pedestrian
and cycle facilities provide considerable safety benefits.
• Reduction in average speeds is always accompanied by reduction in road traffic injuries.
A recent Cochrane review of prehospital care technologies also shows that many techniques and practices
in vogue such as intravenous fluid administration at the site of crash, use of anti-shock garments,
speeding ambulances, use of advanced trauma life support training for ambulance crews, and drug
therapy may not be of much use and may even be harmful in some situations.5 This poses a very
interesting challenge to medical professionals in India as the results go in favour of less expensive systems.
This Cochrane review shows us that it may not be necessary to have expensively equipped ambulances to
provide quality care. It is up to us now to do further work in this area and determine optimal prehospital
care protocols.
In the end, work in India will have to focus on our own specific problems. However, most of the advances
have favoured car occupants over the more vulnerable road users—pedestrians, cyclists and motorcyclists.
In India, these vulnerable road users constitute over 70%–80% of all road traffic deaths, and car occupants
only about 5%. Future road safety work should be redirected to bring the needs of vulnerable road users
to centre stage. The patterns of traffic and crashes in India are very different from those in high-income
countries. Road and vehicle designs that eliminate the risk of serious injuries to vulnerable road users are
not available at present. A much larger group of committed professionals, in every country of the world,
needs to be involved in this work for new ideas to emerge. Disabilities and fatalities caused by road
traffic injuries can only be eliminated with a change in philosophy.
The medical profession can start with demanding the establishment of a National Road Safety Board and
regional data collection centres in hospitals, notification of compulsory helmet laws in all states of India,
speed control measures in cities, and then lobby for all that we know works. If we take this seriously, we
can end up saving thousands of needless deaths and injuries every year.

REFERENCES
1. Road safety is no accident: A brochure for World Health Day, 7 April 2004. Geneva:World Health
Organization; 2004:1–20.
2. Mohan D, Varghese M. Injuries in South-East Asia Region: Priorities for policy and action.
Delhi:SEARO, World Health Organization; 2002:1–19. SEA/Injuries/A1.
3. American College of Surgeons. Statement in support of motorcycle helmet laws [ST–35]. Bull Am
Coll Surg 2001;86.
4. Mohan D. Road traffic injuries—A neglected pandemic. Bull World Health Organ 2003;81:684–5.
5. Cochrane Injuries Group Reviews and Protocols.
http://www.cochrane-
injuries.lshtm.ac.uk/Review%20links.htm#subject
Dinesh Mohan
Henry Ford Professor for Biomechanics and Transportation Safety
Transportation Research and Injury Prevention Programme
Indian Institute of Technology
New Delhi