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. 2002 Aug 3;325(7358):277.

War on the roads

Major change is needed in politicians' and developers' attitudes

J Gordon Avery 1, Penny Avery 1
PMCID: PMC1123783  PMID: 12153930

Editor—The articles about war on the roads in the journal of 11 May1 have given prominence to the plight of vulnerable road users and the need to return the streets to the people in poorer countries.2 They have given less prominence, however, to similar needs in developed countries. graphic file with name avery.f1.jpg

The United Kingdom has for many years had one of the best records in the world for reducing road traffic crashes. The one big anomaly has been in accidents to pedestrians. Steady progress has been made in reducing deaths and injuries to child pedestrians since the early 1970s, but the country is still placed only 15th out of the 29 countries listed in the most recent edition of Road Accidents Great Britain 2000.3

The reason for its poor position lies mainly with the design of the urban environment. Although some good progress has been made—most notably with the development of “home zones”4—the United Kingdom still falls a long way behind its European neighbours in making its urban environment safe for children.

Some 20 years ago we described the enlightened approach being taken by the Scandinavians and the Dutch in creating urban environments that were friendly to vulnerable road users.5 The Dutch had “living streets,” while the Scandinavians had mini village complexes with walkways and cycleways, green belts, play spaces, crèches, and shops all within easy and pleasant access (free of motor vehicles) of the residential areas.

In contrast, the United Kingdom has continued to build tightly packed housing estates with fast moving vehicles and potential walkways and cycleways blocked off for security reasons. It has signs saying “no ball games” on the sparse green areas and playgrounds sited out of sight. No wonder our children spend most of their time watching television. When they come out to play they face a hostile environment.

If we are to make further progress in reducing the high pedestrian death and injury rates we need a major change in attitude from our politicians, planners, and developers. We need to give top priority to vulnerable road users and severely restrict motorists in all urban areas. We need some enlightened planning to redesign and rebuild all our depressed urban areas in a way that may prove more cost beneficial than all the other remedial measures put together. Only then can we change our position in the middle rankings of pedestrian safety to somewhere near the top.

References

  • 1. Editor's choice: Toxic complacency. BMJ 2002;324. (11 May.)
  • 2.Tiwari G. Returning streets to the people. BMJ. 2002;324:1164. . (11 May.) [Google Scholar]
  • 3.Department for Transport, Local Government and the Regions. Road accidents Great Britain 2000. London: DTLGR; 2000. [Google Scholar]
  • 4.Biddulph M. Home zones: a planning and design handbook. London: Policy Press; 2001. [Google Scholar]
  • 5.Avery JG, Avery PJ. Scandinavian and Dutch lessons in childhood road traffic accident prevention. BMJ. 1982;285:621–626. doi: 10.1136/bmj.285.6342.621. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Aug 3;325(7358):277.

This war is sapping NHS of resources and inflicting untold grief

John Dwyer 1

Editor—Analyse the assumptions that drivers make when they complain about road safety campaigns and you must conclude that drivers believe that they and their business are inherently more important than the lives of anyone on foot. There is no other explanation for their attitudes. Scratch a driver and you find someone who really believes—perhaps without even realising it—that he or she has the right to kill people who happen to be in the wrong place at the wrong time.

How else do you explain the way that one acquaintance told me about a neighbour's recent experience? The neighbour had turned too fast around a corner and run into two young girls on a crossing. One was killed, the other badly injured. “Poor chap,” said the man. “He didn't stand a chance.”

No thought of the chances of the children in the neighbour's path. You can be certain that he faced a fine and that the girls' parents wished they had got away as lightly.

This is a British problem. Walk around Vancouver, or Detroit, or even southern Portugal and most drivers will let you cross the road they are turning into—as is still provided by law in the United Kingdom but universally ignored. Drivers in these and other places tend to treat people on foot as no different from themselves.

Perhaps as a legacy of the days when the gentry drove round in carriages, generations of British schoolchildren have been indoctrinated to defer to drivers. If they so much as hear a car, they are told, they should wait until it goes by.

The lesson is that the police and others who indoctrinate children this way are not teaching pedestrians, they are teaching tomorrow's drivers. When these children pass their driving tests they expect to inherit a level of abjection no civilised society should tolerate.

Surely drivers who don't accept a duty of care to other road users and who drive without regard for the safety of others are unwell, whatever the medical term. If you doubt this, think what would happen if they acted similarly in any context other than a conflict between driver and pedestrian or cyclist.

It is a matter that needs to be emphasised in the BMJ because, whatever the (under-reported) statistics tell us, the undeclared war on child and other pedestrians is sapping the NHS of resources and inflicting untold grief among the rest of us.

BMJ. 2002 Aug 3;325(7358):277.

Driving less would reduce so many problems in so many countries

David S Thompson 1

Editor—Bravo to the BMJ for reporting a massive public health problem that most publications are afraid to touch.2-1

In Canada cars have killed more people than all the wars of the past 100 years combined.2-2 That's just the crashes. Air pollution from cars kills 3000-11 000 Canadians a year (www.ec.gc.ca/air/introduction_e.cfm; www.oma.org/phealth/icap.htm#summary).2-3 When crashes and air pollution are combined, cars kill about 125-273 Canadians every week. Compare this with the Solicitor General of Canada's figures of 1-2 deaths a week from murder (http://web.mala.bc.ca/crim/stats/homicide.htm) and 0-1 deaths a week from terrorism.

Sadly, oil addiction is not regarded by the Canadian government as worthy of serious action. While the government is spending huge sums and passing much legislation to deal with the terrorist threat, it is wavering on ratifying the Kyoto protocol on climate change.

Oil addiction in the First World also creates public health risks in other countries, as local populations are mistreated by oil companies and their friends in government. Their problems often ricochet back to the First World—as the Canadian minister of environment and energy recognised recently, stating: “When I am asked what an individual can do to fight terrorism, I say the answer is simple: drive less.”

References

BMJ. 2002 Aug 3;325(7358):277.

Transport has so many health implications that must be considered

Tony H Reinhardt-Rutland 1

Editor—Motoring is dangerous. In the United Kingdom, 3500 road deaths each year compare with 3000 deaths over the entire 175 years that railways have existed.

Safety engineering—seat belts, ABS brakes, and the like—is directed at protecting motorists from themselves, but Wilde's theory of risk homoeostasis predicts that the protection becomes nullified by riskier behaviour.3-1 Pertinent evidence is broadly supportive. For example, speed in built up areas in the United Kingdom increased from 28 mph (45 km/h) in 1981 (before compulsory use of seat belts) to 33 mph (53 km/h) in 1997,3-2 more than nullifying the advantage of seat belts.3-3 Whether one accepts Wilde's argument in full, the assertion by Robertson and Pless that safety engineering has no untoward effects is plainly wrong.3-1

Furthermore, there are issues beyond injuries to motorists. The road network cannot cope with increasing traffic, no matter how much money is pumped in. There should be little surprise: the safe stopping distances given in the Highway Code show the immense space requirements of cars. Of equal importance are health issues arising from sedentary lifestyles that depend on cars. When coupled with treating victims of crashes, the increasing costs of these health issues must be a major factor in the parlous state of the NHS.

So let's increase public transport. But issues need to be addressed here too. One issue is the hostility of an entrenched motoring lobby.3-4 Another presents a paradox: increased use of public transport inevitably leads to increased walking and cycling, if only to access public transport at railway stations and bus stops. That's good for general health. But children are rarely permitted to walk or cycle to school because of the danger posed by motoring, and similar attitudes probably affect all age groups.3-5 The faster driving encouraged by safety engineering seriously impinges on the rights and safety of non-motorists.

To break out of this paradox, we may have to attend to different aspects of risk. Wilde points to incentives for safer driving. I incline to the opposite: disincentives for unsafe driving. Behavioural principles suggest that disincentives must be chosen carefully—for example, fines seem ineffective. Instead, given that most drivers regard use of their car as essential, forfeiture of this privilege must shape motoring behaviour. We have increasingly reliable and cheap technologies ("black boxes” in vehicles, and roadside cameras) to record speed. Given political and societal will, we might learn to use them effectively.

References

  • 3-1.Wilde GJS, Robertson LS, Pless IB. Does risk homoeostasis theory have implications for road safety? BMJ. 2002;324:1149–1152. . (11 May.) [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Reinhardt-Rutland AH. Seat-belts and behavioural adaptation: the loss of looming as a negative reinforcer. Safety Sci. 2001;39:145–155. [Google Scholar]
  • 3-3.Hyden C, Varhelyi A. The effects of safety, time consumption and environment of large scale use of roundabouts in an urban area: a case study. Accid Anal Prev. 2000;32:11–23. doi: 10.1016/s0001-4575(99)00044-5. [DOI] [PubMed] [Google Scholar]
  • 3-4.Reinhardt-Rutland AH. Roadside speed-cameras: arguments for covert siting. Police J. 2001;74:312–315. [Google Scholar]
  • 3-5.Davis R, Coffman A. Safe roads for all. York: Institute of Highway Incorporated Engineers; 2001. [Google Scholar]
BMJ. 2002 Aug 3;325(7358):277.

People at risk get hit by traffic

Nicholas Moore 1

Editor—Nantulya and Reich give a clear view of the traffic conditions in different countries. The people most involved in accidents are those on the streets.4-1 This could have been illustrated by photographs of the typical traffic conditions in the various countries cited. In the United States one would see vast numbers of cars with single users. In Los Angeles, while I was walking down a street, a passing police car stopped to ask whether my car had broken down and I needed help. The pedestrian there is an anomaly. It is not surprising that few pedestrians are involved in accidents and that most victims are drivers. There is nothing much else to hit.

On the other hand, in Ho Chi Minh City (Saigon), there are three million mopeds for nine million inhabitants. Cars are few. Finding 62% of motorcycles involved in crashes is not surprising: a typical street photograph would show a mass of mopeds (usually with several passengers) and bicycles, with one or two cars and a few very full minibuses. It is hard to hit anything other than a moped.

Though I have never been to Kenya, Africa, or India, the pictures and films I have seen of them tend to show large crowds of pedestrians and overflowing buses or cars: the proportion of drivers to non-drivers is low. The probability of hitting another driver is much lower than that of hitting a pedestrian or a passenger.

The profile of the victims is really a reflection of the traffic conditions in a given country. Is the solution to developing countries' victim profiles to develop an American-style road scene, with the ensuing pollution, energy waste, etc?

References

  • 4-1.Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ. 2002;324:1139–1141. doi: 10.1136/bmj.324.7346.1139. . (11 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Aug 3;325(7358):277.

Evidence based prevention of these injuries is necessary

Adnan A Hyder 1

Editor—Nantulya and Reich discuss road traffic injuries in developing countries,5-1 and yet it is critical to understand the evidence base behind their argument.

On an aggregate global level, road traffic injuries disproportionately affect the developing world. These global data, however, are based on a dearth of nationally representative information on traffic injuries from developing countries. Our current knowledge base rests on small studies and special surveillance systems, with a few examples of survey data.5-2 Better national data are required to assess the true magnitude and distribution of the problem and to convince policy makers.

National resources are limited in developing countries, and programmes compete for resources. The proportion of death and disability attributable to injuries overall, and traffic injuries in particular, has been increasing over time.5-3 This, combined with the potential prevention of this loss of life and health, makes a powerful rationale for determining policy and for resource investments.

Interventions are available in the developed world, and yet their effectiveness has not been tested in developing countries. The cost effectiveness of interventions and their acceptability to the community remain unknown in the developing world. These issues need to be answered as we plan prevention and control in developing countries.

I disagree with Nantulya and Reich about the impact of corruption. This is not specific to traffic injuries or the main cause of the problem, and the chances of decreasing corruption are small. It has been argued that corruption may serve an inhibitory role as drivers end up paying police rather than paying fines. It is critical to focus on those factors that are both amenable to change and responsible for the largest share of the injury burden.

High numbers of crashes, multiple deaths per crash, and the high mortality of traffic injuries in the developing world make it important to prevent crashes.5-4 Although primary prevention would be most effective, interventions after the event must be considered. There are no structured assessments of national emergency medical systems; reports from single or selected facilities provide some sense of the inadequacies of acute care in the developing world but are unable to generalise.5-5 It is important to use systematic methods to assess pre-hospital and hospital care and plan interventions.

We are witnessing a different epidemiological transition in the developing world. Infectious diseases have not been conquered; chronic conditions are common; and the burden of injuries and violence is rising. Road traffic injuries are a risk not only to health but also to overall development. It is time for us to use evidence before we lose more lives.

References

  • 5-1.Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ. 2002;324:1139–1141. doi: 10.1136/bmj.324.7346.1139. . (11 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-2.Ghaffar A, Siddiqui S, Shahab S, Hyder A. National injury survey of Pakistan. Islamabad: Health Services Academy; 2001. [Google Scholar]
  • 5-3.Hyder AA, Morrow RH. Applying burden of disease methods in developing countries: a case study of Pakistan. Am J Public Health. 2000;90:1235. doi: 10.2105/ajph.90.8.1235. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-4.Hyder AA, Ghaffar A, Masud T. Motor vehicle crashes in Pakistan: the emerging epidemic. Injury Prevention. 2000;6:199. doi: 10.1136/ip.6.3.199. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-5.London JA, Mock CN, Quansah RE, Abantanga FA, Jurkovich GJ. Priorities for improving hospital-based trauma care in an African city. J Trauma. 2001;51:747–753. doi: 10.1097/00005373-200110000-00021. [DOI] [PubMed] [Google Scholar]
BMJ. 2002 Aug 3;325(7358):277.

Travel on roads 100 years ago was not as easy as nostalgia suggests

Irvine S L Loudon 1

Editor—When we see the appalling mortality from road traffic and the constant traffic jams of today it is easy to yearn for a return to horses and carriages, when travel was slower but safer and traffic jams unknown.6-1 In fact, such nostalgia would be wholly misplaced.

By the early 1900s there were over 100 000 public passenger vehicles and cabs, around half a million trade vehicles, and around half a million private carriages in Britain. In London and other large cities traffic was grinding to a halt because of traffic jams and stabling could not keep pace with the increasing number of horses; the towns of England had to deal with an estimated 10 million tonnes of horse manure a year. Horses and carriages were noisier than cars, not quieter, so that straw was placed on roads outside hospitals and the homes of the sick to muffle the rattle of iron wheels.

And what about safety? In England and Wales in 1905 there were 2424 road deaths from horses and vehicles—a rate of roughly 70 per million population. This is close to the mortality from road traffic crashes today. Of course the comparison is far from exact: we have no data on serious injuries in the early 1900s, and many people who died then from injuries would almost certainly have been saved today. But if we express road transport mortality in terms of road deaths per 1000 vehicles on the road, horses and carriages were undoubtedly a greater danger to the public in 1900 than were motor vehicles in 2000.6-2

Figure.

Figure

CORPORATION OF LONDON/HERITAGE IMAGES

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Horse driven transport was a public danger in the 1900s

The introduction of motor cars (slowly at first but rapidly from about 1905) was seen as the answer to the problems of horse driven transport. There would be no traffic jams because cars and lorries took up less road space than carriages and horse drawn wagons did. Cars would be faster but safer because they did not bolt or swerve unpredictably, were easier to control, and were better able to brake in an emergency; and cars produced no manure.

For people such as doctors the capital cost and running costs of a car were much lower than those for horse drawn transport. Moreover, cars enabled general practitioners to visit far more patients a day with much less exhaustion. No one in 1900 could have imagined the problems of road transport we have today.

References

  • 6-1. Editor's choice: Toxic complacency. BMJ 2002;324. (11 May.)
  • 6-2.Loudon I. Doctors and their transport, 1750-1914. Med Hist. 2001;45:185–206. [PMC free article] [PubMed] [Google Scholar]

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