Road traffic injury prevention

“A 63-year-old woman was in critical condition last night after being struck by a car... as she crossed Sherbrooke St E shortly after 4 pm... It appears the pedestrian and motorist both had a green light, said Constable Lapointe. The driver was turning left when she struck the pedestrian. Police did not believe alcohol or excessive speed were factors in the accident.”

Take this all too common news item and multiply by some large number and you have the daily world total of pedestrian injuries or deaths. Add to this car occupants and bicyclists and you reach the grand total of road traffic deaths, which accounts for 20% of all injury deaths.

Now, after years of preoccupation with other issues, the World Health Organization (with the World Bank) has turned its attention to what is arguably the largest and most preventable of all modern epidemics—road crashes.¹ It matters greatly that the WHO has produced a report on road traffic injury prevention, particularly applicable to those in low income countries. However hamstrung the WHO may be by its need to be politically sensitive, it has enormous influence and can legitimise the issue of injury from road crashes as few other bodies can.

Some may ask, Why the WHO? Isn't road safety the responsibility of transport—or justice, public security, police enforcement, engineering, licensing? Indeed, in many countries, this is precisely how it is regarded—as a problem for a mélange of bodies. (Even in the WHO report “health” is one among many “intersectoral” players.) Yet road safety is above all a health issue because crash victims are killed and maimed. Nothing could be simpler: if road safety is left only to other agencies, and public health agencies refuse (or are forbidden) to speak out, thousands of preventable deaths will follow.

The WHO report issues a powerful challenge that no country can afford to ignore. A death is a death is a death, whether caused by an organism or two tonnes of metal and steel. Health departments everywhere, especially in low income countries, must accept the challenge. There is no reason for perplexity and no lack of specifics about what must be done. The WHO report is exemplary: comprehensive, lucid, detailed, and even passionate.

As too often, however, what happens now may hinge on political considerations which, in turn, depend on who accepts responsibility. The choice isn't between a health agency and any other body. Agencies must work together, but as the report concludes, there must be a “lead agency” and logic demands that it should be public health. Health spokespersons might bring the moral force needed to persuade governments intent on satisfying the motoring lobby that damaged skulls also need to be taken into consideration.

But give credit where it is due. The decline in road deaths in most Western countries over the past 30 years is striking (albeit uneven). For this, transport deserves the kudos, and health can accept little credit, except, perhaps, trauma specialists. But it is also evident how much more could—and should—have been done: controls on speed and alcohol, red light cameras, road design and construction, and vehicle design—the list is long and, sadly, far less applicable to low income countries. One common explanation for failure to fully implement such measures is competing responsibilities.

How far have we come? The human interest story in my morning paper says much about why the WHO has declared road safety its focus for 2004. Ten years ago the paper would probably have ignored this incident, or if it were published it would not have mentioned speed or alcohol as possible causes. The fact that such events are still regarded as “accidents”—that is, not preventable —is disappointing.² Yet most drivers in Montreal would be surprised to learn that pedestrians always have the right of way on a green light and shocked if police actually penalised them for infringing on a pedestrian crossing. Thus, legislation and its enforcement receive an appropriately prominent place in the WHO document.

Experts continue to disagree over the relative importance of the three Es of prevention: education, engineering, and enforcement. For example, Evans is highly critical of litigation and vehicle design improvements and favours changing the behaviour of drivers as the strategy to reverse America's sinking ranking in traffic fatalities.³ In contrast, Vernick and Teret attribute the reduction in road fatalities to “a combination of improving vehicle, roadway, and driver safety.”⁴ McKay wants priority to be given to using restraints and stopping drink-driving.⁵ My conclusion, supported by much of the data in the WHO report, is that the balance tilts toward the Vernick-Teret argument for making cars and the environment safer, and one way to do so (as well as to change driver behaviour) is through legislation and litigation.⁶

The most radical aspect of the WHO report is its emphasis on a systems approach “to identify and rectify the major sources of error or design weakness that contribute to fatal and severe crashes.” This places less responsibility on the victim and more on the architects of the transportation system. We know road deaths can be greatly reduced through improving vehicle and road design, although the car industry may resist this in favour of style and speed. But if the WHO report is read as carefully as it deserves to be the much needed steps are certain to be taken more swiftly and effectively.