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M Peden, R Scurfield, D Sleet, D Mohan, A A Hyder, E Jarawan, C Mathers. (Swiss Fr 30/US $27; in developing countries Swiss Fr 15.) Geneva: World Health Organization, 2004. ISBN 92-4-156260-9.
This impressive report aims to raise awareness about the extent of road traffic collisions globally, to draw attention to their preventability, and to call for a coordinated partnership approach to addressing the problem. In its five chapters it gives in turn a comprehensive catalogue of the fundamentals of road safety, the impact of road trauma across the world, the key factors contributing to crashes and consequential injuries, successful interventions which have been applied (mainly in high income countries) to reduce the problem, with the final chapter containing conclusions and recommendations.
The report points out that over 3000 lives are lost daily to road traffic collisions. While a decrease in road deaths of some 30% is forecast in high income countries (HICs), projected trends in low and middle income countries (LMICs) foreshadow a huge increase in road crash mortality between 2000 and 2020. Hence the report quickly identifies that the priority globally should be effective interventions in LMICs.
In chapter 1 on fundamentals there is a recognition that “technology transfer from high-income to low-income countries needs to fit local conditions and should address research-based local needs”. However chapter 4 on interventions, and to some extent the recommendations, seem to lose sight of this message and dwell upon technologies which have been evaluated only in HICs, as well as new strategies which could be quite unsuitable for LMICs. There is an impression that the HICs have got it right in terms of managing road trauma, and that LMICs should follow the interventions and principles developed in HICs (albeit adapted to local conditions and constraints).
There are, however, at least two key areas where HICs did not get it right during the last 50–60 years when road transport became both more available and cheaper and cheaper for the general population and industry. The first is that we have been reluctant to manage exposure to risk. As noted in chapter 4, exposure management is the least used of all road safety intervention strategies. This is because, in HICs, there has been a fundamental belief in the high value of personal motorised mobility, covering distance in the minimum time consistent with comfort. Thus constraints on exposure, and speed, have been given low priority compared to interventions which collectively could be seen as “patching up” the factors causing the crash and injury consequences of exposure and the kinetic energy derived from speed. It may not be too late for LMICs to challenge the unbridled growth in motorised transport, or at least to give much higher priority to managing exposure through land use policies and transport strategies in general (for example, separating road transport modes operating with disparate speeds and masses; discouraging unnecessary trips; and encouraging the use of safer and non-road travel modes). HICs have begun to challenge their own values in this area, as the costs of road trauma are valued at much higher levels than in the past. HICs should encourage LMICs not to make the same mistakes, by fully recognising the real costs of road trauma against the intangible values of some elements of motorised transport, especially personal mobility.
The second key area where HICs did not get it right is that investment in road safety research and development has been relatively small in comparison with other types of health loss (infectious diseases, etc). The report identifies that funding for interventions, even in the HICs most active in road safety, has been scarce. Road safety efforts in HICs have failed to match the severity of the problem and continue to do so. There are good historical reasons why this was the case, including belief in the accidental nature of the problem and fatalistic acceptance of its inevitability, but the situation has changed in HICs. LMICs need to really believe that the problem is preventable, that it is worth the substantial investment in research and research based action programs, and that successful interventions from HICs cannot simply be transferred to each LMIC without research and development in local conditions. It needs to be recognized that this investment in prevention will need to be substantial, but it is at least as justified as other health program investments because of the enormous and increasing costs of road trauma in each LMIC.
The report highlights the road safety model of Victoria, Australia as a good example of a cooperative partnership which led to substantial road safety benefits. There were attempts to transfer the Victorian model of strong traffic law enforcement supported by high profile mass media publicity to KwaZulu-Natal (KZN) province in South Africa during the late 1990s. There was little effort to adapt the successful Victorian interventions to South African conditions and constraints. Perhaps the advisers (of which I was one) misinterpreted KZN as ready for an HIC-type road safety program. The initial years of Project Victoria (later renamed “Asiphephe”) in KZN saw a 31% reduction in road trauma (deaths and injuries) between 1996 and 1998, but by 2001 road trauma had returned to 1995 levels. Perhaps one of the reasons the government and population of KZN lost their commitment to Project Victoria (J Bodinnar, personal communication) was that they saw it as essentially an HIC approach, not adapted or suitable for local conditions or beliefs.
This is not to suggest that partnerships of public and private agencies are not a key factor in coordinating the range of organisations which would have responsibilities and resources for road safety in a typical LMIC. The failure in KZN was essentially due to the lack of investment in research and development in local conditions to provide the background for the transfer of principles, and perhaps successful interventions, from an HIC. Partnerships, and shared responsibility for the road safety “system”, are key elements of Sweden’s “Vision Zero” strategy which is being seriously considered in HICs to guide their future directions. Perhaps many LMICs would find the ultimate goal of zero road trauma intimidatory and unrealistic given their current resources. The target should not distract attention in either LMICs or HICs away from the systematic and cooperative aspects of the Swedish strategy.
Notwithstanding these concerns about the LMICs making the same mistakes as the HICs if they follow them uncritically, the report is an excellent overview of what has been effective in reducing road trauma in HICs. The report also provides the basis for fundamental strategic thinking in the field, armed with which many LMICs may be able to reduce more quickly or even avoid their burgeoning road trauma problems.
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