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Bereavement and the burden of injury
  1. Brian D Johnston
  1. Correspondence to Dr B D Johnston, ipeditor{at}

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By any measure, road traffic crashes extract a huge burden on societies. The World Health Organization has estimated that 1.2 million die and 50 million are injured annually as a result of road traffic crashes. Although harder to quantify,1 it is clear that a disproportionate burden of road traffic injury is borne in low-income and middle-income countries (LMICs),2 with dramatic increases paralleling economic development.3 Young people whose lives may have been saved by malaria eradication, TB treatment or HIV prevention campaigns are now dying as pedestrians and vehicle occupants on the roadways of the developing world.

There is a pressing need to quantify the burden of injury, and there is a variety of techniques in development to do so. Burden can be viewed from the individual’s perspective, from that of the family, the community, the health services sector or the economy as a whole. While mortality may be easier to measure, the real burden of injury is only grasped when we try to quantify disability, lost productivity and the costs of treatment to families and societies. Hardest to measure is the psychological toll of suffering and loss. This is a loss shared by the victims of road traffic crashes and a web of family, friends and neighbours that encircles each.

In this issue, Sullivan and colleagues present a novel study linking road traffic mortality data from England & Wales to census records in order to estimate the proportion of the population that has lost a close family member to a road traffic crash (see page 364).4 The authors conclude that, on average, a person dying in a road traffic crash could be linked to 3.6 surviving close family members. These bereaved parents, children and spouses were 1.1% of the population of England & Wales in 2005. Using these data, researchers may now be able to add another layer to estimates of the true societal costs of injury on the roads.

A study of this nature is, of course, exploratory and limited by the assumptions necessary. As the authors note, road traffic crashes follow a social gradient; estimates about family size and actuarial survival based on population data may not be directly applicable to the subset of families most likely touched by these events. In addition, and for the same reasons, this estimate is not likely to be generalisable to populations in LMICs.

The authors conclude that their results “imply a greater public health burden of road traffic crashes than previously estimated.” While this is quite likely true, the actual quantification of that burden remains elusive. To understand the effects of this exposure, we would need to measure its effect on quality of life among bereaved survivors. The results may be more complex than expected: some people experience positive “adversarial growth” in response to grief and trauma.5 Although no one would choose this state, we cannot assume that all bereavement is a net personal or societal negative.

The study may also understate the impact of these losses. Because of the nature of the data used, the authors needed to make assumptions about the effect of loss on the basis of familial proximity. But people are embedded in social networks that reach beyond immediate family members—in many cases, ties (and impact) could be stronger with friends than with surviving family members. The role of positive and negative effects rippling through social networks has recently been ingeniously investigated using the Framingham Heart Study population.6 To really quantify and illustrate the impact of bereavement on extended social networks, a similar, longitudinal analysis needs to be pursued. The results of the study of Sullivan et al suggest that the exposure of interest—loss of a close friend or relative in a traffic crash—is anything but rare.

And that, I think, is the real value in this paper. In some sense, we do not need to add even more to our quantification of the burden of road traffic crash fatalities: by any measure, it is huge and likely to grow. What we need is the direction and passion to channel this pain into constructive research, advocacy and policy promotion. The results of this study are not only a measure of impact or burden, but also the identification of a constituency.

Victims and survivors of road traffic crashes are “the primary stakeholders, the natural leaders, in the battle against road injuries and fatalities.”7 Organisations, such as RoadPeace in the UK ( mobilise this community to provide information and support for road victims and to advocate for judicial reform in support of the rights of victims. The potential to engage the passion of these advocates in support of prevention efforts is only beginning to be recognised.

It is time for the prevention research community to reach out to victims’ advocates as our natural partners. They can help us shape meaningful research agendas and work to ensure that research results are seen and acknowledged by those in positions to implement our recommendations. November 15 was this year’s “World Day of Remembrance for Road Traffic Victims” ( This was followed by the “First Global Ministerial Conference on Road Safety”, in Moscow. Perhaps these events will give us the impetus to reach out to the bereaved to form or reinvigorate alliances in support of a common goal.


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  • Competing interests None.

  • Provenance and peer review Commissioned; not externally peer reviewed.

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