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Collision course. Trafficcrashes such as this one inBangkok, Thailand, resultedin 1.2 million deaths world-wide in 2002, with as muchas 90% of those occurringin low- and middle-incomecountries.

E ven though traffic-related death rates in the United States andother high-income countries have been declining steadily forseveral decades, death tolls on the roadways of the world’s poor-

er countries have been skyrocketing. The number of motorized vehicleshas been escalating in developing countries, where roads (often poorlybuilt to begin with) are shared by pedestrians, animal-driven carts, rick-shaws, and bicycles, and traffic safety laws are weak or inadequatelyenforced. The result—an alarming increase in death and injury on theroadways of the world’s poorer nations—is now attracting the attentionof international organizations as a major public health problem.

In recognition of this global problem, the World Health Organization(WHO) designated “road safety” as the theme of World Health Day 2004,held April 7. The same day, the WHO and the World Bank released theWorld Report on Road Traffic Injury Prevention, an exhaustive examinationof the global problem and potential solutions, culminating in a call foraction at both the national and international levels. A week later, theUnited Nations (UN) General Assembly devoted a plenary session to theglobal crisis in road safety for the first time in its history, discussing,among other things, how to implement the report. Then, in May 2004, atthe WHO 57th World Health Assembly meeting in Geneva, delegatesaccepted resolution EB113.R3, “Road Safety and Health,” calling for theWHO to act as a coordinator on road safety issues within the UN system,working in close collaboration with UN regional commissions.

As the WHO/World Bank report makes clear, the increase in trafficdeaths and injuries in the world’s poorer nations has been evident foryears: global traffic deaths have risen from approximately 990,000 peryear in 1990 to nearly 1.2 million per year in 2002, with 85–90% ofthese deaths occurring in low- and middle-income countries. Citing astudy that examined changes in traffic fatality rates in various countriesbetween 1975 and 1998, the report noted that during that time spanCanada’s road fatality rates declined by 63.4%, Sweden’s by 58.3%, andthose in the United States by 27.2%; the reasons for these declines havebeen multifold. At the same time, traffic fatalities increased by 237.1%in Colombia, by 243.0% in China, and by 383.8% in Botswana.

Manslaughter:The Global Epidemicof Traffic Deaths

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Furthermore, the report predicts that ifnothing is done to stop the trend, it willrapidly escalate. By 2020, predict the WHOand the World Bank, if appropriate actionsare not taken, overall global traffic deathswill increase by 67%; an 83% increase inpoorer countries will offset a projected 30%decrease in high-income countries. In 1990,road traffic injuries were the ninth leadingcontributor to the global burden of disease,according to the report. Without appropriateaction, by 2020 road injuries are predicted tobe the third leading contributor.

Many physicians and public health pro-fessionals have been sounding the alarm foryears and voicing frustration over the lack ofinternational response.Samuel N. Forjuoh, aGhanaian-born physi-cian and professor offamily and communityhealth at Texas A&MUniversity College ofMedicine, believes thatpart of the problem hasbeen that road crashesare simply not seen inthe same way as diseases.“For a long time, injurieswere considered haphaz-ard events, acts of God,”he says. “There was abelief that there wasnothing you could doabout them.”

Another reason isthat car crashes occurone at a time, says MarkL. Rosenberg, executivedirector of the U.S.-based nonprofit TaskForce for Child Survivaland Development and former director of theCenters for Disease Control and Preven-tion’s (CDC) National Center for InjuryPrevention and Control. “You have threethousand people a day dying in car crashes,”he explains. “If you had three thousand peo-ple a day dying in one building that collapsesor in a few big airplane crashes, it would getmuch bigger headlines.”

Still another reason is a sense of fatalismon the part of some observers. Rosenbergexplains, “People say, ‘Oh, motor vehicledeaths are just what happens when you startdevelopment in a country. You build roads,you bring in cars, and this is inevitable.’ Butnothing could be further from the truth. It’snot inevitable; [these deaths] are completelypredictable and preventable.”

A Perfect PlagueRosenberg borrows from the popular bookand movie The Perfect Storm, which told

how a rare combination of meteorologicalforces resulted in a monstrously destructiveforce, to describe the escalation in trafficdeaths and injuries in poorer countries.“More and more motorized vehicles arebeing added to roadways that are inade-quate,” he says. “You have these mixes ofvulnerable pedestrians and motorized trafficon main roads with no center barriers. Theroads are poorly marked, and they go rightthrough villages. You have situations wherepeople don’t know how to drive, they don’tobey laws, and even if you have laws, they’renot enforced. So you have this lethal mix,and into this we are adding more and morecars, accelerating the rate of injury and death

as these cars are added. You have the ‘perfectplague.’” Rosenberg says this plague is alsoperfectly predictable because “we know howquickly the motor vehicle manufacturers areplanning to increase their production inthese ripest of markets.”

According to the World Report, a largeportion of the motor vehicle increase inpoorer countries has been in the number ofmotorcycles, minibuses, and trucks. Andtheir increased presence on the roadways ofthose countries has been overwhelming inmany instances. Since 1990, the number ofmotor vehicles in China, for instance, hasquadrupled to more than 55 million. InThailand, the number of motor vehiclesnearly quadrupled between 1987 and 1997.

The new and growing mix of two-wheeled motor vehicles, larger multi-passen-ger vehicles, traditional wheeled vehicles,and pedestrians all often using the sameroadways has created patterns of traffic

death and injury that are much differentfrom those in high-income countries. TheWHO/World Bank report points out thatwhile most of the people who die as theresult of traffic crashes in the developedworld are passengers in vehicles, trafficcrashes in poorer countries are more likelyto involve pedestrians and motorcyclists.The report states that between 1977 and1994 in the city of Nairobi, for instance,64% of traffic fatalities were pedestrians.

Another characteristic of poorer coun-tries is that crashes are far more likely toresult in deaths than crashes in high-incomecountries. Rosenberg explains, “The victims[in developing nations] are much, much

more vulnerable: they arepedestrians or bike riderswith nothing to protectthem.” Further, saysMichael R. Reich, a pro-fessor of internationalhealth policy at theHarvard School of Pub-lic Health, the typicalU.S. car crash involvesthe driver running into atree or into another vehi-cle. In contrast, crashes inpoor countries typicallyinvolve pedestrians orpeople in poorly main-tained multi-passengervehicles, such as mini-buses crammed with 20–30 people and no seat-belts. According to“Road Traffic Injuries inDeveloping Countries:Strategies for Preventionand Control,” a resourcepaper by Reich and

Harvard colleague Vinand Nantulya, 10,000U.S. crashes result in 66 deaths; but inKenya, the death rate per 10,000 crashes hasbeen as high as 1,786, and in Vietnam it’sreached 3,181.

A variety of other factors lend to thetroubling numbers in poor countries.Forjuoh believes that low literacy rates play arole because many drivers can’t understandroad signs. David Sleet, associate director forscience at the CDC National Center forInjury Prevention and Control and a coedi-tor of the WHO/World Bank report, con-tends that many pedestrians in developingcountries have never driven a car and don’tunderstand the basic “rules of the road” gov-erning motorists. They also are inexperi-enced in judging oncoming vehicle speedsand stopping distances.

Yet another factor exacerbating the trafficfatality trend in poor countries is the short-age—and often the absence altogether—of

Street fight. Scenes like this one of congested vehicle and pedestrian traffic in Shanghai arean everyday occurrence worldwide as humans and machines compete for use of the roads.

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emergency medical response. Charles N.Mock, a surgeon and epidemiologist at theUniversity of Washington’s HarborviewInjury Prevention and Research Center inSeattle, has spent time in Ghana and hasworked with groups in Mexico, Vietnam,and India to improve systems of emergencymedical care in those nations. He pointsout that while organizations such asDoctors Without Borders and theInternational Committee of the Red Crosscan provide physicians on episodic bases,such as in response to earthquakes andwars, there really isn’t an available pool ofdoctors that poor countries can call upon toprovide sustained improvement of emer-gency medical response.

Mock admits that the situation maysound dismal, at least at the moment. “Butto sit back and say nothing can be donebecause of the economic problems isn’tfruitful,” he says. “A tremendous amountcan be accomplished. Mortality rates can bedecreased, medically preventable death canbe prevented, disabilities can be prevented,and part of the discrepancies in outcomebetween rich and poor countries can beeliminated by improving organization andplanning for trauma care services withoutnecessarily spending very much more.”

Sensible Responses to the EpidemicMock has been intimately involved in aproject, cosponsored by the WHO and theInternational Society of Surgery, to formu-late a low-cost model that nearly everycountry can implement to greatly improveemergency trauma care. The model identi-fies specific essential elements that are nec-essary for trauma care—human resources,equipment, supplies—for purposes of aid-ing countries in performing needs assess-ments. Mock has spent this year at WHOheadquarters in Geneva working on theplan’s implementation.

Other organizations are embarking onother programs. In 1999, the World Bankcreated an organization called the GlobalRoad Safety Partnership (GRSP), an interna-tional collaboration between business, civilsociety, and government organizations toimprove road safety conditions around theworld. GRSP is currently involved in a vari-ety of projects in 10 countries. For example,in Bangalore, India, GRSP has created part-nerships to launch an anti–drunk drivingcampaign and to improve roadways in high-traffic areas to enhance safety. In addition,the CDC has been working with the min-istries of health and other groups in Mexico,Colombia, and El Salvador to devise creativenew ways to reduce injuries to pedestrians,bicyclists, and motor vehicle occupants. Andthe World Bank is providing $25 million for

the Vietnam Road Safety Project with a goalof achieving continuous, long-term reduc-tion of traffic crashes in that country.

Sleet also points to other local strategiesin place that reduce the likelihood of crash-es. Some cities are pursuing better land usemanagement for optimized traffic flow,and promoting alternative transportationmodes such as mass transit. Other strate-gies target drunk driving and speedingbehaviors, and promote the use of cyclehelmets, seat belts, and other protectivedevices. Still others seek to separate non-motorized traffic (such as pedestrians andcyclists) from motorized traffic.

While these efforts are noteworthy,reducing the epidemic of traffic deaths andinjuries around the globe will be impossibleunless countries adopt the political will to doso on their own, states the World Report. Inthe United States, for instance, the will to dosomething about the nation’s ever-growinghighway death tolls began in the 1960s.Ralph Nader’s 1965 book Unsafe at AnySpeed detailed the minimal attention beingpaid to safety in the auto industry, and thenext year President Lyndon Johnson signedtwo bills to create stricter safety standards incars and roadways. The combination of safercars and roadways coupled with successfulefforts to promote safer behaviors (such asuse of seat belts and “designated drivers”) hasbeen credited with bringing about ever-diminishing rates of traffic death and injuryon U.S. roadways.

While the United States and other devel-oped nations possess the resources to investin safer cars, better roadways, and improvedemergency medical response, an obviousquestion is, how can poorer countriesachieve improvements as well? According toSleet and others who are knowledgeableabout traffic safety, the answer is by adoptingand adapting effective strategies, and bydeveloping local evidence-based solutions.

In Colombia, for instance, a concertedeffort to reduce traffic deaths in Bogotá andother cities has proven to be extremely suc-cessful. In 1995, Colombia first required thatall vehicle owners must be insured and theninstituted a 3% levy on all vehicle insurancepolicies, earmarking that money for a “roadaccident prevention fund.” Colombia hadrecorded its all-time record high for trafficfatalities—7,874—in 1995, according to areport in the March–June 2003 issue ofInjury Control and Safety Promotion by ateam led by Deysi Yasmin Rodríguez, anengineer with the Research Program onTraffic and Transport at the NationalUniversity of Colombia. By 2002, thenation’s traffic deaths had dropped to 6,063.

In Bogotá, the nation’s capital andbiggest city with 7 million inhabitants, a

series of mayors have instituted severalprograms to reduce traffic deaths andinjury, such as closing bars at 1 a.m. insteadof 3 a.m. and urging people to drink inmoderation if they’re driving, reducing thenumber of cars during rush hour by encour-aging workers to find alternative means oftransportation (such as carpooling), andreclaiming sidewalks for pedestrians by pro-hibiting the old practice of allowing driversto park their cars there. The outcome hasbeen striking: the number of traffic fatalitiesin Bogotá declined from 1,387 in 1995 to697 in 2002.

According to Rodríguez, the nationalMinistry of Transport is now finishing plansto broaden the Bogotá approach to the entirenation. “Among the main strategies we haveis the generation of a new culture about roadsafety in the country,” says Rodríguez, who isa consultant on the project.

Still, even though Colombia has madegreat progress, Rodríguez sees distinct obsta-cles ahead. There are “few economic andhuman resources capable of supporting theprograms in a continuous way,” she says.

The WHO/World Bank report includesa series of recommendations to reduce globaltraffic deaths and injuries. It strongly advo-cates the identification of a lead agency inevery nation to be in charge of traffic safety.It then recommends the routine collection oftraffic crash and injury data to document themagnitude of the problem and the key riskfactors. It goes on to recommend the formu-lation of a national plan of action in everycountry, together with implementation ofthe plan using science-based interventions.

But as Rosenberg emphasizes, there areserious impediments to the creation of goodtraffic safety plans in poor countries. “Wesay, ‘Form a coordinating agency in yourcountry,’ but we’ve got to get them theresources to do it,” he says. “Each step takesmoney, and right now they don’t have theresources.”

To Rosenberg, the problem is akin towhere AIDS/HIV stood 20 years ago. “Wetended to the problem just within our ownborders and completely ignored what washappening in sub-Saharan Africa until it wastoo late. We need to learn from that epidem-ic and apply it to this one, because with thisone we have a chance to prevent it,” he says.“When AIDS came twenty years ago therewere no good means to prevent it or treat it,and not even a good test to diagnose it. Butwith traffic safety there are many very clearand effective things we can do. If we let thisone get out of control, we will have noexcuse. We will have failed in our responsi-bility to become good ancestors.”

Richard Dahl