杏吧原创

BETTER Late In This World, Than Early In The Next One, reads the peeling sign
painted high on a rock above a winding road on the way to the Vale of Kashmir.
Naturally, everyone ignores it: from the hardened local driver to the tentative
foreign traveller, they all assume it couldn鈥檛 happen to them.

Unfortunately, it can. In fact, road traffic accidents are reaching epidemic
proportions, especially in developing countries. In 1990, road traffic accidents
ranked ninth in the international league tables of causes of death and
disability, leading to almost as much loss of healthy life as tuberculosis. By
the year 2020, the world road traffic toll will have jumped to third place
worldwide, after clinical depression and coronary heart disease, and to second
place for developing countries, after clinical depression, according to a WHO
report that is due out next week.

The report, Investing in Health Research and Development, which sets
out to identify 鈥渂est buys鈥� for research to improve world health, predicts that
by 2020 traffic accidents will account for 鈥渙ne in every 20 lost years of
healthy life worldwide鈥�.

Poor countries already suffer more than their fair share of the world鈥檚
health problems, such as TB and AIDS, and in the future traffic smash-ups will
kill and maim disproportionately more people in the developing world than in the
industrialised one.

On the face of it, this sounds odd. In the West, there is, on average, one
motor vehicle for every two people, while in developing regions, there are only
three motor vehicles per hundred people. Nonetheless, according to the report,
in 1990 the cost in human health from traffic accidents in sub-Saharan Africa
alone was 鈥渇ully half as much as that in the established market economies鈥�. The
former socialist economies suffered an even heavier burden from traffic
accidents than the market economies. By 2020, the health burden of road traffic
accidents in low and middle-income countries is expected to far exceed that in
the West (see
Diagram).

On closer scrutiny, the forces behind the ascendancy of the traffic accident
as a cause of ill-health and death are not that difficult to fathom: an increase
in the proportion of people under 30鈥� the group most at risk from all
types of injuries; and increasing wealth in the developing world, reflected in
the number of vehicles on the roads. Combine those factors with the dearth of
emergency services, and you have a recipe for disaster.

As worrisome as that conclusion was, it was not the main stimulus for the WHO
team鈥檚 dramatic decision to recommend that preventing road traffic accidents be
a health priority. Instead, the team was motivated by a radical new way of
analysing health statistics which fundamentally challenges the links between
existing healthcare policy and the prospects for economic development in poor
countries.

Up to five years ago, the major obstacles to better health (and by
implication, development) in poor countries were usually quantified in terms of
the things that killed people outright. So international agencies such as the
WHO, which helps provide much of the healthcare for the developing world, put
the lion鈥檚 share of their efforts into targeting infectious diseases through
programmes such as vaccinations for children and pest control.

But those estimates had a major failing: they did not take into account
disability, even although feeding those who can no longer help their families to
survive or their community to prosper is arguably a far bigger burden for a
developing country than the loss of lives.

In the early 1990s, health economist Christopher Murray at Harvard University
in Cambridge, Massachusetts, proposed the Disability-Adjusted Life Year (DALY),
a unit that represents the number of healthy years of life lost due to death and
disability. DALYs are based on a calculation that takes into account how long a
person is disabled, the severity of the disability, and the age at death or the
onset of disability. For the purposes of this calculation, the researchers
assumed that the value of a human life peaks at 25 years old.

Using DALYs, the team headed by Murray and WHO medical demographer Alan Lopez
identified some major areas of neglect in the international health arena. Using
this technique, the chronic, unspectacular illnesses such as heart disease,
stroke, psychiatric, neurological and respiratory conditions, together with
injuries, of which road wrecks are the single largest cause, wreak at least as
much havoc worldwide as infectious diseases and other traditional high-priority
targets for healthcare.

The report goes so far as to suggest that the pandemic of injuries (other
causes besides traffic accidents include fire, poisoning, violent crime and war)
鈥渕ay be among the most neglected health problems of the late 20th century鈥�.

The report also predicts that when it comes to traffic accidents, things will
get very much worse before they get better. Mortality rates per vehicle are
greatest when vehicle use is increasing most rapidly in a country. As driving
skills, and the conditions of the roads and cars, improve, mortality rate per
vehicle wanes. Countries such as India鈥攚here between 1990 and 1993 the
number of four-wheeled vehicles increased by 23 per cent, to 4.5
million鈥攁re destined to become the world鈥檚 road accident hotspots.

And a quick glimpse down the streets of many of the major cities in Africa,
Asia and South America shows just what the WHO is already up against.
There, even the most casual observer sees cars, buses and trucks are often
driven with reckless abandon.

In 1981, Goff Jacobs and colleagues at the Transport Research Laboratory
based in Crowthorne, Berkshire, reported the results of a study in which they
sat and counted how many drivers broke the rules at major junctions and traffic
lights in Kingston, Jamaica, Bangkok, Ankara, Surabaya, Nairobi, Islamabad,
Rawalpindi and London.

The results confirmed the researchers鈥� first impressions. In six cities in
low and middle-income countries, up to 50 per cent of drivers who reached a red
light with no one in front of them jumped them compared with 6 per cent of the
London drivers.

What is more, the London drivers tended to jump the lights in the first five
seconds after the lights had changed, while in the other cities a quarter of the
drivers waited more than five seconds鈥攂y which time traffic is coming the
other way. (Such disregard for oncoming traffic was confirmed by another study
in Pakistan, where the researchers recorded 50 drivers going the wrong way down
dual carriageways.)

Rather than chase the drivers who had jumped the lights, Jacobs鈥檚 team used
questionnaires to survey the driving safety knowledge of people living around
each of the sets of traffic lights. The results showed that from London to
Rawalpindi, drivers have the same basic knowledge of what constitutes safe
driving, regardless of how well they choose to put it into practice on the
road.

Clearly, safety alone is not incentive enough to drive well. Although people
see accidents happen to others, they use their own track records to tell them if
they are safe鈥攁nd even when accidents are common, the odds are that they
will take many risks before they come a cropper. In the developing world, just
as in the developed one, people need to know that if they break the law of the
road there is a reasonable chance they will be caught. But effective enforcement
requires money and political will, both of which may be in short supply in the
developing countries.

Any country could stop the increase in road traffic accidents 鈥渂y increasing
the tax on alcohol, and decreasing the speed limit鈥�, says David Yach, an expert
on health promotion in developing countries at the WHO. But for too many
countries, preventing traffic accidents is a low priority. According to Yach,
some governments actually see a high accident rate 鈥渁s a sign of the country鈥檚
economic success鈥�.

Worse still, the responsibility for dealing with traffic accidents usually
falls between the local police, transport departments and the health sector,
removing any local incentive to reduce the number of accidents.

But what if there was a sudden change of heart, and governments and health
agencies decided to take action to slow the pandemic? Would the experience of
the industrialised nations translate readily to poorer nations? Probably
not.

In the past 15 years, for example, the number of deaths in Britain and some
parts of Western Europe has declined even though the number of vehicles is still
increasing (see 鈥淎 hundred years of carnage鈥�, August 10, p 14). The reasons
include safer cars and roads, better emergency services and changes in the
behaviour of both drivers and pedestrians. (In the US, however, the road traffic
accident rate dropped between 1986 and 1992, but is now creeping up again.)

鈥淭he traffic here doesn鈥檛 look the same,鈥� says Dinesh Mohan of the Indian
Institute of Technology in New Delhi, who studies road safety in low and
middle-income countries. In India, huge numbers of scooters and bikes clutter
the streets, and there are large numbers of buses, trucks, rickshaws and carts,
but relatively few cars. That translates into a completely different type of
road victim, says Mohan.

In New Delhi, for example, 75 per cent of people killed on the roads are
pedestrians, cyclists and motorcyclists, and only 5 per cent are in cars.

In India as a whole, 60 per cent are killed by buses and trucks. By contrast,
in Britain, 49 per cent of people killed on the road are in cars, and the vast
majority of pedestrians who die are killed by cars.

This means that safety measures such as seatbelts and airbags which work in
the West will have little effect on public health in developing countries. 鈥淚f
by magic car occupants were suddenly driving the best cars in Delhi we would
reduce our death rate by only 2 per cent,鈥� says Mohan.

Cutting costs

But Mohan is optimistic that effective and cheap ways of reducing the number
of traffic accidents can be found. 鈥淢alaysia brought in a law two years ago
ensuring all motorcycles use headlights in daytime鈥攁nd the accident rate
has been cut by 20 per cent,鈥� he says. While that kind of intervention required
effective policing, Mohan suggests other ways of reducing accidents that are
just as cheap, and would work with or without extra law enforcement. For
example, he says, 鈥減ainting all bikes yellow at source is a no-cost measure, but
it could cut deaths by 10 to 15 per cent [in India]鈥�.

And if the health costs can鈥檛 convince governments and health agencies to
adopt obvious preventative measures and to do the research to identify new ones,
then the dollar cost might. Road traffic accidents cost each country around 1
per cent of their GNP each year, counting in such factors as lost output, police
time, medical costs, and vehicle and street damage, says Jacobs. According to a
calculation by Jacobs and Angela Astrop of the Transport Research Laboratory and
colleagues at the transport consultancy Ross Silcock in Newcastle upon Tyne, the
global cost of traffic accidents in 1990 alone was around US$230 billion
(拢148 billion), of which the total cost to all developing countries is
US$36 billion.

That鈥檚 equivalent to almost forty times the WHO鈥檚 annual budget.

* * *

The newest demon

THERE may be no place on Earth left to discover, but there鈥檚 still plenty of
room for point-scoring among geographers, anthropologists and other field
researchers. Who works in the remotest region? Who lives most closely with the
indigenous people? Who has had the most 鈥渁uthentic鈥� overseas experience?

Looking back, I was after my share of that authenticity when I set off in the
summer of 1994 to study agricultural practices in Lampung Province on Sumatra. I
arrived with the usual set of preconceptions. I knew, for instance, to fear the
traveller鈥檚 demons of malaria, impure water, snakebites and social unrest.

When, on the other hand, at a language school on Java, the hazards of road
travel came up in conversation, we Westerners joked about it in the manner of
the Lonely Planet guide warnings about 鈥渃razy foreign drivers鈥�.

Ten months later, I was travelling to my research site in a crowded public
bus along the Trans-Sumatra Highway. The driver made one too many foolish
attempts to overtake, and the bus careened out of control, off the road, and
over and over and over.

Silence.

I remember climbing out of a window; picking my way through dead and injured
people. There were no telephones, but the local police arrived quickly, and I
was taken to the village clinic to wait among pools of other people鈥檚 blood.

At this point, my trip took a decidedly inauthentic turn. I paid a local
shopkeeper to drive me to a mission hospital, where I learnt that I had suffered
multiple bone fractures. A week later, I was flown back to England. As I write,
I am about to go into hospital for my third, and final, operation.

Do I regret going overseas for field work? No, I鈥檓 going back to Indonesia.
But I am choosing my next research site, and my mode of transport to and from
it, more carefully. Since my accident, I鈥檝e learnt that about one quarter of all
field researchers are involved in a traffic smash-up of some sort, often forcing
them to terminate their studies early. The traffic accident is my new demon.
Which, as it happens, is as authentic as you can get.

Sumatrans do not fear snakes (they step around them) or impure water (they
boil it). But I鈥檝e seen parents in Lampung fiercely argue about sending their
offspring to the city, weighing monetary gain against the risk of losing a child
on the Trans-Sumatra Highway.

Poverty sometimes forces them to take that risk. I took it because I didn鈥檛
know any better.

Becky Elmhirst is completing her PhD at Wye College, University
of London.