JAMA Forum: Traffic Injuries and Deaths: A Public Health Problem We Can Solve

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Every 30 seconds,  someone dies in a road traffic crash, and 10 people are seriously injured. Road traffic mortality is the fifth leading cause of death in the world, resulting in 1.25 million deaths globally in 2013. For young people aged 15 to 29 years, at the peak of their productive lives, traffic crashes are the leading cause of death. This crushing burden of injury, disability, and death falls disproportionately on low- and middle-income countries and the most vulnerable road users, such as motorcyclists, bicyclists, pedestrians. Although these countries are home to less than half the world’s vehicles, these countries account for 90% of the global toll of traffic deaths.

We call these events “accidents,” suggesting they are not amenable to prevention and amelioration. Even the United Nations’ Sustainable Development Goals (target 3.6), which aims to halve global traffic deaths and injuries, call them accidents. However, traffic crashes are not accidents; they’re preventable. A large body of evidence demonstrates public health interventions work, and they have worked with dramatic effect in reducing fatalities and injuries in most high-income countries.

Low- and Middle-Income Countries Bear the Burden

It is small wonder why low- and middle-income countries suffer so badly from traffic crashes. Travel to virtually any urban area in a poor country to understand why. Streets are densely packed with a dizzying array of cars, buses, trucks, motorbikes, bicycles, pedestrians, and even animals. Roads are unlit, having few, if any barriers dividing traffic. Commuters pile into rickety truck beds, ride several deep on motorbikes, and perch on bicycle handlebars—without the protection of seatbelts, child restraints, or helmets.

Beyond injuries, disabilities, and deaths, traffic crashes cause massive economic and social harm. In low- and middle-income countries, the cost of crashes is estimated at $65 billion to 100 billion, which exceeds the total amount of developmental assistance they receive. Globally, road traffic crashes result in the loss of 3% of gross domestic product (GDP), but increase up to 5% of GDP in low- and middle-income countries. If a main breadwinner is disabled or dies, it has cascading consequences, trapping families in an enduring cycle of poverty. Beyond families, a poor safety record can dampen private investment, with multinational companies concerned about employee safety and efficient distribution of products.

United States Lags

High-income countries have dramatically reduced traffic deaths, despite major increases in the number of vehicles on the road. The United States, as the world’s richest nation, should be in the lead. Although driving is much safer in America than in low- and middle-income countries, it is trending in the wrong direction: 2015 saw a 7.2% increase in traffic deaths from the previous year—the largest rise in nearly a half century. Provisional data from 2016 indicate an additional 8% increase in fatalities over the same period in 2015.

The United States is a unique outlier among high-income countries. Between 1972 to 2011, the United States had lower declines in traffic deaths than 25 peer countries. During this period, for example, US deaths declined by 41%, whereas those in the Netherlands declined by 81%. If US fatalities had declined by 81%, there would have been 22 000 fewer road deaths in 2011. In the 1990s, it was safer to drive in the United States than in Canada and Australia—but it’s not today. Road users are now 40% more likely to die in the United States than in Canada or Australia.

The direct economic costs of motor vehicle crashes totaled $242 billion in 2010, representing 1.6% of the US GDP. When quality-of-life valuation was considered, the total loss approached 6% of the GDP. Each traffic crash sets off a domino effect of costs: disabled vehicles block the road, which delays drivers getting to work; emergency workers respond; injured road users may require hospitalization and often ongoing treatment such as physical therapy, with lost work days. The vehicle requires repair, and insurance and legal apparatus are triggered.

Language and Myths

Word choices matter: By framing preventable traffic deaths and injuries as “accidents,” society engages in a collective shrug, concluding it is not a public health priority. Another myth is that “good” drivers can avoid these accidents. When asked, the public views plane travel as risker than car travel. The reverse is true.

But viewing traffic fatalities in these ways would be a mistake. Evidence-backed policy interventions can meaningfully reduce traffic injuries and deaths. It is true that human behavior matters. The World Health Organization (WHO) identifies 5 behavioral risk factors: speed, driving under the influence of alcohol, and inadequate use of helmets, seat belts, and child restraints. To this list, add distracted driving: using electronic devices while driving for activities such as calling, texting, watching video, and searching the Internet significantly increases the risk of a crash. But even behavioral risks are amenable to change using policy and technology. Laws prohibiting risk behaviors work well, especially if enforced—what WHO calls “best practice” legislation. Still, the most effective public health approaches alter the built environment: safer roads, vehicles, and postcrash responses.

Consider these examples. Legislation in Vietnam requiring motorcycle helmets saw an immediate and dramatic reduction of head injuries. Sweden’s “Vision Zero” targeted high speeds as the major cause of serious injuries and deaths. While lowering the speed limit to 20 mph, it did not rely on enforcement alone. Instead, the country built traffic circles, speed bumps, and other traffic “calming” interventions, with great effect. Over the last 2 decades, Stockholm reduced pedestrian deaths by 31% and overall traffic deaths by 45%. Sweden had 7 traffic fatalities per 100 000 people when Vision Zero launched. Today there are fewer than 3 traffic deaths per 100 000 people, despite a significant increase in the volume of traffic.

Vehicles can also be made safer. Passive restraints, front-end crumple zones, energy-absorbing steering columns, side door beams, roof strength, and antilock brakes save lives. Emerging technologies will reduce or eliminate the behavioral risks. For example, inclement weather (snow, rain, fog, ice) significantly deteriorates road safety and capacity, resulting in 1.5 million vehicular crashes annually in the United States. In the future, “smart” cars are expected to detect and respond to road weather conditions. Crash avoidance systems in autonomous vehicles may one day eliminate human driving errors.

The solutions require an intersectoral-multidisciplinary approach, backed by sufficient resources, including urban planning, transportation, health systems, surveillance, and law enforcement. Governments that have adopted a national road safety strategy, led by a designated lead agency to coordinate the response, have fared particularly well.

In 2010, the United Nations General Assembly adopted the Decade of Action for Road Safety, supported by a WHO Action Plan, but there is precious little research, funding, or action. Interventions can work, but it won’t be easy, especially in resource-poor countries without strong institutions and the rule of law. With an explosion of motor vehicles—resulting dual hazards of traffic and pollution-related deaths—failure to act will have devastating social and economic consequences.

These public health hazards are preventable but not until governments and the international community allocate the resources, implement the policies, and deploy the technologies that research shows will work. And the place to start is by recognizing that these events are not accidents but rather the predictable result of our collective failure to take road safety seriously.


About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).  (Image: Georgetown University Law Center)


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Categories: Health Policy, Injury Prevention & Control, Public Health, The JAMA Forum

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