Unintentional Injuries
Unintentional injuries, particularly road traffic injuries, are another component of the burden of noncommunicable disease.5 Worldwide, unintentional injuries accounted for 3.5 million deaths in 2001, of which more than 90 percent occurred in low- and middle-income countries and accounted for about 7 percent of all deaths in these countries. Of these, road traffic injuries accounted for about 34 percent of deaths from unintentional injuries. While men account for 66 percent of all deaths from unintentional injuries, they account for 73 percent of road and traffic injuries.
"Worldwide, unintentional injuries accounted for 3.5 million deaths in 2001, of which more than 90 percent occurred in low- and middle-income countries . . ."
Road traffic injuries increase when the volume of travel and the use of motorized vehicles, especially two-wheeled vehicles, increase. They also occur more frequently with increasing speed and in places where roads cannot handle the increasing volume and speed of traffic. Injuries also result when pedestrians must share roadways with motorized and nonmotorized vehicles.
"Brazil . . . achieved a 25 percent reduction in traffic fatalities between 1997 and 1998 . . ."
Road traffic injuries tend to increase as countries industrialize and grow economically. Later, as wealth increases and public institutions strengthen, countries invest in safety measures, but waiting for incomes to rise before implementing preventive measures results in the needless loss of millions of lives. Awareness of this historical pattern of rising traffic accidents may help low- and middle-income countries recognize the need to incorporate safer designs when building roads and highways and to promote safe driving.
Many effective interventions are available to reduce the risk of road traffic injuries. The first set of interventions manages exposure to risk. Examples include substituting safer modes of transportation for more dangerous ones and minimizing high-risk scenarios, for example, by raising the legal minimum age for driving a motorcycle. A second set of interventions involves constructing safer roads. This can include placing speed bumps to slow traffic, separating vehicular lanes from paths used by pedestrians and bicycles, constructing median barriers, providing passing lanes, and improving street lighting. A third set of interventions focuses on encouraging people to adopt safer behaviors. These include introducing legislation and enforcing it with respect to speed limits, blood alcohol levels, driving hours for commercial drivers, provision and use of seatbelts, and use of bicycle and motorcycle helmets along with providing education for pedestrians.
DCP2 assesses the cost-effectiveness of several different interventions aimed at reducing traffic accidents, including increased penalties for violating road safety regulations paired with enforcement, speed bumps, and requirements for using bicycle and motorcycle helmets along with enforcement.
". . . education has a much greater impact when it is part of a package that includes strong legislation and increased enforcement because the interventions reinforce one another."
Evidence for the effectiveness of stronger road safety laws is available from Brazil, where a package of three interventions that included legislative changes to increase penalties, broadcast of messages in the media to inform the public about the changes, and better enforcement achieved a 25 percent reduction in traffic fatalities between 1997 and 1998. Even though education about road safety alone can have an impact, studies in Malaysia and Thailand demonstrated that education has a much greater impact when it is part of a package that includes strong legislation and increased enforcement because the interventions reinforce one another.
Speed bumps installed at dangerous intersections or near pedestrian crossings are a simple way to reduce speed and the risk of accidents. Prior surveillance and data collection are required, because to be effective, speed bumps must be installed at the most dangerous locations. Ghana introduced speed bumps in hazardous places and reduced road traffic fatalities at these locations by more than 50 percent.
Bicycle helmets are extremely effective at preventing head injuries; motorcycle helmets are somewhat less so. In China, bicycle-related deaths kill 22 people per million inhabitants each year, while motorcycle accidents kill 16 people per million inhabitants. Case-control studies indicate that bicycle helmets can reduce injuries by 85 percent.
In modeling the cost-effectiveness of these interventions, DCP2 finds that all of them cost less than US$1,000 per DALY averted. For traffic safety legislation and enforcement, cost-effectiveness ranged from US$14 per DALY averted in South Asia to US$584 per DALY averted in Eastern Europe and Central Asia. Putting speed bumps in the 10 percent of intersections that are the most lethal in a city of 1 million would cost only US$2 per DALY averted in Latin America and the Caribbean to US$9 per DALY averted in East Asia and the Pacific. Increasing bicycle helmet use in China would cost US$107 per DALY averted, while increasing motorcycle helmet use would cost US$467 per DALY averted (table 5.1).
[Table .]
"Putting speed bumps in the 10 percent of intersections that are the most lethal in a city of 1 million would cost only US$2 per DALY averted in Latin America and the Caribbean to US$9 per DALY averted in East Asia and the Pacific."
Thus interventions to reduce the risk of traffic injuries are reasonably simple and cost-effective. Nonetheless, investments in such interventions are low. In 1998, Uganda spent only US$0.09 per capita and Pakistan US$0.07 per capita on road safety, or less than 1 percent of public spending on health in each country. Reviews of road safety initiatives found similar underinvestment in road safety in Benin, Cote d'Ivoire, Kenya, Tanzania, and Zimbabwe.
Implementing road safety measures does not require new knowledge: the risk factors are well known. Implementation often fails, however, because of conflicts between government ministries, inefficient civil services, and corruption. While the costs are not negligible, the interventions are cost-effective.
