In 2004, when the World Health Organization (WHO) reported on road traffic tragedy globally, there was particular emphasis on the perceived relationship between public health and road safety. It may have seemed to the leaders at the WHO that the answer to reducing road traffic fatalities, and specifically those in low- and middle-income countries (LMICs) where 90% of the carnage occurs, would reside mainly in public health solutions of changing driver and pedestrian behavior. It appears they also believed these solutions led to the success in reversing the increases in fatalities in rich nations 40 years ago.
Now, looking at essentially the same totals of traffic tragedy more than a decade after the WHO was tasked by the United Nations (UN) with reducing this tragedy, it is clear that the public health approach is not materially decreasing road traffic fatalities. It is also important to understand that the public health approach is not what finally worked in the rich world to reverse increases in these fatalities.
Public Health and Road Safety
Since its founding in 1948, the WHO has taken a public health view on global issues. In 1962, a paper by L.G. Norton, published by the WHO, and further writings by Dr. William Haddon Jr., put forth a philosophy that road safety was a public health issue. Road traffic injury was made equivalent to disease and the concept of epidemiology the solution for it. It was aimed at driver and pedestrian behavior. The typical public health actions of passing laws and regulations, processing and enforcing them and urging behavior change seemed to fit. In countering disease, laws, regulations and proper behavior work. However, in dealing with road safety, there is much more to consider.
In that same year, 1962, road traffic fatalities in America and Western Europe began inexorable annual increases. The American Highway Safety Act of 1966, a grand, well-publicized effort to stem the increases, was packed with behaviorist and regulatory provisions. By federalizing the standardization of these traditional remedies, increases in fatalities were to be curtailed. However, by 1971 fatalities were still rising.
As congressional leaders in the United States began reconsidering highway safety policy, the Federal Highway Administration produced important new data. They learned that two-thirds of American fatalities happened on rural roads. When they combined the fatality data by road system with time of day of the fatal crashes and to the estimates of travel by road system, it appeared it was six times more dangerous to drive on a rural road at night than on an urban street in daylight. It became starkly evident that something about the roads had much to do with the road traffic safety equation.
“...it appeared it was six times more dangerous to drive on a rural road at night than on an urban street in daylight. It became starkly evident that something about the roads had much to do with the road traffic safety equation.”
The reality was that drivers were negotiating hundreds of thousands of miles of roads with no edge lines and often without center lines. Day or night, they were entering thousands of intersections without stop signs or other controls. Warning signs were sparse. On many miles of roadway, they encountered roadside obstacles and an obvious need for guardrails. Many rail-highway crossings had no warning lights, much less automatic gates. In the United States, the Highway Safety Act of 1973 brought significant funding to correcting these deficiencies. Road safety engineering to improve existing roads was adopted in other rich nations as well and was mostly completed by 1985.
There was a powerful realization that the conditions of the roads were critical variables in the road safety equation and whether or not crashes could be prevented. There was also a realization that the locus of road safety happens on roads of varying types: rural, urban, arterial or collector; in daylight, dawn, dusk or night; with traffic light, moderate or heavy; crawling or at typical urban or rural speeds. As crashes occur, the first priority remedy is to improve the roads to help drivers avoid crash causing mistakes.
“There is little in public health or medicine that pretends to deal with the prevention of crashes on real roads. In the end, the idea of some kind of epidemiology did not seem to fit with reality.”
Enforcement of traffic laws, proper court procedures, advanced driver training, strict licensing standards, and detailed vehicle inspections are not subjects in medical or nursing schools or in university public health curricula. How to calm traffic, install reflectorized edge lines and center lines, design lanes for powered two-wheelers, separate pedestrians, regulate intersections and organize traffic crash data are not taught there either. There is little in public health or medicine that pretends to deal with the prevention of crashes on real roads. In the end, the idea of some kind of epidemiology did not seem to fit with reality.
The UN/WHO Efforts
Since the 2004 WHO report on road traffic tragedy, the WHO has produced similar and updated reports in 2009, 2013 and 2015, all pushing mainly for the traditional behavior modification countermeasures to address the issue. The gross number of fatalities reported across the different reports seems to indicate that a levelling off at around 1.2 million annually is happening.
In 2009, an inaugural Global Ministerial Conference on Road Safety was held in Moscow. The Decade of Action for Road Safety 2011-2020 program was proclaimed in 2011 accompanied by the Global Plan for the Decade of Action for Road Safety 2011-2020. During this decade, the program was to save five million lives on the world’s roads.
A follow up global road safety conference was held in Brazil in 2015. No material progress was reported. Also in 2015, the UN adopted Sustainable Development Goals for 2030. For the first time, goals for road traffic safety were included with a specific goal to halve the number of global deaths and injuries from road traffic accidents by 2020. This is clearly an unrealistic and unattainable goal, especially so if the UN/WHO does not dramatically change their approach to the problem.
“The WHO has mostly ignored the impact roads have in the road traffic safety equation and hence mostly omits promoting proven countermeasures dealing with the road network.”
With the help of the UN and the UN System and its road safety related agreements and conventions, the WHO has been positioned as the global leader and expert in road safety and as such advises the global community on what it considers best practices and proven countermeasures. The advice they promote is mostly limited to that seen through a public health lens and is focused on five key risk factors: speed, drink-driving, motorcycle helmets, seatbelts and child restraints. These are all behavior modification countermeasures. The WHO has mostly ignored the impact roads have in the road traffic safety equation and hence mostly omits promoting proven countermeasures dealing with the road network. To our knowledge, no nation successful in minimizing traffic deaths and injuries has ever given that responsibility to a public health agency. It is certainly questionable as to why the WHO, as a public health agency, has become the entity providing road traffic safety advice on a global scale.
What Went Wrong?
There seems to have been a huge misunderstanding by the WHO concerning which road traffic crash countermeasures actually produced the results in high-income nations. The sharp declines in road traffic deaths from 1973 to 1985 on the roads of high-income nations that were not related to the OPEC oil embargo of 1973/1974, did not result from a robust adoption of behaviorist policies or from safety regulations of auto designs. Rather, reduced fatalities resulted primarily from road safety engineering actions that improved existing but safety deficient roads. It was not until the road safety improvements were in place that campaigns for discouraging drinking before driving, encouraging buckling of seatbelts and other road user behavior based countermeasures became meaningfully effective.
A very important adjunct when road safety engineering actions were implemented in the rich world was an apparent improvement in the public response to road safety. Most drivers experienced firsthand significant safety advances on “their” roads, the roads they regularly used. The safety improvements were a passive, but more effective, means to convey the road safety message than any form of advertising or public affairs publication or other instrument of safety harangues. They were tangible and were there every day in plain sight: edge lines signaling a curve to which a driver is approaching too fast, center lines indicating passing zones or a stop sign at a cross roads, a cleared sight distance or a sign warning of roadside obstacles or other dangers. The new, and essential, countermeasures made the existing roads the focus for reducing crashes and fatalities.
Public health messages, on the other hand, can only try to persuade drivers and pedestrians to change their behavior. The messages can easily be ignored by turning off a switch or by simply not listening. This is especially so in developing countries where the populations are conditioned to be cynical about government. Corruption and misuse of power have given many good reasons to be. And, this is assuming that their messages even reach the intended audience. The issue of improved public response to road safety efforts is important beyond calculation in LMICs and the WHO leadership seems to have mostly missed it.
“To make a material impact on a global scale, the need for progress must be focused where most of the fatalities occur, in LMICs, and with countermeasures specifically suited for these countries and their individual level of economic development.”
An additional mistake in the approach taken by the UN/WHO in trying to reduce global road traffic tragedy lie in not separating recommendations for conditions in the rich world from the specific needs in developing nations. Because much of their recommendations are more suitable for high-income countries, this makes their approach mostly impractical for LMICs. The reality is that the route to incremental gains in road safety by high-income nations is vastly different from initial and ongoing gains needed in LMICs. To make a material impact on a global scale, the need for progress must be focused where most of the fatalities occur, in LMICs, and with countermeasures specifically suited for these countries and their individual level of economic development.
Also hindering progress is the difficulty in determining how the UN or the WHO are accountable for anything they do or for reaching any proclaimed objectives or targets. The base of comparison used to measure progress or the lack thereof, road traffic fatalities, keeps changing. In their 2015 report, the WHO modified the way they estimate the fatalities so the numbers reported are not directly comparable to those published in previous WHO reports. In media, at conferences and in general discussions, this inconsistency is never clarified.
For real progress to materialize in LMICs, there is a need for the global road safety community to acknowledge that the public health approach taken by the WHO to address road traffic tragedies is flawed and inadequate for the substantial challenge facing these countries. An obvious observation is that the UN adopted sustainable development goal to halve the number of global deaths and injuries from road traffic accidents by 2020 will not be achieved. With the changing dynamics of rapid increases in vehicle ownership, traffic volumes and new and inexperienced drivers travelling on safety deficient roads, a different, more complete and prioritized approach is needed.
“For real progress to materialize in LMICs, there is a need for the global road safety community to acknowledge that the public health approach taken by the WHO to address road traffic tragedies is flawed and inadequate for the substantial challenge facing these countries.”
The public health approach is not adequate now in LMICs and it is not what worked in the rich world 40 years ago. Instead, as a pre-cursor to a safe system approach, make existing roads as safe as possible as soon as possible with road safety engineering.
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