Dr Edward Duncan, Associate Professor, Faculty of Health Sciences and Sport, University of Stirling
Dr Isabelle Uny, Research Assistant, Faculty of Health Sciences and Sport, University of Stirling
Everyone knows that roads are dangerous, but many people are surprised when they find out just how deadly they can be. As many as 1.4m people are killed every year – about one every 23 seconds – while another 20m to 50m are injured but survive, often with life-changing disabilities. Road traffic collisions are currently the eighth biggest killer in the world.
The vast majority of deaths from these collisions happen in low and middle income countries, such as those in sub-Saharan Africa. They affect productivity, family life and well-being in countries where people are already struggling to survive. Even more startling, these countries have among the lowest ratios of vehicles per person in the world. The impact of road traffic injuries in sub-Saharan Africa is greater than malaria, tuberculosis and – in some countries – HIV/Aids. With the UN’s fifth global road safety week currently underway, things are not getting better.
Most road fatalities in sub-Saharan Africa are pedestrians, cyclists and motorcyclists. Many people have no other mode of transport than walking or cycling. It’s common to see children and adults walking along the edges of extremely busy roads, and vendors selling their goods there. Roads are often poorly designed and inadequately maintained. Barriers, signage and footpaths tend to be poor or nonexistent. Vehicles are often badly maintained, while there are significant problems with driver training, drink driving and police enforcement of traffic laws.
When academics and clinicians think about road collisions, we sometimes talk about the “trauma chain of survival”, which maximises victims’ chances of surviving and making a good recovery: this involves getting early first aid, early life support, early interventions to limit or repair injuries, and early rehabilitation.
In sub-Saharan Africa, this chain tends to be seriously inadequate. When collisions occur, there is often no public emergency ambulance service or universal emergency telephone number like 999 or 911. Trained first aiders are very limited, so bystanders who provide pre-hospital care usually lack the knowledge, training, equipment, experience and transport to help. People often avoidably die as a result.
Hospitals frequently lack the equipment, staff and facilities to deal with road traffic victims properly. Neither are they usually able to provide the sort of early rehabilitation to benefit survivors. It all adds up to what is sometimes referred to as a wicked problem: one so incredibly complex that it’s hard to know where best, or how best, to start to resolve it.
The UN initiative
Wicked problems require interdisciplinary thinking and multifaceted solutions. To this end, the UN General Assembly has been overseeing a Decade of Action for Road Safety. This has been promoting five policy pillars: road safety management; improving road infrastructure; increasing the number of safe vehicles; improving road user behaviour; and developing post-crash responses. The UN has set a global sustainable development goal to halve the number of road traffic related deaths and injuries by the time the project ends in 2020, but it looks very unlikely to be achieved.
This is not for the want of trying. Many African countries have been introducing reforms alongside this campaign. We have seen everything from a campaign in Kenya encouraging passengers to monitor how well they are being driven, to training sessions for motorcyclists in Nigeria over road signage, to life support training for trauma nurses and doctors in Rwanda.
WHO Global Status Report on Road Safety, 2018. World Health Organisation
The World Bank has funded a large range of road safety projects in over 35 developing countries with the Global Road Safety Facility it established in 2006. In 2016, for instance, the fund leveraged a total of US$411m (£316m) in investments.
One recent example is a US$3.4m pilot project to improve emergency medical services on the M1 road between Lilongwe and Blantyre in Malawi, one of the poorest in the world. It involves stationing ambulances along the road, a well known collision hotspot, and training people to operate them. This will inform the development of a formal emergency medical service across the country.
This, however, will only target one part of the support system required to make a difference to the wider problem. And this is very much the challenge in microcosm: even with global institutions putting their shoulders to the wheel, road traffic deaths are still growing too much in poorer countries to achieve a turnaround.
Safe Roads Africa
There is growing evidence that wicked problems are best addressed not by large-scale actions, but by stacking up small wins. We have been trying to put this into practice by participating in a road traffic-related trauma project centred on Malawi.
The road traffic fatality rate in Malawi is 35 deaths per 100,000 people, well above the African regional average of 26.6 deaths, and twice the global average of 17.4. In 2018, the Malawi Police Service reported a 35% increase in road accidents; lately, for instance, the Ntcheu district in central Malawi is still recovering from the deaths of 20 people after a lorry hit a crowd in a popular market town in March.
Our response is called Safe Roads Africa, an interdisciplinary group from Scotland and Malawi that includes clinicians, academics, NGOs and community workers. We have been running pop-up events and community meetings in two areas of the country. These have included using role play and community theatre to explore how people response to traffic collisions, and how this can be improved. We have also extended these events to neighbouring Zambia with encouraging results.
In areas particularly at risk in both countries, the project hopes next year to begin training local people to become road safety champions. These people will promote best practice and provide sustainable lifesaving first aid to accident victims in their area.
The aim is that the Safe Roads Africa programme will be adaptable for the whole region. Obviously community interventions like these are only part of the solution to a vast issue. Clearly there are no easy answers, but by continually raising awareness and being determined not to lose momentum when the UN decade of action comes to an end, the hope is that in time, this pernicious problem can finally be forced into reverse.
This article first appeared on The Conversation in May 2019.