Road Traffic Injury Is an Escalating Burden in Africa and Deserves Proportionate Research Efforts

doi:10.1371/journal.pmed.0040170.g001 Road Traffic Injury Is an Escalating Burden in Africa and Deserves Proportionate Research Efforts Emmanuel Lagarde emmanuel.lagarde@isped 0 1 0 Emmanuel Lagarde is with INSERM, U593, Equipe Avenir Sante et Insecurite Routiere , Bordeaux , France , and Institut de Sante Publique et de Developpement, Universite Victor Segalen Bordeaux 2, Case 11, Bordeaux , France 1 Abbreviations: DALY, disability-adjusted life year; WHO, World Health Organization - Rdeveloping countries is scarce, esearch into road safety in especially in Africa. This is inconsistent with the size of the problem: it has been predicted that by 2020, road traffic injuries will rank as high as third among causes of disabilityadjusted life years (DALYs) lost [1]. While South-East Asia has the highest proportion of global road fatalities (one-third of the 1.4 million occurring each year in the world), the road traffic injury mortality rate is highest in Africa (28.3 per 100,000 population when corrected for under-reporting, compared with 11.0 in Europe [2]). I selected African countries with recent available data on road mortality and number of vehicles in use (Table 1). When comparing death per 10,000 vehicles, the contrast appears even more stark, with 1.7 deaths per 10,000 vehicles in high-income countries across the world [3] and more than 50 in low-income African countries. In addition, while developing countries already account for more than 85% of all road traffic deaths in the world [46], the upsurge in the number of vehicles per inhabitant will result in an anticipated 80% increase in injury mortality rates between 2000 and 2020 [2]. In Africa, it has been estimated that 59,000 people lost their lives in road traffic crashes in 1990 and that this figure will be 144,000 people by 2020, a 144% increase [7]. By contrast, developed countries have experienced a decreasing trend since the 1960s. Because road traffic injuries have long been considered to be inevitable and caused by random, unpredictable events, the international communitys response to this worldwide public health crisis came relatively late. The World Health Organization (WHO) The Essay section contains opinion pieces on topics of broad interest to a general medical audience. arranged a consultation meeting in April 2001, which led to a report entitled A 5-year WHO strategy for road traffic injury prevention that summarises the main recommendations from the working group [8]. In 2003, the United Nations Secretary-General sounded the alarm with an official statement [9] describing the global public health challenge posed by road traffic injuries and encouraging Member States to address the problem. One of the recommendations is to promote and facilitate research on this subject, especially in low-income countries where knowledge gaps often jeopardise appropriate resource allocation. Much needs to be done. Global research and development funding for road traffic injuries were estimated in 1996 to range from US$24 to US$33 million, compared with more than US$900 million for HIV/AIDS [1]. Moreover, the overwhelming majority of this money is spent in developed countries. I reviewed published studies from Africa in the field of road traffic injuries to identify pending priorities for future research programmes that would enable the promotion of effective public health policies in road safety. The number of vehicles per inhabitant is still low in Africa: less than one licensed vehicle per 100 inhabitants in low-income Africa versus 60 in highincome countries. Fleet growth leads to increased road insecurity in developing countries [1012]. This explains, for example, the reported 400% increase in road deaths in Nigeria between the 1960s and the 1980s [13]. Available historical data from developed countries show that it is only when a development threshold is achieved that the road mortality starts to decrease [7,14,15]. Such a threshold is far from being reached in sub-Saharan Africa. Indeed, in South Africa, the most developed African country, there were already 17 licensed vehicles per 100 inhabitants in 2005, and no decline in road traffic deaths has been observed so far [16]. Competing Interests: The author has declared that no competing interests exist. Copyright: 2007 Emmanuel Lagarde. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Crash and Casualty Characteristics A comprehensive literature review published in 1997 showed that pedestrians accounted for between 41% and 75% of all road traffic deaths in developing countries [17]. In Africa, pedestrians and passengers of public transportation are the most affected [17]. They represented 80% of all road traffic deaths in Kenya in 1990 [18] and 67% of all road traffic injuries as recorded in Ghana in the 19891991 period [19]. Pedestrians alone accounted for 55% of road traffic deaths in Mozambique in the 1993 2000 period [20], and 46% of road traffic deaths in Ghana between 1994 and 1998 [21]. This large proportion of vulnerable road users is explained by a traffic mix of incompatible users (pedestrians, cyclists, motorbikes, cars, and trucks) with, for example, communities living within the vicinity of roads or the lack of pavement along large urban streets. The severity of road traffic crashes is also likely to be much greater in Africa than anywhere else, because many vulnerable road users are involved, but also because of the poor transport conditions such as lack of seat belts, overcrowding, and hazardous vehicle environments. Death/injury ratios are, however, not easy to compare because of the differential reporting bias for fatal and non-fatal injuries. The paucity of surveillance data from African countries leads to uncertainties, and probably to major under-estimates of the size of the problem [22]. Implementing an effective and sustainable information system related to road traffic injuries should be among the first priorities, as this enables us to address three decisive objectives. First, the monitoring of trends in road traffic injuries is a unique tool to assess the effectiveness of new prevention policies. Second, such a tool also allows for a useful account of the characteristics of traffic insecurity, helping the prioritisation of effective interventions (identification of hot spots, vulnerable road users, regional variations, and so on). Third, issuing persuasive figures through regular national or regional reports will help advocate for the allocation of appropriate resources. Current efforts from many African countries need to be encouraged and evaluated, and success stories should be replicated. Data can come from death statistics [23,24], hospital registries [18,20,25,26], and even from population surveys [2730]. Collection of police repo (...truncated)