Andrew Moscrop: Road traffic injuries in Pakistan

Lying on his back, a trail of his drying blood scuffed across the dusty concrete floor, the young boy was alive and screaming. As he drew his knees up to his chest I watched his right foot flop and flap from the end of a mangled segment of shattered bone, shredded muscle, and tattered skin. His left leg looked a little better; snapped and flayed, but managing to retain some resemblance to a limb. He was hit by a truck—one of the gaily painted Bedford’s that ply the highways in Pakistan. Trauma cases are mercifully rare at the Kuchlak clinic, but being located on the main road to the Afghan border means being prepared for anything. Someone competently inserted a cannula, some pain relief and fluids were given, and the pieces of the flailing boy were stretchered into the back of an ambulance and sent to one of the hospitals in Quetta.

Later, after the adrenaline of the open tibia and fibula fractures had diminished, I recalled two men who had attended the health centre earlier that morning. The first was a sixty year old man who had fallen from one of Pakistan’s ubiquitous Honda 70 motorcycles four months earlier, injuring his right wrist. He complained that he could no longer use his right hand to eat and showed me his injury: a mended, but grossly mal-aligned wrist fracture bent, with no lack of irony, into the shape of a dinner fork. Soon after, I met a thirty year old man, paralysed from the waist down, who had also been involved in a motorcycle crash some months prior. Left wheelchair-bound with an in-dwelling catheter, he had now developed brutal pressure sores; fist-sized ulcerations punched deep into the muscle on either side of his pelvis.

Author JG Ballard suggested that if we really believed in the awful truths of car crashes we would never step inside a motor vehicle. Similarly perhaps, if we truly acknowledged the global morbidity and mortality associated with road traffic injuries (particularly in the developing world) we would be making more concerted preventative interventions.

The burden of road traffic injuries (RTIs) falls disproportionately on developing nations. More than 85% of all deaths worldwide due to road traffic crashes occur in developing countries (reasons cited include more multi-passenger vehicle crashes, poor roads, poor enforcement of traffic and vehicle safety regulations, and limited access to healthcare of limited quality).[1] Within these countries it is frequently the poor and the weak who are disproportionately affected (it has been observed that “most of the victims will never own a car, and many are children”).[2] Recent data from Pakistan also evidences the devastating financial impact of road crashes upon already vulnerable individuals, with many crashes affecting family bread-winners and healthcare costs amounting to more than the monthly salary of most victims.[3]

The World Health Organisation has observed that “If current trends continue, road crashes are predicted to become the fifth leading cause of death by 2030.” Meanwhile, 2011-2020 has been declared the Decade of Action for Road Safety by the UN and a Global Status Report on Road Safety will be released by the WHO later this year. Sceptics might note that the situation has shown little improvement since the WHO first reported on road traffic accidents in 1962, urging then that “this catastrophic loss and injury is a public health problem demanding urgent attention…

In the fifty years since that initial WHO report, the demand for “urgent attention” seems to have been largely ignored. Increasing global incidence of traffic injuries has far outstripped interest in the issue. Prevention of traffic crashes has not been prioritised in global public health research and policy, and I have not found any international medical, humanitarian, or development agency engaging directly with this “neglected epidemic.”

We have been tragically accepting of fast-moving vehicles and their capacity to kill and maim. Yet a grotesque injustice is perpetrated when the lives and limbs of a society’s most vulnerable members are traded for the allure of speed and power, and the myths of freedom and progress that are sold in the form of a motor vehicle.

It may be too much to hope for the situation to improve imminently, but there are perhaps some positive signs. The shift in language from road traffic accidents (RTAs) to road traffic injuries (RTIs) dispels the idea that these are blameless chance events and draws attention to the health consequences for individuals involved. Meanwhile, new health research is demonstrating that RTIs can be studied, understood, predicted, and prevented in a manner similar to non-communicable diseases. Legislators, city planners, and vehicle manufacturers may be ultimately responsible, but health research and advocacy can be powerful forces for change: there is a role for doctors outside of emergency departments in tackling road traffic injuries.

1. Nantulya VM, Reich MR. The neglected epidemic: road traffic injures in developing countries. BMJ 2002; 324: 1139.
2. Roberts I, Mohan D, Abbasi K. The public health community must intervene. BMJ 2002; 324: 1107.
3. Razzak JA, Bhatti JA, Ali M, Khan UR, Jooma R. Average out-of-pocket healthcare and work-loss costs of traffic injuries in Karachi, Pakistan. International Journal of Injury Control and Safety Promotion. 2011 Sep;18(3):199-204. doi: 10.1080/17457300.2011.551942.

Andrew Moscrop qualified as a GP last year and will be working with MSF in Pakistan for six months.