For many people in low-resource countries, riding a motorcycle isn’t just a way to get around—it’s their livelihood as “taxi” drivers. But for far too many, it’s also how they lose their life.
About half of all deaths caused by road traffic crashes involve motorcyclists, cyclists and pedestrians, a group that’s disproportionately high in low- and middle-income countries. Likewise, the vast majority of road traffic injuries occur in these countries. And to make matters worse, many who suffer these injuries in low-resource settings aren’t able to access the care they need, often leading to devastating health outcomes.
Road traffic injuries pose a major and growing global health challenge. Currently the eighth leading cause of death worldwide, they’re predicted to become the third leading cause by 2020.
“To put things in perspective, there are more deaths due to injury than HIV, malaria and TB combined, and road traffic injuries account for a significant proportion of these,” said Catherine Staton, assistant professor of emergency medicine and global health. “In Tanzania, for example, more than two-thirds of injury deaths are due to traffic crashes.”
And while high-income countries have seen a substantial decrease in these injuries in recent years, numbers in low-resource settings have skyrocketed. Risk factors common in these settings—such as a lack of safety equipment, increased vehicle density, poor road infrastructure, inadequate pedestrian pathways and limited enforcement of traffic laws—all contribute to this problem.
Despite the World Health Organization’s call for a “Decade of Action for Road Traffic Injuries” from 2011 to 2020, progress has remained stagnant. Knowledge and recognition of the global burden of road traffic injuries—and resources to support research in this area—have been woefully insufficient to turn the trend around.
“Other fields, like infectious diseases, have done a great job of using fear as a tool to attract funding for initiatives, but people aren’t scared of traffic injuries—they just see them as accidents that happen,” said Staton. “But they are as preventable as many infectious diseases.”
And the research that is funded, especially in low- and middle-income settings, faces a host of limitations, including incomplete and low-quality data sources, lack of electronic health records and the fact that many people die in traffic crashes without making it to the hospital.
Staton, though, has met these challenges head-on. In 2013, as an emergency medicine doctor collaborating with faculty partners at the Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania, she recognized that understanding the burden of injury at KCMC was a critical first step toward improving outcomes for these patients.
To this end, with funding from the Duke/KCMC Medical Education Partnership Initiative, Staton and her colleagues initiated an ambitious multi-year project that would become the foundation for their entire injury research program at KCMC: a traumatic brain injury patient registry.
“KCMC was the perfect place to embark on this project, because they have an excellent research infrastructure, but at the time, they were doing very little research on injuries,” said Staton. “Traumatic brain injury is the leading cause of death for injury patients, and half of injury patients at KCMC have a traumatic brain injury.”
The registry has proven to be a vital resource for traumatic brain injury research in Moshi, with demographics, injury type and severity, treatment received and outcomes for more than 4,000 patients to date. Once the registry data began to accumulate, Staton discovered that about half of the patients in the registry were injured in traffic crashes. “When we realized that traffic injuries made up such a huge proportion of the population, we wanted to learn more about this subgroup,” she reflected.
Further investigation revealed that about half of the traffic injury patients were motorcyclists, many of whom were boda boda drivers who make their living transporting people from Point A to Point B throughout the city, usually without a helmet.
But while many motorcyclists are victims of traffic injuries, Staton and her colleagues have also tapped them as part of the solution to the problem.
Understanding where and why crashes occur lays the groundwork for effective and efficient safety and prevention planning. Road safety audits in low-resource settings are riddled with challenges. Most countries rely on police, pre-hospital or hospital-based data to identify traffic hotspots, but these sources are widely known to be incomplete in these settings, missing up to 40 percent of serious injury incidents.
Given these limitations, Staton and her colleagues, including Duke Global Health Institute professor Truls Østbye and assistant professor of emergency medicine João Ricardo Vissoci, wanted to devise a quick and inexpensive, yet reliable, alternative data collection method.
Their solution? Crowdsourcing. They would survey motorcyclists about road traffic “hotspots”—areas of high-density crash locations—in the region. They hypothesized that the people who spend their days traversing across town would have valuable insights that could help inform future road safety interventions. It turns out they were right.
Staton, Vissoci, Østbye and Luciano Andrade, a post-doctoral researcher working with Staton, initially tested this method in Kigali, Rwanda, and Galle, Sri Lanka, in collaboration with Stephen Rulisa in Rwanda and Vijitha Da Silva in Sri Lanka. They asked moto drivers in Rwanda and tuk-tuk (three-wheel) drivers in Sri Lanka to identify dangerous locations in the region and label the severity of danger of each location. Then, the researchers compared police data to the information the drivers provided.
The study not only showed that data from these “high road utilizers” aligned well with police data, but also identified potential additional hotspots. The research team also found that this crowdsourcing approach is less costly than collecting police data and is easily reproducible, adaptable and interpretable. They were able to replicate the study in Moshi, Tanzania, a year later in collaboration with KCMC researcher Mark Mvungi and got similar results.
“We tested this data collection method in three countries to make sure it’s applicable across different environments and populations,” said Staton. “Now, we hope this method can be further integrated into road safety planning for low- and middle-income countries where police data might be challenged by underreporting.”
The next step, says Staton, is to formulate targeted, cost-effective interventions to minimize the risk in these traffic hotspots. These interventions might include measures such as adding speed bumps; improving road pavement conditions, visibility and signage; and promoting helmet use.
Staton and her colleagues are exploring partnerships with public planning experts and students to help them develop effective solutions. “We need collaborators to continue,” she said, “and for this project, seeking out new partners has been particularly fun because we’re reaching out to people whose expertise lies way outside of the medicine world.”
There are more deaths due to injury than HIV, malaria and TB combined, and road traffic injuries account for a significant proportion of these.