No One Should Have to Pay a Price for Mobility

Millions of lives are lost every year across the globe because of traffic accidents. “It is an unacceptable price to pay for mobility,” Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, said earlier this year at a global conference on road safety in Stockholm, Sweden.

People living in low- and middle-income countries — where 93 percent of the world's road-related deaths happen — are disproportionately affected, even though they boast only about 60 percent of the world’s vehicles, according to WHO.

DGHI’s Catherine Staton and João Ricardo Vissoci have been working together, pooling their unique skills — Staton’s clinical background in global health and injuries and Vissoci’s penchant for population health, health systems and data science — to study and address how to prevent and treat road traffic injuries in low- and middle-income countries. 

The partnership between Staton, associate professor of surgery and global health at Duke, and Vissoci, assistant professor of surgery and global health, works well because of the unique perspectives the two bring to the issue.

“I see data as patients, as people. João uses that data to predict who’s more at risk and to create clinical guidelines. We can adapt treatment based on how much risk there is of dying,” Staton says.

Last year, they published a study in the International Journal of Injury Control and Safety Promotion that looked at the relationship between motorcycle taxi driver behaviors and road traffic injuries in Rwanda. The aim was to learn more about the safety behaviors of commercial motorcyclists in Kigali, Rwanda. Along with colleagues from Duke, State University of Maringá in Brazil and the University of Rwanda, they surveyed 609 commercial motorcyclists in January 2014 and reported that more than 38% experienced a crash during their lifetime, of which more than half suffered injuries. Close to 39% of those who reported injuries ended up being hospitalized and 14% resulted in disability.

One of the challenges in emergency medicine globally — in low- and middle-income countries, specifically — is that there is not an established field of emergency medicine, Staton explains. 

“It’s a brand new field and most in it are very young, junior practitioners. Some have extensive experience and others don’t,” she says.

In the global health world, the focus for so long has been on infectious diseases such as malaria, dengue and HIV, Staton says. But with approximately 1.35 million deaths and as many as 50 million injuries due to road traffic crashes annually worldwide — and with many leading to a disability — innovations are much needed in this area of medicine, too.

“Patients who had injuries were not only sitting in clinics without anyone looking after them, there were no clinical resources, no global infrastructure for them. Injuries are a lot like non-communicable diseases in that they are increasing drastically as there’s more and more economic growth. That growth leads to more forms of transportation, like motorcycles, which are often less safe,” Staton explains.

Adding to safety concerns, is a lack of injury prevention messaging. 

“Motorcycle taxi drivers have to make a certain amount of money a day to pay the motorcycle owner first, then what ever is left is their take-home, so they’re racing to make their money. There are no stop lights in Moshi, Tanzania, one location where we work. There are helmets, but they’re cost prohibitive. If a strap breaks on a helmet, it renders it useless in a crash. There are no incentives for doing the safe thing. I’ve seen more helmets tied to a bike than people wearing them. Many locations don’t have true safety regulations in place and when there are, they aren’t enforced,” she says.

Lines designating driving lanes and limiting road use so that pedestrians, motorcycles and trucks aren’t all on the same thoroughfares are some of the preventive measures that could reduce injuries and fatalities.

Vissoci says it takes a multi-pronged approach and close work with partners. He and Staton have been working with partners in Tanzania and Brazil.

“We’ve been trying to address this in both ways, from a clinical perspective but also to look at policy and its potential impact. When we did a study to understand the road structure and environment related to how people are getting into a crash and the mortality, we found that the quality of roads in Tanzania and stop signs on roads weren’t related. Having a stop sign doesn’t make a difference if you don’t have good road quality,” Vissoci says.

He notes that there are multiple areas where they can help impact change.

“It’s not just what we’re used to in the states that will make a difference. If I make better roads in Tanzania, people are going to drive faster because there’s no speed limit. There needs to be a holistic view, along the same lines as the COVID-19 pandemic. Healthcare growth needs to be related to economic growth. You have to grow infrastructure and policy at the same time we are trying to address patient risk and use resources to their best ability,” Vissoci says. 

Staton agrees, noting that they recently began a new project, a randomized clinical trial to address alcohol use, “one of our most concerning issues.”

“There’s very little regulation for alcohol use, and no AA, no understanding of the impact of alcohol use or that drinking and driving is bad. But we now have an intervention in Swahili adapted to a Tanzanian setting — appropriate for the language and culture. We’re starting a randomized clinical trial ready for implementation and we hope to start enrollment soon,” she says. 

She further explained that their partners in Brazil — where Vissoci is from — are also collaborating by culturally adapting this intervention to Portuguese and the Brazilian setting.

Vissoci adds, “We are leveraging our partnerships in Brazil and Tanzania for mentoring, training, doing data analysis and planning implementation. It ensures that the process is team-focused and that there’s equity.”

Last year, they published a study in the International Journal of Injury Control and Safety Promotion that looked at the relationship between motorcycle taxi driver behaviors and road traffic injuries in Rwanda. The aim was to learn more about the safety behaviors of commercial motorcyclists in Kigali, Rwanda. Along with colleagues from Duke, State University of Maringá in Brazil and the University of Rwanda, they surveyed 609 commercial motorcyclists in January 2014 and reported that more than 38% experienced a crash during their lifetime, of which more than half suffered injuries. Close to 39% of those who reported injuries ended up being hospitalized and 14% resulted in disability.

One of the challenges in emergency medicine globally — in low- and middle-income countries, specifically — is that there is not an established field of emergency medicine, Staton explains. 

“It’s a brand new field and most in it are very young, junior practitioners. Some have extensive experience and others don’t,” she says.

In the global health world, the focus for so long has been on infectious diseases such as malaria, dengue and HIV, Staton says. But with approximately 1.35 million deaths and as many as 50 million injuries due to road traffic crashes annually worldwide — and with many leading to a disability — innovations are much needed in this area of medicine, too.

“Patients who had injuries were not only sitting in clinics without anyone looking after them, there were no clinical resources, no global infrastructure for them. Injuries are a lot like non-communicable diseases in that they are increasing drastically as there’s more and more economic growth. That growth leads to more forms of transportation, like motorcycles, which are often less safe,” Staton explains.

Adding to safety concerns, is a lack of injury prevention messaging. 

“Motorcycle taxi drivers have to make a certain amount of money a day to pay the motorcycle owner first, then what ever is left is their take-home, so they’re racing to make their money. There are no stop lights in Moshi, Tanzania, one location where we work. There are helmets, but they’re cost prohibitive. If a strap breaks on a helmet, it renders it useless in a crash. There are no incentives for doing the safe thing. I’ve seen more helmets tied to a bike than people wearing them. Many locations don’t have true safety regulations in place and when there are, they aren’t enforced,” she says.

Lines designating driving lanes and limiting road use so that pedestrians, motorcycles and trucks aren’t all on the same thoroughfares are some of the preventive measures that could reduce injuries and fatalities.

Vissoci says it takes a multi-pronged approach and close work with partners. He and Staton have been working with partners in Tanzania and Brazil.

“We’ve been trying to address this in both ways, from a clinical perspective but also to look at policy and its potential impact. When we did a study to understand the road structure and environment related to how people are getting into a crash and the mortality, we found that the quality of roads in Tanzania and stop signs on roads weren’t related. Having a stop sign doesn’t make a difference if you don’t have good road quality,” Vissoci says.

He notes that there are multiple areas where they can help impact change.

“It’s not just what we’re used to in the states that will make a difference. If I make better roads in Tanzania, people are going to drive faster because there’s no speed limit. There needs to be a holistic view, along the same lines as the COVID-19 pandemic. Healthcare growth needs to be related to economic growth. You have to grow infrastructure and policy at the same time we are trying to address patient risk and use resources to their best ability,” Vissoci says. 

Staton agrees, noting that they recently began a new project, a randomized clinical trial to address alcohol use, “one of our most concerning issues.”

“There’s very little regulation for alcohol use, and no AA, no understanding of the impact of alcohol use or that drinking and driving is bad. But we now have an intervention in Swahili adapted to a Tanzanian setting — appropriate for the language and culture. We’re starting a randomized clinical trial ready for implementation and we hope to start enrollment soon,” she says. 

She further explained that their partners in Brazil — where Vissoci is from — are also collaborating by culturally adapting this intervention to Portuguese and the Brazilian setting.

Vissoci adds, “We are leveraging our partnerships in Brazil and Tanzania for mentoring, training, doing data analysis and planning implementation. It ensures that the process is team-focused and that there’s equity.”