India's hurried quest for development and its disregard for road safety have resulted in a major public health problem that demands serious thought and action.

The high mortality and morbidity associated with road traffic injuries are a major public health challenge worldwide. Every year, road traffic crashes kill an estimated 1.2 million people. The figure for the injured is over 50 million. Significant increases in these estimates are projected over the next decade. However, the scale of individual tragedies rarely attracts media and world attention.

Ninety per cent of such injuries occur in the developing world. India has had the dubious distinction of high rates and a steady increase in road fatalities over the past three decades. The poor and the vulnerable (pedestrians and cyclists) bear the brunt. The majority of the victims are men aged between 15 and 40 and economically active. Road accident injuries often overwhelm emergency and casualty departments of most hospitals, which result in their coping poorly with the patient load. A significant proportion of non-fatal injuries results in traumatic brain damage and substantial disability. Deaths of breadwinners often push families into poverty. The social and economic costs are massive and often difficult to quantify.

First world highways and third world context: The last decade saw many new national and State highways connecting different parts of the country. These modern marvels have shortened transit times, thanks to greatly increased speeds of travel. However, the designs of these highways did not take into account the local reality. They were built on existing roads, which connected small towns. These motorways now go through towns; they bisect villages. Pedestrian crossings, near towns and villages, make for killing fields. Lack of fencing around and elevation of the highway allows animals to encroach upon the road, setting the stage for crashes.

The absence of overbridges, underpasses and alternative roads for village traffic means that speeding vehicles compete with slow-moving farm and rural traffic (cycles, rickshaws, hand and animal-drawn carts and tractors). It is common to see rural and farm vehicles travelling in the wrong direction on dual carriageways. In addition, alcohol outlets along the highway and the absence of routine checks by highway patrols encourage drunken driving and add to consequent disasters.

Quick-fixes with no master plan: Flyovers and elevated roads dot many major Indian cities. However, these are essentially quick fixes. Most cities do not have long-term master plans for transport and traffic. Ad hoc and non-uniform solutions to local road situations are common. The absence of traffic lights and roundabouts at most road junctions results in ambiguity over the right of way. Routing heavy vehicular traffic through densely populated areas, and poor and non-standardised road signs and markings also compound the problem. The location of bus stops and traffic lights often leaves much to be desired.

Lackadaisical enforcement: There is a basic lack of knowledge of road safety rules among users. Driving tests in India never examine the actual driving skills on regular roads. “Mirror-signal-manoeuvre” is unheard of, overtaking on the left is the norm and red traffic lights are considered suggestions rather than absolutes. Periodic tests for the safety of older vehicles and drivers are non-existent. Vehicles with just one headlight on or those with misaligned high beams are a common sight. They make driving after dark a hazardous experience.

Slow vehicular traffic hogging the fast lanes is a common sight on highways; so are heavy vehicles parked on slow lanes, with no tail and emergency lights. Seat belts in cars and crash helmets for pedal and motorcycles are not used regularly, increasing the risk of serious and fatal injury. Excessive speed, novice drivers with no knowledge of road safety and those with high blood alcohol levels contribute to serious road crashes. The failure to maintain adequate distance between vehicles also makes driving on Indian roads perilous. Vehicles overloaded with people, produce and products go unchecked. In addition, those identified for breaking road safety rules are often a source of additional income for enforcement personnel.

Different rules for different vehicles: Traffic rules are more often observed in the breach. Vehicles have the right of way over pedestrians even at pedestrian crossings; bigger vehicles have a right of way over smaller vehicles. Flashing headlights imply an immediate claim to right of way. Idiosyncratic signalling is common among truck drivers (for example, the use of the right-turn indicator to allow overtaking) and this increases ambiguity and risks of crashes.

Fragmented responsibility: The design, construction and operation of different classes of roads lie with different government agencies, resulting in a fragmentation of responsibility. The rural-urban and the legislation-implementation divides, and the lack of coordination among different authorities result in road safety falling in no-man's land. This also results in a lack of accountability. The consequent lack of leadership in the area of road injury prevention adds to the difficulties.

Social issue and equity: The extent of a society's civilisation can be judged by its regard for pedestrians' rights. In India, there is little respect for such rights. Road injuries disproportionately affect the poor. The burden of such injuries, harm and consequent disability is much greater among pedestrians and those who use pedal and motorcycles. Large sections are at risk for such injury, making it an urgent social issue. The increase in vehicular speeds on unsafe roads raises concerns about equity, justice and fairness for a large section.

The way forward

India needs to aim for safe and sustainable road systems. Research and development over the past few decades in the West have proved that a range of interventions exists to prevent crashes and injury. India has many good intentions, rules and statutes on its books but the gap between what is known to be effective and what is actually practised on the ground is often wide. A commitment to injury prevention is lacking. Mobile ambulance and curative health services are no substitute for prevention. As with all public health approaches, road injury prevention requires effective management to put in place sustainable and evidence-based measures and overcome obstacles to implementing safe practices.

India does not seem to have a road injury surveillance system. Under-reporting of road injuries is common and hides a major public health problem; police and health data only provide partial accounts of the magnitude and nature of the issues. This is particularly true of non-fatal, yet severely disabling, outcomes. There is need for accurate data collection systems. These will aid in planning interventions and designing better and more appropriate road systems.

There is also need to seriously examine and correct lapses and inadequacies in road design and planning. Periodic fitness certification for all motorised vehicles, universalisation of road signs and enforcement of law and safety regulations are crucial. Driving tests should be made more stringent and should test knowledge in addition to driving skills. They need to be conducted on regular roads. Refresher training and re-testing should be introduced. We should have zero tolerance of underage drivers. India needs to consider severe penalties for violations; cumulative penalties for recurrent infringements should result in temporary withdrawal of licences or a permanent ban on driving.

Road traffic systems are highly complex and can be dangerous to human health. Injury prevention requires an extremely coordinated effort on the part of the government and society. It mandates a “systems approach;” understanding the system as a whole, the interaction between its elements, and the identification of points of intervention. Road safety is a shared responsibility. It requires political will and administrative commitment from the government, industry, public works departments and law-enforcement and health agencies. Governments need to identify lead agencies to guide the effort, research the problems and policies, prepare the strategy and action plans, allocate human and financial resources and implement specific interventions. Non-governmental and community organisations can play an important role by highlighting the issues, studying local problems, educating and informing the general public and suggesting solutions.

A combination of legislation, enforcement of laws and education of road-users can significantly improve compliance with key safety rules, thereby reducing injuries. While strategies from developed countries can be adopted, there is also need to study the local context and implement relevant interventions and plans to improve road safety. The current rates of morbidity and mortality due to road injuries are both unacceptable and avoidable. Road safety should be high up on the political, administrative and community agenda.

(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)

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