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Lanka’s road accidents - preventable disasters
Making his presidential address to the Sri Lanka Medical Association last month, Professor A.H. Sheriffdeen FRCS, FRCSE drew attention to a new study on the rising rate of motor accidents and outlined the need for urgent action to curb the problem. We publish here extracts from his address
A tsunami killed around 40,000 and disadvantaged over a million people in Sri Lanka. No disaster could possibly match it. Sri Lanka has also had its share of human losses from wars, civilian conflicts and industrial and home accidents.

Travel accidents including motor accidents are another disaster group. In spite of early warning systems there is very little we can do about natural disasters but the one disaster we could possibly prevent is motor traffic injuries. In the UK, a sustained campaign resulted in a steady reduction of the "death index" from road traffic injuries, from 116 in 1965 to 90 in 1980. A steady decline annually thereafter has been recorded.

There are similar graphs from Japan and Sweden. The strategies that these countries used were broadly similar. These included: 1. Identification of accident black spots at local level. 2. Cooperation between police and engineers. 3. Continuous research on national policy 4. Small units in different departments working in consensus to improve safety.

In Sri Lanka, however, newspapers continue to report sensational accidents and horrendous deaths daily. The dead include foreigners, doctors, businessmen, children, adults and families. Even traffic policemen have been affected on what has been dubbed "the killer roads of Sri Lanka".

Worldwide there are over 3,000 deaths daily at a cost of 2% of GNP in most countries. Eighty-five percent of these accidents occur in low and middle-income countries such as India, Pakistan, Africa and Sri Lanka. The WHO predicts that the Disability Adjusted Life Year (an index of the disease burden) from Road Traffic Injuries in these countries will go up from 9th to 3rd place by the year 2020.

Soaring accidents
The importance of motor traffic injuries is now recognized globally, so much so that the WHO dedicated World Health Day 2004 to road safety. A worldwide campaign, the 'Road Safety Week', was mounted globally on April 7, 2004. Several articles were written in newspapers and journals. Other media campaigns were organized, books written and activities conducted at enormous cost, but what effect has it had in Sri Lanka?

Whilst the figures in UK, Japan and Sweden for mortality following motor traffic accidents are progressively falling, the figures in Sri Lanka keep rising. From 2002 to 2004 (figures available for the first nine months) the death rates, grievous injuries and total accidents are showing a steady increase. In 2002, there were 2,038 fatal accidents, and 16,011 grievous injuries caused by a total of 54,911 accidents recorded. If the present trend is not halted, in the next 20 years there would be over 40,000 dead, over 320,000 injured and over 1 million vehicles damaged. The cost estimated at 11.6 billion rupees a year would add up to a phenomenal Rs. 220 billion!

The effect on human lives would be equivalent to the effect of a tsunami hitting Sri Lanka every 20 years. No outpourings of grief for those affected, no promise of international or local aid for those families affected, no psychosocial or mental health rehabilitation for those traumatized, no massive media coverage for this silent "creeping tsunami".

The unprotected road-user (motorcycle, bicycle and pedestrian) is the most affected while the largest number killed formed pedestrians (815 in 2002 and 747 in 2003). The culprit usually escapes since the recorded number of drivers killed in such fatal accidents is comparatively the smallest (205).

The Epidemiology Unit of the Ministry of Health ranks Motor Traffic Injuries next to cerebrovascular disease, ischaemic heart disease and cancer as the most common causes of death in Sri Lanka (each averaging over 2,000 deaths a year). Deaths due to vector-borne diseases (dengue, malaria etc) cost 162 lives, yet the GMOA wants a director for vector-borne diseases while there is only one Director for Non-Communicable Diseases who is in charge of the first four leading causes of death totalling over 8,000 deaths per year.

We, therefore, undertook a study of the injured following Motor Traffic Injuries admitted to the Accident Services of the National Hospital of Sri Lanka. The researchers included Dr. Thisara Samarawickrama, the principal investigator, Dr. Anil Jasinghe, Director Accident Services, Dr. N. Pinto, Consultant Orthopaedic Surgeon in charge of the Accident Services and Dr. W. Gunathunga who did the statistics. I coordinated the study.

Results
Of those admitted to the Accident Services over this six-month period, there were 2,158 who could respond. Fatalities and patients receiving outpatient treatment were not included.

The highest number of injured was in the 20-40 age group, 82% were male and 72% had an education below Grade 10. (Worldwide mortality figures for accidents show that the commonest cause of deaths in this 20 to 40 age group is Motor Traffic Injuries.)

There was no seasonal variation although accidents were lowest on Fridays with a rise in numbers on Saturdays, peaking on Sundays. The lesson is that weekend drivers must be especially careful.

Vehicle
Vehicular defects contribute significantly to motor traffic injuries as shown up by the fact that 17.8% of the vehicles had serious defects, which according to the drivers had contributed to the accident. These included faulty brakes, faulty clutch, poor condition of tyres, defective lights and malfunctioning brake lights.

In this study, 14.5% of three-wheeler drivers had tampered with the handle lock to improve on their turning circle. This significantly shifts the centre of gravity of the vehicle especially when this manoeuvre is effected at speed, causing the vehicle to topple. Prof. Mohan de Silva, in another study, found that 24 out of 29 three-wheelers that had met with such accidents had handle locks that had been tampered with. It may be that his advocacy has had some effect.

Those travelling in unprotected vehicles like motorcycles, three-wheelers and push bicycles were at a higher risk of suffering injuries. Although these are a poor man's popular mode of transport, if we cannot reduce the numbers of such vehicles on the roads we must at least make a concerted effort to make such modes of transport safe for the user.

The vehicles that the accident occurred against were predictably the protected and heavy vehicles of which vans, lorries, buses and cars came highest, with three-wheelers ranging next in frequency. Twenty-nine percent of the injured were pedestrians and constituted the largest group (as we earlier mentioned this was the largest group killed) and again the group that was least liable to injury was the drivers.

The vehicle colour was not significant although there is a popular belief that vehicles with lighter colours are less prone to accidents. A significant number, 77.7%, had not switched their lights on after dark.
The Injury Severity Score (ISS) which is an index of the severity of the injury sustained was understandably highest in those who had sustained injury from or while in heavy vehicles.

Environment
It may be surprising news that accidents were commoner in roads of normal or narrow width (over 55%) compared to those on major highways. Carpeted surfaces as opposed to rough roads, and light or no traffic on the roads (as opposed to heavy traffic) and also when vision and weather were clear were the environmental conditions which set the scenario for higher accident rates and injuries to the subjects in the study. The above conditions appear to be a temptation for drivers to drive fast on the unfavourable road width giving the driver less room for error. Making the road surface a disincentive for fast driving seems a logical answer.

A significant percentage of pedestrian victims who met with accidents after dusk wore dark clothes. There appears to be a case for advising such pedestrians to wear luminous arm-bands when walking on the roads under such conditions

Drivers
While 19.67% were after alcohol and 9.8% admitted to being under its influence, only four of the subjects had been tested with a breathalyzer. It has been shown that the risk of crashing is four times higher if the driver is using a mobile phone while driving. Six used mobile phones during the accident. One was a pedestrian whose mobile phone rang while he was crossing the road and he was run over when he paused on the middle of the road to take his phone out of his pocket!

Only 4.7% were wearing seat belts. There is no legislation and thus no compulsion for wearing seatbelts even though every car and van imported to Sri Lanka is fitted with them. While 78.9% were self-taught some had registered with a driving school so as to only facilitate the obtaining of the driving licence. The former is a significant statistic.

Fatigue and micro sleep (where drivers fall asleep momentarily for a fraction of a second and wake up almost immediately) are significant driver-related causes of accidents. Twenty-three percent of drivers had driven continuously for over five hours during the preceding 24 hours. A majority admitted to feeling sleepy prior to the accident.

Twenty percent of motorcycle riders and 35.8% pillion riders were not wearing helmets at the time of the accident. However, only 5% had had accidents within the last two years. One should not be complacent and take risks just because one has not met with an accident. Very significantly, 12.2% of car drivers and 26.8 % motorcycle riders did not possess driving licences. This appears to add weight to the argument that more spot checks are necessary.

Six of the drivers who sustained injuries after accidents had a major illness. This included severe visual impairment, a cerebrovascular event resulting in a stroke and a myocardial infarct leading to loss of consciousness.

Swerving to avoid potholes or oncoming vehicles resulted in accidents and injury in15%, half these were in trying to avoid an oncoming vehicle. Careless driving need not necessarily result in an accident to that person but it certainly is a source of risk to others. There is no law to prosecute such irresponsible drivers.

Returning from work and from parties is statistically a significant health hazard as accidents and injury are commoner than when proceeding to work or to parties. Seventy-eight percent who were returning from parties admitted to being under the influence of alcohol.

Most of the vehicles, according to the injured party estimation, were driven at excessive speed, 68% were fast to medium and 29.3% were definitely fast. Forty-three percent of the injured were either travelling in or knocked down by a speeding bus.

Pedestrians
The study showed that 32.8% were jay walking outside the pedestrian crossings. Ten percent were getting on or off a bus indicating the scant respect the bus driver has for his passengers. Those trying to board a bus fell when the bus suddenly pulled away and they were either run over by the rear wheel of the bus or by the vehicle behind the bus. Darting across the road after emerging from behind a parked vehicle contributed to 3.8% injuries. Pedestrian crossings placed in front of a bus are a hazard especially to schoolchildren. About 5.3% of injured pedestrians were under the influence of alcohol, while 62.8% of the injured pedestrians wore dark clothes after dusk.
(Next week: What we can do about it)

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