Transportation and Global Health, an Underestimated Challenge

If the present trend continues, road traffic injuries (RTIs) are expected to kill approximately 1.9 million people per year by 2020, which would raise them to rank three of the leading causes of death. RTIs are the most important cause of death among young people between 15 and 29 years of age.  And the burden is hardly shared equitably around the world: over ninety percent of the fatalities occur in low- or middle income countries
 Promoting non-motorized forms of transport, notably walking and cycling, comes with the double benefit of both mitigating the triple health burdens of RTIs, climate change and air pollution and of providing the positive health benefits of increased physical activity. This double advantage appears true both for cities in high-income industrialized and in middle-income industrializing countries

 Transportation and Global Health, an Underestimated Challenge

by Iris Borowy

Institute for the History, Theory and Ethics of Medicine, RWTH Aachen UniversityGermany

Mobility is a crucial part to people’€™s lives everywhere. People need to get around to go to work, to schools or to university, to reach stores or markets and to get to doctors and hospitals to receive medical care. People also need to be able to transport goods, either on a private basis to buy and transport home what they need and to see what they produce, or commercially, to sell and buy the products that sustain the economy. Of these functions, access to medical care has the most direct connection to health, but, in reality, all factors affect central determinants of health: education, employment, income and access to the necessities of life. Generally, a functioning economy is vital to population health, and in many ways, increasing transportation possibilities increases the health potential of a society. However, increasing transportation also increases its health risks, and, depending on its form and circumstances, at some point, the health burden of mobility risks overwhelming its health benefits.

 Nothing epitomizes this risk as poignantly as the meteoric rise of the car. A mere 150 years ago, cars were unheard of. In a matter of a few generations, this new invention revolutionized the way people in industrialized countries traveled, worked, shopped and lived in spaces that were increasingly designed to accommodate car traffic. The number of cars and trucks in the world exploded from roughly one million in 1910 to 50 million in 1930, 100 million in 1955, 500 million in 1985 and one billion in 2010. It has kept rising since. In high- and increasingly in middle-income countries, car traffic has determined how people move around, how and where they live, work, buy what they need and how they spend their free time.  In addition, average driving distances expanded, further increasing overall traffic exposure.  In many places, cars represent the dominant or even the only prevalent means of transportation beyond walking distances. For many people, having a car represents freedom and a sense of options in life.

In global health terms, the price for this development is stiff. One area of health risk, which has been attracting substantial attention in recent years, involve road traffic injuries (RTIs). Every year, approximately 1.24 million people die of RTIs as a result of crashes involving a motorized vehicle. Between 20 and 50 million people suffer non-fatal injuries. Economic costs are estimated to range between one and three percent of national GNPs.   RTIs rank ninth among the ten leading causes of death, and seventh in upper middle income countries. And the numbers are rising. If the present trend continues, RTIs are expected to kill approximately 1.9 million people per year by 2020, which would raise them to rank three of the leading causes of death. RTIs are the most important cause of death among young people between 15 and 29 years of age.  And the burden is hardly shared equitably around the world. Over ninety percent of the fatalities occur in  low- or middle income countries.

 Those particularly at risk are the “€žvulnerable road users”€œ, i.e. pedestrians, cyclists and motorcyclists. They are also the heaviest users of roads in low-income countries and are, themselves, often poor, demonstrating the social gradient involved in RTI risks. The distribution of different groups of RTI victims varies dramatically between countries of different income levels. Approximately 45% of road traffic fatalities in low-income countries are among pedestrians, but only 29% in middle-income and 18% in high-income countries. These changes reflect similarly different absolute numbers.  227,835 pedestrians are estimated to die in low-income countries each year, compared to 161,501 in middle-income and 22,500 in high-income countries. In addition, there is a distinct gender gap. Worldwide, men are almost three times as likely to be killed in a road accident as women. Given the age and gender specificities, the victims of RTI form the economically most active group. Often, families depend on their income, and if they die or are incapacitated, many people are affected. In a larger sense, the societies at large suffer from the disproportionate risk carried by their potentially most productive members.  Thus, the present and future health burden of RTIs is disproportionately borne by people, who cannot afford to own cars, and by  countries that can least afford to meet the health service, economic and societal challenges.

 RTIs prevalence is not fate. It is the result of a complex combination of circumstances and policies and, thus, amenable to changes. Industrialized countries have seen a drastic decline in RTI mortality since its peak in the 1970s. For instance, in Australia, RTI fell from 30.4/100,000 in 1970 to 5.7/100,000 in 2012. Declines were similarly steep in Austria (34.5 to 6.3), France (32.6 to 5.8), Germany (27.3 to 4.9) and Italy (20.5 to 6.0). In 2012, RTI mortality in industrialized countries ranged from 2.8/100,000 in the United Kingdom and Iceland to 10.7/100,000 in the USA. This development reflected changes in a broad range of relevant factors, falling under the responsibility of various actors. A key factors involve the behavior of individual traffic participants, notably the prevention of speeding, drunk driving and the use of protective gear, especially helmets and seat-belts. A focus on the role of vehicles points to the responsibility of manufacturers and the role of car designs and equipment, such as air bags. Several factors highlight the responsibility of administrations, which decide on the set-up of roads, notably their size, surface, markings, signs and maintenance, but also its structure which may or may not allow the separation of different traffic participants with different lanes for cars, bicycles and pedestrians. The establishment of pedestrian zones also falls into this category. Administrations are also responsible for the extent to which traffic regulations exist and are enforced. Meanwhile, medical services have an important role to play. Generally, the quantity and quality of ambulances and hospitals and, more specifically, the degree to which staff is trained to treat RTIs all help determine in how far traffic crashes translate into long-term injury and disability. Most of these factors improve with the economic development of a country. High-income countries simply tend to have better cars, better roads, better regulations, better law enforcement and better medical services. This point is borne out by a comparison with RTI mortality data with low- and middle-income countries, which are comparable to those experienced in industrialized countries some decades ago, such as the Dominican  Republic (41.7), Iran (34.1), Malaysia (25.0), Nigeria (33.7) or Thailand (38.1).

 This observation has given rise to the theory that the development of RTIs generally follows a Kuznets-curve like trend, i.e. RTIs first increase with rising national income along with growing but largely unregulated motorization, but then decrease after a peak, as regulations and improved material quality and services take over. Consequently, it has been suggested that low- and middle-income countries would have to undergo a developmental process.  This view was taken by, among others, a World Bank report of 2003, which predicted that “€žthe fatality rate will rise to approximately 2 per 10,000 persons in developing countries by 2020, while it will fall to less than 1 per 10,000 in high-income countries.”€œ This prediction has largely become true, and these data appear to support an underlying assumption that low-income countries would repeat the past experience of industrialized countries, that things will have to get worse before they get better and that the best policy to reduce the burden of RTIs would be to foster economic growth. A similar claim is still being made, albeit with a focus on wealth, reduced corruption and improvements in medical care and technology. Not surprisingly, this approach has been popular in the industrial sector. Thus, a 2007 study that was financially supported by the automobile industry found that lives could be saved by lowering either vehicles per capita or the fatalities by vehicle but ruled out the first strategy since it was “€œinextricably linked to economic growth. Consequently, the focus should be on reducing fatalities per vehicle.”€ Clearly, this approach would limit anti-RTI strategies to those not harmful to the interests of the car industry. It also portrayed RTIs as a regrettable but temporary side effect of modernisation.

However, this perspective is questionable for several reasons: from an ethical and even a medical point of view it seems difficult to accept that this dramatic number of lost lives should be the price to be paid for increasing economic well-being and for -€“ eventually -€“ a reduced health risk of traffic. Besides, the logic is flawed. According to a 2003 report by the UN Secretary General, WHO and the World Bank, estimated global costs of the RTI burden amounted to $ 518 billion per annum and $ 100 billion in developing countries “€˜twice the annual amount of development assistance to developing countries.”€™ Thus, instead of price that must be paid for a generally beneficial economic development RTIs must primarily be understood as a powerful impediment to development.

Besides, one must question the theory that it will be possible for low-income countries to repeat the development of industrialized countries, with a traffic system largely based on individual motorized vehicles. For many years, this assumption determined many development aid and investment decisions, which focused on the construction of streets and motorways. Thus, 73 percent of the -€“ substantial -€“ World Bank commitments to the transport sector in supported countries between 1996 and 2006 were dedicated to road construction. The rationale provided referred to the impact of road transportation on poverty reduction but also to the importance of roads to free market trade and to the immense growth potential of the automobile sector in emerging economies like India and China. In other words, the export interests of industries in Northern countries influenced development decisions in and for Southern countries in support of modes of transportation that mimicked infrastructures of industrialized countries and favored motorized traffic participants at the expense (and the risk) of the others, privileging the needs of a minority of affluent citizens, who could afford cars, over those of a majority, who could not. But even if such self-interested motives are discounted, a repetition of the industrialized transportation model all over the world is neither desirable nor realistic. The long-term availability of fuel is obviously in doubt. But even assuming that the discovery of new oil wells and of new alternative techniques of oil exploitation such as fracking, will postpone fuel shortages for many decades to come, a very optimistic assumption, it is difficult to imagine that the planet should be able to provide the material resources for the production, the operation and the disposal of a cars on a scale of motorization in industrialized countries today. In the USA, the most motorized country of the world, there were 808 motorized vehicles for every 1,000 people in 2012. The corresponding numbers in other parts of the world are 187 in Brazil, 81.5 in China, 33.6 in Africa and 24.4 in India. A ten-fold increase in China alone would roughly double the number of cars in the world today.

But even if this was materially possible, the health burden resulting from the environmental effects would be unacceptable. According to a WHO study, published in 2000, motor vehicles are a major source of a series of air pollutants, emitted very close to people and often near nose height, estimated to cause between 36,000 and 129,000 adult deaths in European cities or approximately twice the number of deaths resulting from RTIs (!). Road traffic related air pollution is also believed to cause substantial increase of chronic bronchitis and asthma. An addition, motorized traffic accounted for approximately one quarter of all CO2 emissions in EU countries, establishing a direct link between road traffic and climate change. The potential health impact of climate is truly frightening.  A study by the Potsdam Institute for Climate Effects, published by the World Bank in 2013 describe a scenario of an increase of world temperature by four degrees centigrade, foreseeing, among other effects, a substantial increase in infant mortality, of respiratory, cardiovascular, gastrointestinal and vector-borne diseases, of loss of lives and livelihoods resulting from increasingly frequent extreme weather events and a decrease of global food production. Given the uneven distribution of these effects, climate change would also increase global inequalities, increasing the likelihood of violent conflict.

 Theoretically, it is conceivable that one day we may have a means of individualized transportation that does not require fossil fuels, does not emit harmful exhaust fumes, and uses recyclable material.  But in the foreseeable future, no such solution is in sight on a mass and affordable scale. Clearly, an evaluation of the health effect of transportation must take these considerations into account.

 To some degree, comprehensive approaches to the health repercussions of transportation have emerged in high-income countries. Between the 1970s and the 1990s, most industrialized countries sought to decrease the health risk of transportation related air pollution by prohibiting leaded fuel, by making catalytic converters mandatory and by generally tightening emission standards. However, these policies have largely been considered in a context of air pollution, disconnected from considerations of overall concepts of transport and mobility. Most efforts in that regard have focused on reducing RTI mortality, a more direct and immediately visible link between road traffic and public health. In recent years, these efforts have given rise to various, sometimes contradictory approaches. They included Vision Zero in Sweden, which shifts the responsibility for traffic safety from the participants to a system, designed to allow increased traffic flow while reducing crashes (ideally to zero) through a strict separation of traffic participants. On the other hand, there has been a long list of initiatives to restore urban space as shared  living space for all citizens and to reduce traffic accidents by forcing all participants to assume the full responsibility for their own and each other’€™s safety.

Meanwhile, until recently, the health burden of transportation in the rest of the world has long been a somewhat neglected topic compared to other burdens of diseases of comparable magnitude. The picture changed in the early twenty-first century when a host of international activities have addressed the issue, of which the following are only a few pivotal examples. By 2002, RTIs were coined a global public health problem. In  2003, a UN study on the Global road safety crisis called attention to the importance of the issue in low- and middle-income countries. Taking inspiration from developments in urban areas in high-income regions, it advocated integrating RTI consideration into a broader vision of urban development and transportation planning, which avoided a one-sided concentration on car-based system of traffic but also included alternative modes of transport. Its call for a “systems approach” was echoed in a large-scale study published jointly by the WHO and the World Bank a year later. After an extensive analysis of the issue, this document recommended, among other measures, indirect but highly relevant strategies of designing the material and organizational infrastructure that would satisfy human needs for food, household items, work and leisure activities while reducing transportation needs. This goal would require a reorientation of city planning, aiming at clustered, mixed-use community services and making ample use of electronic long-distance communication. Remaining unavoidable transportation should de-emphasize individual motorized forms of mobility. However, though offering a wide visions and far-sighted considerations, these recommendations only took a relatively small part of the very comprehensive report, a lot of which focused on more conventional measures such as speed control and the use of seat-belts. It appears that follow-up activities have largely focused on these tangible measures, which promised to make road traffic safer without requiring fundamental systemic change.

 As a case in point, the WHO Global status report on road safety 2009 presented recorded or estimated RTI data of 178 countries, while its analysis and recommendations focused on five key items: speed, drinking and driving, use of motorcycle helmets, seatbelts and child restraints, as well as related legislation.  They are still identified as the major risk factors and the WHO criticizes than only 28 countries, representing a mere 7 percent of the world population, have adequate laws that address all five factors. There is no doubt that these factors are crucial and improving them would go far in reducing the immediate health burden of RTIs. But they have little to do with a comprehensive vision of local, national and global transportation and mobility that would best serve long-term health considerations.

It is difficult to quantify yet impossible to overlook that many initiatives in recent years have carried the sign of involvement of the automobile industry, which strove to improve its reputation and maintain the acceptance of car traffic by supporting measures that would improve its safety without challenging its principle. Notably, the FIA Foundation, an association of automobile clubs and motorsport associations, became involved in high-level international initiatives to promote road safety, thus narrowing the question from how to provide healthful forms of communication and mobility to that of safe roads. Thus, it was one of many partners, including international organizations, governments, NGOs and the private sector, when the UN declared a Decade of Action for Road Safety 2011-2020, meant to energize participating countries into taking active measures in the field. Its agenda focuses on five “€œpillars”€: Road safety management, safer roads and mobility, safer vehicles, safer road users, and post-crash response. These recommendations, while mentioning the need to promote alternatives to private motorized transportation, tended to bury them in a majority of technical recommendation on ways to make car and motorcycle traffic safer.

 The latest examples in this series of high-level international publications upgrade non-motorized traffic to some extent. The 2013 update  Global status report on road safety 2013 designed as a baseline report for the Decade of Action Road Safety Campaign, published by the WHO and the Bloomberg Foundation, included a chapter on existing programs to promote non-motorized transportation and on the importance of making public transportation safe. Recently, even the Make Roads Safe Campaign, an initiative jointly carried by NGOs, public health advocates, automobile associations and the car industry, have included walking and the safety of pedestrians in their call for “€œsafe roads”, otherwise more interested in maintaining the acceptance of car traffic on those roads. Similarly, a road safety manual on Pedestrian Safety, jointly published by the WHO and FIA Foundation addressed various measures to make pedestrians traffic safer, including the separation of pedestrian from motorized traffic and the encouragement of public transportation.

These signs are encouraging and should be welcomed. But at a time of continuing increases in the number of cars on roads worldwide, they also appear painfully inadequate. They show that the international attention to RTIs in low- and middle-income countries, though crucially important and badly overdue, have also been a mixed blessing. By restricting the focus on technical approaches within a narrow focus on RTIs as the supposedly central factor of health relevance, it has effectively prevented a larger view on the relation of transportation and health, including important aspects of air pollution, climate change and physical exercise.  This is unfortunate, since the health costs of continuing a transportation system based on individual motorized traffic are far higher than measurable in RTIs and, by the same token, the health benefits of a changed system are far higher and multi-faceted.

 Promoting non-motorized forms of transport, notably walking and cycling, comes with the double benefit of both mitigating the triple health burdens of RTIs, climate change and air pollution and of providing the positive health benefits of increased physical activity. This double advantage appears true both for cities in high-income industrialized and in middle-income industrializing countries. A comparison of different scenarios of possible future traffic developments in London and Delhi, supported and published by Lancet in 2009, found that major public health benefits could be achieved by a combination of reduced motor vehicle use, more walking and cycling, and the use of low-carbon-emission motor vehicles. In Delhi, this scenario entailed a 10-€“25% cut in heart disease and stroke, a 6-€“17% reduction in diabetes and a 33 percent reduction in RTIs while cutting CO2 emissions by three fifth. Consequently, the authors, scholars of various institutes in Britain and in India, conclude that “€œreplacing motor vehicle trips with walking or cycling is a win-win in both developed & developing countries”,€ that “€œpedestrians and cyclists have the right to direct, pleasant and safe routes”€ and that motor vehicles should be restricted in terms of “€œspeed, road space and convenience.”€

 Indeed, in the long run, the crucial challenge for safeguarding population health in the future appears to be not so much how to coordinate private motorized traffic, public transportation and non-motorized traffic in a way that maximizes the safety of all participants, but how to replace private motorized traffic while safeguarding the health benefits of a modern economy in general and of efficient transportation in particular. Making transportation compatible with population health will require a fundamental transformation of how people and societies interact. Concepts of what such a transformation could or should like vary. Sociologist John Urry sees the demise of the dominance of the car on mobility and life in general during the twenty-first century. He envisages a “…€žpost-car system”€œ, a  high-tech system whereby the digital world is integrated for coordination and payment of a variety of individual and collective transportation means  and also an improvement of virtual forms of communication leading to a reduction of face to face meetings. If and to what extent such a transformation will be applicable on global scale remains to be seen. Presumably, different places will require different approaches, adapted to local needs and traditions. But to be truly conducive to health in high- as well as low-income countries, any concept will have to take into account a combination of social determinants, including the risk of accidents, air quality, climate stability and the access to rural and urban space for a variety of activities. This will require a changes in industry (including but not limited to the car industry), of employment, of local and global trade and, by extension, of production and consumption. It will require creativity, courage and optimism. Above all, it will require acknowledging the significance of transportation and mobility as a public health issue for today and far into the future.