1

Road Map to Road Safety in India

Dr. G. Gururaj

Professor & Head

Department of Epidemiology

WHO Collaborating Center for Injury Prevention and safety promotion

National Institute of Mental Health & Neuro Sciences

Bangalore – 560 029

Phone - +91-80.26995244/45

Fax - +91-80-26564830/2121

Email : guru@nimhans.kar.nic.in ; epiguru@yahoo.com

Website: http://www.nimhans.kar.nic.in/epidemiology/

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Abstract

As India embraces globalization and makes rapid strides in economic growth,

motorization , road infrastructure expansion and industrialization have become hall mark

features of our growth and development. This phenomenon is reflected in all areas of

society life with change of values and life styles. Consequently, transport and mobility have

become an integral part of human life and travel today is a necessity rather than luxury.

After a decade of rapid motorization and infrastructure development efforts, a question to

be addressed at this stage is “has mobility and safety been integrated and go together OR

are we pushing only mobility without accompanying safety on Indian roads? “

Answers to this question are shown by limited data available in the country.

Today Road deaths account for more than 1, 10,000 deaths ( estimated to be 1,25,000 at

least ), 20 million hospitalizations and more than 70 million injuries every year. The

numbers could be much higher as several injuries and few deaths go unnoticed and

unreported. Road traffic injuries and deaths contribute for 10 – 50 % of hospitalizations,

1/3rd

of disabilities and more than 3 % of GDP in terms of. economic losses. Hospital

emergency rooms and wards are filled with RTI patients ,in a country where trauma care is

still in infantile stages The young, males, poor and middle socioeconomic households,

pedestrians – two wheeler occupants – bicyclists, are affected most and suffer highest.. The

pain, agony and suffering are difficult to measure even with advanced research

methodologies.

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Global experience and research has proved that RTIs are predictable and

preventable. A combination of engineering (motor vehicles / roads), enforcement,

education and emergency care through integrated and well coordinated approaches in a

systems approach has been found to be the key for reducing deaths, and injuries. All

programmes need to be scientific, coordinated, monitored and evaluated for efficacy,

effectiveness, cost and sustainability. A real change should be seen in actual reduction in

deaths, injuries and disabilities. Road deaths and injuries should not be the dark side of our

growth and development and it is time, we decided to make a real change on Indian roads.

Dr. G. Gururaj

Professor & Head

Department of Epidemiology

WHO Collaborating Center for Injury Prevention and safety promotion

National Institute of Mental Health & Neuro Sciences

Bangalore – 560 029

Phone - +91-80.26995244/45

Fax - +91-80-26564830/2121

Email : guru@nimhans.kar.nic.in ; epiguru@yahoo.com

Website: http://www.nimhans.kar.nic.in/epidemiology/

4

With rapid globalization, urbanization, industrialization, migration, media

influences and changing life styles of people, injuries have emerged as a major public

health problem in India. However, it is still considered as a transport, police, social and

behavioral problem and are commonly referred to as accidents. With gradual decline in

communicable and infectious diseases, injuries will continue to increase in the coming

years. Globally, it is estimated that nearly 5 million people died due to injuries contributing

for 10% of total deaths in 2002 (1)

. Nearly 80% of these deaths occur in developing

countries like India where health care resources are limited and prevention is still not the

focus. Injury is defined as “a body lesion resulting from acute exposure to sudden

mechanical, electrical, thermal, chemical or radiate energy, interacting with body in

amounts that exceed the threshold of Physiological Tolerance” (2)

. Thus, the concept,

mechanism and prevention of injuries extend beyond the simple notion of “accidents”, to a

process of energy development and transfer to human beings. This understanding has

resulted in developing approaches for injury prevention and safety promotion in many parts

of the World.

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In India, the injury mortality rate is 40/100,000 with 2/3 of these occurring in

younger age groups of 15-44 yrs, with an overall male to female ratio of 3:1. Research

studies in India have revealed injuries contribute to 13-18% of total deaths (3,4)

. The

Survey of Causes of Death (5)

and the Medical Certification of Cause of Death (6)

revealed

that nearly 12% of total deaths are due to injuries. Nearly, 10-30% of total hospital

registrations are due to injuries with case fatality rates ranging from 5-20% across

studies. Several population based studies have documented the increasing occurrence of

injuries, being much higher than the nationally reported figures (7)

. All these conclusive

point out that injuries are a leading cause of deaths, hospitalizations and disabilities. It is

essential to note that for every death, nearly 15-20 would be hospitalized and more that

50 receive care in emergency room departments of hospitals. A recent national review

estimated that there are nearly one million deaths that occur due to injuries with 20

million hospitalization and more than 50 million minor injuries (7)

.

India Injury pyramid, 2005India Injury pyramid, 2005

Deaths (1)Deaths (1)

Serious Injuries (20)Serious Injuries (20)

MinorMinor Injuries (50)Injuries (50)

8,50,000 (upto 10,00,000)8,50,000 (upto 10,00,000)

17,000,000 (upto 20,000,000)17,000,000 (upto 20,000,000)

42,500,000 (upto 50 million)42,500,000 (upto 50 million)

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India is witnessing a rapid increase in the number of vehicles added on to the

roads along with rapid expansion of road infrastructure networks. The country has a total

road network of approximately 33.84 lakh kms, with national highways, state highways

and urban roads constituting 2%, 4% and 7% , respectively. The national highways carry

around 40% of total road traffic contributing for more than 1/3 of deaths of deaths and

injuries. It is commonly believed that economic growth leading to motorization and

infrastructure expansion results in an increase of road deaths and injuries. However, this

has turned out to be a myth, as noticed by the fact that despite increase in motorization

and infrastructure expansion, road deaths have decreased in many high income countries

of the world.

Road traffic fatality defined as “any person killed immediately or dying within 30

days as a result of an injury or accident” is the commonest definition followed in India (8)

Among the various types of injuries, RTIs occupy a major share of burden and impact.

RTIs were the 9th

leading cause of death and are expected to move to 6th

place by 2020 (9)

.

Globally RTIs are the second leading cause of death in 15 – 29 years age group

Beginning with the invention of motor vehicles in the 18th

Century, the World has lost

millions of people in road crashes. As per WHO, RTIs are the 6th

leading cause of death

with a greater share of hospitalization, disabilities and socio-economic losses (10)

. Apart

from deaths and hospitalization, the burden on the health sector is phenomenal towards

pre-hospital/acute care and rehabilitation. Commonly affecting the young and middle age

groups of society, the socioeconomic losses are huge, though unmeasured. While large

scale poverty alleviation and reduction programmes are planned and implemented in the

7

country, it is paradoxical that RTIs and other injuries keep on contributing to the growing

cycle of poverty.

The growth of the motor vehicle industry has been impressive and phenomenal in

the last decade due to liberalized economic policies of successive government (s), growth

of the motor vehicle industry, influence of media along with increasing purchasing power

of the people. The total number of vehicles increased from 5.3 million in 1981 to nearly

80 million by 2005(11)

. This impressive growth is largely seen in the increase of

motorized two wheelers with more than 70% belonging to this category. Only 15% are

comprised of cars and even if the present economic growth continues, it will be several

more years before a true reduction in motor cycles will be seen in the country.

Detailed studies of transport and travel patterns of Indian population are lacking,

Nevertheless, few of the limited studies reveal that pedestrians, motorized two wheelers

and bicycles contribute for a larger proportion of traffic on Indian roads. Studies by

TRIPP, New Delhi, indicate that the share of non-motorized transport varies from 30-

70% during peak hours in some of the cities. Even among those traveling by cars, a

substantial proportion of travel is through walking and every motorized trip includes a

significant proportion of non-motorized travel (12)

. In a study of 13 cities, personalized

modes of transport comprised more than 90% of vehicles, while public transport was

< 1%(13)

. It is common to see even on all the highways, a substantial proportion of road

users are pedestrians, two wheelers and bicyclists. Indian highways pass through a large

number of densly populated villages and towns with the spatial distribution of community

organizations like, schools, colleges, religious places, markets and others. This results in

8

varied exposure of different road users to different vehicles in a heterogeneous traffic

environment.

The National Crime Records Bureau (NCRB) is the national nodal agency for

collecting, analyzing and disseminating information on road traffic deaths and injuries in

India. According to latest reports, RTI deaths increased from 50,700 to more than

100,000 during the 15 year period of 1991-2006. In 2006, 105,272 persons died due to

road crashes in the country. Similarly, RTIs increased by 4 times from 100,000 to more

than 500,000 in the same period. The overall national mortality rate of RTI in India was

10/100,000 for the year 2005(14)

. However, signification variations across the states are

seen with Tamil Nadu reporting 20/100,000 to as low as 2/100,000 in Nagaland. Some of

the independent reports like the Survey of Causes of Death (5)

and the Medical

Certification of Causes of Death (6)

have reported that nearly 2% of total deaths are due to

RTIs in India. Data from the Ministry of road transport and highways indicates that more

than 1/3 of deaths and injuries occur on national highways. It is interesting to note that –

(i) only 15% of fatalities occur in the urban India while large number of deaths and

injuries are seen in district and rural parts of the country, (ii) the economically

progressive states of Tamil Nadu, Andhra Pradesh, Kerala, Karnataka, Maharashtra and

others have higher than the national average rates, and, (iii) the death to injury ratio

varies as per the reporting practices.

Figure 1 : Road deaths in

India, 1980 - 2006

0

20

40

60

80

100

120

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

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Figure 2 : Road Traffic Injuries in India , 1985 - 2006

Figure 3 : State wise distribution of RTI deaths in India, 2005

National Average – 104 / million Population

0

5 0

1 0 0

1 5 0

2 0 0

2 5 0

3 0 0

3 5 0

4 0 0

4 5 0

5 0 0

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

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State Rate / Tamil Nadu 216 Goa 178 Haryana 143 Andhra 137 Sikkim 135 Himachal 134 Delhi 130 Chandigarh 128 Karnataka 124 Rajasthan 111 Chhattisgarh 105 Maharashtra 103 Gujarat 97 Kerala 96 Uttaranchal 96 Madhya 82 Jammu & 80 Arunachal 77 Orissa 75 Punjab 63 Tripura 61 Manipur 61 Mizoram 56 Uttar 55 West Bengal 52 Assam 52 Meghalaya 50 Jharkhand 44 Bihar 24 Nagaland 20

In contrast to these national figures, hospital based studies indicate that 20-50% of

emergency room registrations and 20-30% of hospital admissions are due to RTIs (15)

. In

a survey of 23 hospitals in Bangalore, RTIs contributed for 12% of Casualty registrations,

52% of total injury registrations, 22% of admissions and 35% of injury death (16)

. At the

same time, few of the population based studies indicate that RTIs are one among the three

leading causes of deaths in the age group of 5-44 years with a male preponderance (15)

. In

a population based survey of nearly 100,000 individuals, the mortality and incidence of

RTIs was found to be 34 and 649 / 100,000 population (17, 18)

. These observations

highlight that under reporting of RTIs is a serious problem and the need for strengthening

information systems and research in India. A recent working committee of the Planning

11

Commission has estimated that the ratio of deaths to serious injuries and minor injuries is

in the range of 1:15:70(19)

.

Undoubtedly, RTIs are a major public health problem of young, affecting the

economically productive sections of society. Data from hospital based, population based

and independent reviews are in similarity with this observation. Further, studies also

indicate that males are involved in significant numbers with a male to female ratio of 4:1.

As per NCRB report of 2005, 2/3 of deaths occurred in the age group of 15-44 yrs, with

children and elderly accounting for 7% and 8% of deaths, respectively (14)

. Almost all

studies also indicate that motorized two wheeler occupants, pedestrians and bicyclists –

“vulnerable road users”, are killed and injured in large numbers. This is a reality as these

road users are directly exposed to traffic, unprotected, and crash with heavy vehicles

result in greater energy transfer resulting in higher number of deaths and injuries.

Hospital studies in Bangalore during 1993, 1998, 2005 and 2007 indicate that VRUs are

involved in 70-80% of crashes (15)

. Consequently, deaths, injuries and disabilities in this

category are extremely high.

The severity, nature and outcome from RTIs are influenced by a variety of factors

in the epidemiological triage of agent-host environment interactions. As per Trunkey,

nearly 50-60% of deaths occur at the site of crash or during transport to a hospital, 20-

30% during hospital stay and 5-10% after discharge from a hospital (20)

. Indian data

reveal that 30-50% die at crash sites (varies as per location of urban / rural: highway /

inner-city roads), 10-15% enroute to hospital and the rest during or after hospital contact

(15). Hospital based studies indicate that 2-3% are brought dead. Several studies indicate

that injury to head and extremities predominate with polytrauma observed in 20-40% of

12

RTI patients (21, 22)

. Brain injuries are extremely common among RTI patients with >50%

of hospitalized patients suffering from Traumatic Brain Injury (21)

.

With the decline of communicable diseases, disabilities due to polio and other

conditions will decline in the coming years. With growing increase in RTIs, this will be a

leading cause of preventable disability in young and middle age groups. As per WHO,

nearly 100% of severe, 50% of moderate and 10% of mildly injured persons need long

term rehabilitation services (23)

. Hospital based studies reveal that 20-40% of those

discharged after an RTI are likely to have long term disabilities (21)

. It is estimated that

among the 3.5 million people in India, nearly 2 million are related to RTIs. The

consequences of a road traffic crash can be severe and varies affecting the physical,

social, economic, spiritual and psychological aspects of an individuals and family’s life.

The socioeconomic impact of RTIs are huge and phenomenal though unmeasured.

The direct and indirect costs due to acute/long term medical care, vehicle and property

damages, legal and funeral expenses, loss of work and school, depletion of savings and

extra loans made, work replacement and support are significant, but difficult to measure

even with advanced research methodologies. The pain, suffering, agony and anxiety are

difficult to comprehend and can only be learnt and understood from the experience of

affected individuals and families. In a review of the economic impact of RTIs, it is

13

estimated that the losses due to RTIs are to the tune of Rs. 550,000 million every year or

nearly 3% of India’s GDP (with the base year of 2000) (12)

. The cost could be much

higher as revealed by a recent Delhi based study with the cost of fatality estimated at Rs.

1.3 million using the willingness to pay approach (24)

.

Understanding the causes is the most crucial step to develop remedial measures

for prevention of RTIs. Further, unfurling the nature, severity and impact of RTIs is

essential to develop measures for secondary and tertiary prevention of RTIs. A number of

factors in human, vehicle and environmental spheres contribute for the occurrence of

RTIs. Some of the recent reports have discussed these issues and various responsible risk

factors in detail. Some of the known factors include presence of a heterogeneous traffic

mix, unsafe design of roads and vehicles, increasing speeds, non-use of helmets and seat

belts, drinking and driving, poor visibility, failure to implement safety laws, poor status

of trauma care and several others (12, 15)

. A system’s approach to road safety with

mechanisms for coordinating, implementing and evaluating road safety activities is

lacking in India. It is only recently, that a national road safety policy is under the

consideration of Parliamentarians and Law makers.

Trauma care in India, though evolving as a specialty is totally without direction

and at cross roads. Several problems have been identified in some of the recent

reviews(25)

. Inadequate emergency and trauma care along with lack of trauma audits and

systems contribute for a large number of deaths and disabilities. Studies have identified

some major contributing factors like lack of immediate first-aid, delays in transfer of

patients, longer time interval between crash and reaching a hospital (definitive hospital),

absence of triage, poor status of facilities in public hospitals as some major problems

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prevalent in trauma care services in India (25, 26, 27)

. Studies in Bangalore have shown that

more than a third of the patients reach hospital beyond 3 hours, less than a quarter is

transported in ambulances (majority reach in 3 wheeled autos or private vehicles) and

higher referral from hospitals as issues of concern (25)

. Proliferation of ambulances,

institutions, investigative facilities in private sector combined with lack of facilities in the

public sector have worsened the scenario with increasing referrals. In an environment of

absence of - insurance, clear guidelines, standards and protocols for trauma care, the

issues need greater attention. Some of the recent initiatives by the Government of India,

in terms of establishment of trauma care centres, increasing ambulance facilities on the

highways, development of emergency medical care personnel need to be systematically

monitored and coordinated for optimum results. Even the existing minimal highway

ambulance care programmes of India have not been evaluated for efficacy and

effectiveness and systematic evaluations is the need of the hour. Improvement in trauma

care services are found to contribute for a reduction of approximately 20% of deaths in

RTIs, beginning with the time of crash and continuing there after. Recent WHO reports

have outlined that a systematic approach to trauma care should focus on augmentation of

basic facilities and availability of skilled man power as two important steps to strengthen

trauma care (28, 29)

. Needless to mention evaluation at periodical intervals will be a key

step in the coming years

Global experience has revealed that RTIs are predictable and preventable (30)

. This

is based on the experience of high income countries that have built road safety in a

systematic manner based on research and through coordinated activities. The global

experience on strengthening road safety revolves around Engineering, Enforcement,

15

Emergency care and Education resulting in economic benefits to the society. A system’s

approach to road safety is strongly recommended as number of activities and stakeholders

needs to be integrated and coordinated to obtain optimum results. A mechanism to

implement road safety with a clear vision, mission and objectives is urgently required in

India.

The current Indian efforts are strongly centered around education of people to

adapt safe behaviors along with expansion of roads The ongoing road safety education

programmes are isolated events happening once in a while and not been systematically

evaluated. Global experience and WHO recommendations (30)

reveal that a positive

change can be visible when education is combined with enforcement and engineering

solutions. A stand alone vertical approach will have less impact in actually reducing

deaths, injuries and disabilities, while knowledge might increase for short spells of time.

This observation warrants that much more needs to be done in terms of developing

improved urban planning approaches, safety engineering solutions, better design of

vehicles, improved enforcement practices, and augmented trauma care systems. Some of

the recent engineering approaches for design and maintenance of roads need evaluation

from an Indian point of view.

Strengthening trauma care is crucial at this juncture. WHO has cautioned that

many expensive technological practices like early large intravenous fluid administration,

pre-hospital spinal immobilization, advanced life support training for ambulance crews

are not effective in decreasing the morbidity and mortality to RTIs (31)

. At the same time,

improving basic emergency medical care, enhancing skills of emergency care personnel,

better communication and notification systems, improving basic facilities in hospitals,

16

developing uniform guidelines/standards/protocols, promoting triage and trauma audits,

are likely to yield positive benefits (15)

.

RTIs in India are a major public health problem and needs a public health

approach. This approach requires the active participation, cooperation and coordination

between different ministries of the government, automobile industry, parliamentarians,

law makers and the public at large. Political will, systems approach, programmes driven

by research and evidence, monitoring and evaluation are the central pillars required for

this new approach. Identifying the risk factors and causative mechanisms, implementing

known and proven solutions and moving forward with strategic approaches are urgently

required. Progress is inevitable, but not at the cost of millions of deaths, injuries and

disabilities. The Indian society need to realize and awaken to the growing epidemic of

RTIs and move from pessimistic/fatalistic approach to an optimistic/scientific approach.

Road Traffic Injuries (RTIs) are the only public health problem where society and

decision makers still accept death and disability on a large scale among young people.

This human sacrifice is deemed necessary to maintain high levels of mobility and is seen

as a necessary “externality” of doing business. Discussion revolves around the number of

deaths and injuries we are willing to accept.

(Mohan D, The Road ahead, TRIPP, New Delhi ,2004.

17

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21

State Rate / million

Tamil Nadu 216

Goa 178

Haryana 143

Andhra Pradesh 137

Sikkim 135

Himachal Pradesh 134

Delhi 130

Chandigarh 128

Karnataka 124

Rajasthan 111

Chhattisgarh 105

Maharashtra 103

Gujarat 97

Kerala 96

Uttaranchal 96

Madhya Pradesh 82

Jammu & Kashmir 80

Arunachal Pradesh 77

Orissa 75

Punjab 63

Tripura 61

Manipur 61

Mizoram 56

Uttar Pradesh 55

West Bengal 52

Assam 52

Meghalaya 50

Jharkhand 44

Bihar 24

Nagaland 20