By Nilanjan Bhor, Indian Institute for Human Settlements and HSG Member
Are pedestrians safe from road accidents in Indian cities? Due to rapid urbanization and economic opportunities in cities, there is a substantial increase in vehicle density and heterogeneity in road users. Collisions between vehicles tends to receive the most attention, Conversely, incidents where pedestrians are injured or killed by moving vehicles (either directly or indirectly) receives relatively less attention and there is growing serious concern over implementing safety measures for pedestrians. As per Government of India road accident statistics, fatal road accidents have increased from 19 per cent in 2005 to 29 per cent in 2017, with an increase in accident severity (i.e. the number of persons killed per 100 accidents) from 21.6 in 2005 to 31.8 in 2017. The share of accident fatalities (including injury) in urban areas decreased in 2017 compared to 2016. Similar trends are observed across 50 cities in India with a population of one million or more.
But there are no data available for urban areas on pedestrian fatalities and injuries as a result of road accidents. Overall, it shows that hit pedestrian cases increased substantially from 2016 to 2017 from 10.5 per cent to 13.8 percent fatalities, respectively. However, the Global Burden of Diseases, Injuries, and Risk Factors Study reported that pedestrians constitute 35 per cent of all deaths due to road accidents in 2017, and the rate was much higher in females than for males. The study also concluded that there is a very slight decrease in death rates between 1990 to 2017, and if a similar trend continues, then India is unlikely to achieve the Sustainable Development Goal target of reducing the death rate for road injuries by half by 2030.
Therefore, there is a need for a concrete prevention and preparedness strategy to address road accidents in India. This blog is a reflection from a tragic road accident as a case study and examines the preparedness of the Indian health system to manage road injuries.
A 58 year old woman was returning home from work, with no idea that her life would drastically change and that she would depend on an artificial limb for the rest of her life. Would she be able to walk and perform everyday activities? Would she be able to live her retired life happily? This life event had not only affected this woman, but her loved ones too.
It was a small town in Hooghly district of West Bengal. As it was around 7pm, streetlights lit the Grant Trunk Road. The road was not very wide, and it had a few potholes. The so-called footpath was dug-up, and mud and soil were dumped over it, looking like construction work was in progress. Though the bus stop was just one kilometer away, as traffic was not moving, the woman got down from the front door of the bus just in front of the dumped soil so that she could enter her house approximately 10 steps away. She found that there was no room to move forward and waited for a while. Once traffic started moving, the woman then saw that the back portion of the bus was coming towards her, and to save herself, she went back a little but slipped and fell, and her ankle went under the wheel of the bus.
Determinants of road accidents
Road conditions (e.g. the width of the road, ensuring there is a concrete footpath for pedestrians), vehicle design measures (e.g. doors that close whilst the bus is in transit), and driver expertise are very important determinants and should be taken into consideration to prevent road accidents. Often, a problem such as the width of a road is not addressed, and many times, this is not considered a determinant. But cases like this one show that these determinants matter and should be demanded everywhere!
Is the health system equipped to support road accident victims?
Do healthcare services in small towns provide appropriate treatment to victims of road accidents? If yes, why the woman was taken to a government multispecialty hospital at the Kolkata metro city that was about 12 kilometers away? The response of health systems to road traffic accident victims is very important during the pre-hospitalization phase (i.e. from the time of accident till the time the victim has reached a hospital). In this case, there was a need of a trained emergency health professional to act immediately after the accident who could have helped the woman to reduce bleeding, dress the injuries and make appropriate decisions about how to respond to that situation. Once in hospital, surgery was performed to fit seven metal rods to support her injured leg. As she had been admitted for three days and not recovered from pain and mental distress, the woman had decided to submit her retirement to the establishment where she used to work. This allowed her to be transferred to a hospital about 280 kilometers away in a neighboring state to avail insurance coverage for further treatment.
Particularly in this case, out-of-pocket expenditure over waiting for insurance coverage could have prevented the woman from having her leg amputated. For nearly a month, the woman was in hospital and no treatment was provided during this time except cleaning and dressing services and medications especially pain killers. The lack of further treatment was due to the insurance process between the establishment and insurance company. Which leads us to ask: are health insurance companies providing patient-friendly, and patient-centered services to its customers? It must function beyond just a documentation process for financial benefit.
Finally, the woman was transferred again to a super specialty hospital in the southern part of India, located approximately 1,700 kilometers away to treat her condition with insurance coverage. Over one and a half months, she underwent two major surgeries in this hospital. Unfortunately, gangrene had formed and spread up to her knee due to the delay in treatment and doctors, with the consent of the woman, had to amputate her left leg below the knee. Even after five years with an artificial limb (imported from Germany, as the Indian manufactured limb was too heavy for her), she has not yet received her disability certificate.
In India, the road is a political metaphor. Though road safety is the joint responsibility of government and citizens using the road (including pedestrians), existing policies and programmes have failed to improve road infrastructure, traffic law enforcement and strengthening health system measures to equip the health system to address injuries due to road accidents. Response to the golden hour (i.e. the first hour) of a road emergency is still weak. Very limited resources are available to address the golden hour: ambulance is not the only solution. There is a need to re-examine the golden hour from the experiences of victims, including pedestrians, injured due to road accidents in order to influence policy. It is also essential to improve surveillance systems and reporting of disabilities due to road accidents in India.