Leading article

The truth about road traffic accidentsI. RobertsClinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK (e-mail: ian.roberts@lshtm.ac.uk)

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.7786

Increasing motor vehicle use is now amajor threat to the quality of urbanlife in many parts of the world. Motorvehicles kill thousands of pedestri-ans and cyclists daily, disabling tensof thousands more. With rising roaddanger, everyday walking and cyclingis declining in popularity and thismay be a factor in the obesity epi-demic, particularly in the Westernworld. Against this backdrop, it wouldseem appropriate that public healthand health services are judged againstthe criterion not only of improv-ing well-being but also of reducinginequality and preventing environ-mental degradation.

Trauma is a disease of poverty.Although anyone can be the victimof a violent attack or a road trafficaccident, the risk is much higher forthe most disadvantaged. In the UK,children in the lowest social class are20 times more likely to be injured aspedestrians than those in the highestsocial class1. The strong link betweenroad trauma and poverty is also seenin low- and middle-income countries,where people who will never own acar represent the majority of trafficvictims2. The injuries sustained can bea cause of poverty as well as a conse-quence. A study in Bangladesh foundthat many households were made des-titute by the death or injury of a familymember in a road traffic crash. Med-ical costs, funeral costs and the loss offamily income can lead to decreasedfood consumption, a fall in living stan-dards and increased indebtedness3.

Ensuring that walking and cyclingare the safest, most enjoyable andmost convenient modes of urbantransport is critical for improving

health, reducing inequality and ensur-ing ecological sustainability. Meetinggreenhouse gas emission targets in thetransport sector requires substantialincreases in walking and cycling withcorresponding reductions in car use.Based on the evidence linking physi-cal activity and health, it is estimatedthat the necessary increases in walk-ing and cycling would dramatically cutrates of chronic disease, with around10–20 per cent less heart disease andstroke, 12–18 per cent less breast can-cer and 8 per cent less dementia4. Sus-tainable transport would also improvemental health with an estimated6 per cent less depression. Reducingthe speed and volume of traffic inurban areas is the cornerstone ofreducing danger on the roads. Doc-tors can play an important advocacyrole by working with victim orga-nizations in calling for road dangerreduction5.

The evidence base for the preven-tion of road traffic accidents is strongand the major obstacles to preventionare largely political. When it comesto providing effective healthcare fortrauma victims, however, the evidencebase is weak and we cannot be surethat even current treatment proto-cols do more good than harm6. TheClinical Randomisation of an Antifib-rinolytic in Significant Haemorrhage(CRASH) 2 trial7 recently showedthat providing reliable evidence aboutthe effectiveness of emergency traumacare is possible. This study recruited20 211 patients from 274 hospitals in40 countries and demonstrated thattranexamic acid safely reduced mor-tality. If given promptly, this inex-pensive treatment can reduce therisk of bleeding to death by about

a third8. Economic analysis showedthat tranexamic acid administrationwas highly cost-effective in high-,middle- or low-income countries9.If all injured patients with signifi-cant bleeding around the world weregiven tranexamic acid, this could avoidmore than 100 000 premature deathseach year. On the basis of the resultsof the CRASH-2 trial, tranexamicacid has been included on the WorldHealth Organization’s list of essen-tial medicines. Its benefits to humanhealth have clearly outlived patentprotection. Indeed, because strongscientific arguments can be madethat it could also improve outcomesin other types of bleeding, furtherclinical trials are either planned orunder way in life-threatening postpar-tum, gastrointestinal and intracranialbleeding.

The identification of a highlycost-effective treatment for traumaticbleeding could and should benefitsome of the most disadvantaged peo-ple in the world. Regardless of impacton economic growth, the ability toavoid premature death from trau-matic injury clearly adds to humandevelopment. These benefits will notbe realized, however, without con-certed efforts to ensure that resultsare disseminated and the drug is freelyavailable. At the same time, in set-tings where global economic injusticeimposes major resource constraints, itmust be acknowledged that if a largerhealth gain can be achieved througha different use of the same resourcesthen, all other things being equal, thealternative use should be prioritized10.

There are some important threatsto evidence-based trauma care. The

2011 British Journal of Surgery Society Ltd British Journal of Surgery 2012; 99(Suppl 1): 8–9Published by John Wiley & Sons Ltd

The truth about road traffic accidents 9

increasing off-label use of recombi-nant activated factor VII (rFVIIa)is a shameful example of howpatient interest is poorly servedby unreliable evidence and uneth-ical marketing. There is no evi-dence from randomized controlledtrials that rFVIIa improves survivalof injured patients with significanthaemorrhage11. There is evidence,however, that rFVIIa increases therisk of arterial thrombosis12. Despitethe lack of proven efficacy, serioussafety concerns and the high cost,extensive marketing through the med-ical literature has resulted in ris-ing off-label use13,14. At the sametime, tranexamic acid, which is safe,effective and inexpensive, is hardlyused outside specialist trauma centres.These facts show clearly that the avail-ability of reliable evidence is necessarybut not always sufficient to reducethe burden of suffering from traumaand that ensuring medical knowledgeis used for the benefit of patientsrequires the ongoing commitment oftrauma care professionals around theworld.

Disclosure

The author declares no conflict ofinterest.

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2011 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2012; 99(Suppl 1): 8–9Published by John Wiley & Sons Ltd