Emergency call

Emergency call

Kailash Jha, 46, a resident of Purnia in Bihar, has been immobile for almost six months now. In February, while returning home from a pilgrimage to Deoghar in Jharkhand, a truck hit the vehicle he was travelling in. When Jha regained consciousness two days later, he realised a spinal cord injury had left him bed-ridden.

The harrowing months since then have taken Jha to hospitals in Purnia, Patna, Siliguri and finally, Delhi. Doctors at Jai Prakash Narayan Apex Trauma Centre in New Delhi have placed a steel rod in his back. For more than 15 days, the trauma centre’s guest room has become the new home for Jha, his wife and two sons.

The family has already borrowed Rs 4 lakh for the treatment and is set to fall into a debt trap. Jha’s younger son Roshan could not take his class XII board exams. Ashutosh, his elder son, had to drop out of his second year of graduation. “Doctors have left my father’s recovery upon god. I do not know how we will survive,” says Ashutosh.

In Patna, 74-year-old Bindeshwari Pandey, father of four daily wage workers in Delhi, lies in coma at the government-run Patna Medical College and Hospital (PMCH). Pandey, resident of Pachgachia village in Bihar’s Motihari district, met with a road accident in July-end. His son Awadh has borrowed Rs 70,000 from a moneylender to meet the medical expenses. “I have taken the money after mortgaging our farm land. I am not sure if I can repay,” he says with tears in his eyes.

The 16-katha (0.2-hectare) farm was a vital source of income for the family. “It was our lifeline. We took rice grown on this land to Delhi where prices are exorbitant,” he says. The accident threatens to snap the family’s ties with the village. The brothers have decided to shift Pandey to Delhi if he survives.

Recovery from road accidents often depends upon the survivor’s socio- economic condition. K Venugopalan, professor of physics at Mohanlal Sukhadia University in Udaipur, has been wheelchair-bound after an accident at Nagarcoil, but he is luckier than Jha and Pandey. One of the four passengers of the ill-fated vehicle he was travelling in died while Venugopalan sustained multiple fractures. He spent two weeks in hospital. The bill came to a little over Rs 4 lakh. “We luckily had a medical cover for Rs 5 lakh. The bill was settled through insurance except non-medical expenses of about Rs 20,000,” says his wife Lakshmi. Venugopalan, however, is not a typical road accident survivor in India.

TRAUMA ON THE ROAD

From Delhi to Patna to down south, hospitals are overflowing with road accident victims. Down To Earth (DTE) found that deaths due to road accidents are much more than those caused by, say, communicable diseases.

The trauma centre of All India Institute of Medical Sciences (AIIMS) in Delhi, can handle only 15,000 cases a year. It received 60,000 patients in 2013. Data shows the number of patients has been rising by 10 per cent annually. Similarly, “In Nagpur, I have observed at least 10-15 per cent rise in road accidents,” says ChiragBhoj, head of the casualty department, Indira Gandhi Government Medical College and Hospital in Nagpur. On an average, the hospital gets 20 accident cases every 24 hours. One-fourth of them are serious.

According to National Crime Record Bureau (NCRB) figures, 137,432 people died in road accidents in 2013. This is about 40 per cent of the population of the Maldives. While communicable diseases (excluding HIV/AIDS) together killed 74,146 people, road accidents accounted for almost double that number (see ‘It’s a risky ride on the road’). The majority were two-wheeler riders and pedestrians. A total of 34,187 people were on two-wheelers which accounted for 24.9 per cent of the deaths. Similarly, 12,385 pedestrians lost their lives because of others’ mistakes. Besides the fatalities, 469,900 people sustained injuries in 443,001 road accidents reported in 2013.

According to an analysis by Delhi-based Centre for Science and Environment (CSE), over the last two decades, while the total number of accidents and injuries show a small dip, fatalities have increased sharply. The proportion of fatal accidents in all road accidents has increased from 18 per cent in 2003 to 25 per cent in 2012. Road accident deaths account for more than one-third of total accidental deaths, including suicides and rail-related accidents.

Road injuries and deaths have seen a dramatic rise globally. The recent estimates of Global Burden of Disease (GBD) have changed the way health impacts of motorisation are understood by including deaths and illnesses from road accidents and air pollution within its ambit. GBD is an initiative involving the World Health Organization which tracks the number of productive years lost to diseases. Its report ranks road injuries as the world’s eighth leading cause of death and the biggest killer of people between 15 and 24 years of age. If deaths due to road injuries and vehicular air pollution are combined, they exceed the tally from HIV/AIDS, tuberculosis or malaria.

“In a middle-class family, chances of a child going to hospital due to road accident is much higher than due to any serious disease like cancer,” says Dinesh Mohan, professor emeritus, IIT-Delhi.

Yet, road accidents hardly get the attention they deserve. They evoke some interest only when the annual NCRB data is released or when a high-profile person is the victim. Rural development minister Gopinanth Munde died in a road accident in Delhi on June 3 this year. The debates that the case generated have fizzled out. Even the members of Parliament seem to have forgotten their colleague’s death.

An analysis of parliamentary questions to the Ministry of Road Transport and Highways between December 2009 and July 2014 show that of the total 4,090 questions on roads and highways, only 325 were on accidents (see ‘House not bothered’). There are no innovative insurance schemes for accident victims. “Across the globe, the insurance sector actively works to help victims deal with the cost of accident. Unfortunately, in India this sector is dormant,” says Rohit Baluja, director of Institute of Road Traffic Education, which works on road safety.

Worse, India substantially under reports road injuries, says Rajendra Prasad, senior consultant neurosurgeon at Indraprastha Apollo Hospitals and director of Indian Head Injury Foundation. “If someone suffers a road injury when drunk, he may not report it to the police,” he says.

A recent World Bank report “Transport for Health” states that in India the number of road injury deaths is more than double the official data. In China, the actual figure is four times. Baluja says road accident investigation by the police is often arbitrary and unscientific. As a result, remedial measures are arbitrary, too. An expert committee report on road safety by the Planning Commission indicates that the actual number of injuries could be 15 to 20 times the number of deaths.

Poor, pedestrians, cyclists vulnerable

It is disturbing that road accidents kill more pedestrians, cyclists, people from the lower middleclass and the economically poor. Of all the deaths, pedestrians account for nine per cent. Two-wheeler users account for the highest figure, almost 25 per cent. At PMCH, the emergency ward receives 12 to 20 cases of road accidents in a day. “Most victims are financially deprived and malnourished,” says Deepak Tandon, chief casualty officer at the hospital. Worse, many victims are young. This a great loss to human resource. Amit Gupta, additional professor of trauma surgery at AIIMS, says 31 per cent of the road accident patients are in the age group of 21-30; 19 per cent of them are in the age group of 31-40. A research paper published in British Medical Journal in 2013 states that in 2012, pedestrian deaths occurred to those who had less education, and to those who had less educated parents.

A research done in 2004 for the non-profit Global Road Safety Partnership in Bengaluru has highlighted how road accidents push families towards financial crisis. Often, relatives of victims borrow money, sell assets, give up studies or take up extra work just to survive. The research concluded that 71 per cent of the urban poor and 53 per cent of the rural poor bereaved households were not poor before the accident. Among the seriously injured, 17 per cent of the urban and 25 per cent of the rural households were not poor before the injury. In an analysis published in National Medical Journal of India in 2008, G Gururaj, medical expert at the National Institute of Mental Health and Neurosciences (NIMHANS), states that in 2005 road traffic injuries resulted in economic loss to the tune of three per cent of the GDP. There were 110,000 deaths, 2.5 million hospitalisations and 8-9 million minor injuries.

It is disconcerting that many road accident victims are either pedestrians or bicycle owners. About 14,000 cyclists have to use roads meant for heavy traffic as no space is designated for them.

Ill-equipped health sector

The health sector in the country is not equipped to handle the large number of accident victims. “Emergency medical services are new to India even in metropolitan cities. Ambulances from public and private sectors are not well-equipped or staffed by well-trained personnel capable of managing pre-hospital care,” states a paper titled ‘Developing Trauma Sciences and Injuries Care in India’ published in International Journal of Critical Illness and Injury Science in 2014. The lapse has led to almost one-third patients succumbing to death even before reaching the hospital, and only one-fifth receiving any medical care within an hour.

The paper states that the country does not have dedicated trauma surgeons and very few trauma centres. The present pre-hospital care set-up is largely for handling medical emergencies, not traumas. “In Kerala, the number of hospitals may be higher than those in Western countries, but there are very few experts specialised in trauma injuries,” says Shajahan S, head of the neurosurgery department, Kerala Institute of Medical Sciences.

Limited action on injury prevention

In India, the common approach towards road safety is limited to ensuring safety of motorists, and not all road users. The Central Motor Vehicles Act requires manufacturers to include a range of safety gadgets. Experts believe one of the measures to prevent serious road injury could be use of crash avoidance technologies like Antilock Braking System (ABS) and Electronic Stability Program in vehicles. ABS prevents the wheels from getting locked as it continuously monitors the wheels and adjusts hydraulic brake pressure. It prevents skidding. But the technologies are not mandatory and are available only in high-end models. A person has to spend Rs 100,000 or more to buy a car model with these options, says Mohan.

On January 31, 2014, New Car Assessment Programme (NCAP), an independent charity registered in the United Kingdom, released results of its first crash test on some of India’s popular small cars. The models tested include India’s best-sellers—Suzuki-Maruti Alto 800, Tata Nano, Ford Figo, Hyundai i10 and Volkswagen Polo. All the cars were awarded zero-star adult protection rating in a frontal impact at 64 km per hour. NCAP chose the entry-level version of each model so none were fitted with air bags. The levels of safety in these models are 20 years behind the five-star standards now common in Europe and North America. While Indian car manufacturers became defensive the government remained unresponsive.

The story gets murkier when we turn to vehicle usage. Rules on use of seat belts and helmets are violated with impunity. The courts have had to intervene from time to time to enforce them. Religious objection to helmets further compromises safety of motorists.

Anil Shukla, additional commissioner, Delhi traffic police, says road accidents happen due to several problems, beginning from drunken driving and over-speeding to poor lighting. Policing is not the complete solution; people get bail easily, he says.

Moreover, it is not mandatory for drivers to get training before obtaining licence. The quality of training is also poor, and there is no prescribed curriculum for training. Facilities for training of trainers are limited, or nonexistent. “How can licensed drivers, most of whom have not been through any formal driver’s training, be trained in accident prevention techniques?” asks Save Life Foundation, a non-profit fighting for strong legislation for road safety, in its recommendations to the government.

Road design increases risk

The impact of road design on road safety is not well understood in India. Roads are being increasingly designed to allow seamless movement of vehicles at high speed, and not for safe access for people.

There is now enough evidence to prove that car-centric road design phenomenally increases accident risk. A CSE analysis of accident hot spots in Delhi shows that 40 per cent of the accidents occur near flyovers. A study by Transportation Research & Injury Prevention Programme shows when cities adopt signal-free corridors with flyovers, the probability of pedestrian fatality in collision can increase by 200 per cent.

Cities are aiming to increase speed limit for motor vehicles to 60-65 km per hour. Expressways are being designed for 100-120 km per hour speed. It is scientifically proven that speed more than 30 km per hour increases the intensity of impact and fatality several times over. This is why many global cities are aiming to reduce speed limit inside cities to 30-40 km per hour.

CSE’s road safety audit in Delhi shows that road safety features are needed to protect all road users, including walkers, cyclists and public transport users (see ‘All roads CSE audited...’).

All roads CSE audited were poor     Delhi-based non-profit Centre for Science and Environment (CSE) recently audited roads in the national capital that are most dangerous to pedestrians and cyclists. The researchers selected a total of 27 km of accident-prone roads on Mehrauli-Badarpur Road, Mathura Road, Ring Road, Outer Ring Road, VikasMarg and Noida Link Road and assessed them on the basis of their engineering and user-friendly design. CSE found that all the roads audited scored from poor to very poor. Only 55 per cent of the roads have footpaths; they are constructed much higher than the standard 150 mm on all locations except for some areas in Vikas Marg. So bus users prefer to come down on the road and climb the vehicle. Many bus stops are constructed on the footpath itself. Cycle tracks exist on only 10 per cent of the roads. All the roads surveyed have been ranked poor on the environmental front, amenities and aesthetics. Mehrauli-Badarpur Road, Noida Link Road and VikasMarg have only a handful of public toilets. These, too, either remain locked or are badly maintained. Besides, the roads can become a challenge to negotiate for the differently-abled people.

In most areas, well-designed and barrier-free footpaths are not available which force people to walk in sheer conflict with motorised vehicles on the road. In many sections, the median of the road is cordoned off with railing to stop people from crossing. So people are forced to cross amid high-speed traffic. The crossings are not well-designed or equipped with safe crossing facilities.

There is now a growing tendency to build foot over bridges and subways to push people out of road and clear the way for vehicles. Surveys by the traffic police in Delhi show high number of accidents near foot over bridges. People find climbing foot over bridges inconvenient and prefer to cross at grade amid high-speed traffic. The situation worsens on highways. Highways are being designed for high speed with no or very limited engineering measures to reduce speed of vehicles. Most highways cut across densely populated cities and rural habitation. Data on accident hot spots in Delhi shows high accident numbers on National Highway-24 and NH-8. This is worrying given the frenzy of road construction in India today. The length of national highways with two lanes increased from 25,395 km in 1996 to 41,518 km in 2012, and those with four lanes and above, from 1,170 km to 17,774 km.

Whither policy?

Road safety laws are archaic and do not reflect an approach towards removing danger from built environment. The Motor Vehicles Act 1988 and Rules (1989) do not protect pedestrians, cyclists and public transport users. Shukla says the law puts a penalty of only Rs 100 on traffic violators. Without deterrence the number of violations cannot be reduced. Delhi Police experimented a month-long camera-based drive to stop over-speeding at one junction in Delhi. It recorded over 100,000 people violating the speed limit. Police do not have the capacity to handle such large-scale violations.

The Motor Vehicles (Amendment) Bill to amend the Act was introduced in Parliament in 2012 that enhances penalties for offences, and provides different penalties for first and subsequent violations. It is yet to be passed by Parliament.

The government took the first step towards road safety in 2010 when it adopted the Road Safety Policy. The National Road Safety Fund and National Road Safety Board proposed under this policy are an opportunity to overhaul the system. But it needs a clear roadmap.

The National Urban Transport Policy administered by the Union Ministry of Urban Development addresses the requirements of walkers and cyclists and their safety. But these are only guidelines without a statutory backup.

The weakest link in the current law is the lack of stringent statutory provision for implementation of pedestrian- and cycle-friendly road design guidelines. All road construction agencies follow Indian Roads Congress guidelines that have been revised to be more sensitive to walkers and cyclists. But these are mostly voluntary and can be bypassed or implemented partially unless made part of the agreement with the construction agency.

Learners' guide

It may be tempting to conclude from the global accident data that the rich countries have fared better in securing road safety. But developed and developing countries are not directly comparable as they have different levels of motorisation, travel practices, land use patterns and urban design. If more motorists are dying in developed countries, there are more pedestrians dying in developing countries.

A 2013 study by Dinesh Mohan shows that even in the rich world, road transport injury rates vary among cities with similar incomes and populations because of urban and road design. Cities with higher proportions of wide streets and low density road network have much higher fatality rates compared to more compact cities. However, cities across the world are changing policies and road design to protect walkers and cyclists, reducing vehicle speed, improving public transport connectivity to reduce dependence on automobile.

Sweden has Vision Zero road safety policy that prioritises safety over speed. It promotes low urban speed limits, pedestrian zones and barriers to separate cars from cycles. It has proposed a speed limit of 30 km per hour. Safer roads and crossings along with strict policing have halved the number of pedestrian deaths over the past five years. The Netherlands has Sustainable Safety Vision policy. Infrastructure measures alone have reduced the number of fatalities by 30 per cent. Japan has done a phenomenal job in reducing road accidents. It has taken steps like narrowing of streets, giving priority to pedestrian and bicyclists, partial street closure, speed breakers and roundabouts. Between 1990 and 2011, accident deaths per 100,000 people fell by 64 per cent and the fatality risk per distance travelled fell by 67 per cent.

In several European Union countries the focus is on slowing down traffic, separation of vulnerable people from motorised traffic, awareness campaigns, more safe pedestrian crossings, and effective fines for violation of pedestrian spaces. In the EU, fines are prescribed by the law.

In Germany, a computerised point system for traffic violations is in place. One can incur up to three points if the offence endangers traffic safety. Once there are eight demerit points, the licence is revoked. To get it back, the motorist must pass a physical and mental status examination.

Step forward

In India, criminal apathy towards road safety risk must stop. It is time to reserve space for walkers, cyclists and public transport users on roads. Urgent legal reforms are needed to comprehensively enforce safety guidelines to achieve zero fatality. India needs a Central legislation to notify the revised Indian Road Congress guidelines and make its implementation mandatory across the country. Pre- and post-construction safety audits of roads must become mandatory for all road projects. All public transport plans must integrate plans on safety and accessibility of roads.

The Motor Vehicles Act and Rules need revision to reduce speed limit in cities to 30-40 km per hour and make penalties more stringent. Many cities have planned big investments for road safety. These must be effectively deployed to ensure surveillance of traffic violations, effectiveness of traffic calming measures and removal of encroachments on pavements.

The need is to design cities for people, not vehicles.

Reportage inputs from Alok Gupta in Bihar, M Suchitra in Andhra Pradesh and Kerala, and AparnaPallavi in Maharashtra

`Hardly one per cent of the GDP is allocated to healthcare'   M C Mishra, director of All India Institute of Medical Sciences, Delhi, says that trauma care centres should have efficient pre-hospital service. But prevention of accidents should be on the top of government's priority list. Edited excerpts from interview How is our healthcare system prepared to take care of casualties related to road accidents? We must heighten awareness and reduce road accidents. Three per cent of the country's GDP is going to trauma care whereas hardly one per cent of the GDP is allocated to healthcare. Prevention should be our first priority. Then we should think about having a robust trauma care system. At present, it is available but in bits and pieces. We need efficient pre-hospital service, and trauma and rehabilitation centres. Is the reporting system of injuries and road accidents in India satisfactory? At present, injuries are not notified the way polio and other diseases are. We need to have a strong database. The US has a very good reporting system of injuries and road accidents. The country collects all data related to injuries the way it does for diseases like cancer. This can become possible in India through hospitals or community-based monitoring. It is definitely not easy but certainly not impossible. Do you think we have enough doctors to deal with trauma care? No, there is deficiency of both medical and paramedical staff. The problem is not just in India, but across the globe. We cannot provide doctors overnight. It takes 11-and-a-half years to prepare a specialist like neurosurgeon. If we think of getting doctors today, the result may come in 20 to 25 years. Apart from preparing doctors, what needs to be done to prepare the entire system? We cannot create stand-alone trauma centres the way AIIMS has; it would neither be feasible nor functionally relevant. If we create stand-alone facilities how will we get a good number of experts? The idea is to designate hospitals, medical college hospitals and institutions as level one, two or three trauma centres based on their facilities.

Research inputs: Anumita Roychowdhury,Priyanka Chandola, Vivek Chattopadhyay, Ruchita Bansal