Road Safety and Injury Prevention Program:

Results and Learning, 2007 - 2010

National Institute of Mental Health & Neuro Sciences Department of Epidemiology WHO Collaborating Centre for Injury Prevention and Safety Promotion Bangalore – 560 029,

BANGALORE

ESTD 1980

Bangalore City Traffic Police

Sagar Hospitals Bangalore City Traffic Police Bengaluru Metropolitan Bowring & Lady Curzon Bruhat Bengaluru Bengaluru City Police Victoria Hospital Transport Corporation Hospital Mahanagara Palike

BANGALORE

ESTD 1980

Sanjay Gandhi Institute M. S. Ramaiah Kempegowda Institute Ambedkar Medical St. John’s Hospital of Trauma and Memorial Medical of Medical Sciences & College & Hospital Orthopaedics Hospital Research Centre

Rajarajeswari Medical Vydehi Medical MVJ Medical College & ESI Hospital Sri. Siddhartha Medical College & Hospital College & Hospital Research Hospital College, Tumkur

Bangalore Road Safety and

St. Martha’s Hospital Injury Prevention Program: HOSMAT Hospital Results and Learning, 2007 - 2010

Chinmaya Mission St. Philomena’s Hospital Hospital

Sagar Hospitals

Sagar Hospital Bengaluru Baptist Hospital Columbia Asia Suguna Hospital Hospital

Command Hospital D.G.Hospital Mallige Medical Centre District Hospital, Ravi Kirloskar Memorial Tumkur Hospital

In Collaboration with

World Health Organization, Indian Council of Medical Ministry of Health & New Delhi Research, New Delhi Family Welfare, New Delhi Bangalore Road Safety and Injury Prevention Program: Results and Learning, 2007 - 2010

NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCES Department of Epidemiology WHO Collaborating Centre for Injury Prevention and Safety Promotion Bangalore – 560 029, India Title: Bangalore Road Safety and Injury Prevention Program: Results and learning, 2007 - 2010

Copyright: NIMHANS

ISBN no: 81-86432-00-X

NIMHANS publication No: 81

Year of publication: 2011

Key words:

Injury; surveillance; Data; Mortality; Morbidity; Disability; Road Traffic Injury; Suicide; Burns; Poisoning; Injury Prevention and Care: Capacity strengthening; policy and program

Suggested citation:

G Gururaj and Bangalore Road Safety and Injury Prevention Program Collaborators Group. Bangalore Road Safety and Injury Prevention Program: Results and learning 2007 - 2010, Publication No. 81, National Institute of Mental Health and Neuro Sciences, Bangalore, 2011

For further details about the program, contact any of the program nodal officers or –

Dr. G. Gururaj Program Coordinator Professor & Head Department of Epidemiology WHO Collaborating Centre for Injury Prevention and Safety Promotion NIMHANS, Bangalore - 29 Email: [email protected]; [email protected]

BRSIPP 2011 Nodal Officers

Sri. N.D. Birje (Bangalore city police-Traffic), Sri. Nitin Hegde and Sri. Jagadish (BMTC), Dr. Alfred C Roy and Dr. Niranjan (Bangalore Baptist Hospital), Dr. Bhanumurthy (Bowring & Lady Curzon Hospital), Dr. Rizwan Ali Khan (D.G. Hospital), Dr. Ajith Benedict Rayan (HOSMAT Hospital), Dr. K. Nagaraj (Jayanagar General Hospital), Dr. Devaraj and Dr. Ashwath Narayana (Kempegowda Institute of Medical Sciences), Dr. Mali Manjunath and Dr. S.P. Suryanarayana (M.S. Ramaiah Medical College and Teaching Hospital), Dr. Ramareddy and Dr. Sudharshini (Mallige Medical Centre), Dr. Rajeev Mathew (Sagar Hospital), Dr. Prabhakar and Dr. Shivalingaiah (Sanjay Gandhi Institute of Trauma and Orthopedics), Dr. Mabel Vasnaik and Dr. Varghese (St. John's Medical College & Hospital), Dr. Mallikarjun V. Abdulpur (St. Martha's Hospital), Dr. Riyaz Basha (Victoria Hospital), Dr. Salma Jabeen (Employee State Insurance Model Hospital, Rajajinagar), Dr. Murali Kumar (Chinmaya Mission Hospital), Dr. Nithya A (Suguna Hospital), Dr. Satish Kumar (Vydehi Institute of Medical Sciences), Dr. Srividya V (Rajarajeshwari Medical College and Hospital), Dr. Ceema Sam and Dr. Nischal (Columbia Asia Hospitals), Dr. Divakar SV (Ambedkar Medical College and Hospital), Dr. Ashok J and Dr. Venkatesh (Siddhartha Academy of Higher Education), Gp. Capt. M. Shukla (Command Hospital, Airforce), Dr. Nagaraj (MVJ Medical College and Research Hospital), Dr. Sateesh V.L, Dr. Chandrashekar and Dr. Girish .N.Rao (National Institute of Mental Health and Neuro Sciences). Partners in Program

STATE CRIME RECORDS BUREAU Sri. Sanjay Sahay, IPS, Inspector General of Police

Bangalore City Police E Sri. Shankar Bidari, Commissioner of Police Bengaluru City E Sri. Praveen Sood, Additional Commissioner of Police (Traffic and Road Safety) E Sri. N D Birje, Nodal Officer and Assistant Commissioner of Police (Traffic & Planning) E Sri. Panduranga Rane, Deputy Commissioner of Police (Traffic West) E Sri. B A Muthanna, Deputy Commissioner of Police (Traffic East) E Sri. Mohemmed Sajjad Khan, Inspector (Traffic Planning)

Traffic Training Institute, Bangalore E Sri. S A Pasha, Assistant Commissioner of Police E Sri. Byrappa, Sri. Kulkarni and Inspectors

Traffic Automation Centre E Sri. Sudheer, Inspector, Sri. Vijayakumar

City Crime Record Bureau E Sri. Vijaya Kumar, Assistant Commissioner of Police E Smt. Girija, Inspector of Police and Sri. Venkatarao Sub Inspector E Smt. Lalitha, Mr. Pradeepkumar, Mr. Ravi, Mr. Prasanna, Mr. Suresh

Transport Department Sri. Bhaskar Rao, IPS, Commissioner for Transport and Road safety Sri. Vijaya , Joint Commissioner for Transport (Enforcement) Sri. Muniveeregowda, Joint Commissioner for Transport, (Administration) Sri. Hemanth Kumar, Joint Commissioner for Transport, (E-Governance and Environment) Sri. R.V.D. Souza, Joint Commissioner for Transport, (Bangalore Rural and Urban)

Bangalore Metropolitan Transport Corporation Sri. Syed Zameer Pasha IAS, Managing Director Sri. J. Arun Chakravarthy IPS, Director (Security and Vigilance) Sri. K. S. Vishwanath, Chief Traffic Manager Sri. Jagadish, Assistant Traffic Manager, In-charge Divisional Traffic Officer Sri. Nitin Hegde, Nodal Officer and Divisional Traffic Officer (Accident) Sri. Shankara Bharathi, Assistant Traffic Superintendent Smt. Mahadevamma, Smt. Komala, Smt. Anitha and Smt. Vinutha, Assistants

Karnataka State Road Transport Corporation Sri. Gaurav Gupta, IAS, Managing Director Sri. M. A. Saleem, Security and Vigilance Officer Sri. K.A. Rajkumar Director (Operations) Sri. Dastagir Shariff, Chief Traffic Manager

Bruhat Bangalore Mahanagara Palike Sri. K.R. Niranjan, Special Commissioner Dr. Govindaraju, Former Special Commissioner, Health Sri. Govindaraju, Former Joint Commissioner, Health Dr. L. T. Gayathri, Chief Health Officer Sri. B. Shankarappa, Joint Director (Statistics) Mr. Narayanaswamy, Former Joint Director (Statistics) Sri. Srinivasamurthy, Asst Statistical Officer

BRSIPP 2011 Bangalore Baptist Hospital Dr. Alexander Thomas, Medical Superintendent Dr. Alfred C Roy, and Dr. Niranjan, Nodal Officers Dr. Norman Gift, Consultant,Community Health Casualty Medical Officers: Dr. Ahmed Iqbal Masood, Dr. Vishwas, Dr. Monika Sharma Medical Records Department: Mrs. Vimala, Mr. Vimal Raj

Bowring & Lady Curzon Hospital Dr. H. Satishchandra, Medical Superintendent Resident Medical Officer and Nodal Officers, Dr. Rajanna and Dr. Bhanumurthy Sri. Khaja Mohiddin, Public Relation Officer Casualty Medical Officers: Dr. Shankar K.N, Dr. Lokesh G, Dr. Aravind, Dr. Dhananjaya, Dr. G. Mohan Kumar, Dr. Shivashankar N.A, Dr. Keshavamurthy, Dr. Sashan Kumar, Dr. Nasrulla Babajan, Dr. Roopa B Govindagouder, Dr. Anilkumar K.C, Dr. Mohamad Mujthaba, Dr. H.M. Srikanth, Dr. K.R Smt. Chomu Murthy, Nursing Superintendent Staff Nurses: Mrs. T. Selvi and Mrs. Prabhavathi Medical Records Department: Mr. Nagaraja and Mr. Narayana Department of Forensic Medicine and Toxicology: Dr. Beemappa Havanur, Professor Dr. Venkataraghava, Assistant Professor

Chinmaya Mission Hospital Dr. M.R. Chandrashekar, Director Dr. A.S. Ramachandraiah, Resident Medical Officer Dr. Murali Kumar, Nodal Officer Casualty Medical Officers: Dr. A. Sathya Devi, Dr. , Dr. Selvarasi Nursing staff: Ms. Shashikala, Ms. Suja, Ms. Rekha, Ms. Sony, Ms. Berly, Ms. Bincy, Ms. Geethu Medical Records Department: Smt. Devaki

Columbia Asia Hospital, Hebbal Dr. Ajoy, Chief of Medical Services Dr. Ceema Sam, Nodal Officer Mr. Yadunandana H.L. Executive officer of EMRD

Columbia Asia Hospitial, Yeshwanthapur Dr. Aravind Kasaragod, Chief of Medical Services Dr. Nischal, Nodal Officer Mr. Maria Das. P. Manager of EMRD

Command Hospital (Air Force) Air Cmde. H.S.Nanda Dr. A. K. Patra, Nodal officer. Casualty Medical Officers: Dr. Arijith Mukherjee and Dr. Lovneet Kaur

D.G. Hospital Dr. Ramesh H. D, Chairman Dr. Rizwan Ali Khan, Nodal Officer Dr. Vishvas, Casualty Medical Officer

Dr. B.R Ambedkar Medical College and Hospital Dr. S.V. Divakar, Medical Superintendent Casualty Medical Officers: Dr. . Dr Bhanumathi, Dr. Raghunath, Dr. Mahesh, Dr.Gopalaiah Nursing staff: Smt. Prema, Smt. Shashirekha, Mr. Siddaraj Department of Forensic Medicine and Toxcicology: Dr. B.M. Nagaraj, Professor and Head Dr.Karthik, Associate Professor Employee State Insurance Model Hospital (ESI), Rajajinagar Dr. A.K. Khokhar, Medical Superintendent Dr. Malagi, Additional Medical Superintendent Sri. R. Kesavan, Registrar Dr. Salma Jabeen, Nodal Officer Casualty Medical Officers: Dr. P. Selvakumar, Dr. Raghavendra B, Dr. Ravishankar M, Dr. Roopa B.N, Dr. Sindhu, Dr. Suresh, Dr. Ravikumar Bellubbi, Dr. Rekha, Dr. Muralidharan K.A, Dr. Pankaj M Deshmane, Dr. B, Dr. Raghvendra G Dr. Dhananjay S, Consultant Psychiatrist Nursing Staff: Mrs. Umamani, Mrs. Chandravathi, Mrs. Rajunnisa

HOSMAT Hospital Dr. Thomas Chandy, Medical Director Dr. Ajith Benidict Rayan, Nodal Officer Casualty Medical Officers: Dr. Chetan Ray, Dr. Karthik and Dr. Swaminath Mrs. Reena, Staff Nurse Mr. Surgirth Raj, Medical Records Officer

Jayanagar General Hospital Dr. Nagaraj K. Medical Superintendent Dr. Kishore C. Kumtakar, Resident Medical Officer Casualty Medical Officers: Dr. Kiran Kumar, Dr. Pushparaj, Dr. Pappu Vitalachar, Dr. Prameela, Dr. Sandya, Dr. Geetha, Dr. Revanna, Dr. Raghunandan, Dr. Rajkumar Naik, Dr. Sathya B. H, Dr. Sandhya, Dr. Vidya, Dr. Rajesh, Dr. Babu Rao, Dr. Divakar, Dr. Saroja, Dr. Lakshmi, Dr. Rathna, Dr. Ravindra Mohan, Dr. Prathima Devi, Dr. S.T. Sridhar, Dr. Jayamma, Dr. Prabhakar Nursing staff: Mr. Anil Kumar, Mr. Mohamad Rafiq, Mrs. Lalithamma, Mrs. Geetha Medical Records Department: Mrs. Pattar

Kempegowda Institute of Medical Sciences and Research Centre Dr. Capt. Venkatesh, Director Dr. M. K. Sudarshan, Dean and Principal Dr. Anjanappa T. H, Medical Superintendent Dr. Devaraj, Casualty Medical Officer and Nodal Officer Casualty Medical Officers: Dr. Ramesh, Dr. Shankar, Dr. Roopak, Dr. Prasanna Kumar, Dr. Dinesh Department of Community Medicine: Dr. Ashwath Narayana D. H. and Dr. Chitra Medical Records Department: Mr. E. Selwyn Jebasingh and Mr. Lingappa Dept of Forensic Medicine and Toxicology: Dr. Ananda K, Professor and Head, Dr. V.T. Venkatesha, Professor Dr. Shantha Kumar H.P, Associate Professor, Dr. Jagannath S.R and Dr. Naveen T, Assistant Professors Dr. Gopal B.K, Dr. Ramesh C. and Dr. Sridhar N.C. (Postgraduates)

M. S. Ramaiah Medical College and Hospitals Dr. S. Kumar, Dean and Principal Dr. Sundaresh, Medical Director, M S Ramaiah Medical Teaching Hospital Dr. Naresh Shetty, Medical Director, M S Ramaiah Memorial Hospital Dr.Narendranath, Joint Medical Director, M S Ramaiah Memorial Hospital Dr. Col. M.S. Murnal. Joint Administrator, MSRMTH Dr. Asha R. Executive Hospital Administrator Nodal Officers: Dr. Mali Manjunath and Dr. Suryanarayana S. P. Chief of Emergency Services: Dr. Aruna Ramesh Casualty Medical Officer: Dr. H.M. Gopalappa Prof. Pruthvish .S Professor and Head of Community Medicine Medical Records Department: Mrs. Wilbert Mary, Mrs. Margaret Rosy, Mrs. Shyamala, Mrs. Padma Dept of Forensic Medicine and Toxicology: Dr. Harish, Professor and Head, Dr. Girish Chandra, Associate Professor Dr. Satish N.T. Assistant Professor

BRSIPP 2011 MVJ Medical College and Research Hospital Dr. T. Rajeshwari, Dean and Director Ms. Dharini Mohan, Chief Administrative Officer Dr. Vivai, Medical Superintendent Dr. Nagaraj, Nodal Officer Department of Community Medicine: Dr. Sagorika Mullik, Professor and Head, Dr. T. Mahadevamurthy, Associate Professor, Dr. Lokesh, Assistant Professor Dr. Diwakar, Casualty Medical Officer Mr. Armugam, Medical Records Officer Department of Forensic Medicine and Toxicology: Dr. M. Somashekar, Professor and Head

Mallige Medical Centre Dr. Sriram, Medical Director Dr. Rama Reddy, Nodal Officer Mrs. Jessy. Y, Medical Records Department

National Institute of Mental Health and Neuro Sciences Dr. P. Satish Chandra, Director / Vice Chancellor Dr. S. K. Shankar, Former Director / Vice Chancellor Dr. Nagaraja D, Former Director / Vice Chancellor Dr. Ravi V, Registrar Dr. V. L. Sateesh, Medical Superintendent Dr. Chandrashekar V. S, Resident Medical Officer and Nodal Officer

Department of Neuro Surgery Dr. Sampath, Dr. Indira Devi, Dr. Chandramouli and all units staff

Casualty Medical Officers Dr. Muralidhara K, Dr. Neetha Nagaraj, Dr. Asgari Banu, Dr. Sridhara, Dr. Yashoda, Dr. Amit Acharya, Dr. Leena, Dr. Kasturi, Dr. Swathi, Dr. Lakshmi Rajamma

Medical Records Department Mr. Pulla Reddy, Mr. Nanjappachar and Mr. Vivekappa

Rajarajeshwari Medical College and Hospital Dr. Ramachandra, Director Dr. Govindaraju K. M, Medical Superintendent Dr. Srividya V, Nodal Officer Sri. Harihara Subramanian, S.S., Public Relation Officer Casualty Medical Officers: Dr. Nagaraj B S, Dr. Subramanya S.K, Dr. Gopalkrishna .K, Dr. K P Das, Department of Community Medicine: Dr. Shashikala M, Dr. K. Jayanthkumar Department of Forensic Medicine and Toxicology: Dr. Chandrashekaraiah, Professor and Head Dr. Pradeep Kumar, Associate Professor, Dr. Anand P. Ryamani, Assistant Professor

Sagar Hospital Dr. Hemachandra Sagar, Chairman Dr. Rajeev Mathew, Nodal Officer Casualty Medical Officers: Dr. Murali Mohan, Dr Radhika, Dr. Vetrivel Ramar, Dr. Fareeda U. R Raham Nursing Staff: Smt. Manjula, Mr. Manjunath and Mr. Kumar Medical Records Department: Mr. W. Wellesly Stephen

Sanjay Gandhi Institute of Trauma Care and Orthopaedics Dr. S.Prakash, Director Dr. K. Chandra Shekara Naik, Formerly Director Dr. Shivalingaiah, Resident Medical Officer and Nodal Officer Dr. Prabhakar, Fmr Resident Medical Officer Casualty Medical Officers: Dr Pavan, Dr. Girish, Dr. Suresh Medical Records Department: Mr. Agilasithan, Mr. Yashvanth, Mr. Dhananjaya Smt. Susheela, Nursing Superintendent, Smt. Meera, Staff Nurse St. John’s Medical College & Hospital Fr. Lawrence D'Souza, Director Dr. George A D'souza, Medical Superintendent Dr. Savio Pereria, Associate Medical Superintendent Dr. Prem Pais, Dean Dr. Mabel Vasnaik and Dr Varghese P. S, Nodal Officers Department of Emergency Medicine: Dr. Shakunthala Murthy, Professor and Head; Dr. Praveen Kumar and Dr. Srikanth, Department of Community Medicine: Dr. Arvind Kasthuri, Professor and Head, Dr. Dominic Misquith, Dr. Bobby Joseph Medical Records Department: Mrs. Irine Jacob and Mrs. Maria Joseph Department of Forensic Medicine and Toxicology: Dr. Varghees P. S, Professor and Head Dr. Betty and Dr. Babu Rao

St. Martha’s Hospital Dr. Surg. Comd. A J Moraes, Medical Superintendent Dr. Mallikarjun V. Abdulpur, Resident Medical Officer and Nodal Officer Dr. Shashikanth, Legal Consultant Casualty Medical Officers: Dr. Farid, Dr. Vidya, Dr. Kamini. H, Dr. Pai A G Medical Records Department: Mr. Anthony and Smt. Geetha

St. Philomena's Hospital Dr. Shankar Prasad, Medical Superintendent Casualty Medical Officers: Dr. Mansoor Pasha, Dr. Rajani, Dr. Subbalakshmi, Dr. Lakshmikantamma, D.K. Prasad Nursing staff: Ms. Mary Stella, Ms. Mini, Ms. Shashikala, Ms. Bincy, Ms. Honey, Ms. Tina, Ms. Monisha, Ms. Princy, Ms. Tintu, Ms. Rintu, Ms. Sumithra, Ms. Kathrine, Ms. Marcel Medical Records Department: Mr. George Pinto

Suguna Hospital Dr. Ravindra, Director Dr. Radhika Raveendran, Medical Superintendent Dr. Nithya A, Administrator Dr. Krishnaswamy, Nodal Officer Casualty Medical Officer: Dr. Shantha Kumar, Dr. Suraj Medical Records Officer: Mrs. Geetha

Victoria Hospital Dr. O.S. Siddappa, Dean and Director Dr. G.T. Subhash, Former Dean and Director Mr. Prabhakar, Chief Administrative Officer Dr. B.G.Tilak, Medical Superintendent Dr. Kantharaj J, Resident Medical Officer Dr. Riyaz Basha, Nodal Officer Casualty Medical Officers: Dr. A. Vishwanath, Dr. Cheluvanarayana, Dr. Rajareddy, Dr. Siddeshwar, Dr. B. Vishwanath, Dr. Vijayashri, Dr. Thyagaraj, Dr. H.V Shivakumar, Dr. Varalakshmi, Dr. R. Ramesh, Dr. Sathyanarayana, Dr. Manjula, Dr. Satheesh S.R. Vishwakarma, Dr. Madhusudan Das, Dr. Priyadarshini, Dr. Pradeep, Dr. Rashmi, Dr. Shivakumar, Dr. Shailaja, Dr. Santhosh and Dr. Jagadish. Mrs. Kunjumol, Nursing Superintendent Medical records department: Smt. S. Lakshmidevi, Mr. Sudhindra, Smt. Vasundara Department of Forensic Medicine and Toxicology: Dr. Devadass P.K, Professor and Head, Dr. K.V. Satish, Associate Professor, Dr. C.N. Sumangala, Assistant Professor, Dr. V. Suresh, Assistant Professor, Dr. Dileep Kumar K.B, Senior Resident, Dr. Yadukul .S, Dr. Murali Mohan M.C, Dr. Chandrakanth Kokatanur, Dr. Vinay H.N, Dr. Yogesh .G, Dr. Vinay Kautilya, Dr. Ravikumar, Postgraduates Dr. Vasantha Kamat, Professor and Head, Department of Medicine Dr. Shivaswamy, Professor and Head, Department of Surgery Dr. N. Vijay Kumar, Professor and Head, Department of Orthopaedics Dr. T.S. Ranganath, Professor and Head of Community Medicine

BRSIPP 2011 Vydehi Institute of Medical Sciences Mrs. Kalpaja D. A, Medical Director Maj. Gen. Dr. Anju Manchanda, Administrator Dr. (Mrs) Kantha S, Advisor Dr. Sandhya Belawadi, Principal and Dean Dr. G. Mohan. Medical Superintendent and Nodal Officer Casualty Medical Officers: Dr. Shivayogi, Dr. Murugan, Dr. , Dr. S. Hemavarneshwari Medical Records Department: Mr. Pratap Department of Forensic Medicine and Toxicology: Dr. Sudhamshu Raj Sharma Khanal, Professor and Head Dr. Jagadish N, Professor, Dr. P. G. Bagli, Associate Professor, Dr. M.S. Kiran and Dr. Padmini Kannan Noone, Assistant Professors, Dr. Raviraj K.G, Dr. Shobhana S.S, Dr. Fairoz Khan, Tutors (PG.s)

RURAL CENTRE - Tumkur District

E Dr. Somashekara C, Deputy Commissioner and District Magistrate

Police E Dr. Harsha P S, IPS, Superintendent of Police E Sri. Nagarajaiah, Assistant Sub Inspector; Sri. Narasimhaiah and Sri. Chandrashekar, Ms. Bharathi, Head Constables; Deepa R, First Divisional Assistant

District Hospital Dr. Pratap Surya, District Surgeon Dr. Rangaswamy, Resident Medical Officer Casualty Medical Officers: Dr. Manjunatha Gupta, Dr. Srinivasamurthy, Dr. Nanjundappa, Dr. Chandan, Dr. Chandrashekhar, Dr. Sureshbabu, Dr. Veerabhadraiah, Dr. Muktamba, Dr. Eashwarappa, Dr. Govindaraju, Dr. Gowda V, Dr. Manjunatha K.R, Dr. Kallesh, Dr. Nagendrappa, Dr. Rekha, Dr. Rukmini, Dr. Srinivasmurthy, Dr. Sowmya Nursing staff: Ms. Sumitra C.S, Ms. Savitri H.B.

District Health and Family Welfare office Dr. Channamallaiah, District Health and Family Welfare Officer

Siddartha Academy of Higher Education (Deemed to be University) Dr. Shivaprasad G, Director and Chancellor Dr. Krishnamurthy K.A, Vice chancellor Dr. M. Z. Kurian, Registrar Dr. A. G. Srinivasamurthy, Principal Dr. C. R. Kodandaswamy, Medical Superintendent Dr. Ashok J and Dr. Venkatesh, Nodal Officers Dr. Rajanna M.S, Professor and Head, Dept of Community Medicine Casualty Medical Officers: Dr. K. R. Srinath, Dr. Muddukrishna, Dr. Anil Kumar, Dr. Sadananda Medical Records Department: Mr. Sridhar and Mr. Girish

Co-ordinating Centre at National Institute of Mental Health and Neuro Sciences Dr. P. Satish Chandra, Director / Vice Chancellor Dr. Gururaj G, Program Coordinator, Professor and Head of Epidemiology

Staff Department of Epidemiology Dr. Girish N Rao, Dr. Kavita R Mr. Manjunath D.P, Mr. Basavaraju K.S, Mr. Chandrashekara A. Mr. Lokesh M, Mr. Venkataramanappa G, Mr. Rajappa R, Mr. Chandrashekhara, Mr. S.L. Ramesh, Mr. Murali S.L, Mr. S.M. Amaresh, Mr. Mounesh Y, Mr. Saijan Cyriac, Smt. Rajani, Ms. Manjula, Mr. Girish B.G

All staff working in emergency rooms - medical record divisions of partner hospitals, Bangalore Metropolitan Transport Corporation and in all police stations of Bangalore city and Tumkur District Table of Contents

Foreword i Messages ii Executive Summary v

Section A: Injury and Violence in India A1. Introduction 1 A2. Scientific basis of injuries 2 A3. Injury and Violence as a Public Health problem in India 2 A4. Burden of injury and violence in India 3 A5. Burden of injury and violence in 6 A6. Data mimitations 10 A7. Data requirements for road safety and injury prevention 10 A8. Injury surveillance 11 A9. Data sources for surveillance 12

Section B: The Program and Methods B1. Bangalore road safety and injury prevention program 14 B2. Methods 15 B3. Fatal injuries 15 B4. Non fatal injuries 16 B5. Population based observational surveys 17 B6. Data pooling 17 B7. Monitoring of activities 17 B8. Sharing and disseminating of information 18

Section C: Program and Results C1. Bangalore - A profile 19 C2. Motorisation and infrastructure development 21 C3. Mortality profile and patterns 22 C4. Non fatal injuries 23 C5. Young men and women are affected most 28 C6. Violence and injury occur all throughout the year 28 C7. Injury and violence in Bangalore 30 C8. Road traffic injuries 32 C9. Falls 55 C10. Burns 56 C11. Poisoning 59 C12. Assault and violence 61

Section D: Trauma Care Issues 63

Section E: Road Safety and Injury Prevention & Control E1. Current scenario 67 E2. RTI / injury surveillance: strengths, opportunities, barriers and limitations 69 E3. Sustainability issues 73

Section F: Activity Profile of 2010 75

Section G: Bangalore Road Safety and Injury Prevention Program - An Evaluation 82

References 84 Annexure I: Data capture format for road deaths 87 Annexure II: Data capture format for injury deaths excluding RTIs 89 Annexure III: Mortuary injury data capture format 91 Annexure IV: Emergency Trauma Care Record for non-fatal injuries in hospitals 93

BRSIPP 2011 List of Figures

Figure1: Causes of injury deaths in India in 2009 5 Figure 2: State wise distribution of RTIs in India, 2009 5 Figure 3: State wise distribution of suicides in India, 2009 6 Figure 4: Causes of injury deaths in Karnataka in 2009 6 Figure 5: Use of data for public health and safe system approaches 10 Figure 6: Designing and building a surveillance system 11 Figure 7: Sources of information for injuries 15 Figure 8: Vehicular growth in Bangalore 21 Figure 9: Motorisation trends in Bangalore, 2001 - 2010 21 Figure 10: Composition of vehicles in Bangalore 21 Figure 11: Major causes of death, 2009 22 Figure 12: Age - sex distribution of deaths in Bangalore, 2009 23 Figure 13: Distribution of injury deaths BBMP data, 2009 23 Figure 14: Age - sex distribution of injury deaths, 2009 (BBMP) 28 Figure 15: Age - sex distribution of fatal and non fatal injuries in 2010 28 Figure 16: Fatal and non-fatal injuries as per month of occurrence 29 Figure 17: Fatal and non-fatal injuries as per time of occurrence 29 Figure 18: Causes of fatal and nonfatal injuries in urban and rural areas, 2010 30 Figure 19: Intent of injury 31 Figure 20: Alcohol use in fatal and non-fatal injuries, Bangalore 31 Figure 21: Comparison of non-fatal RTIs registered with the police and hospitals 32 Figure 22: Bangalore RTI pyramid 32 Figure 23: Fatal RTIs in Bangalore city during 2001 to 2010 32 Figure 24: Nonfatal RTIs in Bangalore during 2001 to 2010 32 Figure 25: Age sex distribution of fatal and non fatal RTIs in urban and rural areas 33 Figure 26: Place of road traffic crashes 33 Figure 27a: Fatal crashes under different traffic police stations, 2010 35 Figure 27b:Conditions and characteristics of crash locations 35 Figure 28: Areas and roads with high fatal crashes, 2010 35 Figure 29: Road user catagories 36 Figure 30: Collision of vehicles with pedestrians 37 Figure 31: Pedestrian activity at the time of crash, 2010 37 Figure 32: Location of fatal pedestrian crashes, 2010 37 Figure 33: Pattern of two wheeler collision, areawise 38 Figure 34: Pattern of two wheeler collisions, 2010 37 Figure 35: Location of fatal two-wheeler crashes 37 Figure 36: Use of helmets among two wheeler riders 39 Figure 37: Cases booked by Bangalore city police for nonuse of helmets 40 Figure 38: Helmet use among two wheeler riders: results of an observational study 40 Figure 39: Seat belt use among car drivers in Bangalore city 41 Figure 40: Cases booked by the Bangalore city police for not wearing seat belts 41 Figure 41: Alcohol presence in road crashes in Bangalore 42 Figure 42: Trend of drink driving cases booked by the Bangalore city police 42 Figure 43: Persons driving under the influence of alcohol: Results from an observational study 43 Figure 44: Alcohol presence in injury cases 43 Figure 45: Alcohol involvement in various injury causes 43 Figure 46: Effect of speed 44 Figure 47: Trend of overspeeding cases booked by the Bangalore city police 44 Figure 48: Road crossing behaviour: Results of observational study 47 Figure 49: Number of deaths by involvement of BMTC buses 49 Figure 50: Number of serious injury by involvement of BMTC buses 49 Figure 51: Month wise distribution of fatal crashes, 2008 - 2010 50 Figure 52: Time of occurrence of BMTC crashes, 2010 50 Figure 53: Age of BMTC drivers involved in fatal crashes, 2010 50 Figure 54: Experience of drivers involved in fatal crashes, 2010 50 Figure 55: Age - sex distribution of fatally injured persons in BMTC crashes, 2010 50 Figure 56: Collision patterns in fatal BMTC crashes, 2010 51 Figure 57: Road user category of fatal bus crashes, 2008 - 10 51 Figure 58: Patterns of collision, 2010 51 Figure 59: Patterns of collision with other vehicle 51 Figure 60: Crash location of fatal bus crashes, 2010 51 Figure 61: Place of death among fatal crashes, 2010 51 Figure 62: Age - sex distribution of non-fatal fall injuries 55 Figure 63: Place of injury in non-fatal falls 55 Figure 64: Age - sex distribution of non-fatal burn injuries 57 Figure 65: Place of injury in non-fatal burns 57 Figure 66: Products involved in non-fatal poisoning cases 60 Figure 67: First aid in injury cases prior to reaching a definitive hospital 63 Figure 68: Mode of transportation in non-fatal injury cases 64 Figure 69: Time interval between injury and registration in the hospital for non-fatal injury cases 64 Figure 70: Time interval between injury and deaths in fatal injuries 64 Figure 71: Place of death 64 Figure 72: Pathways of research 69

BRSIPP 2011 List of Tables and Boxes

Table 1: Haddon's matrix as applied to two wheeler road traffic injury 2 Table 2: Deaths and injuries in India, Karnataka state and Bangalore city due to various causes, 2009 4 Table 3: Top 10 causes of death by age groups in India: Male 7 Table 4: Top 10 causes of death by age groups in India: Female 8 Table 5: Top 10 causes of death by age groups in India; Person 9 Table 6: Profile of Bangalore city 20 Table 7: Non-fatal injury registrations in ERs of participating hospitals, January-December 2010 24 Table 8: Leading causes of death in all age groups in Bangalore, 2009 25 Table 9: Leading causes of death among males in Bangalore, 2009 26 Table 10: Leading causes of death among females in Bangalore, 2009 27 Table 11: Injury related deaths in Bangalore during January - December 2010 29 Table 12: List of areas with high road deaths in Bangalore, 2010 34 Table 13: Highlights of BMTC services for Bangalore city 49

Box 1: Infrastructure projects completed till date in the city by 2010 22 Box 2: Cell phone use and road crashes 46

List of Abbreviations

BRSIPP : Bangalore Road Safety and Injury Prevetion Program BMTC : Bangalore Metropolitan Transport Corporation BBMP : Bruhat Bengaluru Mahanagara Palike CMO : Casualty Medical Officer CC : Co-ordinating Centre CCRB : City Crime Records Bureau CDs : Communicable Diseases ER : Emergency Room FIR : First Information Report HICs : High Income Countries ICD : International Classification of Diseases ICECI : International Classification of External Causes of Injuries ICMR : Indian Council of Medical Research IPC : Indian Penal Code LMICs : Low and Middle Income Countries MCCD : Medical Certification of Cause of Death MLC : Medico-Legal Case NCRB : National Crime Records Bureau NIMHANS : National Institute of Mental Health & Neuro Sciences NCDs : Non-Communicable Diseases NGO : Non-Governmental Organization OTC : Over The Counter RMO : Resident Medical Officer RTI : Road Traffic Injury WHO : World Health Organization Acknowledgements

Our sincere thanks to

E Prof. Satish Chandra P, Director/Vice-Chancellor, NIMHANS

E Dr. Bela Shah, Deputy Director General, Indian Council of Medical Research

E Dr. J.S. Thakur, Cluster focal person for NCDs, World Health Organization, India Office

E Dr. Margie Peden, Coordinator, Department of Violence and Injury Prevention, World Health Organization, Geneva

E Dr. Ann Dellinger, Epidemiology Division, Centre for Disease Control and Prevention, Atlanta, USA

E Sri. Shankar Bidari, Commissioner of Police, Bangalore City

E Sri. Praveen Sood, Additional Commissioner of Police (Traffic), Bangalore City

E Sri. Sunil Kumar, Additional Commissioner of Police (Law & Order), Bangalore City

E Sri. Sanjay Sahay, Inspector General of Police, State Crime Records Bureau, Karnataka

E Sri. Bhaskar Rao, Commissioner for Transport,

E Sri. Syed Zameer Pasha, Managing Director Banglaore Metropolitan Transport Corporation

E Sri. K.R. Niranjan, Special Commissioner, Bruhat Bangalore Mahanagara Palike

E Dr. C. Somashekhara, Deputy Commissioner, Tumkur

E Dr. P. S. Harsha, Superintendent of Police, Tumkur District

E National Informatics Centre, Bangalore

E All Non Governmental Organizations

E All partner hospitals in the program

E Dr. Girish N, Dr. Kavita Rajesh, Mr. D.P. Manjunath, Mr. Lokesh M and Mr. Basavaraju for involvement and support in all activities.

BRSIPP 2011 Foreword

As India progresses to greater economic growth and rapid motorization, the burden of injuries has been increasing significantly. The death of an estimated million people due to injuries has been a matter of great concern to all of us. Apart from those who report to the hospitals, daily, thousands more get injured either on the roads, at home or in their workplaces. Most of the injuries result in serious damage to the brain and many fail to recover completely and have residual morbidity, often leaving affected individuals and families in desperation and loss of hope. We can quote the numbers of injured and those dead, but it is important to realize the presence of a family behind every injury or death. The pain, suffering and the long term impact on the families and the society is indeed very significant, but difficult to measure.

The continually increasing Road Traffic Injuries and/or deaths, points to the need for making more systematic efforts to make our society safe. It is unfortunate that this modern epidemic affects mainly the young and productive members of our society. While we all seek development and progress, we need to ensure that this development happens with a human face. Often, we blame the individuals for the several mishaps. Global experience and scientific evidence shows that safe systems can be built and developed to overcome human failures. Even though we have the knowledge and technology, our combined efforts are still far from satisfactory in addressing this human disaster; several interventions, which, if properly implemented can save " lives and limbs".

Good quality data is often the first step in building sustainable and robust programs. I understand that the Bangalore Road safety and Injury Prevention Program (BRSIPP) has satisfactorily completed three years in this field. This unique public health endeavor undertaken as a collaborative activity with nearly 30 hospitals in Bangalore City, the Bangalore City Police, the Bangalore Metropolitan Transport Corporation has been co-ordinated by NIMHANS. During the three years, information from more than 1.5 lakh hospitalized and injured persons and nearly 15,000 injury deaths has been systematically collected and analyzed. Apart from the annual reports for the year 2008, 2009 and 2010, the program has also brought from these years, 10 fact sheets, 5 public alerts and 4 strategy papers. Collating the learnings from these years, a fact book about injury and violence in India and a framework document for implementing road safety programs with reference to a developing county like India are also being published this year. I take this opportunity to congratulate and compliment all the stake holders for their perseverance and commitment in this untiring effort.

Good decisions are possible only with reliable data; programs would be adhoc, crisis - ridden and importantly non - sustainable in the absence of data. BRSIPP has shown that it is possible to develop information systems which can guide and prioritize intervention activities. It has taken the first step in our country to develop a sustainable and replicable model for injury prevention and control. The collaborative program has laid the foundation to make a dent in the rising injury graph and, society will immensely reap the benefits over the years to come.

Greater political will and administrative determination is needed to develop programs which are contextual to our society and culture. I am sure that the lessons learnt would be very valuable to the policy makers and health managers, not just in India, but also across the globe. Prof. P. Satish Chandra Director / Vice-chancellor, NIMHANS, Bangalore. i Message

World Health Organization Country Office of India

At the outset, I would like to congratulate the Bangalore Road Safety and Injury Prevention Program for successfully completing three years. Apart from collecting data, the program undertook many capacity building programs, advocacy activities, campaigns and strengthened research using data generated from the program. This data was readily available to develop road safety and injury prevention program by the police, transport, health and all other involved sectors.

Worldwide, injuries account for over 1 million deaths and 50 million injuries every year. In India, more than 5,00,000 persons die due to different injury causes as per reports of the National Crime Records Bureau. Apart from deaths and hospitalizations, the pain and suffering of affected families are difficult to measure and quantify.

The reports developed under this program will provide useful and required information. I am hopeful that the policy makers, law enforcement agencies, Government departments, researchers, media & NGOs shall benefit from the available resource materials.

I take this opportunity to compliment all the partners in this initiative, particularly National Institute of Mental Health and Neuro Sciences, and the WHO Collaborating Centre for Injury Prevention and Safety promotion for coordinating respective activities. The lessons learnt will be helpful for all road safety initiatives in India and other parts of the world. I wish the programme its best in the coming years.

Dr Nata Menabde WHO Representative to India

ii BRSIPP 2011 Message

India has witnessed an unprecedented pace of motorization during the last two decades and Bangalore city leads with 90 lakh vehicle population; of which nearly 28 lakh are two wheelers. This growth has been impressive; it is rather unfortunate that nearly 1000 deaths and thousands of hospitalizations take place due to road traffic injuries every year. Most often, it is the pedestrians and two wheeler riders who get killed and injured in crashes on the roads of Bangalore. This consistent finding from the three years of the Bangalore Road safety and Injury Prevention Program has been a major worry for all interested in safe travel. The pain and suffering of the affected families are difficult to measure and needs to be understood by all policy makers and public at large.

We need to make our roads safe and also ensure that the vulnerable road users are protected. In this direction, Bangalore City Police are striving hard to change present scenario. Introduction of technology, increased manpower, training for police and greater penalties are helping in improving the scenario. Over speeding, drunken driving, risky behaviours on the road, not using helmets, using cell phone are some major issues to be addressed in all cities.

Simultaneously, there have been several initiatives at the city level by different agencies. Improving public transport, implementing safety rules, public awareness and other areas needs further strengthening. As policies and programs of all agencies in this direction have an impact on safety and mobility of people, it needs to be continuously monitored and evaluated. These learning's are helpful to many other cities for incorporating safety in day to day activities.

The Bangalore Road safety and Injury prevention program has been helpful by highlighting critical areas in enhancing road safety. The program with a major focus on strengthening and improving information systems will help in developing data led interventions over time. This year, for the first time in the country, data collection has been improved with electronic online transmission for developing a system and all our staff have been trained in this process.

Most significantly, it has brought all stake holders and different hospitals into network for collective thinking and developing activities. I would like to take this opportunity to compliment all the stakeholders who have come together to undertake this unique initiative. I very much hope that the policy makers and administrators would take serious note of the magnitude of the problem and important lessons learnt over the last three years of the Bangalore Road Safety Injury Prevention Program. I am also confident that the report for the year 2010 along with framework for implementing road safety programs in India and, Injury and Violence in India fact report will be helpful to all policy makers and professionals in various departments. I wish this program all the best.

Mr. Praveen Sood, IPS, Addl. Commissioner of Police, Traffic & Road Safety Bangalore City

iii Message

Road networks and mobility are the neural networks for growth and prosperity. The last two decades have witnessed an unprecedented growth of motor vehicles in India and Bangalore has been no exception to this change. India with a total road length of 3.34 million kms is the second largest in the world and this carries 65% of freight and 85% of passenger traffic. Nearly 80 million vehicles traverse the length and breadth of the country transporting people and goods on a regular basis. Transport systems are the nation’s building blocks which bring in economic gains, binds societies as well as people. This impressive growth has brought an unforgettable tragedy in terms of road deaths and injuries. It is imperative that we ensure that the road systems are safe and cause no or little harm to the users.

The transport department is vested with the responsibility of ensuring and co-coordinating road safety activities ranging from vehicle registration to ensuring its fitness to driver licensing and most importantly to make roads safer. This process of making roads and people safe requires good quality information that can drive good programs.

While information is needed to take action, it's essential and critical that various stake holders come together to undertake coordinated and concerted action. In this context, I would like to congratulate all partners in the Bangalore Road Safety and Injury Prevention Program (BRSIPP) for working together towards making our roads safe. NIMHANS has always been in the forefront of several road safety initiatives. I am happy that as co-coordinator's of the BRSIPP, they have continued to dialogue with multiple stake holders. I am sure that the third annual stake holders meet would be good opportunity to discuss and suggest a model for injury prevention and control for the country.

Bhaskar Rao, IPS, Commissioner for Transport & Road Safety, Government of Karnataka

iv BRSIPP 2011 Executive Summary

India with a population of 1.2 billion is witnessing a major shift in its health problems due to epidemiologic and sociodemographic transition. With marginal decline in communicable and infectious diseases, Noncommunicable Diseases and injuries have become the leading causes of deaths, disabilities and hospitalisations in the country. While vaccine preventable diseases are major problems in children, NCDs are a problem of middle aged and elderly. In the young population of 15 - 44 years, injuries have become leading killer diseases.

With an estimated million deaths, injury and violence is a major burden on health care systems. The younger age of occurrence and suddenness of the event makes injury and violence, an unbearable situation for families. Health systems are faced with major challenges of providing care and rehabilitation for millions of people. The affected families go through immense suffering, pain, grief and anxiety due to the loss of their near and dear ones. In recent times, injury and violence in Indian society has become extremely common that no single day passes without reading, hearing or witnessing these events. Injury and violence is a problem in both urban and rural parts of the country and is shifting from metros to grade B and C cities and into the rural areas as motorisation, urbanisation and impact of globalisation begin making inroads.

Despite huge increase in the burden of injuries, there are no systematic policies and programs in India. In recent times, some initiatives have begun to address road safety concerns. The injury surveillance pilot studies, training programs in police and transport sectors, computerisation of police stations across the country, revision of Indian Motor Vehicles Act, steps to constitute a National body for RTIs and efforts to address road concerns have all been initiated recently. Despite an increase in suicides and other types of violence, these problems remain unaddressed. Burns, poisoning, drowning, occupational injuries are not in the public domain as public health problems. Trauma care is more of an urban phenomenon and people in rural areas neither have access nor can afford good quality health care due to increasing costs and absence of social insurance systems.

In order to formulate sound policies and programs, strong and robust data is an essential prerequisite. In India, except police sources, all other data systems are in infantile stages. The police data have major limitations and health sector data is virtually absent. Without proper collection, analysis, interpretation and application of data, sound policies and programs cannot emerge to control the problem. Evidence led programs based on intersectoral approaches are key to injury prevention and control in India. Surveillance, registries, good reporting systems and systematic research in academic institutions are still not in vogue in the country.

The city of Bangalore is a living testimony to the impact of technological and socioeconomic changes. The city has many positive developments in terms of education, information technology, raising living standards, vibrancy and hope for millions. The dark side of this growth and development is also coming to the forefront due to absence of safety policies and programs. The Bangalore Road Safety and Injury Prevention Program

v was started as a collaborative activity between 25 hospitals, city police, city transport department, civic administration and NGO's in 2007 with the broad goals of developing scientific programs to reduce the burden of injuries. The program adapted a surveillance approach for information gathering and brought together all stake holders to develop integrated programs. Surveillance was developed with available resources and within existing systems along with appropriate strengthening at different levels. The program has been operational in both urban and rural areas and has been facilitated by WHO and ICMR and coordinated by the WHO Collaborating Centre for Injury Prevention and Safety Promotion at NIMHANS.

In 2010, nearly 6000 persons died due to acts of injury and violence in the city. Nearly 60,000 injured persons reached the study centres for care and more than half of survivors were discharged with disabilities of short or long term duration. In reality, more than a lakh would have reached hospitals as the coverage was from only 25 hospitals. Road traffic injuries and suicides were the leading injury causes. Majority (> 70%) of those killed and injured were in younger age groups of 15 to 44 years and predominantly men. Pedestrians, two wheeler riders and pillions, and pedal cyclists were involved in nearly 75% of road crashes. Consumption of insecticides, pesticides and drugs, occurring at a time when the person was alone at home was the common pattern for suicides. Burns, poisoning, falls were other major injuries responsible for deaths and hospitalisations. Trauma care was often found to be inadequate for the injured persons.

In 2010, data was used to provide inputs for policies and programs at national and state levels. Further, it was used to strengthen and support helmet use in the city, scaling up enforcement of drinking and driving, promoting seat belt use, and to increase awareness on hazards of speeding. The city police took the initiative of data collection and submission through online transmission with support from National Informatics Centre. Discussions with policymakers and professionals have indicated that the data developed has been useful to develop new activities as well as monitor existing programs.

After 3 years of systematic activities, it is time to seriously look at the sustainability and strengthening of the program. This will be taken up in consultation with all partners, WHO, ICMR and Ministry of Health and Family Welfare, Government of India in the coming days. Along with further strengthening of surveillance, there is need for capacity building, systematic training, advocacy, increasing public awareness, facilitating interventions, and monitoring of all activities. More research needs to be undertaken for risk factor delineation and finding solutions through both ongoing and new activities. Most importantly, there is need to build programs and interventions. This year, the program has also brought out the "India Injury and Violence Fact Report" and the "Framework document on Road Safety" along with this report. The earlier reports, fact sheets and public health alerts have been helpful to many and used by professionals and media.

Across the world, especially in HICs, research - knowledge - evidence and data changed the understanding of injuries. Political commitment, professional involvement and proactive media supported policies and programs. Today, it is well acknowledged that injuries are predictable and preventable. Preventing road crashes, suicides and other injuries requires a "proactive approach" rather than a "reactive approach". Action from police, transport, urban - rural development ministries, highway authorities, land development authorities, product and vehicle manufacturers, civic authorities, NGOs, public, media and others are required to save lives and limbs. If safety is given priority, injury and violence should not occur; even if it occurs, it should not lead to deaths and disabilities. It is our strong hope that India wakes up to this public health problem and initiates appropriate policies and programs. vi BRSIPP 2011 Section A: Injury and Violence in India

A1. Introduction

With a population of more than a billion, India is significant progress in NCD prevention and control facing many challenges to meet health needs of its programs along with expansion of trauma care people. The triple epidemics of Communicable and services. The augmentation of facilities and services, infectious diseases, Noncommunicable diseases though marked in urban areas and deficient in rural (NCDs) and injuries pose many challenges for health areas, has been receiving attention of policy makers systems and to our policy makers. Various policies and administrators. In recent years, increasing and programs by successive governments at both participation of the private health sector comprising central and state level have had some success in of specialty hospitals, corporate hospitals, teaching changing some vital indicators. Despite this hospitals, nursing homes and other family noticeable change, the consequences of globalisation, practitioners along with the public health sector has urbanization and motorization have emerged as been noticeable. Simultaneously, increasing costs of major challenges amidst existing social inequities health care, greater burden on individuals and and wide disparities in health systems between and families, and the limited and adverse impact of within states. Absence of efficient health systems as various policies and problems has also been a matter revealed by the inadequacies related to planning, of great concern. financing, human resources, infrastructure, supply systems, governance, information, and monitoring Recent data indicates that NCDs and injuries are some well known problems of our health care contribute for nearly three fourths of deaths and systems (Patel et al, 2011). disabilities in India (Patel et al, 2011). Even though recent years have witnessed some concerns from India has witnessed rapid and unprecedented changes policy makers on the growing incidence and burden in urbanization, motorization, industrialization and of injuries, the problem has not received major migration along with changing life styles, habits attention in terms of a unified approach to address and value systems of people. The ongoing the problem. While some of the recent programs epidemiological, demographic, economic and social are making systematic efforts to address the growing transition has resulted in the emergence of injury burden of NCDs, efforts for injury prevention and and violence as a major public health problem in control are totally lacking as they are not even the 21st century. India has been making small and recognized as public health problems in India.

1 A2. Scientific basis of injuries

Traditionally and for too long, injuries have been mechanisms at different time periods and at various considered as accidents. The term accident simply levels (Haddon, 1968). This concept that originated means that it just happens and nothing much can be in 1970s brought in a new understanding of injury done about it. Consequently and for a long time, the mechanisms by identifying the contributory factors fatalistic attitudes in our communities have persisted among people, vehicles or products, and the and continue even today. Injuries have been referred environment (Table 1). Within each of these three to as - acts of God, sins of past life, price one has to domains, factors that operate before, during or after pay, and several such understandings. Due to this the crash that influence the possible outcomes can be prevailing thinking by politicians, people and even delineated. Identifying and developing mechanisms professionals, the field of injury prevention and to address each of these for different injuries has helped control has not taken deeper grounding in India. in reducing RTIs and other injuries.

The epidemiological triad of agent, host and In recent years, the “Safe Systems approach” is an environment has been in practice for several extension of this model by identifying measures for years that evolved from the understanding of safe people, safe vehicles and safe roads for prevention communicable disease control. “Haddon Matrix” and control of RTIs. This approach considers different is a very scientific method to understand injury interactions between and within each component and is based on physiological tolerance of individuals. It Table 1: Example of Haddon’s matrix as is based on the understanding that human body is applied to two wheeler road traffic injury extremely vulnerable for injury and that people are Human Vehicle Environment likely to make mistakes. Hence, road crashes are the Pre-event Increase Increase Implement outcomes of different interactions among a number awareness visibility of safety features about helmet vehicle on roads of factors and interactions. Based on this wearing, drink understanding it is essential to address multiple driving, safe driving, etc. components that cause injuries by different partners Event Early transfer Better braking Crash (Mohan et al, 2006). This approach focusses on to hospital systems of two protective Safe people, Safe roads and Safe vehicles. This and required wheelers road side care stationary understanding has revolutionized the field of Road objects safety as well as injury prevention and control over Post- Rehabilitate Improve safety Facilities for time and it has been possible to identify injury event and improve technologies early rescue health care and compo- of injured prevention programs that can be effectively services nents persons implemented.

A3. Injury and violence as a public health problem in India

Commonly, injuries are classified as unintentional and custodial institutions. Another method of classifying intentional based on intent. Unintentional injuries injuries is based on the mechanism of injury as it include Road Traffic Injuries (RTIs), falls, burns, happens in road traffic injuries, poisoning, falls and poisoning, drowning, work related injuries, fall of others. The third method of classification is based on objects, injuries in disasters and animal bites. the place of occurrence like roads, home, play sites Intentional injuries include suicides and violence. or work places. The anatomical type and location of Violence includes a wide variety of conditions like injuries depending on the injured body organs like youth violence, violence against women, children and head injuries, intracranial injuries, fractures and elderly, communal violence and those occurring in dislocations are the fourth method of classification.

2 BRSIPP 2011 Several international frame works like the WHO The understanding that injury is damage to one or international classification of diseases (WHO, 1998), more body organs, which occur quite rapidly due International Classification of External Causes of to sudden energy transfer being the cause, Injuries (WHO, 2004a), and the International revolutionized the science of injury prevention and Classification of Functional Impairments are available control. The definitive interaction between agent, for more detailed understanding of injury process and host and environment along with energy transfer mechanisms (WHO, 2001a). results in injuries of varying nature and severity. The chances of repeated occurrence are also frequent. It is common to see, read, hear or witness injury Over time, moving from this concept, the safe deaths and events in our lives on a day to day basis. systems approach has evolved for prevention and Like any health condition, injury and violence also control. has the typical epidemiological understanding of agent (product), host (person) and environmental Any health problem is a public health problem, if it association. The term, injury, by definition means affects large sections of society, has identifiable and that – it is a body lesion due to an external cause, measurable risk factors, is amenable to prevention either intentional or unintentional, resulting from a and can be addressed through public health sudden exposure to energy through mechanical, approaches (Detels et al, 2009). Due to lack of good electrical, thermal, chemical or radiate sources that quality data on the burden, pattern and impact of is generated due to interaction between agent and injuries, the problem remains unrecognized and host (WHO, 1999). This definition has been consequently unaddressed in India. However, the expanded to include impairments and others. The death of nearly 5,00,000 persons as per official interaction of these elements results in transfer of reports every year indicates the enormous energy to the host, which when it exceeds the magnitude of the problem. Injuries predominantly physiological tolerance of the individual results in affect the young people in the society, primarily in damage to body organs. Depending on the product, the age group of 15-44 years and men, with majority the energy that is responsible can be mechanical (as belonging to lower and middle income strata of the in RTIs), chemical (as in poisoning), thermal society. International research and experience reveals (burns), electrical or radiant in nature. It is also that the risk factors of injuries are clearly discernable possible that injuries can occur due to sudden and are amenable for prevention as seen by a decline withdrawal of a vital requirement of the body as in in injury deaths and disabilities in recent decades in drowning due to lack of oxygen. many High Income Countries (HICs)(WHO, 2004b).

A4. Burden of injury and violence in India

The only major source of information on injury and In 2009, there were 4,76,576 accidental deaths in violence in India is the National Crime Records the country due to manmade causes (Table 2). Bureau (NCRB) under the Ministry of Home Affairs, A total of 6,47,904 unnatural accidents caused Government of India. NCRB publishes annually 4,76,576 deaths and injuries among 1.5 million ‘Accidental deaths & Suicides in India’ and ‘Crime in persons with a male to female ratio of 3: 1. A 4.3% India’.The reports of 2009, published in 2010, gives increase in accidental deaths has been reported, while salient findings on injury burden and patterns from a 7.2% decrease was noticed from deaths due to different states, union territories and the mega cities natural causes. Significant variations exist across of India (NCRB, 2009a & b). Despite limitations of the states due to population characteristics and levels reporting and timely publication, the report offers of motorisation and urbanisation. valuable insights into the current situation of injury and violence. Some of the salient observations are The major unnatural cause of death was road traffic also provided in the accompanying report entitled injuries, which resulted in death of 1, 26,876 persons “Injury and violence in India: facts and figures” in 2009. The share of accidents due to natural (Gururaj, 2011). causes decreased from 7% in 2008 to 6.2% in 2009. 3 Table 2 : Deaths and injuries in India, Karnataka state and Bangalore city due to various causes, 2009 Bangalore Karnataka India Sl. No Causes Injured Killed Injured Killed Injured Killed A Unintentional injuries I Air-Crash 0 0 0 1 0 12 II Collapse of Structure (Total) 0 9 9 282 556 2847 1 House 0 0 8 146 242 1091 2 Building 0 1 1 17 47 265 3 Dam 0 0 0 0 15 30 4 Bridge 0 0 0 0 32 44 5 Others 0 8 0 119 220 1417 III Drowning (Total) 5 43 6 2014 553 25911 1 Boat Capsize 0 0 0 51 33 984 2 Other Cases 5 43 6 1963 520 24927 IV Electrocution 4 29 11 365 453 8539 V Explosion (Total) 1 4 3 9 735 668 1 Bomb Explosion 0 0 0 0 491 261 2 Others (Boilers, Gas Cyld. etc.) 1 4 3 9 244 407 VI Fall (Total) 7 108 14 470 2416 10622 1 From Height 3 100 10 442 959 8796 2 Into Pit/Manhole 4 8 4 28 1457 1826 VII Factory 0 2 4 33 598 1467 1 Machine Accidents 0 2 4 32 552 1044 2 Mines or Quarry Disaster 0 0 0 1 46 423 VIII Fire (Total) 32 449 55 1625 3034 23268 1 Fireworks/Crackers 0 11 0 12 258 547 2 Short-Circuit 0 19 2 126 207 1328 3 Cooking Gas Cylinder/Stove Burst 13 89 34 341 241 4127 4 Other Fire Accidents 19 330 19 1146 2328 17266 IX Fire-Arms 0 15 0 18 671 1504 X Killed by Animals 1 1 5 50 198 962 XII Poisoning (Total) 20 388 25 2491 5269 26634 1 Food/Accidental intake of Insect. etc. 0 57 5 181 1662 8154 2 Spurious/Poisonous liquor 2 22 2 180 109 1450 3 Leakage of gases etc. 0 0 0 13 10 247 4 Snake Bite/Animal Bite 1 2 1 722 1900 8035 5 Other 17 307 17 1395 1588 8748 XIII Stampede 6 0 6 12 6 110 XIV Traffic Accidents (Total) 5705 742 61697 10163 470941 152689 1 Road Accidents 5705 742 61697 8714 466649 126896 2 Rail-Road Accidents 0 0 0 0 477 1516 3 Other Railway Accidents 0 0 0 1449 3815 24277 X V Other Causes 74 676 78 1022 4500 35906 XVI Causes Not Known 63 0 66 1125 1389 17534 Total of unintentional injuries 5918 2466 61979 19680 491319 308673 B Intentional Injuries XVII Intentional Injury Deaths 1 Homicides 0 256 0 1702 0 32369 2 Dowry deaths 0 50 0 264 0 8383 3 Suicides 0 2167 0 12195 0 127151 XVIII Other Intentional Injuries 1 Attempt to commit murder 338 0 1607 0 29038 0 2 Rape 65 0 509 0 21397 0 3 Kidnapping and abduction 270 0 892 0 33860 0 4 Molestation 251 0 2186 0 38711 0 5 Sexual harassment 35 0 64 0 11009 0 6 Cruelty by husband and relatives 367 0 3185 0 89546 0 7 Other IPC crimes 9992 0 61108 0 865541 0 Total of intentional injuries 11318 2473 69551 14161 1089102 167903 Grand Total (A+B) 17236 4939 131530 33841 1580421 476576 Source: NCRB report, 2009a & b

4 BRSIPP 2011 Under the broad category of traffic accidents, In the same year, several more died due to other 4,21,628 road accidents, 2080 rail-road accidents injury causes as shown in Figure 1. Nearly 1,27,151 and 27,575 other railway accidents were reported. persons ended their lives voluntarily in suicidal acts, RTIs and suicides were the major causes while 26,634 died due to accidental poisoning and contributing for 31% & 27% respectively. (Figure1). 23,268 due to burns. The data also shows the huge The report highlights an increase of road crashes extent of underreporting of injuries in official reports in the country by 7.3% during 2009 compared to as seen by the fact that injuries were less than deaths. 2008. reported highest rate of road As deaths are only the tip of iceberg, for every death, accidents contributing for nearly 21% of the nearly 30 – 50 reach hospitals and it is estimated national total (Figure 2). Road accidents in India that the actual number of hospitalised persons are increased by 1.4% during 2009 as comared to 2008. likely to be in the range of 30 – 40 million every In total, 4,15,855 road accidents were reported, year (Gururaj G, 2005a). that resulted in death of 1,26,896 persons with an accident severity index of 30%. The annual In 2009, 1,27,151 persons ended their lives in a mortality rate was 10.9/1,00,000 population. The suicidal act. The five states of West Bengal (11.5%), four states of Tamil nadu, Maharashtra, Karnataka (11.4%), Tamil Nadu (11.3%), and Kerala accounted for 47% of total road Maharashtra (11.2%) and Karnataka (9.6%), accidents. The 32 mega cities contributed for 14% contributed for more than half of suicides in the of total road deaths. country (Figure 3). The five southern states registered 40% of total suicides in the country. The four cities of Bangalore (2,167), (1,412), Delhi Figure1: Causes of injury deaths in India in 2009 (1,215), and Mumbai (1,051) together reported nearly 44% of total suicides among the 35 mega cities of the country. Bangalore city had the highest rate: 38.1 per 1,00,000 population. In the total series, 1 out of every 3 suicides occurred in the age group of 15-44 years with an overall male to female ratio of 2:1. However, in young children less than 14 years, male to female ratio was almost equal. One out of every 5 suicides was registered among housewives.

The age sex distribution of the affected populations varied across the country. As per the national report, majority of the deaths due to injuries were in the

Figure 2: State wise distribution of RTIs in India, 2009 (National average 10.9/100,000 population)

State Rate State Rate Tamil Nadu 20.48 Jammu and Kashmir 9.07 Haryana 20.07 Punjab 8.87 Goa 19.17 Uttarakhand 8.80 Andhra Pradesh 17.43 Orissa 8.78 Himachal Pradesh 16.77 7.58 Karnataka 14.97 Meghalaya 7.48 Sikkim 14.50 6.63 Rajasthan 13.69 Assam 6.50 13.07 Tripura 6.41 Gujarat 12.04 Mizoram 6.30 Maharashtra 11.99 West Bengal 5.62 Delhi 11.80 Manipur 4.68 Madhya Pradesh 11.34 Bihar 4.60 Kerala 11.04 Nagaland 2.25 Arunachal Pradesh 10.25

5 Figure 3: State wise distribution of suicides in India, 2009 National average - 10.9/100,000 population

State Rate State Rate Sikkim 39.9 Arunachal Pradesh 9.0 Kerala 25.3 Himachal Pradesh 8.4 Chhattisgarh 24.4 Delhi 8.3 Tamil nadu 21.5 Rajasthan 7.7 Karnataka 21.0 Mizoram 6.9 Tripura 20.7 Meghalaya 4.3 Andhra pradesh 17.4 Jharkhand 3.6 Goa 16.4 Uttarakhand 3.5 West Bengal 16.4 Punjab 3.1 Maharashtra 13.2 Jammu and Kashmir 2.5 Madhya Pradesh 12.9 Uttar Pradesh 2.1 Orissa 10.8 Nagaland 1.4 Gujarat 10.7 Bihar 1.1 Haryana 10.3 Manipur 1.0 Assam 9.7

younger age groups of the population. Nearly 6.5% unintentional injuries and intentional self harm. of deaths were in children less than 14 years and Injuries were the leading cause of death in the 5 - 14 majority of deaths were in the age group 15-44 years. years age group. In total, motor vehicle injuries contributed to 3.7% of deaths in 5-14 years and 6.9% Data from the million death study identified in 15-24 years. Injuries were the 8th and the 9th cause unintentional and intentional injuries as a leading of death in 25-69 years of age group. The top 3 causes cause of death in younger age groups (RGI, 2009). of death in 15-24 years were due to other unintentional Most importantly, unintentional injuries were the injuries (14.7%), intentional self harm (14.3%), and 4th leading cause of death in 1 to 4 years, while it motor vehicle accidents to the extent of 12.4%. Injuries was the number one cause of death in 15-24 years were one among the top 10 leading causes of deaths with 11.8% and 15.6% for the two groups of in all the groups as shown in tables 3, 4 and 5.

A5. Burden of injury and violence in Karnataka

Karnataka with a population of 66 million is one of persons were injured as per police reports giving a the most progressive states in India. The state with a ratio of nearly 1:8 for deaths injuries. Considering motor vehicle population of 3.69 million is underreporting of injuries, the number hospitalized predominantly rural with an urbanization rate of could have both 1 – 1.2 million during the year. 37% (http://www.municipaladmn.gov.in/ dmaWebsite/urbanization.htm). With literacy rate Figure 4: Causes of injury deaths in Karnataka in of 66.7% and per capita income of Rs 40,998(RBI, 2009 2010), the state is an evolving knowledge and industrial hub of the country.

During 2009, 33,481 persons (19,680 accidental and 12,195 suicidal deaths) died due to injury and violence in the state (Figure 4). Among the major causes, road traffic crashes (8714) and suicides (12,195) topped the list, respectively. Among other causes for injury deaths, 2491 were due to poisoning and 2014 due to drowning. Intentional injury causes like homicide and dowry resulted in 1702 and 264, deaths respectively. In the same year, 1,31,350

6 BRSIPP 2011 (9.3) (6.7) (6.4) All Ages Ill-defined Respiratory Senility (4.0) Unintentional Cardiovascular diseases (20.3) infections (5.4) neoplasms (5.4) conditions (4.6) Tuberculosis (7.1) Tuberculosis Diarrheal diseases respiratory diseases Perinatal conditions Perinatal injuries: Other (5.2) Malignant and other COPD, asthma, other (7.3) 70+ (15.7) Ill-defined origin (2.8) Respiratory Unintentional Cardiovascular diseases (26.5) Senility (13.1) ever of unknown uberculosis (4.5) infections (3.4) conditions (4.4) neoplasms (4.6) F Diarrheal diseases T respiratory diseases injuries: Other (3.7) Malignant and other COPD, asthma, other (6.1) 25-69 (11.4) (10.1) Diarrheal Ill-defined Intentional Tuberculosis Unintentional diseases (4.0) Malaria (2.4) Cardiovascular diseases (26.3) self-harm (3.3) neoplasms (7.8) conditions (4.8) Digestive diseases respiratory diseases injuries: Other (5.0) Malignant and other COPD, asthma, other (5.2) (5.1) (6.0) (14.7) (12.4) 15-24 Maternal uberculosis Ill-defined Intentional T Unintentional Motor vehicle diseases (6.3) Malaria (4.8) conditions (-) injuries: Other accidents :; ;;, Cardiovascular self-harm (14.3) conditions (7.2) parasitic diseases Diarrheal diseases Other infectious and death by age groups in India: Male (2.9) 5-14 (19.4) (15.2) (13,5) Ill-defined Respiratory origin (2.5) Unintentional Malaria (8.1) Motor vehicle injuries: Other accidents (5.3) ever of unknown infections (8.4) neoplasms (3.8) conditions (5.4) parasitic diseases Digestive diseases F Diarrheal diseases Other infectious and Malignant and other 0-4 (9.8) Perinatal Diarrheal Ill-defined Congenital Nutritional origin (1.5) Respiratory Unintentional Malaria (2.4) diseases (12.3) ever of unknown anomalies (3.0) conditions (3.5) infections (20.7) parasitic diseases deficiencies (2.4) F conditions (36.9) Other infectious and injuries: Other (3.4) Table 3: Top 10 causes of Top 3: Table 1-4 (15.5) Diarrheal Digestive III defined Nutritional Congenital Respiratory Origin (3.1) Unintentional Malaria (6.6) Diseases (1.6) diseases (22.0) Infections 21.4) ever of Unknown conditions (5.3) Anomalies (1.9) parasitic diseases deficiencies (4.3) F Other infectious and injuries: Other (9.3) Ref: http://cghr.org/publications/FINAL%20REPORT-Millon% 20Death%20study%202001-2003%20-phase%201.pdf http://cghr.org/publications/FINAL%20REPORT-Millon% Ref: <1 (9.0) (7.9) Perinatal III defined Congenital Nutritional origin (0.9) Respiratory Unintentional Malaria (0.9) ever of unknown infection (20.5) anomalies (3.4) conditions (2.9) parasitic diseases F deficiencies (1.8) conditions (49.2) Diarrheal diseases injuries: Other (1.5) Other infectious and 1 2 3 4 5 6 7 8 9 10 Rank

7 (9.9) (8.0) (6.2) All Ages Ill-defined Respiratory Senility (6.5) Unintentional Cardiovascular diseases (16.9) infections (7.1) neoplasms (6.0) conditions (5.0) Diarrheal diseases Tuberculosis (4.7) Tuberculosis respiratory diseases Perinatal conditions Perinatal injuries: Other (4.5) Malignant and other COPD, asthma, other (9.8) 70+ (12.4) Ill-defined origin (3.9) Respiratory Unintentional Cardiovascular diseases (24.8) Senility (18.4) ever of unknown infections (3.4) neoplasms (3.5) conditions (4.5) F Tuberculosis (2.6) Tuberculosis Diarrheal diseases respiratory diseases injuries: Other (4.6) Malignant and other COPD, asthma, other (3.5) (6.6) 25-69 (10.4) male Ill-defined Intentional Unintentional Malaria (3.4) Cardiovascular diseases (22.5) self-harm (2.6) uberculosis (8.3) conditions (6.0) Digestive diseases neoplasms (11.8) Diarrheal diseases T respiratory diseases injuries: Other (4.1) Malignant and other COPD, asthma, other (4.4) (7.2) (7.2) 15-24 Maternal Intentional Motor vehicle Unintentional diseases (6.3) Malaria (4.6) Cardiovascular accidents (1.7) self-harm (16.9) parasitic diseases conditions (12.6) Tuberculosis (7.5) Tuberculosis Diarrheal diseases injuries: Other (9.1) Other infectious and Ill-defined conditions (2.8) 5-14 (19.6) (16.7) injuries: Ill-defined Respiratory origin (3.3) Other (12.0) Unintentional Motor vehicle Malaria (10.7) ever of unknown accidents (2.1) conditions (4.6) neoplasms (2.0) parasitic diseases infections (11.1) F Digestive diseases Diarrheal diseases Other infectious and Malignant and other 0-4 (15.3) (11.2) Perinatal Ill-defined Congenital Nutritional origin (1.6) Respiratory Malaria (3.0) Unintentional ever of unknown anomalies (2.3) conditions (3.4) infections (23.3) parasitic diseases deficiencies (3.2) F conditions (29.2) Diarrheal diseases Other infectious and injuries: Other (2.9) Table 4: Top 10 causes of death by age groups in India: Fe 4: Top Table 1-4 (1.8) (16.2) Diarrheal III defined Nutritional Congenital Respiratory Origin (3.1) Malaria (6.6) Unintentional diseases (25.2) ever of Unknown anomalies (1.3) conditions (3.9) Infections (23.3) parasitic diseases deficiencies (5.1) Digestive diseases F Other infectious and injuries: Other (6.2) Ref: http://cghr.org/publications/FINAL%20REPORT-Millon% 20Death%20study%202001-2003%20-phase%201.pdf http://cghr.org/publications/FINAL%20REPORT-Millon% Ref: <1 (8.8) Perinatal Diarrheal III defined Congenital Nutritional Respiratory origin (0.9) Unintentional Malaria (1.3) Diseases (10.6) ever of unknown infection (23.3) anomalies (2.8) conditions (3.2) parasitic diseases deficiencies (2.3) conditions (43.1) F Other infectious and injuries: Other (1.3) 1 2 3 4 5 6 7 8 9 10 Rank

8 BRSIPP 2011 (8.7) (8.1) Perinatal All Ages Ill-defined Respiratory Senility (5.1) Unintentional Cardiovascular diseases (18.8) infections (6.2) conditions (6.3) neoplasms (5.7) conditions (4.8) Diarrheal diseases Tuberculosis (6.0) Tuberculosis respiratory diseases injuries: Other (4.9) Malignant and other COPD, asthma, other (8.5) 70+ (14.1) Ill-defined origin (3.3) Respiratory Unintentional Cardiovascular diseases (25.7) Senility (15.7) ever of unknown infections (3.4) conditions (4.4) neoplasms (4.1) F Diarrheal diseases (3.6) Tuberculosis respiratory diseases injuries: Other (4.1) Malignant and other COPD, asthma, other (5.0) 25-69 (5'1> (10.2) Ill-defined erson Intentional Unintentional Malaria (2.8) Cardiovascular diseases (24.8) neoplasms (9.4) conditions (5.3) self-harm ' (3.0) uberculosis (10.1) Digestive diseases; Diarrheal diseases T respiratory diseases injuries: Other (4.6) Malignant and other COPD, asthma, other (11. 8) 15-24 Maternal Diarrheal Ill-defined Intentional and parasitic Unintentional Motor vehicle diseases (6.3) diseases (6.2) diseases (4.8) Malaria (4.7) injuries: Other Cardiovascular accidents (6.9) Other infectious self-harm (15.6) conditions (7.2) conditions (6.5) Tuberculosis (6.8) Tuberculosis death by age groups in India; P (2.9) 5-14 (15.7) (15.1) Diarrheal Ill-defined Respiratory origin (2.9) Unintentional Malaria (9.4) Motor vehicle injuries: Other diseases (17.4) accidents (3.7) ever of unknown infections (9.7) neoplasms (2.9) conditions (5.0) parasitic diseases Digestive diseases F Other infectious and Malignant and other 0-4 (10.5) Perinatal Diarrheal Ill-defined Nutritional Congenital origin (1.5) Respiratory Malaria (2.7) Unintentional diseases (13.8) ever of unknown anomalies (2.7) conditions (3.4) parasitic diseases infections (22.0) deficiencies (2.8) F conditions (33.1) Other infectious and injuries: Other (3.2) Table 5: Top 10 causes of Top 5: Table 1-4 (1.7) (15.9) Diarrheal III defined Nutritional Congenital Respiratory origin (3.1) Unintentional Malaria (6.6) diseases (23.8) ever of Unknown anomalies (1.5) conditions (4.5) Infections (22.5) parasitic diseases Deficiencies (4.8) Digestive diseases F Other infectious and injuries: Other (7.5) Ref: http://cghr.org/publications/FINAL%20REPORT-Millon% 20Death%20study%202001-2003%20-phase%201.pdf http://cghr.org/publications/FINAL%20REPORT-Millon% Ref: <1 (8.3) Perinatal Diarrheal III defined Congenital Nutritional origin (0.9) Respiratory Unintentional Malaria (1.1) diseases (9.7) ever of unknown infection (21.8) anomalies (3.1) conditions (3.0) parasitic diseases F deficiencies (2.0) conditions (46.3) injuries: Other (1.4) Other infectious and 1 2 3 4 5 6 7 8 9 10 Rank

9 A6. Data limitations

Data from NCRB report the total number of deaths official reported deaths were 22,000 in the same for the country and also for different states and 32 year. mega cities. Even in official reports, the number of injured are far less than deaths in some injuries. This Reflecting on the data further, it is observed that shows that many nonfatal injuries are not reported national reports provide gross numbers & trend data to police and reasons could be several. The reasons with additional information on age and gender, urban for underreporting lie in social, cultural, economic and rural, month and time, sociodemographic and administrative issues and vary from cause to correlates like education and occupation and broad cause. Three of the studies from India undertaken in causes for RTIs and suicides. Further, data is not readily Bangalore (Gururaj et al, 2000), Haryana (Varghese available for researchers & policy analysts in the public and Mohan, 2003) and Hyderabad (Dandona et al, domain for analysis & interpretation. This data is 2008) reveal that the actual burden of RTIs to be supplemented further with few research studies from higher than official figures. The Bangalore study different parts of the country on different injury causes. reported that RTI deaths and injuries were underreported by 5 – 10% and > 50%, respectively. In summary, comprehensive data required for policies Dandhona et al (2008) reported from Hyderabad and programs is not available in the country. It is that the RTI mortality rate was 38 / 1,00,000 time that national institutions like Department of population, much higher than officially reported Health Research (ICMR) and health professionals take figures. The ratio of deaths: critically injured: mild keen interest in developing good quality national level injuries was 1: 29: 65 among the surveyed villages data on injuries through a combination of quantitative of Haryana. NIMHANS study on suicides showed the and qualitative research methods. There is also need ratio of completed: attempted: suicidal ideations was for information from other disciplines like engineering, 1: 10: 100 based on data from hospitals and general transport, industry, law and other sources on different population survey (Gururaj et al, 2004). Sanghvi aspects of injuries. Information from all sources needs et al (2009) reported the number of deaths due to to be available to examine different aspects and to burns to be 1,63,000 based on estimates, while the provide inputs for policies and programs.

A7. Data requirements for road safety and injury prevention

Unlike communicable disease programs, there is and professionals to develop meaningful and evidence need for variety of data for road safety and injury based policies/programs and interventions. As per prevention. Primarily, good quality – reliable – and WHO (WHO, 2010a) reliable and accurate data can comprehensive data is required for policy makers help build political will to prioritise road safety by: E documenting the nature and magnitude of the Figure 5: Use of data for public health and safe road traffic injury problem; system approaches E demonstrating the effectiveness of interventions Set targets that prevent crashes and injuries; and monitor performance E providing information on reductions in socio- Formulate economic costs that can be achieved through strategy Identify risk effective prevention. factors, priorities Define Informative and good road crash data systems should problems provide information on (Figure 5)

10 BRSIPP 2011 E Magnitude of the problem in terms of deaths, in many areas of burden, characteristics and hospitalisations, disabilities and impact impact. At each level, different data is required E Characteristics of vehicle, the road user and and this has to be obtained from different sources the road/environment by varied methods. A comprehensive road safety E Situation – context – and circumstances of road data system would therefore encompass data crashes collection and analysis mechanisms that cover - E Risk factor identification for selection of deaths and serious injuries to road users, countermeasures characteristics of the crashes; exposure information: E Effectiveness of interventions in terms of speed, seat-belt and helmet use rates, drink driving, reduction and changes in the burden, and and vehicle and infrastructure safety ratings; and E Provide reliable output in a timely manner to impact data in terms of socioeconomic costs to the facilitate evidence-based decisions. society. As discussed in the earlier sections of this report, such data is not readily available in Using variety of data from different sources, India. indicators can be developed to measure progress

A8. Injury surveillance

Strong and robust data is an essential prerequisite prioritizing issues and provides a situation analysis to formulate effective road safety and injury of the current scenario. The data from surveillance prevention programs (WHO, 2010a). Information is programs needs to be essentially used for required on the number of fatal and non fatal injuries, prioritization of issues, capacity strengthening and characteristics of the affected people, the place and human resource development, identifying areas for time of injury occurrence, the various contributing interventions, and monitoring and evaluation of risk factors and causes, trauma care details and activities. Road safety and injury surveillance data other aspects. This type of comprehensive information and its availability and utilization will Figure 6: Designing and building a support development and implementation of policies surveillance system and programs. 1. Identify 2. Define system stakeholders objectives Surveillance is a very familiar concept in public 4. Identify 3. Define health research and refers to ongoing, continuous data sources “ a case ” and systematic collection, analysis, interpretation, dissemination, utilization and feed back of data for reducing the burden of any public health problem 5. Assess available 6. Inform and involve resources stakeholders (WHO, 2001b). A similar approach has been used for injury prevention and control as well in many 7. Define HICs. It includes gathering information on individual data needs cases or assembling information from different sources, analysing and interpreting information, 8. Collect data dissemination and providing feed back into programs (Figure 6). It is essential to note that 12. Monitor and surveillance is a continuous activity with an inbuilt evaluate 9. Establish a data processing system feedback mechanism and an action component.

Surveillance helps in recognizing the existing and 11. Train staff and 10. Design and activate system distribute reports changing burden of injuries, understanding various patterns, identifying new emerging problems, Source: WHO, 2001b

11 can be a meaningful input to several programs and Surveillance program can be built within existing activities of different ministries, government systems with minimal resources. These existing departments, health professionals and all others systems can be improved, strengthened and utilized involved in these activities. It is extremely important to develop the requisite information (Gururaj et al, to realize that surveillance moves beyond “just data 2010). collection” to “actually using data for policies and programs”(WHO, 2001b). Further, it is also essential For surveillance system to be effective, operational, to understand that surveillance alone will not be and sustainable, it should be simple, acceptable, an answer and needs to be supplemented with sensitive, reliable, representative, sustainable, timely, variety of different data to pinpoint selection of cost effective, and most importantly useful. The interventions. In India, due to absence of central essence of surveillance is to collect small amounts coordinating agency and data not being valued, most of good quality reliable information by scientific of the surveillance data remains underutilized, even approaches and utilize the information to develop in Communicable Diseases surveillance activities. policies programs and interventions. As surveillance is an ongoing activity the data would reveal the Many, including professionals believe that RTI/injury efficacy and effectiveness of interventions as seen by surveillance requires building entirely new systems change in the injury burden and patterns. that involve huge resources. This is not true.

A9. Data sources for surveillance

There are multiple sources of data for injuries in interpretation is not undertaken at state or local India. Each source collects different types and levels. quantum of data for its own purposes. The common E Similarly, information on transport injuries is sources of data are from vital registration systems, also collected by the transport department. police, transport, health, welfare, insurance, legal Apart from information on type and number sector and others. of registered vehicles, the department also collects and publishes data on deaths and E Injury deaths in India are considered medico injuries. The published reports are somewhat legal events since historical times. similar to NCRB reports with some additional Consequently, the police department undertakes information on highway deaths and few investigation on all accidental and unnatural established indicators of road safety. However, deaths and details are documented as per the periodicity of reports is not uniform and official procedures. Information on traffic there are delays in publication of these reports. deaths is collected by the traffic division, while E The vital registration system in every city and intentional injury deaths are documented by district collect and compiles data on births and the crime division. Information on few other deaths at local levels. Information on deaths is injury deaths is also collected by law and order collected (form no.4) and compiled regularly. ICD division of police department. The available 10 coding is used in few cities and districts for information varies from place to place and this purpose. The use of ICD 10 varies from place summary statistics are sent to NCRB which to place and depends on completion of death compiles and publishes national statistics. certificates in institutions and coding by However, the information collected is mainly physicians. The local level data is available on from an administrative, criminal and legal age, sex, place, cause while, ICD code details point of view and mechanisms to use are available in some situations. The accuracy information for policies and programs are of information is influenced by completeness of totally lacking. Further, data analysis and registration and quality of data at the local level.

12 BRSIPP 2011 E Information on injuries and related deaths is E Data on injury deaths are also available from also collected by mortuary centres of selected insurance sector. However, this data is not in institutions as per legal requirements. Mortuary the public domain and cannot be accessed data is collected by forensic medicine easily for policy or research purposes. professionals and stored for longer periods of In summary, time due to legal requirements. Information there are multiple sources of data on sociodemographic details, cause of death, depth and quality of information varies situation- context – circumstances of injury, from agency to agency description of injury details and cause of death no national or professional guidelines are documented for every case. However, no exist for data collection (except for MLC collective analysis is being done by any agency. summary formats) Currently, an ongoing study in Bangalore is no uniform format exists for reporting examining mechanisms to use autopsy data from hospitals for injury surveillance purposes (Gururaj, quality and nature of information has not 2010a). been examined E All hospitals document details of injury patients except NCRB, there is no national and deaths for care and administrative reasons. coordinating agency There is no uniformity and the practice varies no agency exists for analysis, from hospital to hospital. There are no national interpretation and dissemination, and or state level guidelines for documenting details data is rarely used for interventions, of injury patients or even other patients. policies and programs Unfortunately, hospitals do not even bring out summary statistics of their respective A major drawback of the current situation is that institutions. The MCCD system collects data total information on all aspects of injuries is not from specific institutions for national and state available in the public domain for planners, policy reporting systems (GOK, 2010). analysts and researchers as the existing information systems are fragmented, and piece meal in nature.

13 Section B: The Program and Methods

B1. Bangalore road safety and injury prevention program

The Bangalore Road Safety and Injury Prevention The overall goal of BRSIPP is to achieve a reduction Program (BRSIPP) was started in 2007 to develop in injury (RTIs, suicides and others) deaths, systematic activities for prevention and control of hospitalisations and disabilities in Bangalore along road traffic injuries and other injuries. At the national with strengthening injury information systems. level, information available from the National Crime Records Bureau through its annual reports of The specific objectives of Bangalore Road Safety and “Accidental deaths and Suicides in India” provides Injury Prevention Program were to: information on number of fatal and non fatal injuries, 1. Collect and analyse data from police sources, age – sex profiles, state and city wise distribution, selected participating health care institutions, education and occupation levels, road user categories and transport sector on specific aspects of RTIs for RTIs, time and period distribution, and a vague and other injuries through a surveillance distribution of causes for road traffic injuries, approach. suicides and all accidental deaths. While this 2. Use data for road safety and injury prevention information is definitely helpful from a national programs at the city level to facilitate perspective, local data is required for a number of development of road safety and injury activities. Hence, a surveillance approach was prevention through advocacy activities adopted to gather information from multiple sources 3. Facilitate application and utilization of data in the city. This demonstration program attempted for planning and implementing general and to develop systematic road safety and injury specific countermeasures through various prevention programs based on data and evidence programs. adopting comprehensive and multiple approaches.

14 BRSIPP 2011 B2. Methods

In Bangalore, under the program, attempts were undertaken during 3 years based on data collected made to generate data through specific mechanisms are discussed in later sections of this report. Some and pool data from different sources. The program salient aspects of data collection are highlighted below. has been strengthened during the last three years and attempts are in progress to develop an integrated Figure 7: Sources of information for injuries data collection system. The extent, type and nature of data to be collected were finalized in consultation with stakeholder’s at the beginning of program.

Details of data collection activities have been discussed in earlier reports of 2009 and 2010 (Gururaj et al, 2008 and 2010). The development phase focused on consultation with stake holders, sources of data, selection of centres, inventory of hospitals, pilot study, organizing logistics of data collection, training programs, testing validity and reliability of data collection methods, feedback mechanisms and data utilization aspects. The various sources of data in the program are shown in Figure 7. Activities

B3. Fatal injuries

Information on fatal injuries was collected from two The proforma has five sections of basic identification sources: city police and vital statistics division of details, injury details (intent, type, place of injury, the city administration. As all injury deaths are product involved etc), details of Road traffic injuries considered either unnatural or accidental, they (place of occurrence, collision patterns, risk factors are routinely reported to police. Investigations (alcohol), use of safety devices (helmet and seatbelts) are undertaken as per established norms and and trauma care details (first aid, mode of procedures. Under the program, information transportation etc) (Annexure 1). was initially collected (in 2008 and 2009) through paper based formats. Under the leadership of the Since it was not possible to collect detailed Additional Commissioner (Traffic and Road Safety), information on other non-traffic injury deaths Sri. Praveen Sood, the paper version has been (Annexure 2), primarily deaths due to intentional replaced with a web based format in 2010. The computerization support was provided by the staff of National Informatics Centre in the city. Since all police stations in the city have been computerized and there are identified writers and computer programrs in each station, it was considered timely and economical to shift to this method. Number of training programs has been conducted for writers and inspectors of traffic divisions in each police station during 2009 and 2010 to implement and improve the system. The writers complete a two page proforma for every road death soon after completing investigation formalities.

15 injuries, in the urban component of the program, in the city. In consultation with senior officials, a summary statistics was obtained from the office of procedure was introduced to document details of the City Crime Records Bureau. This was compiled each fatal crash involving buses. The proforma is for 2010 on different parameters and injury causes. completed by the designated trained staff of BMTC and transferred to Co-ordinating Centre (CC) on a A similar mechanism has been developed under the monthly basis. rural component of Bangalore Road Safety and Injury Prevention Program in Tumkur. Since there are no Information was also collected from city vital networked computer systems in the district, a paper statistics division and latest data available was for based format is being used and data is collected by the year 2009. Under the Births and Deaths the team of trained research officers from NIMHANS. Registration Act, each death has to be registered The designated staff from the coordinating centre using specific formats which include the cause of collect information from individual records of traffic death. In Bangalore, under the MCCD scheme, data and non-traffic deaths (primarily accidental and is collected from the different hospitals and is intentional injuries) from the police headquarters of compiled at the city level. This was also used to Tumkur District. With computerization process in examine injury deaths under the program. the offing, it is hoped that there will be a shift to a web based format in due course of time. This A feasibility study has been initiated in December mechanism is being strengthened through an ongoing 2010 to collect data from 9 mortuary centres in the District Road Safety and injury Prevention program city with support from WHO. Considering the with support from WHO and Ministry of Health advantages of small number of centres and the legal (Gururaj, 2010b). requirements of autopsy for all injury deaths, a mechanism has been developed to obtain accurate In addition, a separate program has been established and reliable data from all autopsies of injury deaths in the Bangalore Metropolitan Transport department (Gururaj, 2010a) (Annexure 3). (BMTC) to record information on all fatal bus crashes

B4. Nonfatal injuries

Information on non fatal injuries was collected in and it is expected to lead towards a sustainable long 2010 from hospital sources in both urban and rural term mechanism (ETCR, Anneure 4). components of the program. In Bangalore City, the program that was started in 2007 continued with The collection of data is done by the ER team (nurses all the hospitals (3 of the hospitals discontinued due or doctors) using Emergency Trauma Care Record. to variety of reasons). Based on the feasibility study During the last 3 years, a number of training and the practical difficulties encountered in 3 of the programs were conducted for ER staff at regularly. hospitals (Victoria hospital, Bowring hospital and The work in each hospital is supervised by a nodal St. Johns Hospital), data collection in these places is being done by the CC staff. In all other hospitals, data collection is undertaken by the hospital designated team in the emergency room division, which varies from institution to institution.

In rural areas, the information was collected by the Casualty Medical Officers (CMOs) in Sri Siddhartha Medical College Hospital. In the district hospital and three of the community health centres, this is undertaken by the hospital staff themselves from 2011

16 BRSIPP 2011 officer of the hospital and monitored on a weekly / E Details of other types of injury and deaths monthly basis by the CC staff. The focus of (intent, place, type), information collection was on E Pre-hospital care (first aid, transport, referral) E Basic identification and brief socio- E Management and outcome demographic details E Information on Injury and death (place, type, The research component of the program was activity, intent) approved by the institutional ethics committee of E Details of road traffic deaths (where, who, how NIMHANS in 2007. and selected risk factors)

B5. Population based observational surveys

In addition to the routinely collected data, special use patterns, drinking and driving issues, speed surveys were undertaken by the coordinating centre monitoring by police, seat belt use and pedestrian during January-February 2011 in focused areas. safety issues. Detailed survey procedures are given These population based surveys in the geographically in later sections of the report under individual defined boundaries of the city focused on helmet areas.

B6. Data pooling

Data pooling was done during the year from Further, data on infrastructural projects of the city information available with transport department was collected from Bruhat Bengaluru Mahangara especially with regard to motorization changes and Palike (BBMP) and Bangalore Development Authority patterns. Information available in the annual report (BDA) to identify completed projects during the year. was made use of for this purpose and remaining data was collected from individual RTOs in the In summary, different sources of data were identified city. and relevant information was collected to develop a comprehensive picture of fatal and nonfatal injuries Information on traffic violations was collected from for the city of Bangalore. Even though the major the Traffic Management Centre under Bangalore City focus was on road deaths and injuries, data was Police of the city to examine pattern and nature of collected for other injury causes as well. In addition, violations, fines collected and level of enforcement the collected data was used for number of activities in the city. as detailed in later sections of this report.

B7. Monitoring of activities

Inbuilt mechanisms have been developed to ensure Coordinating centre staff ensure uniformity and systematic monitoring of the program. completeness of data collection with random checks and independent monitoring of 5% cases. E At the hospital level, data collected from E A weekly meeting (Saturday) was held regularly casualty is cross checked with medical records to monitor progress, recognize problems, and statistics to ensure coverage of cases. identify solutions and review progress. E At the ER level, the nodal officers ensure E All received forms from different sources were inclusion of all cases, completeness of all forms, examined for coverage and completeness. transfer to a location in ER for storage and Missing information was filled up from other transfer to coordinating centre periodically. institutional records, wherever possible.

17 E Meeting with all nodal officers once in 3 months E The program coordinator and the team visit helped in reviewing progress, identifying police stations and hospital departments at remedial measures for problems, ensured periodical intervals and held discussions with better cooperation, and work out future nodal officers, ER staff, medical record staff steps. and hospital administrator. E Continuous contact of CC staff with all E All data received from different sources were institutions was an inbuilt activity under checked for coverage, completeness and quality the program. Periodical visits and by CC staff. Data was then entered into the communications on a regular basis was computer on a day to day basis. Data entry undertaken to ensure completion of all activities and check formats have been developed using as per time schedule. EPI - INFO package.

B8. Sharing and disseminating of information

E Surveillance is an ongoing continuous activity, Data was constantly reviewed in the nodal and the analysed data has to be shared with officers meeting and used in all training all the partners; hence, feedback becomes a programs. regular feature of the program. As discussed Specific detailed information has been in the stakeholders and nodal officer’s meeting, made available to member institutions as information was disseminated in number of and when required. ways. The primary reason for using so many In 2009 and 2010, the annual reports, set combined methods was to encourage people of 10 fact sheets (Injury, Child injury, to get actively involved and also to ensure that Injuries among elderly, road traffic injury, feedback becomes an inbuilt activity. two wheeler safety, pedestrian safety, E All reports have been developed, circulated and suicides, falls, burns, poisoning), 5 public disseminated under the title of “Bangalore Road health alerts (Helmets, Seatbelts, Drinking Safety and Injury Prevention Program” and driving, Speed management, trauma E Individual institutions were provided with care) and 4 injury prevention series their respective data (on a CD) on a regular (Education, Engineering, Enforcement basis. Member institutions were encouraged to and Emergency care) have been published examine, use and develop reports for their and disseminated under the program. institutional activities.

18 BRSIPP 2011 Section C: Program and Results

As discussed in the methods section of this report, highlight the injury burden and its characteristics with data was collected from multiple sources and data a focus on road traffic injuries and other injuries. pooling was done with available data from different Further analysis of data on different aspects and in sectors during 2010. The results in this section focused areas will be undertaken during the year.

C1. Bangalore – a profile

The city of Bangalore is the capital of Karnataka and its growth in the last few years has been phenomenal. is well known globally for its technological prowess The city is characterized for its cosmopolitan nature and economic growth. The city is vibrant and is host and has witnessed rapid growth in the past few years. to a number of educational and technology Some salient features of the city are given in institutions. Known as the “Silicon Valley” of India, Table 6.

19 Table 6: Profile of Bangalore City SI. No Parameters 2010 Source 1 Area 800 sq. kms 1 2 Population 7 million 1 3 Density 2980/sq.km 2 4 Contribution to Karnataka state population (%) 11 5 5 Sex Ratio (Females/1000 males) 915 3 6 Life expectancy at birth 64.2 years 5 7 Crude birth rate/1000 20.2 1 8 Crude death rate/1000 6.2 1 9 Decennial growth rate (%) 1.3 5 10 Literacy rate% 83.91 6 11 Total number of slums 733 4 12 Total population in slums 4,30,501 5 13 Slum population% 8 2 14 Socially disadvantaged population (%) 40 5 15 Total number of schools and colleges 7674 7 16 Total number of factories 3121 8 17 Total number of police stations 142 9 18 Total number of hospitals (including public, private hospitals & nursing homes) 583 10 19 Total number of Drug stores 4445 11 20 Total number of General practitioners 5000 10 21 Total number of registered vehicles 3.69 million 14 22 Total number of 2 wheelers 2.65 million 14 23 Total length of roads 5821.46 kms 1 24 Number of alcohol selling outlets (CL-2, 4, 5, 6, 6A, 7, 9, 14 & 15) Licensees 2400 13 25 Total number of police personnel (traffic) 2881 9 26 Total number of police personnel (law and order) 11,908 9 Source: 1 Bruhat Bangalore Mahanagara Palike 8 Small, Medium and Large scale industries Corporation 2 www.bangaloreit.com 9 BCP Bangalore City Police 3 http://www.experiencefestival.com/slum 10 KSPCB Karnataka State Pollution Control Board 4 http://www.hindu.com/2007/04/28/stories/2007042802250200.htm 11 Karnataka state Drugs control General 5 www.censusindia.com 12 Bangalore City Police 6 www.des.kar.nic.in 13 Karnataka State Beverages Corporation Limited 7 Karnataka Education Departments 14 RTO, Government of Karnataka

The City of Bangalore with a population of 7 million the country. The city has more than 200 health care spread over nearly 800 square kilometres has a institutions of different nature, facilities, and population density of 2980 per sq. km. The city has services. achieved significant progress over the decade with declining birth and growth rates and an increase in The global economic recession that impacted life expectancy at birth. The male to female ratio is India and its cities, appears to have eased and approximately 1000:915. Interestingly, despite a the economic growth has revived. However, the significant economic growth, the percent of socially surging inflation in the same period affected the disadvantaged communities in the city is 40%, with lives of many people. During the year, as per 8% of the population living in slums. The overall media reports, employment, travel, hotel, literacy rate in the city is considerably higher at 84%. entertainment and other industries seem to have The city has large number of educational institutions, recovered and also increased exposure of people to industrial units and is a hub of knowledge growth in traffic.

20 BRSIPP 2011 C2. Motorisation and infrastructure development

The motorization patterns in the city have changed city, the Bangalore City Police have nearly 2,881 significantly and, at present, nearly 3.7 million police personnel at different levels with large vehicles are registered in the city, up from 1.47 numbers being at lower and mid levels. Similarly, million in 2001 (Figure 8) During the year 2010, the city has nearly 12,000 police personnel for law 2,68,876 vehicles were added to the city roads (while and order management. 1,79,666 two wheelers and 62,717 cars came onto the city roads, 216 buses joined the existing fleet). The metro work continued in the city and the first Sixty nine percent of the vehicle population within phase is expected to be opened for the public by the city are two wheelers and the proportion of cars April 2011. Remaining phases of the metro work is has doubled in a matter of just two years (from 9% expected to be completed by 2013 – 14, thus opening in 2008 to 18% in 2010). Figures 9 & 10 show the up the possibility of mass public transportation increase in number of vehicles, percentage change facility for the first time in the city. However, the in different vehicles and also selective distribution ongoing metro construction itself was a major of different categories of vehicles. impediment and bottleneck for the traffic flow and resulted in few deaths of workers. The To accommodate the increasing number of vehicles, environmentalists, NGOs and public were up in arms the city has a total road net work of 5,821 kilo meters for the felling of hundreds of trees considered with 4,491 kms of asphalted roads and 590 kms of essential for metro works and new infrastructure major arterial roads. To manage the traffic in the projects and consequent loss of critical green

Figure 8: Vehicular growth in Bangalore

Figure 9: Motorisation trends in Bangalore, Figure 10: Composition of vehicles in Bangalore 2001 - 2010 total 34,91,000

21 cover in the city. To ease traffic congestion and Due to these changes, the travel patterns of people to accommodate the growing traffic, a few have changed and exposure to traffic might have infrastructure projects like subways (10) and flyovers come down considerably (the total km travelled data /skywalks (12) and construction of several rigid is not available) in some areas and increased in few concrete medians in few locations were undertaken areas. There have been no evaluations or monitoring by Bangalore Development Authority and Bruhat reports indicating effectiveness and usefulness of the Bangalore Mahanagara Palike. various infrastructure projects affecting the overall mobility and safety of people.

Box 1: Infrastructure projects completed till date in the city by 2010 Flyovers Pedestrian Subways 1. Sirsi circle flyover 1. Hebbala 2. Richmond circle flyover 2. CBI jucniton 3. Anand rao circle flyover 3. jucntion 4. Dairy circle flyover 4. Rajabhavan road 5. Jayadeva hospital flyover 5. Sheshadri road 6. Hebbal flyover 6. Dr. Ambedkar veedhi 7. Old airport flyover 7. KR circle (towards PWD Office) 8. Yeshwanthpura flyover 8. Nrupatunga road 3 9. H.S.R Road ORR Junciton 9. Old post office road 10. Sarjapura ORR junction 10. Town hall 11. Magadi road, ring road junction 12. National college at Basavangudi Underpasses using pre - cast elements Underpasses 1. BDA junction 1. Malleshwaram underpass 2. Cauvery junction underpass 2. Modi hospital underpass 3. CBI junction 3. Rajajinagar entrance underpass 4. Sanjaynagar 4. Marath halli outer ring road underpass 5. Anandnagar 5. ORR & Hennur road junction 6. at 6. Underpass at Rama Murthy nagar 7. Palace road Maharani college junction 7. Underpass at Tollgate Junction, West of Chord 8. K.R. circle Road 9. international airport road

C3. Mortality profile and patterns

During the year 2009, 33,601 persons died in the Figure 11: Major causes of death – 2009 (%) city with a death rate of 5.1 per 1,000 population. Communicable disease registered a decline from 19% to 16% of total deaths. Injuries accounted for 10% of total deaths in city (Figure 11). Cardiovascular diseases topped the list with 5,124 deaths, followed by 3,644 deaths due to neoplasm’s and cancers. Injury and violence occupied the 3rd position with 2,823 deaths. The injury mortality rate was 403 / million population in the city.

Injury and violence was the leading cause of death in the city

Among the total deaths in the city, two out of three deaths were among men. One out of three deaths

22 BRSIPP 2011 was among the elderly, while children <15 years emerging as one of the leading cause of death among accounted for 5.3% of total deaths. Nearly 20% of women. The nationally representative study of deaths were in 15 – 44 years and 30% among Million death study by the office of the Registrar 45 – 64 year age group with slight gender variations General of India also reported similar observations (Figure 12). Interestingly, more deaths (34%) were with regard to age groups (RGI, 2009). seen among elderly women as compared to men (27%). Among the various injury causes, transport injuries and burns topped the list accounting for 23% and Figure 12: Age – sex distribution of deaths in 28% of deaths, respectively (Figure 13). Suicides, Bangalore, 2009 primarily due to hanging were responsible for 12% of deaths. It is essential to note that majority of burns and poisoning could be suicidal in nature. As suicides occur due to poisoning, hanging, burns and drowning. The number of deaths was to be determined based on intent

Further, the pattern and nature of deaths is dependent on the cause of death as mentioned in death certificates.

Figure 13: Distribution of injury deaths as per Injuries have been a major cause of death in all age BBMP death data 2009 (%) groups and both sexes. Transport injuries and suicides were the leading cause of death in younger age groups of 15 – 44 years (Tables 8, 9 and 10). Among men, transport injuries were the leading cause of death in 15 – 44 years, while suicides (primarily due to burns) were the major cause among women. Male suicides were also common in this age group primarily due to poisoning. However, among women, suicides due to burns were the leading cause in same age group. With increasing mobility due to education and work, transport injuries are also

C4. Non fatal injuries

Data from the 3 years of BRSIPP indicate that nearly cases with more nonfatal injuries in falls and higher 6,000 persons died of injuries and violence in number of deaths in burns. Bangalore city. Pooled 3 years data indicate this ratio with regard to RTIs to be 1 : 18 (10-33) : 30 Nearly half of injury and violence deaths in (25-50)in the city of Bangalore. Data also indicate city are due to traffic crashes and suicides. the ratio of deaths : hospitalisations : minor injuries to vary from hospital to hospital and from injury to Injury and violence are the leading cause of injury. Information on distribution of injuries and death in both men and women in 15 – 44 RTIs across hospitals in Bangalore is shown in years Table 7. This ratio is likely to vary as per injury

23 deaths Total RTI RTI Total 20.2 37% Total injury injury deaths Total deaths in deaths in the Hospital  Total RTI RTI Total admissions 6.7 51.7 Total injury injury Total admissions Total Hospital admissions  RTI registrations Total Casualty Total Casualty 17.7 46.7 Total Injuries Casualty Casualty NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 8057 632 393 9203 369 278 12 0 0 3330 2210 1480 3901 2377 9949 1006 1119 1153 28101 35 12 800 21 732 357 41 41 1717 2640 2467 1702 1848 1702 1686 2643 1372 1671 7991 324 23 856 22 234 23 50 3831 40 33 202 142 104 3 3 11708 2058 20236 2642 565 13504 4467 18344 975 18888 2118 13244 736 1822 23376 22444 1024 407 1234 447 2390 14802 154 727 280 409 571 1 8733 394 1376 138 41 2 330 45 384 25 14692 876 120 15 266 273 2 17851 199 310 80 35 92 234 5 4 11752 1901 83 13815 2642 10885 11888 1655 1368 195 26683 1343 17292 286 17 17435 505 718 56 12208 998 349 280 4599 1 30184 13069 481 542 767 2 18 5051 70 10022 1461 650 15 7257 450 27 106 11649 705 26 12958 528 166 195 17413 304 7 115 2680 10230 7 1 380 453 2 2050 40861 5612 233 246 263 798 17609 1107 12 3164 321 35 4 33302 284 33864 2873 7 634 643 18274 6 778 31306 14381 18261 415 463 14609 1030 674 196 3259 205 51 23 383 19464 597 134 11 35011 348 5010 4 2206 2 1291 3 233 3011 1154 280 104 70 56 Registrations Total Casualty Total Casualty  Table 7 : Non-fatal injury registrations in ERs of participating hospitals, January-December 2010 Table Name of Hospital Hospital of Name V`HVJ :$V Ambedkar Medical College And Hospital Hospital And College Medical Ambedkar Hospital Baptist Bangalore Bowring & Lady Curzon Hospital Hospital Mission Chinmaya Columbia Asia Hospital Hebbal Columbia Asia Hospital Yeshwanthpur CommandHospital (Air Force) D.G. Hospital Rajajinagar Esi Hospital Total 392358 69480 32466 375300 25144 13004 10318 2080 770 General Hospital, Jayanagar Jayanagar Hospital, General Hospital Hosmat Kims Hospital Hospital Teaching Medical Ramaiah M.S. Hospital Memorial Ramaiah M.S. Centre Medical Mallige Hospital College & Research MVJ Medical Nimhans Rajarajeshwari Medical College& Hospital Sagar Hospital & Trauma of Institute Gandhi Sanjay Orthopaedics Hospital Sparsh College Medical John’S St. Hospital Martha’S St. St. Philomena’S Hospital Suguna Hospital Hospital Victoria Hospital And College Medical Vydehi

1 2 3 4 5 6 7 8 9 Sl 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 No 

24 BRSIPP 2011 otal Burns 33601 crashes diseases diseases diseases diseases diseases disorders uberculosis Transport Other CNS Pulmonary Neoplasms Respiratory T Hypertensive Liver diseases erinatal deaths Miscellaneous heart diseases Urinary system P Cerebrovascular Ischaemic heart Diabetes Mellitus 13459 diseases diseases diseases diseases diseases diseases diseases disorders Neoplasms Pulmonary Other CNS Diarrhoeal Pneumonia Tuberculosis Hypertensive heart diseases Liver Diseases Miscellaneous Ischemic heart Urinary system Cerebrovascular Diabetes Mellitus Other circulatory Lower respiratory 5615 - 64 yrs Above 65 yrs T Other crashes diseases diseases diseases diseases diseases disorders uberculosis Transport Other CNS Neoplasms Pulmonary Pneumonia T Hypertensive Miscellaneous Liver Diseases heart diseases Ischemic heart Urinary system Cerebrovascular bacterial diseases Diabetes Mellitus Lower respiratory 4357 crashes diseases diseases diseases diseases diseases disorders disorders Transport Neoplasms Pulmonary Pneumonia Tuberculosis Hypertensive Liver Diseases heart diseases Haemopoeitic Miscellaneous Ischemic heart Urinary system Other bacterial Cerebrovascular Diabetes Mellitus Lower respiratory 2956 Burns crashes diseases diseases diseases diseases diseases disorders uberculosis Transport Diarrhoeal Neoplasms Pneumonia T Hypertensive Viral diseases Miscellaneous Liver Diseases Ischemic heart Urinary system Pulmonary heart Diabetes Mellitus Lower respiratory yrs 35 - 44yrs 45 - 54yrs 55 2249 Burns crashes Suicide disease diseases disorders Poisoning Transport uberculosis Neoplasms Pneumonia T Viral diseases Liver Diseases Miscellaneous Ischemic heart Urinary system CNS infections Rheumatic heart Diabetes Mellitus 1072 Burns deaths oisoning Suicide crashes diseases diseases disorders disorders Maternal P Table 8: LeadingTable causes of death in all age groups Bangalore, 2009 Transport Other CNS Diarrhoeal Rheumatic Neoplasms Tuberculosis Viral diseases heart diseases Haemopoeitic Miscellaneous CNS infections Other bacterial 255 Burns Suicide crashes diseases diseases diseases disorders disorders Transport uberculosis Neoplasms Other CNS Diarrhoeal Congenital Pneumonia T Viral diseases Haemopoeitic Miscellaneous CNS infections malformations Other bacterial Rheumatic heart 1491 Burns deaths crashes diseases diseases diseases Perinatal disorders disorders Transport Diarrhoeal Neoplasms Other CNS Congenital Pneumonia Tuberculosis Viral diseases Haemopoeitic Miscellaneous malformations CNS infections Other bacterial Rheumatic heart 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Total SlNo. 0-4 yrs 5 - 14 yrs 15 - 24 yrs 25 - 34

25 otal Burns 21373 crashes diseases diseases diseases diseases disorders disorders uberculosis Transport Pulmonary Other CNS Neoplasms Respiratory T Hypertensive Liver diseases heart diseases Miscellaneous Urinary System Perinatal deaths Perinatal Ischaemic heart Cerebrovascular Diabetes mellitus 7970 crashes diseases diseases diseases diseases diseases diseases diseases disorders Transport Neoplasms Pneumonia Other CNS Tuberculosis Hypertensive Liver Diseases Miscellaneous Ischemic heart Urinary system Cerebrovascular Pulmonary heart Other circulatory Diabetes Mellitus Lower respiratory 3741 - 64 yrs Above 65 yrs T crashes diseases diseases diseases diseases diseases diseases disorders uberculosis Transport Pulmonary Pneumonia Other CNS Neoplasms T Hypertensive heart diseases Miscellaneous Liver Diseases Ischemic heart Urinary system Other bacterial Cerebrovascular Lower respiratory Diabetes Mellitus 2941 crashes diseases diseases diseases diseases diseases diseases disorders Transport Neoplasms Pneumonia Other CNS Tuberculosis Hypertensive Liver Diseases Miscellaneous Ischemic heart Urinary system CNS infections Cerebrovascular Pulmonary heart Diabetes Mellitus Lower respiratory 2071 Burns crashes Suicide diseases diseases diseases diseases disorders Transport uberculosis 35 - 44yrs 45 - 54yrs 55 Neoplasms Pneumonia Diarrhoeal T Hypertensive Viral diseases Liver Diseases Miscellaneous Ischemic heart Urinary system Pulmonary heart Diabetes Mellitus 1410 Burns crashes Suicide diseases disorders Poisoning Transport uberculosis Neoplasms Pneumonia Rheumatic Pulmonary T heart disease heart disease Liver Diseases Miscellaneous Ischemic heart Urinary system CNS infections Diabetes Mellitus 690 Burns Table 9: Leading causes of death among males in Bangalore , 2009 9: Leading Table Suicide crashes diseases diseases Malaria disorders disorders Poisoning uberculosis Transport Rheumatic Neoplasms Other CNS Diarrhoeal T Viral diseases heart diseases Miscellaneous Haemopoeitic CNS infections Other bacterial 144 crashes Suicide diseases diseases diseases disorders disorders Transport uberculosis 5 - 14 yrs 15 - 24 yrs 25 - 34 yrs Congenital Other CNS Diarrhoeal Pneumonia Neoplasms T Viral diseases Liver diseases Haemopoeitic Miscellaneous malformations CNS infections Other bacterial Rheumatic heart 959 Burns deaths crashes diseases diseases Perinatal disorders disorders disorders Transport uberculosis Congenital Diarrhoeal Neoplasms Other CNS Pneumonia T Viral diseases Haemopoeitic Miscellaneous malformations CNS infections Urinary system Rheumatic heart 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Total SlNo. 0-4 yrs

26 BRSIPP 2011 otal Burns 12228 crashes diseases diseases diseases diseases disorders disorders uberculosis Transport Neoplasms Pulmonary Respiratory T Hypertensive Liver diseases Haemopoeitic Miscellaneous heart diseases Urinary system Perinatal deaths Perinatal Ischaemic heart Cerebrovascular Diabetes mellitus 5489 diseases diseases diseases diseases diseases diseases diseases diseases disorders Diarrhoeal Neoplasms Other CNS Pneumonia Tuberculosis Hypertensive Liver Diseases Miscellaneous Ischemic heart Urinary system Other bacterial Cerebrovascular Pulmonary heart Diabetes Mellitus Lower respiratory 1874 - 64 yrs Above 65 yrs T crashes diseases diseases diseases diseases diseases diseases disorders disorders Transport Neoplasms Pneumonia Tuberculosis Hypertensive Haemopoeitic Liver Diseases Miscellaneous Ischemic heart Urinary system Other bacterial Cerebrovascular Pulmonary heart Diabetes Mellitus Lower respiratory 1416 diseases diseases diseases diseases diseases disorders disorders Neoplasms Pulmonary Rheumatic Pneumonia Tuberculosis Hypertensive heart disease heart diseases Liver Diseases Haemopoeitic Miscellaneous Ischemic heart Urinary system Other bacterial Cerebrovascular Diabetes Mellitus Lower respiratory 885 Burns crashes diseases diseases diseases disorders disorders Transport Neoplasms Pulmonary Rheumatic Pneumonia Tuberculosis Hypertensive heart disease Liver Diseases heart diseases Haemopoeitic Miscellaneous Ischemic heart Urinary system Diabetes Mellitus Lower respiratory yrs 35 - 44yrs 45 - 54yrs 55 839 Burns Suicide crashes diseases diseases disorders Poisoning uberculosis Transport Rheumatic Neoplasms Pneumonia T heart disease Viral diseases Liver Diseases Miscellaneous Ischemic heart Urinary system Other bacterial Maternal deaths eading causes of death among females in Bangalore , 2009 382 Burns Suicide crashes diseases diseases diseases disorders Poisoning Table 10: L Table Transport Pulmonary Neoplasms Diarrhoeal Tuberculosis Heart disease Viral diseases Haemopoeitic Miscellaneous CNS infections Other bacterial Rheumatic heart Maternal deaths 111 Burns crashes Suicide diseases diseases diseases disorders Transport uberculosis Pulmonary Neoplasms Diarrhoeal Other CNS Pneumonia Congenital T Viral diseases heart diseases Miscellaneous CNS infections malformations Other bacterial Rheumatic heart 532 Burns deaths diseases diseases diseases Malaria Perinatal disorders disorders Diarrhoeal Neoplasms Other CNS Congenital Pneumonia Tuberculosis Viral diseases Haemopoeitic Miscellaneous malformations CNS infections Other bacterial Rheumatic heart 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Total SlNo. 0-4 yrs 5 - 14 yrs 15 - 24 yrs 25 - 34

27 C5. Young men and women are affected most

Injuries primarily affect the young people. Commonly, Figure 14: Age - sex distribution of communicable and infectious diseases are frequent injury deaths – 2009 (BBMP) in children and non-communicable diseases are seen beyond the age of 50 years. In the young population of 15 – 44 years injuries are a leading cause of deaths, hospitalisations and disabilities. Data from vital statistics division of BBMP and BRSIPP study findings confirm this observation as nearly 70% (65% of male and 74% of female) of deaths were in 15 – 44 years with a male to female ratio of 2:1 (Figure 14 and 15).

Figure 15: Age-sex distribution of fatal and non fatal injuries in 2010

Urban Rural

Urban Rural

C6. Violence and injury occur all throughout the year

Unlike many of the natural disasters that occur once though some months registered higher numbers in a while, injuries and RTIs are disasters of everyday. (Figure 16). In rural areas, 20% of fatal RTIs While natural disasters bring massive human occurred in July and reasons need to be ascertained suffering and property damage at one time and all for the same. This pattern of injury and violence of a sudden, injuries continue to kill and injure often obscures and hides the injury burden and people, and damage property, day after day and year highlights need for examination in a different after year (Table 11). Data from BRSIPP reveal that framework. Many policy makers tend to dismiss injuries were distributed across all months, even injuries as a major public health problem since a

28 BRSIPP 2011 few people are affected every day, and hence, a this has to be examined as per different injury causes, cumulative examination is crucial to understand the the distribution does not follow a classic and uniform distribution of injuries. pattern. Hence, because of its occurrence throughout different age groups, time periods and different Similarly, injuries continue to occur throughout the places, they are different as per compared to other day at different time points (Figure 17). Even though, problems.

Table 11 : Injury related deaths in Bangalore during January - December, 2010 (%)

Months Road Fire / Suicides- Other Accidents Falls Burns Poisoning Hanging Drowning Fall of Assualt / accidental Total Poisoning Objects Homicides deaths Others Jan 7.1 8.6 7.5 5.8 8.7 8.3 9.7 7.7 7.2 7.75 Feb 8.5 3.3 10.9 8 7.6 6.7 9.7 7.7 5.9 7.64 March 6.5 11.8 9.6 7.6 8.4 7.5 16.1 10.3 8.7 8.34 April 7 8.6 8.6 10.2 8.7 10.8 9.7 10.3 7.1 8.17 May 9.1 9.9 9.9 9.1 8.9 11.7 9.7 2.6 8.9 9.09 June 9.5 5.9 9 8 6 7.5 9.7 7.7 7.6 7.55 July 10.6 5.9 8.8 11.6 8.7 7.5 12.9 7.7 8.7 9.16 Aug 8.1 7.2 8.6 8.7 8.4 9.2 0 15.4 10.8 8.85 Sep 7.8 7.9 7.5 6.9 9.7 7.5 0 5.1 10.4 8.87 Oct 9.1 12.5 6.9 7.3 8.6 10 6.5 7.7 8.5 8.56 Nov 10.5 7.2 5.7 10.2 8.9 7.5 9.7 10.3 8.7 8.85 Dec 6.3 11.2 6.9 6.5 7.3 5.8 6.5 7.7 7.6 7.16

Figure 16: Fatal and non-fatal injuries as per month of occurrence (%) Urban Fatal RTI's Non-fatal all injuries Non fatal RTI's

Rural Fatal RTI's Fatal all injuries

Figure 17: Fatal and non-fatal injuries as per the time of occurrence (%) Fatal Non-Fatal

29 C7. Injury and violence in Bangalore

As per official police reports, during 2010, 4,542 RRR Nearly 500 persons die in Bangalore persons died in Bangalore due to one or more acts city every month of violence and injury. The number of deaths registered by police agencies was higher compared Among the various injury causes, Road traffic with vital statistics registration, probably due to injuries and suicides were the major causes, incomplete and improper registration of deaths. contributing for more than half of deaths in both Scientific studies from all over the world, including urban and rural areas and for both fatal and non- few from HICs, have documented underreporting in fatla injuries (Figure 18). One out of 5 deaths were official agencies, Studies from Bangalore (Gururaj due to RTIs, while one out of three deaths was G et al, 2000), Haryana (Varghese and Mohan, 2003) suicidal in nature. There could be possible and Hyderabad (Dandona et al, 2008) have revealed misclassifications for suicides and violence as this underreporting of RTIs. Deaths due to late is mainly based on intent and family members complications of injury and violence are not reported would like to conceal due to stigma, police enquiries with official agencies. Further, underreporting is and related issues. Burns due to self immolation – possible due to other injury causes like falls, accidental fires – and homicidal causes were drowning, burns and poisoning. responsible for nearly 500 deaths. In view of these issues, it is estimated that every year, nearly 6,000 deaths are likely to occur in the RRR Road traffic injuries and suicides city of Bangalore. This essentially means that nearly are the leading cause of deaths, 500 persons die every month due to an injury cause. hospitalisations and disabilities This estimate is also strongly supported with data from mortuary centers with autopsies done on more Road traffic injuries were the leading cause of death than 7,500 deaths in 2009. in both rural and urban areas for both fatal and non

Figure 18: Causes of fatal and nonfatal injuries in urban and rural areas, 2010 (%) Urban Fatal Non-Fatal

Rural Fatal Non-Fatal

30 BRSIPP 2011 Figure 19: Intent of injury (%) Urban Rural Fatal Non-Fatal Fatal Non-Fatal

fatal injuries. Nearly, 20% of deaths in urban areas RRR Alcohol consumption is a major risk and 32% of deaths in rural areas were due to road for deaths and injuries traffic injuries. Similarly among all non fatal injuries 47% in urban and 74% in rural were due to road Alcohol consumption is a major risk factor for traffic injuries. Remaining causes varied as per the injuries. Alcohol, even in small quantities, affects place. Among other causes, assaults due to violence vision, reflexes, judgement, coordination and was the second leading cause of hospitalizations in predisposes for occurrence of injuries. Data on both urban and rural areas. The 3rd leading cause alcohol is difficult to obtain from injury records in was mainly poisoning followed by falls. both hospitals and police due to medico legal problems. In our training programs, it was strongly RRR Majority of the injuries are emphasised about the need to document the unintentional in nature involvement of alcohol as it helps in recognition of the problem and taking corrective measures. Majority of the injuries were unintentional in nature in both fatal and non fatal categories. Unintentional Following these efforts, the recording of alcohol did injuries contributed for more than 2/3 of total non improve, even though this is far from ground reality. fatal injuries in Bangalore (70%) with fatal injuries Selective examination of alcohol use among men, in due to suicides and assault contributing for 28% of 16 + years and those injuries occurring between 6 pm injuries. In rural areas, intentional injuries accounted – 2 am, revealed that 7% of fatal and 20% of nonfatal for 25% of deaths with unintentional injuries injuries showed alcohol involvement (Figure 20). contributing for 1/3 of deaths (Figure 19). Alcohol not only predisposes, but also poses problems in care and management of individuals, especially those with brain injuries.

Figure 20: Alcohol in fatal and non-fatal injuries, Bangalore (%) Fatal Non-Fatal

31 C8. Road traffic injuries

In 2010, nearly 1000 persons died due to road crashes of the participating hospitals. In the same period in Bangalore. Apart from 858 registered deaths, there 13,004 persons were admitted for care with serious were 47 were UDRs (primarily crashes occurring with injuries. It is estimated that a minimum of 100,000 fixed objects which are documented separately) persons are likely to contact hospitals for emergency registered in the city. With an estimated 10% care. Based on data pooling for the period 2008-10 underreporting of late deaths, it is estimated that the it is estimated that, the ratio of fatal to hospitalized total number would be 1000 of deaths. As discussed to minor RTIs could be in the range of 1 : 40 : 70 in earlier, majority of these deaths occurred among young the city of Bangalore (Figure 22). men. The RTI mortality rate for 2010 was 14 / 1,00,000 population per year, which is much higher Due to increasing motorisation, industrialisation, than the national average of 11 / 1,00,000. migration and therby increasing exposure of people to vehicles and traffic, there has been a continuous The police agencies registered 5667 nonfatal injuries increase in road deaths in the city. The number during the same period in a ratio of 1 : 7 for fatal to of fatal RTIs has increased from 700 in 2001 to nonfatal injuries. There has been a gradual decline 858 by 2010, an increase of 25% over the decade of registered nonfatal injuries over time. This is due (Figure 23). Nonfatal injuries are also increasing to the fact that people register a case with police over time, even though many are not registered with only when there is requirement of an FIR for legal police and hospitals do not send any regular monthly or insurance purposes. or annual reports (Figure 24).

Data from 25 urban hospitals during the same period Figure 23: Fatal RTIs in Bangalore City saw a total of 32,466 nonfatal RTI registrations. during 2001 to 2010 8.3% of the total casualty registrations (Figure 21). For every 1 police registration, there were 6 hospital registrations. The number of nonfatal injuries could be much higher as data was collected from only 25

Figure 21: Comparison of non-fatal RTIs registered with the police and hospitals

Figure 24:Nonfatal RTIs in Bangalore during 2001 to 2010

Figure 22: Bangalore RTI pyramid

Deaths (1) 1000 A 25% increase in RTI deaths and a

40,000 phenomenal increase of nonfatal RTIs are Serious Injuries (40) seen during the last decade in Bangalore city. As shown in the figure 25, among the total deaths 84% were men. Nearly 5% of deaths occurred among Minor Injuries (70) 70,000 children < 15yrs and 13% among elderly. RTI deaths in the age group of 15 - 44 yrs contributed for 61 %

32 BRSIPP 2011 Figure 25: Age sex distribution of fatal and non fatal RTIs in urban and rural areas (%)

Urban Fatal Rural Fatal Urban Non-fatal

of total deaths. The pattern was similar for non fatal This analysis revealed that in each area one or two injuries. In rural areas, 86% of RTI deaths occurred roads accounted for large number of deaths. For among men and 50% of total were in 15 - 44 yrs. example, Tumkur road in limits registered 27 (42%) of the 64 deaths. Similarly, The Bangalore E Crash Locations - Bellary road contributed for 60% (38/63) of deaths. Generally, this analysis revealed that roads connecting The design and characteristics of roads plays a major to national / state highways and new peripheral ring role in RTI occurrence. The location of RTIs as per roads accounted for 3/4th of total crashes as shown different categories of roads helps in identifying major in Figure 28. and Table 12. Further, in all the areas, types of roads with high occurrence. One fourth of pedestrians and two wheeler riders were involved in urban fatal RTIs and half of rural RTIs occurred on 43.5% and 30.8% of fatal crashes respectively. The highways, highlighting the need to build safe analysis of road charecteristics revealed that crashes highways. The proportion of nonfatal RTIs in occured on stright roads, pucca roads and during both areas was around 12–15%, indicating the only nights. This type of information is useful for occurrence of severe crashes resulting in more number local area traffic and safety improvement programs of deaths (Figure 26). Every 3 out of 4 injuries in the for city planners. In particular, there is a need to city occurred on municipal roads, while rural roads improve and implement road safety programs on were responsible for one third of injuries in rural these roads. areas.

Urban and rural infrastructure has to be designed keeping safety of people.

In 2010, 858 road deaths registered with city police occurred in different locations. Information on crash location was also collected from police records. Among the 39 police stations, 503 (61%) took place in 13 police station limits as shown in Figure 27a.

Figure 26: Place of road traffic crashes (%) Urban Rural

33 Others Lorry Drivers Car Drivers Cyclists Two Wheelers 9 9 1 0 0 3 0 0 1 9 21 10 0 1 0 6 0 1 0 21 10 14 19 1 0 0 3 0 0 1 14 19 10 12 0 1 0 0 0 1 0 10 12 28 24 3 1 0 8 0 1 3 28 24 5 0 1 1 20 36 2 0 2 0 22 20 2 0 2 2 0 14 0 0 1 25 5 4 0 1 1 11 14 12 14 1 2 0 1 0 2 1 12 14 2 0 0 2 12 13 30 17 2 1 2 0 2 1 2 30 17 % Pedestrians % Pedestrians 4.3 13.2 40.5 20.6 25.8 29.0 36.4 21.2 s 5 7.8 1 1.6 9 26.5 3 6.5 2 5.3 4 12.9 8 36.4 14 26.9 11 23.9 18 58.1 17 56.7 27 51.9 31 81.6 38 60.3 26 56.5 22 59.5 23 74.2 20 87.0 27 42.2 No of Death Major Roads Major Roads Others 5 Others 15 Others 1 Tumkur Road Road Tumkur Hesaraghatta Road Ring Road 10 Bellary Road 15.6 Doddaballapur Road Ring Road 7 Hosur Road 11.1 Ring Road Mysore Road Ring Road Nice Road Hosur Road Nice Road Bellary Road Old Madras Road Ring Road 18 Bellary Road 52.9 Bellary Road Ring Road Ring Road Bannerghatta Road B T M Ring Road 17 Bellary Road 58.6 4 Doddaballapur Road 13.8 2 road Tumkur H M T Main road 8.7 C V Raman road 2 4 9.1 18.2 Others 22 34.4 Others 22 27 Others 17 Others 11 13.0 Others 6 Others 7 Others 8 Others 9 Others 13 43.3 27.6 Others 13 Others 8 Others 8 38 37 23 2010 Total Deaths Total 37 28 28 2009 Total Deaths Total Table 12: List of top areas with high road deaths in Bangalore, 2010 (n=500/858) Table ------50 25 64 50 25 63 45 39 52 56 55 46 48 56 34 98 39 31 18 14 31 22 15 32 24 30 32 24 29 26 24 22 49 30 2008 Total Deaths Total Name of the Area Peenya Peenya Yelahanka Madivala Byatarayanapura Chikkajala K R Puram R T Nagar Hebbala Banasawadi Micolayout Devanahalli Yeshwanthpura 1 2 3 4 5 6 7 8 9 Sl 10 11 12 13 No

34 BRSIPP 2011 Figure 27 a: Fatal crashes under different traffic Figure 28: Area and roads with high fatal police stations, 2010 crashes, 2010

Figure 27b: Conditions and characteristics of crash Large numbers of pedestrians and two locations, (%) wheeler rider / pillion are killed and injured on the roads of Bangalore and in rural areas

Collision pattern varies in urban and rural areas and depends on number of factors. In urban areas, collision with pedestrians, hit from back and skid and, fall were the commonest types that resulted in nonfatal injuries. For fatal RTIs, colliding with pedestrians, hit from back and collision with a vehicle in front were frequent and seen among two wheeler riders and pillions. Hit and run was common C 8.1 Road user categories in rural areas, and especially on highways. Nearly 5% of crashes were due to collision with fixed objects In both urban and rural areas, pedestrians were most like medians, light poles, trees and other objects. frequently injured: for fatal injuries, varied from Colliding with a vehicle in front was seen in both 32 – 45% of total RTI deaths, and the numbers varied urban and rural areas to the extent of 10% and slightly from 24 – 30% for nonfatal injuries. Two commonly resulted in death due to high speeds in wheeler riders and pillions accounted for 42 - 56% such collisions. of nonfatal injuries in rural and urban areas, while 35 – 40% of deaths were in this group. Deaths and In fatal crashes, pedestrians were mainly hit by buses injuries among pedal cyclists varied from 2 – 5% in and trucks (25 – 28%), two wheelers (20 – 27%), the series. Car occupants ranged from 2 – 4% in cars (19-30%) in both urban and rural areas. The both urban and rural areas, except for the high heavy size of vehicle and impact of collision resulted numbers, primarily due to severe crashes occurring in higher number of deaths among pedestrians. on highways. The three wheeled auto rickshaws Collision between pedestrians and two wheelers was contributed to 10% of nonfatal injuries in rural areas extremely common in both urban and rural areas (Figure 29). resulting in nonfatal injuries. Pedestrians were mainly hit by two wheelers on the roads in nearly half of

35 Figure 29: Road user catagories (%) Urban Fatal Non-fatal

Rural Fatal Non-fatal

non fatal crashes. Cars had collided with pedestrians 6% at T junctions, 4% in round abouts and 4% at in 10-15% in both urban and rural areas. signal lights (Figure 32). Interestingly, in rural areas nearly 14% of collisions took place between pedestrians and buses while For two wheeler crashes, collision between two similar number in urban areas was 7% (Figure 30). wheelers was the commonest pattern for nonfatal injuries in both urban and rural areas. Nearly 50% Pedestrians were commonly injured while walking or of fatal in urban and 40% in rural were due to crossing roads in 20–40% of road crashes. collision with heavy vehicles (Figure 33). Most of Surprisingly, 10% of rural pedestrian deaths occurred the fatal two wheeler crashes (45%) took place in when they were hit by vehicles, as they were standing the middle of the road and one third of them while on road. Nearly 40% of pedestrians were killed while they were hit from the back (35%). The other walking on roads, indicating the unsafe environment common locations were road curves (7%), T junctions for walking in the city. Activity at the time of pedestrian (12%) and even on road humps (3-7%). Head on crash revealed that 2/3rds were crossing the road collisions were recorded in 10% of crashes, while and ¼th walking on the road. 8 children died while skid and fall was seen in 8% of deaths. Collision playing, 5 persons while working and 19 even when with a vehicle in front was documented in 18% of they were just standing in the road. (Figure 31). fatal crashes and 16 persons died due to crashes with fixed objects like concrete medians. (Figure 34 Nearly 38% of pedestrian deaths occured due to and 35). collisions in mid block areas, 6% near cross roads,

36 BRSIPP 2011 Figure 30: Collision of vehicles with pedestrians (%) Urban Fatal Non-fatal

Rural Fatal Non-fatal

Figure 31: Pedestrian activity at Figure 33 on next page the time of crash, 2010 (%)

Figure 34: Pattern of two wheeler collisions, 2010 (%)

Figure 32: Location of fatal pedestrian crashes, 2010 (%)

Figure 35: Location of fatal two wheeler crashes, 2010 (%)

37 Figure 33: Two - wheeler collison patterns (%) Urban Fatal Non-fatal

Rural Fatal Non-fatal

C 8.2. Risk factors for road crashes wheeler riders and pillions is the appropriate use of standard helmets. The helmet primarily reduces C 8.2.1 Helmet use impact of collision and consequent injury to the brain by - acting as a mechanical barrier between the The city is characterized by a phenomenal number skull and the impacting object; reducing the of two wheelers as shown in the previous sections of deceleration of the skull and hence the brain the report. The convenience of driving, easy movement; providing a cushioning effect through availability, rising income levels, media promotion, the padding thermocole lining which absorbs the inability to afford cars and lack of public impact ; spreading the force of the impact to a larger transportation have contributed for an increase of area so that energy is distributed through the outer two wheelers in the city. The distribution of injury patterns among two wheeler indicate that majority of them sustain injury to head and face in both fatal and non fatal injuries. Injury to a vital part of the body like brain, which controls all major activities of an individual, can have devastating effects on the life of affected individuals and their families. Injuries to the brain, spinal cord and facial structures can lead to instantaneous death and long term disabilities among two wheeler riders and pillions.

One of the recommended, proven and, cost effective interventions for reducing brain injuries among two

38 BRSIPP 2011 shell of a helmet. The shell also protects against done in this phase. A just completed study on penetration of the skull by any sharp pointed objects ‘prevalence of non-standard helmet use’ in Bangalore and by keeping the helmet on the head in a crash (www.rtirn.net) provides detailed interviews also. through chinstraps. (Gururaj 2005b and 2008a; WHO, 2006). E Examining helmet use among those killed and injured, though not a direct measure, indicates On November 6, 2006, Karnataka introduced partial the pattern of use and effectiveness of helmets helmet legislation (in select cities and only for riders) among those with different levels of injury as a safety strategy to reduce brain injuries based on severity. Data showed that 49% of urban and the directives from the High court of Karnataka. The 80% of rural injured motorcyclists had not worn Karnataka Motor Vehicle Rules, 1989, rule 230 makes helmets at the time of crash (Figure 36). Among it mandatory for motor cycle riders (covering urban fatal crashes only a third had worn motorcycles, scooters and mopeds) to wear protective helmets at the time of crash. The use of helmets head gear of such quality that will reduce impacts was totally deficient in rural areas as there is in crashes. The rule also highlights that helmets no legislation at present nor any awareness should confirm to standards and carry reflective tapes activities conducted in rural areas. Recently, of 2x13 centimetres to increase visibility. an independent study on prevalence of non

Figure 36: Use of helmets among two wheeler riders (%) Urban Rural Fatal Non-fatal Non-fatal

In 2010, data regarding helmets was collected from standard helmet use has been completed and multiple sources in the city. The use of helmets at report development is in progress. the time of crash was collected from patients in ER and also from the investigations by police in fatal E In recent times, enforcement by police for crashes. The level of enforcement was measured by helmet law has been stepped up and people the number of cases booked and fines collected by have been booked for violation of the law with the Bangalore City Police. In addition, focused a fine of Rs. 100. In 2010, nearly 2,57,072 2 population based observational surveys were wheeler riders were booked by Bangalore City undertaken by a team of trained research officers in Police for not wearing helmets. As shown in 78 traffic locations within the city. The observations figure 37, there has been an increase in number were made during both day and evening times on a of cases booked (1,98,651 in 2009 to 2,57,072 rotational basis at traffic intersections covering in 2010). different traffic movements and directions. During the period of 26th January 2011 to 8th February E The use was directly linked to the type of 2011, a total of 1,45,789 two wheeler riders were vehicle, time and location of observations. Our observed for helmet use. Two wheeler riders were observational surveys revealed that majority of observed at traffic intersections about helmet two wheeler riders were wearing helmets. wearing, type of helmets and whether they were Among the users, 53.7% were wearing full face appropriately strapped or not. No interviews were helmets, 11.1% half face and 31.8% open type

39 Figure 37: Cases booked by Bangalore city police E The survey was done during day time and during for non use of helmets working days, which showed greater one on the country our observations during other times and other days found lower helmet use among riders. Most of the pillions were not found wearing helmets as the present law does not cover these categories of riders.

or construction hat helmets (Figure 38). As open type helmets are not recommended, it can be inferred that the use of helmets was only 64% . It was also observed that many had not strapped their helmets properly as chin straps were not tied and helmets were likely to fall off any time. Further, many were also using damaged (cracked) helmets that are not likely to offer any protection. These observations indicate that (i) enforcement is more focused around day times and in central business Figure 38: Helmet use among two wheeler riders: parts of Bangalore, and (ii) public awareness on proper results of an observational study (%) use of helmets were extremely low.

Helmets reduce brain injury, related hospitalisation, consequent disabilities or deaths and accompanying economic costs significantly. Helmet laws should be expanded to the whole state and strictly implemented along with increasing awareness among public

Strategies to increase helmet use

The existing legislation should be expanded to cover the entire country. Legislation should also cover all 2 wheeler riders. Penalty should be increased to a minimum of Rs.1,000 for not wearing helmets. The police department must scale up enforcement on helmet rule implementation across the state. Public awareness activities should be E The use of helmets was significantly lower undertaken in all parts of the state, in during evening and night times, early morning both urban and rural areas about the hours, in residential areas, in outer and advantages of wearing proper – standard peripheral parts of the city, during weekends helmets. and holidays and for short distance travel.

40 BRSIPP 2011 C 8.2.2. Use of seat belts selected petrol bunks. Car drivers were observed from a close distance as to whether they were wearing seat An important safety measure for car drivers and belts at the time of entering and stopping for filling passengers at the time of collision is the availability petrol in the bunks. and proper use of seat belt. In crashes where cars collide with vehicles in front, hit stationery objects E Data from the hospitalized and killed car drivers or when hit by vehicles from back, car occupants and passengers indicated that 3 out of 4 injured are injured and killed due to the sudden impact of and all those killed in crashes had not worn the crash. Drivers and passengers are thrown in seat belts at the time of crash. Majority of the different directions, hit objects in front or on side injured car drivers had not worn seat belts and and hence sustain injuries to chest, abdomen, neck, were also travelling at high speeds (Figure 39). head and face. Figure 39: Seat belt use among car drivers in A properly worn seat belt and one of a good quality Bangalore city (%) keeps the occupant of the vehicle in place inside the vehicle and reduces /minimizes sudden movements that occur soon after a crash. It stops the driver and passengers from hitting interior objects and by preventing the driver - passenger from being thrown out of the vehicle. Such safety harnesses also distribute the forces of rapid deceleration over larger parts of the body, thus, minimizing the impact and damage to one particular area. The seat belt slows down the body movement by stretching and holding Data from the enforcement wing of Bangalore the occupant in the seat and thus will not be thrown city traffic police indicate that the number of around during the crash (Gururaj, 2008b; Foundation cases booked for not wearing seat belts for Automobile Safety, 2009). increased from 636 in 2007 to 1,689 2010 (Figure 40). The amended Central Motor Vehicle Rules of 1989, stipulates that all cars manufactured after 1998 shall Figure 40: Cases booked by Bangalore City Police for not wearing seat belts be fitted with seat belts and should be in conformity with AIS:005-2000 and AIS:015-2000 specifications. It is of particular interest to note that all cars in recent times are provided with seat belts for use. However, the implementation of seat belt is left to the states and enforcement is strongly required to increase seat belt use.

Data regarding seat belt use was collected from injured patients brought to ER rooms of hospitals and police documentation details of fatally injured persons. Enforcement levels were obtained based on the number Observational surveys at different locations in of cases booked and fines collected by the Bangalore petrol bunks indicated that among the drivers City Police. To examine use of seat belts among car the seat belt use rate was 17.1%. Enquiries drivers, focused observational surveys were undertaken with police officers indicated that much by the field research team on a sample of 258 drivers emphasis was not given for penalizing as they were entering petrol bunks. Observations were violators of seat belt use due to difficulties in made by the team on a sequential basis at 5 randomly observation / identifying violators.

41 Strategies for increasing seat belt use those under alcohol influence at the time of injury (Gururaj et al, 2004; Gururaj, 2005).

The existing legislation with penalty levels should be made aware to the public Data on consumption of alcohol among the injured The police department must scale up and killed in any injury event is not readily available enforcement on seat belt law in India due to medico legal reasons. The attending implementation across the state. physician is usually hesitant and not willing to Public awareness activities should be document alcohol influence and presence, based on undertaken for informing advantages of smell of alcohol in the injured or killed person, as it wearing seat belts is not considered proof of evidence by courts of law. Blood or breath alcohol estimations are not done in The numbers who own cars are gradually both police investigations and hospital registrations. increasing in India. Seat belt laws reduce In addition, as compensation is not awarded for injuries and deaths among car drivers and alcohol related injuries, attending physicians do occupants. These laws should be expanded to not document information about alcohol with a view the whole country and state and strictly to help individuals and families. implemented by traffic police along with increasing awareness among public. In addition, Information on alcohol presence at the time of injury child restraint laws should also be introduced or during hospital contact or among deaths has been for safety of children in cars. included in the surveillance program, amidst above mentioned difficulties. In all training programs over C 8.2.3 Drinking and driving time, this has been emphasized repeatedly. During the year, informal discussions were held with the police People driving or even walking, under the influence in all 39 police station limit about the status of of alcohol not only injure themselves but also injure implementation of drink drive programs, nature of and kill others. World over, alcohol is identified as implementation and difficulties encountered. a major risk factor for traffic crashes, falls, suicides, violence and other injuries. Studies from India have E Data from BRSIPP for the year 2010 shows also documented increasing presence of alcohol in that nearly 20% of hospitalized patients were different injuries. Consumption of alcohol leads to under alcohol influence at the time of injury poor judgment, slow reaction, poor visual attention, (based on chosen criteria of being men, improper coordination, delayed reflexes and 16+ years and injuries occurred between 6 pm difficulties in risk perception on road, thus affecting to 6 am) (Figure 41). This figure increased to the driving performance. The pseudo euphoric 25% in rural non fatal injuries based on data effect of alcohol makes a person less inhibitive, from a small sample. Information on alcohol consequently leading to violation of safety behaviours in fatal injuries of both urban and rural areas on road (GRSP, 2007). Previous studies from was not available. NIMHANS have shown the severity and impact, deaths, duration of hospitalization, extent of E The drink drive law implementation has been disability and economic losses are higher among up scaled since 2007 as seen by an increasing

Figure 41: Alcohol use in those involved road crashes in Bangalore Figure 42: Trend of drink driving cases booked by the Bangalore City Police

42 BRSIPP 2011 number of convictions. In 2010, nearly 66,930 interviewed all injury patients for presence or persons were booked for driving while absence of alcohol with confirmation by intoxicated. Despite the increase in positive breath smell as certified by attending enforcement, it is well acknowledged that physicians. The data was examined based on drinking and driving still remains a major select criteria of being men, 16 + years and problem (Figure 42). those reaching the 3 ERs between 7 pm – 7 am. Among the total 2,743 injury patients, it E According to information gathered from the was observed that 42.8 % were under alcohol various traffic police stations on drink drive influence at the time of crash. The rate varied enforcement that are conducted regularly, it was as per injury causes and sex. More number of observed that 6,202 vehicles were stopped and falls and assaults were linked to alcohol the drivers were checked with breathalysers during (Figures 44 and 45) the period January-February, 2011. Among them, persons driving under the influence of alcohol Figure 44: Alcohol presence in injury cases (%) varied from 2 – 20% in different locations of the city. The numbers stopped and checked varied across police stations from 20 - 200 per night. The numbers tested positive was dependant on time (more between 10–12 pm) and month (most often, high numbers were seen in the beginning of month) (Figure 43).

Figure 43: Persons driving under the influence of alcohol: Results from an observational study (%) Figure 45: Alcohol involvement in various injury causes (%)

E During informal observations and discussions with officials in 39 police stations of the city, it was observed that all police stations: have been provided with breathalysers varying from 3 to 6 in each station. The required tubes and related materials like printer were also available, though few were not functioning in some stations. implement the program at least E In order to identify the number of persons with 2 days in a week. injuries under alcohol influence, we undertook check for enforcement generally for a rapid one month survey in 3 large hospitals 2 – 3 hrs between 9 to 12 pm. of the city. This was considered essential as chose places for testing drivers nearer to documentation of alcohol was poor in routine the police station, as impounded vehicles surveillance. In the 3 identified hospitals of could be easily transported from the Victoria hospital, Bowring hospital and location to the station (drivers are not NIMHANS, a trained team of research officers permitted to drive if found positive).

43 needs to be strengthened with tubes, Figure 46: Effect of speed printers, reflective barricades and jackets. needs systematic training for enforcing officials on drink drive enforcement. need to develop a systematic action plan for drinking driving enforcement.

Strategies for scaling up enforcement on drinking and driving

Drinking and driving should be totally unacceptable and there is need to increase public awareness. The existing legislation In recent times, the infrastructure in the city of with penalty levels should be made aware Bangalore, though far from satisfactory has been to the public given greater attention. The construction of new roads The police department needs to draw up has favoured high speeds with the absence of safety an action plan for the whole city and in features. Under the program, speed studies have each police station limits for uniform – not been undertaken and clear data is not readily visible and random testing. available; however, anecdotal evidence indicates that It is important that the program majority of the fatal crashes include an element of targets men in 18-45 years, teenage speed as most crashes occur on peripheral roads, drivers, drivers of two wheelers and cars, ring roads and high ways where high speeds are night time drivers and should be focused common. more on outer areas, peripheral areas and all high ways. E The Bangalore City Police have been using combined enforcement strategies on speed Alcohol consumption increases the risk of injury limitations like speed cameras, automated and violence significantly. People under alcohol enforcement systems, interceptors and others. influence not only kill and injure themselves, The number of violations booked in the city but also injure and kill innocent people on roads increased from 6589 in 2005 to 74,787 during and at homes. 2010 (Figure 47).

C 8.2.4. Speed limit enforcement Figure 47: Trend of overspeeding cases booked by the Bangalore City Police It is well acknowledged and widely reported that inappropriate speeds and related behaviours like overtaking from wrong side are key risk factors in road crashes. Crashes occurring at high speeds result in greater transfer of mechanical energy. When this exceeds the physiological tolerance of the individual it results in damage to different body organs. The level of damage is associated with several factors like nature and speed of vehicle, type of the counterpart vehicle, rigidity of the object along with Inappropriate and excessive speeds are the biggest velocity of the impact. An increase in mean speed contributors for deaths on Indian roads. Collision of levels by 5% results in an increase of crashes by heavy vehicles/ cars with pedestrians, two wheeler 10% with 20% increase in fatality (Gururaj, 2008c; riders and cyclists result in greater number of GRSP, 2008). sudden deaths and severe disabilities.

44 BRSIPP 2011 Strategies for scaling up speed greater growth was observed in rural areas. The management programs increasing teledensity of mobile phones in India is bound to increase the problem.Use of mobile phones

Driving at excessive speeds within and while driving is an offence under the IMV and attracts outside cities and on highways should be a fine of Rs 100. There is very little systematic totally condemned by the society and wide information regarding impact of mobile phone use range of awareness programs needs to on road crashes from India. be undertaken to curb this practice. Passive speed control measures with use of road engineering approaches (speed bumps, rumble strips, roundabouts, traffic lights, and others) should be incorporated in city management programs. Police department needs to be strengthened with speed cameras, surveillance cameras and other devices for enforcement along with capacity building and training at all levels. Penalties for speed violations should be increased to bring offenders to books. Programs should target men in 18-45 E Our informal observations on road side on a years, teen age drivers, drivers of two sample of 1,45,789 drivers indicated that 6.5% wheelers and cars, night time drivers and of drivers were using cell phones during driving should be focused more on outer areas, and this was commonly seen among two peripheral areas and all high ways. wheeler driver and car drivers. This was found All urban residential areas and places with to be a common practice in traffic intersections traffic generators should confirm to low as they were awaiting change in signals. Many speeds and limits should be developed continued driving while speaking on the cell scientifically for Indian road conditions. phone after the lights turned to green. E A study undertaken in 2008 in 11 colleges in C 8.2.5. Use of cell phones Bangalore city looed at mobile phone use. In all, 436 students from pre-university, degree, Distracted driving is one of the known risk factors post-graduate, engineering, dental and medical for road crashes and use of cell phones is a common colleges responded to the pre-tested, structured feature. Mobile phone use (while driving or walking) and self administered questionnaire and also is an emerging risk factor for RTIs and is a risky provided information regarding cell phone behaviour for road crashes. While, use of hand held addiction. The sample consisted of an almost mobile phones (without earphones) hinder equal number of males (209) and females maneuverability of the vehicle, even the hands free (227). Almost all (97%) used the mobile phone or blue-tooth devices distract and make drivers / for making calls and 8% used it for more riders inattentive to details on the road, thereby than 5 hours/day. More than two-thirds (66%) compromising safety and increasing the risk of 'talked and walked' and more than half (52%) injury. Cell phone use and distracted driving lead to used their mobiles while driving; 44% had road crashes, people using cell phones while driving tripped, bumped into someone or narrowly not only kill and injure themselves, but also injure missed an accident while on their mobiles. and kill innocent people on roads. More than two-thirds (67%) expressed a fear As on 31st January 2011, there were nearly of being out of mobile phone contact 807million mobile subscribers in India giving a (Nomophobia). Interestingly, 29% reported teledensity of 68 mobile connections for 100 persons; experiencing headaches, 43% loss of sleep and

45 64% Ringxiety (sensation and the false belief Strategies for regulating mobile phone that one can hear the mobile phone ringing or use while driving feel it vibrating, when in fact it is not doing

so). While 28% had shown a high risk behavior There is need for appropriate legislation in mobile use, 3.2% could be considered as discouraging use of mobile phones while addicted to mobile phones (Masthi & driving Yashaswini, 2009). Public awareness programs are essential to inform public of dangers with The Government of India has been making efforts to regard to use of cell phones. formulate a specific legislation in this regard. It is anticipated to be in place in the coming days.

Box 2: Cell phone use and road crashes Driver distraction is an important risk factor for messaging services among drivers is likely to road traffic injuries. There are different types of make this an important road safety concern. driver distraction, usually divided into those where Young drivers are more likely to be using a mobile the source of distraction is internal to the vehicle phone while driving than older drivers, and are - such as tuning a radio, or using a mobile phone, particularly vulnerable to the effects of distraction and those external to the vehicle - such as looking given their relative inexperience behind the wheel. at billboards or watching people on the side of the road. The impact of using a mobile phone on crash risk is difficult to ascertain, but studies suggest Studies from a number of countries suggest that that drivers using a mobile phone are the proportion of drivers using mobile phones approximately four times more likely to be while driving has increased over the past 5-10 involved in a crash. This increased risk appears years, ranging from 1% to up to 11%. The use of to be similar for both hand-held and hands-free hands-free mobile phones is likely to be higher, phones, suggesting that it is the cognitive but this figure is more difficult to ascertain. In distraction that results from being involved in a many countries the extent of this problem remains conversation on a mobile phone that has the most unknown, as data on mobile phone use is not impact upon driving behaviour, and thus crash routinely collected when a crash occurs. risk.

Using mobile phones can cause drivers to take This includes: their eyes off the road, their hands off the steering E collecting data to assess the magnitude of the wheel, and their minds off the road and the problem and identify where and among whom surrounding situation. It is this type of distraction it is most prevalent; - known as cognitive distraction - which appears E adopting and enforcing legislation relating to have the biggest impact on driving behaviour. to mobile phone use; There is a growing body of evidence that shows E supporting this legislation with strong that the distraction caused by mobile phones can enforcement and public awareness campaigns impair performance in a number of ways, e.g. to emphasize the risk of the behaviour and longer reaction times (notably braking reaction the penalties associated with transgression of time, but also reaction to traffic signals), impaired the law. ability to keep in the correct lane, shorter E Other measures that offer potential reduction following distances, and an overall reduction in in risk include: technological solutions, for awareness of the driving situation. Using a mobile example, applications that detect when the phone for text messaging while driving seems to phone is in a moving car and direct in-coming have a particularly detrimental impact on driving calls to a voice messaging service; behaviour. Text messaging is often a low-cost form E company policies that regulate employees' use of communication, and the increasing use of text of mobile phones while driving.

Source: WHO, 2011

46 BRSIPP 2011 C 8.2.6. Visibility issues roads in a haphazard manner in all places, whether or not a traffic light was present Good vision and eye care play a critical role in en- (Figure 48). suring better road safety. Data in India on visibility aspects of driver are not available. E In addition, despite recent improvements, it was observed that few of the signal lights were E During the 22nd road safety week of 2010, Shankara eye hospital in Bangalore undertook Figure 48: Road crossing behaviour: Results of observational study (%) free comprehensive eye screening camps for drivers and employees of government and private organisations. Nearly 370 drivers of buses, cars and other vehicles were screened for visual problems. The screening showed that 14% of the drivers had a significant visual defect with 5% of them requiring treatment. The drivers were unaware of the impact of poor vision on performance on roads. Among the several risk factors for road crashes - poor visual status, not working, cycle timings were low and lights strain on eyes due to long hours of driving, glare had blown off in several places. A general and bright light effects and dangers persisting observation was that people respected traffic on the roads due to lack of illumination are lights only in major intersections and that too, some contributory factors for road crashes at only when a policeman was present near by. night times. (; January 29, 2011). E The pedestrian use of subways was observed at 9 places by the team of trained research C 8.2.7. Pedestrian road behaviours officers during Jan 25 - Feb 7, 2011. Three subways were closed for pedestrian use In a heterogeneous traffic environment, a pedestrian’s walking and road crossing behaviour influence risk of road deaths and injuries. Pedestrians and vehicle drivers consider each other a nuisance on the roads. With shrinking walking and crossing places, it is a difficult task on Bangalore's roads to walk/cross. In recent years, small investments are being made by the city administration to provide some facilities ( ! ). How far are they useful is the question.

E Pedestrian road crossing behaviours were observed at 82 locations in the city during 8 am - 8 pm involving nearly 31,000 pedestrians. The number of observations varied from 100 - 150 depending on the location and timings. On a rotational sampling basis, research staff observed the timing cycles of traffic lights and corresponding people's road crossing behaviours. Even though there were wide variations among age and sex of individuals and locations, generally it was observed that one third in waiting crossed the roads when lights were red, 6% did not cross while it was green and one out of five crossed

47 (Malleshwaram, Nrupatunga road, Chalukya circle) and remaining are kept open for restricted hours. Each subway was observed for a period of one hour during day time. Discussions were held with with users on an informal basis related about their opinion, use, difficulties and other issues. The use of subways was dependant on area, timings, access and location to bus stops. Security guards were posted round the clock in 4 of the subways and 5 other were not manned by anyone. Among the total of 10,971 observations, 2,369 (22%) Strategies for pedestrian safety did not use subways. Use of subways was higher, if it was located near a bus stop, visible City planners and administrators should both outside and inside, clean and hygienic, design and make roads that are people presence of heavy traffic and presence of friendly which encourage walking. This security. People were unlikely to use such concept should be a part of urban facilities if they had to walk long distances, it development and infrastructure policies was dark and dingy, offensive smelling, and programs. hawkers being present, construction in Footpaths must be restored or created on progress, antisocial elements being around etc. all roads for people to walk and use roads Children, women, physically challenged in a proper way. people, youngsters, elderly, pregnant women Number of road engineering measures like were not using subways and mentioned that it traffic separation, round abouts, traffic was difficult for them to use. calming measures should be done on all E Similarly, use of sky walks was observed at roads, at greater risk. 7 locations during January 25 - February 7, Pedestrian safety should be a larger 2011 by a team of trained research officer integral part of road safety at the city that between 8am - 6 pm ( this was also the also addresses speed management, drunk maximum time of use). Discussions were driving and others. held with both users and non users at entry Pedestrians should be separated from side and exit points. The distance to the motorized traffic on all roads. nearest bus stop varied between 20-200 meters. Among the 2,597 person observations Nearly 40% of people killed and injured on our made, only 46% used sky walks. The usage roads are pedestrians. The city should have long was found to be high in places of heavy traffic term vision for developing pedestrian facilities. and where traffic separation was in place. One of the sky walks (opposite to Santosh C 8.2.8. Safe Public Transport theatre) was used less due to presence of hawkers, antisocial elements, drug peddling In a city with a population of around 8 million, and soliciting sex. The use of skywalks was public transport systems play an important role in less if traffic was less, during weekends and movement of people. As public transport becomes holidays and if located at inconvenient the nerve link for travel in the city, it is also important places. Children, elderly, physically that it should be safe, convenient, economical and challenged, pregnant mothers, sick and reliable for people to travel. Safety, both within and disabled were found using less. outside buses is of high importance for people. Thus, it is essential to consider the needs of people and their convenience and safety in With 6100 buses, 5758 schedules and 19,842 drivers, designing and developing such facilities. Bangalore Metropolitan Transport Corporation (BMTC) the sole organization for public transport

48 BRSIPP 2011 Table 13: Highlights of BMTC services for Bangalore City

YEAR 2001-02 2002-03 2003-04 2004-05 2005-06 2008-09 2009-10 Schedules 2535 2932 3291 3827 3957 5344 5758 Fleet 2658 3036 3460 3925 4106 5642 6093 Daily Average Scheduled kms {per lakhs} 5.77 6.19 7.18 9.02 9.33 11.32 12.28 Routes 1212 1345 1523 1690 1726 2368 2443 City Services 817 988 1029 1131 1102 583 1307 Suburban Services 1412 1647 1985 2382 2542 1785 4146 Pushpak services 306 297 287 314 313 308 305 Growth in Depots 19 20 24 24 25 33 35 New Vehicles Added 401 588 678 613 426 949 1218 Average age of vehicles held [ in lakhs kms ] 3.19 3.55 3.42 3.13 Total Scheduled Kms { lakhs} 2107.68 2261.09 2628.91 3042.86 3306.36 4130.33 4483.49 Daily service Kms { in lakhs} 5.63 6.07 7.11 8.15 8.67 11.13 12.10 Passengers carried per day [ in lakhs ] 26.25 26.75 30.35 32.07 34.78 40.27 42.59 Daily Traffic Revenue [ Rs Lakhs ] 82.79 93.69 120.87 138.68 170.78 211.5 277.34 Accidents per 1,00,000 kms 0.22 0.22 0.23 0.18 0.16 0.15 0.12 Total number of road crashes 417 414 472 456 467 637 565 Gross Revenue Turnover [ Rs Lakhs ] 32232.47 37333.47 48621.9 57219.35 70340.15 100062.69 113032.66 Effective Kms operated per day outside city 5.63 6.07 7.11 8.15 8.67 11.13 12.11 Gross Revenue 322.32 373.33 483.47 572.19 703.4 1000.63 1130.33 Revenue from Advertisements 130 220 220.72 190.19 284.88 498.79 518.13 currently in Bangalore, transports nearly 42,00,000 Figure 49: Number of deaths where BMTC buses persons everyday. The average age of vehicles is about were involved, year wise 3.13 lakh kms and the number of routes has expanded from 1212 in 2001 to 2443 by 2010 (Table 13). BMTC is popularizing bus services with the introduction of "luxury buses "and "Bus Days "for nearly 6 months now. Apart from daily revenues of Rs.277 lakhs, the organisation has been receiving bouquets and brickbats regularly; it has been criticised by both public and media for crashes involving the buses.

Figure 50: Number of serious injury where BMTC In 2010, data was collected by the trained team of buses were involved, year wise BMTC on all fatal bus crashes and is being planned to expand to include all serious crashes from 2011. During 2010, 101 persons died and about 500 were seriously injured due to road crashes involving BMTC buses in the city. (Figure 49 and 50). Commonly after a crash, huge crowds gather at the scene, passersby protest, buses are damaged, (people throw stones or set the bus on fire), police arrive on the scene to control crowd and the injured and / or the

49 dead are transported to hospital. Most of the times, Figure 53: Age of BMTC drivers involved in fatal the driver flees from the scene and an enquiry is crashes, 2010 undertaken. Compensation for victims or their families or to drivers is announced.

Month wise distribution of crashes revealed no major variations even though some peaks were seen every alternate month(Figure 51). Nearly half the crashes occurred during morning hours (6 am to 12 noon), which are also the busy traffic hours. The second peak was during 3 pm to 9 pm to the extent of 28% Figure 54: Experience of drivers involved in fatal (Figure 52). crashes, 2010

Figure 51: Month wise distribution of fatal crashes, 2008 - 2010

Figure 55: Age – Sex distribution of fatally injured persons in BMTC crashes, 2010

Figure 52: Time of occurrence of BMTC crashes - 2010

28% in 16 – 20 years and 21% in 60 + years were females indicating the greater travel patterns of women. Male preponderance was seen in 31 – 40 years and 12% of victims were school children.

In a city packed with people and two wheelers and The average age of the bus fleet was about 3.2 years characterized by heterogeneous traffic, the collision and majority of crash involved drivers were in pattern of BMTC buses indicate that more than 80% 25 – 34 years (55%). The number of fatal crashes of crashes involved pedestrians and two wheeler decreased over remaining age groups. Interestingly, riders / pillions. While, the pattern has remained 2 out of the 3 crash involved drivers had less consistent over time, the proportion of these two than 4 years experience, highlighting the need groups has been increasing (Figure 56 and 57). The for systematic and continuous driver training small size of pedestrians and consequent low visibility programs (Figure 53 and 54). along with movement patterns of these people in crossing or walking on roads makes them highly Nearly half of those killed and injured in BMTC vulnerable. Similarly, the smaller size, low visibility crashes were young people in 20 – 40 years (50%) and driving patterns combined with non-separation (Figure 55). This observation is similar with data of traffic makes two wheelers highly vulnerable in for the entire city for the year 2010. Surprisingly, crashes.

50 BRSIPP 2011 Figure 56: Collision patterns in fatal Speed(s) of vehicles is an important risk factor in BMTC crashes, 2010 (%) crash occurrence. This observation is supported by the fact that 3 out of 4 crashes occurred on straight roads. The internal investigations have revealed that one or both vehicles were in high speed and were either overtaking each other or violating traffic rules in specific locations.

Figure 60: Crash location of fatal bus crashes, 2010

Figure 57: Road user category of fatal bus crashes, 2008 – 10

Collision of buses with pedestrians or small size vehicles like two wheelers and occurring at high While collision with pedestrian was common, hit speeds can lead to massive transfer of energy and from back and head on collision were the others lead to instantaneous deaths and poor outcomes. common patterns. In 5% of fatal crashes, BMTC Analysis of data revealed that more than half died buses had run off road or hit fixed objects like even before they could reach hospital(Figure 61). medians and poles. In collision with other vehicles during 3 years, head on collision and rear end collisions increased significantly (Figure 58 and 59). Figure 61: Place of death amongfatal crashes, 2010

Figure 58: Patterns of collision - 2010

Figure 59: Patterns of collision with other vehicle

51 Strategies for safe bus fleets on health, social, psychological, enforcement and behavioural aspects of road safety. i. Even though safety, reliability and efficiency Integrated training programs should be has been the focus of the organisation, a mandatory for all high risk drivers and those safety policy within the organisation that is frequently involved bus drivers. holistic, comprehensive and integrated needs x. Drivers screening and training programs for to be developed by the organisation. health conditions, use of drugs, alcohol ii. The policy should focus on driver working consumption, fatigue, sleeplessness and hours, driver training, operation systems and working hours should be undertaken at fleet mechanisms. Revenue earnings should periodical levels. not be the only focus. xi. As increasing speeds are found to be the iii. Safety within BMTC cannot be evolved in single largest contributor for crashes, all isolation and is an integral part of the larger drivers must be exposed to periodical safety policy and program of the city. Since sensitization and orientation programs on such mechanisms are absent now, BMTC speed related issues within the organisation together with other stake holders should work along with ensuring the availability of speed towards developing a Road safety Policy and governors in all buses. Drivers should be Program for the city. instructed to compulsorily follow the iv. Capacity strengthening of all senior prescribed speed limits within and outside professionals within the organisation to city limits, and in particular near all traffic promote and ensure safety of people on roads generators like schools, colleges, temples, needs to be undertaken as involvement is hospitals etc. required at different levels. xii. Strict mechanisms should be established to v. A safety wing of professional experts has to address drivers issues specially those be established within the organisation, involved in fatal crashes. This needs examine fleets and drivers issues. developing a uniform policy within the vi. Fleet safety mechanisms with compulsory organisation not to exempt drivers with inspection and certification of all buses from simple penalties or suspension where they every safety angle should be introduced and can come back. promoted in a systematic manner. This xiii. Specific and focused research studies should should include all activities to be undertaken be undertaken on driver’s knowledge - by the technical wing of the organisation in practice to obtain baseline information on coordination with depot manager and these issues for further integration with drivers on a periodical basis. driver training programs. vii. All buses must be subjected for periodical xiv. The type of information required for safety inspection and compulsory certification by promotion in BMTC was highly inadequate. senior technical managers within the system It is important that all fatal and serious and this should be an ongoing activity. crashes should be investigated by an viii. All buses should have complete and independent crash team (outside the agency) integrated inclusion of safety features like to specifically recognize modifiable risk indicators, large mirrors, compulsory factors. Data from this research should be pneumatic or manual doors, GPA systems, used to strengthen safety programs within speed governors and others. the organisation. ix. Since majority of crashes involved young and xv. A simple reporting system as developed in inexperienced drivers, systematic training the current Bangalore Road Safety and Injury programs for all newly inducted and existing prevention program should be implemented drivers should be implemented. All driver for monitoring of all road crashes within training programs should include sections BMTC.

52 BRSIPP 2011 Forty nine year old ‘R’ is working as a watchman in a private company in Bangalore. Originally from an interior district of Karnataka, he and his family migrated to Bangalore about 2 years in search of a better life. In Bangalore, his wife was working as a helper in a garment factory, while his mother and two sisters did some odd jobs near to their home. Not interested in doing a watchman’s job, Mr. R had started using alcohol to forget his problems. On a Sunday night, R met with an accident on the NH – 4 highway. The night before the incident, Mr. R had spent his monthly pay to pay his old debts and also to buy alcohol. When his wife confronted him during dinner, he was evasive and walked out of the house after a verbal fight. He went to his office and drank a whole bottle of whisky. Being restless, he stepped out of the factory and started walking on the main road. Being under the influence of alcohol Mr. R did not know where he was walking and nothing registered in his mind. He did not hear the horn of the lorry that was coming behind. The high speeding sand laden lorry did not stop at the right time and he was hit from the back. He was found bleeding profusely from his right hand and face. Blaming the lorry driver, nearby people got him admitted to a private nursing home where he was treated for about 2 days. Not able to continue the treatment and having still not recovered, he came and got himself admitted to the government hospital. Doctors inform that he has 2 fractures and few open injuries on the face. They say he would require at least 6-8 weeks to recover totally. His employer is planning to serve him a termination notice.

Mr. Y was returning home from work, he was quite excited about the promotion now, that his monthly salary reached 5 figure number. He was anticipating the rise since almost 3 months and had planned to surprise family member, he had a new car booked and wanted to take delivery and reach home to take his wife and 3 children for a ride. On the way he thought he would call up home and picked up the mobile in his pocket. Trying to dial the number, he missed seeing the 2 wheeler which was overtaking him from the left side. Not wanting to hit the car in front he steered and hit the median. The impact made his head hit the dash board. He had not worn the seat belt. He immediately lost consciousness. On getting a missed call his wife was trying to reach him but found no one answering. A stranger later informed that Mr Y had met with an accident and was being taken to the hospital. In the hospital he was diagnosed to have had hemorrhage in the brain and had to be operated immediately. The entire recovery process would possibly take 15-20 days and also the final deficit would be known only over a period of time.

Ms. S, 19 years, was very happy as it was her first day at the engineering college. She had secured a merit seat and her father had gifted her a two-wheeler to travel. Along with this, she was also the proud owner of her own new mobile. This gave her plenty of things to brag with her friends. She was also happy that she was able to get a full driving license and not be restricted to ride only gearless vehicles. However, on a Wednesday, she was coming home after her special classes in the evening. A speeding auto rickshaw driver knocked her down to race past the red signal at a traffic intersection. After the collision, she fell down, and the auto driver was caught by the bystanders. He had consumed alcohol and was in a hurry to reach home. The fateful crash resulted in not just bruises over her hands and on the face but also a fractured collar bone on the left side. While the recovery took nearly 2 months, she is now scared of driving on the city roads and uses the auto everyday, which costs her approximately Rs.100 per day. She still gets pain in her left arm and unable to do fine movements.

53 Print media reporting of injury events

Newspapers are a common source of information on day to day events for public at large. Media plays a major role in informing public as well as shaping and changing the attitudes of the general population. A study was undertaken during the period July – December 2010 (6 months) to understand the coverage given for RTIs and for prevention - control in particular. Three major newspapers were reviewed by a trained research officer for information on road crashes on a daily basis. The information was transferred to an excel sheet under specific categories. Some general observations are as follows:

During the period, newspapers reported a total of 70 -110 (20-25% road crashes in the city), while 423 crashes occurred as per city traffic police.

Every month, an average of 15 RTI deaths were reported in the print media.

The articles generally reported date of death, name, age, sex, place of crash, collision pattern and road user category e.

The most common road user categories involved were pedestrians and two – wheeler riders/ pillions.

Newspapers commonly reported incidents on the scene like public reactions at crash site, driver running away, bus set on fire and others.

Most of the cases reported included spot deaths and mass casualties.

Information on the use of personal protective devices like helmets, seatbelts were not reported.

The commonest cause of road crashes as reported were “over speed, negligence, careless driving, driving not noticing other vehicles, etc.,”

Information on environmental and vehicle factors were totally absent.

Newspaper reports did not mention information on some common risk factors like driving under the influence of alcohol except occasional cases.

Reports did not highlight the way the perticular crash could have been prevented or the severity of injuries lessened.

Newspapers also carried information on new or old infrastructure projects, public attitudes on the same and reactions of respective government officials.

Public educational activities were extremely minimal and no campaigns were seen during the period (sponsorer’s of campaigns have to pay large amounts for inserting messages).

Articles on mechanisms to reduce road crashes like helmet use, seat belt, speed management, control of drink and driving, good trauma care practices, road engineering were reported occasionally.

54 BRSIPP 2011 C9. Falls

Injuries due to falls are a major cause of deaths and E Every alternate fall injury occurred at home, disabilities. Since fall injuries can be accidental, while 15% were in work places and 24% intentional, or at times undetermined, it falls into occurred on roads (Figure 63). both intentional and unintentional categories. As only intentional falls are considered medico legal, Figure 63: Place of injury in non-fatal falls (%) majority of the fall related deaths are not included in police reporting systems. Research in this area in India is also extremely limited further limiting our understanding of the epidemiology of falls. Falls can occur at any location like homes, roads, public places, construction sites, schools and others, even though domestic falls are the commonest events. The precise causes of falls differ as per situation, context, and circumstances and require focused research in this area.

During the year 2009, 10,622 deaths and 2,416 injuries due to falls were reported by NCRB at the E Majority of the injuries occurred during day national level. Once again, nonfatal injuries were time. significantly underreported in police sources. Further E Falls due to intentional nature were less than details are not available in this area at the national 1% and majority were unintentional. level. Data available from CCRB, Bangalore revealed E In the select categories of males and being that 152 persons died due to falls in 2010. Attempts 16+ years, alcohol consumption was found in will be made in future to obtain more details of 25.2% of total non fatal injuries at the time of these cases. Data was also collected from the hospital contact. participating hospitals of BRSIPP for the year 2010 E Majority of the injured did not receive any first and, 5,490 cases were registered in the hospitals, aid care at the site of injury and 2/3 were contributing for 9.8% of non fatal injuries. provided first aid in the nearby hospitals or health care centres. Nearly 45% were E Nearly 22% of non fatal fall injuries occurred transported from the first contact hospital to among children less than 15 years, while 8% the definitive hospitals by ambulances. were in elderly beyond 60+ years. Nearly 53% of falls occurred in 15-44 years with a higher number among men (Figure 62). E The male to female ratio was 4:1 with a male preponderance.

Figure 62: Age-Sex distribution of non-fatal fall injuries

55 E 2% of the patients were brought dead to the Strategic approaches for prevention hospitals and 1.8% died in the emergency

rooms. Parental supervision of children has to be E More than 2/3 of fall injuries (64%) were improved at all times to ensure safety of moderate to severe in nature with more than young children at all times and in all places half sustaining injury to the head and face Security has to be strengthened along with regions. Every alternate fall injury had injury barricades and balcony railings in all high to upper and lower limbs, commonly resulting rise buildings in fractures and dislocation. Nearly 5% of All playgrounds should be made safe with injured persons had definitive injuries to spine energy absorbing materials for safety of and vertebral column, chest and also to the children along with safety certification vital parts of the body. measures. E More than half of injured persons (51%) had Anti skid floorings and materials should to be hospitalised for intensive care and be encouraged for safety of elderly people. management. Vulnerable members have to be provided supportive care to remove suicidal ideations Falls among children and elderly are through early interventions. extremely common and result in deaths and serious disabilities

‘A’ (10 year Old) was playful, chubby child in school and was liked by all. Now he is recovering from the fall he sustained while he was playing with his friends at school. After finishing their lunch boxes, A and friends decided to play games. In the midst of the game, the bell rang and they had to rush back to classes. Jostling each other to reach the class room on the 3rd floor, ‘A’ rushed forward only to trip and fall from the 2nd floor. The temporary barricades which were put up were insufficient to hold him and prevent his fall. He sustained a compound fracture of both lower limbs and had to be operated couple of times to set the bones. Because of these medical and surgical procedures and frequent visit to hospitals, he has missed school for more than 6 months. His daily activities have also come to a halt as he is in bed most of the times.

C10. Burns

One of the most commonest injury frequently reported injuries are not known due to lack of surveillance by the media are fire related injuries. Every day, 2 to 3 systems, reporting mechanisms and research. burns deaths are reported in the news papers and in local television channels. Burns have a high rate of In the city of Bangalore, 477 deaths were reported mortality and disability. The survivors of burns to police authorities during the year 2010. In the 25 are left with various types of disfigurements and participating hospitals of BRSIPP, 2,566 persons were contractures and, individuals with facial disfigurements registered in the same period with a ratio of 1 : 6 go through enormous pain and suffering. between fatal and non fatal injuries.

At the national level 23,268 deaths were reported E Unfortunately, 15% of non fatal injuries were due to burns in 2010. This is often an underestimate among young children less than 5 years and of the magnitude of the problem. Sanghvi et al an equal number in 5-14 years (Figure 64). estimate that the number of burn deaths was E More than half (54 % ) of burn injuries among 1,63,000 in 2001, six times more than the police women occurred in the age group of 14-29 reports (2009) . The characteristics of non fatal burn years with another half in 29 to 44 years.

56 BRSIPP 2011 Figure 64: Age- sex distribution of non-fatal burn injuries

E The male to female distribution was almost equal with slightly higher numbers among E Information from the police records in Tumkur women. under the rural injury prevention program E More than 80% of burn injuries occurred at revealed that 13% died at the site of burns, 3% home and mainly during day time hours on the way to hospital and 84% during the (Figure 65). course of hospital stay. E The real causes of burns were unknown in the Figure 65: Place of injury in non-fatal burns (%) surveillance program, even though kerosene stoves, gas cylinders, oil lamps and hot liquids were implicated in the causation. Investigations by the Bangalore based “Vimochana” revealed that majority of burn deaths were either suicidal or homicidal in nature.

Collecting information on burn injuries in hospitals poses difficulties as patients and their family members are unable to give total information due to the serious nature of the injured person, presence E In the hospitals, more than 80% were declared of police and medico legal complexities. The constant as unintentional injuries with only 14.6 % being fear of police and courts makes people not to report intentional injuries, mainly suicidal in nature. the real circumstances. In view of this, it is important This information needs to be interpreted with to undertake focused population based studies using caution due to medico legal barriers and well defined research methods to understand the real stigma, as majority could be intentional, either nature of the problem. suicidal or due to violence. E More than 80% of burn injuries had more than Recently, the Bangalore based Vimochana, an NGO 60% burns and had to be hospitalised for long working with families of burns affected patients in periods of time. The long term outcome was Victoria hospital has compiled a ten year report of not clearly known and requires further research. burns among women (The Hindu, 16th March 2011). E No first aid support was provided at home (even The report outlines series of problems faced by women simple measures like pouring cold water are in receiving appropriate care and support at times of found to be extremely helpful) and the first place crisis. Even though the official records indicate stove of care was the nearby hospital. burst and cylinder explosions as the common causes, E Majority of the patients were semi conscious the real causes are found to be different. Majority are or unconscious at the time of hospital found to be either suicidal or homicidal in nature. registration and were unable to provide exact The medico legal problems in terms of courts, details. The information provided by the family investigations, enquiries, dying declarations are huge members may not be totally reliable. and interfere in recovery of patients.

57 Affected people are still continuing care for a variety of health problems No affected person or their families have received any compensation, even though an amount of Rs. 2,00,000 to the next of kin of the deceased and Rs. 50,000 for the injured for reimbursement of hospital expenses was announced. Some of the patients reported that they could not even receive free hospital care at the time of crisis. A year after tragedy………….. The hearing in courts are still in progress with shifting of the cases from the office of On 23rd February 2010, the Carlton Towers fire the additional chief metropolitan tragedy resulted in death of 9 young people magistrate to the fast track civil service court. and injuries among several (exact numbers Several loopholes in the construction and are not availabl) who were employed in operation of the building were reported by information technology industries. The tragic the media like - obstruction of ingress and event not only brought immense suffering for egress, construction of pillars in open the affected families, but also resulted in wide spaces, obstructing the movement of fire ranging media debates on safety issues in the fighting equipments, lack of natural city. The tragic event was widely reported in ventilation, blocked passages, unauthorized the media, investigations were commissioned, parking, and lack of adequate equipment to rescue operations were done and fight by the fire department. Most compensations announced. The coverage of the importantly, no follow-up action has been news disappeared in the media over time taken since the tragedy. Meanwhile, a new possibly due to neglect, lack of follow-up and association of the agencies working earlier competing nature of other news stories. A year in the building has been formed, but are yet after the tragedy…….. to obtain the required permission for The pain and suffering of the families continuation of work. continue due to loss of their loved ones. Source: Deccan Hearld, 24 Feb, 2010

Mrs. P, residing in Bangalore, is a 28 year-old widow admitted for management of burns at Victoria hospital. Belonging to a family of 4 female children, she was married to Mr. A, who expired 3 years after marriage and is currently living with her in-laws. She lives in a small house in a low income locality and used to work as a garment factory worker. Her parents had given Rs.1,50,000 as dowry along with other household items. Insufficient dowry was a source of constant friction between her in-laws and Mrs P, particularly after the death of Mr A. Her in-laws used to demand more money from Mrs. P and attributed death of their son to her bad luck. Once, in a fit of rage, her in-laws physically abused her and also poured boiling water on her; unable to tolerate problems, Mrs. P decided to walk out of her in-laws place. However, over the next few days, they were adamant not to send the 3 year old child and said “only you can leave”. When the arguments reached a crescendo over time, in a fit of anger, Mrs. P went to the top floor, locked herself and poured a bottle of kerosene on herself and lit a match. Hearing the commotion, the neighbours rushed in and doused the fire and shifted her to the nearest nursing home. Since the local hospital could not manage her due to higher extent of burns, she was referred to Victoria hospital after initial first aid. Currently, she is in a critical stage and her 3 year old daughter looks on innocently at her mother lying in the burns ICU ward in the hospital.

58 BRSIPP 2011 Strategic approaches for prevention

Parental supervision has to be improved in all homes to keep children away from inflammable materials. Vulnerable family members have to be provided supportive care to remove suicidal ideations through early interventions. First aid measures like generous pouring of cold water to affected areas should be made known to the public. Household applications of cotton, cloth, match paper and others can lead to infections and complications. All electrical fittings should be made safe and should be beyond the reach of children. Long term measures like changing cooking and living practices should be supported Electrical appliances in all buildings must be certified Training for fire fighting personnel should be systematically developed along with provision of equipments

Burns in India is a common cause for deaths and injuries. Many deaths among young women are suicidal or homicidal in nature.

C11. Poisoning

Poisoning, a common cause of injury, has been difficult to understand due to the complex nature of events and its misclassification between accidental, suicidal and homicidal nature of events. Data from NCRB revealed that during 2010, 26,634 persons died due to accidental poisoning. In addition, 42,783 persons died due to poisoning of suicidal nature. The number of non fatal injuries was less indicating huge extent of underreporting. Information from CCRB indicates that nearly 1,000 persons died due to both causes in 2010 in the city of Bangalore.

59 Information from the participating institutions of the the cases the nature of the product was not BRSIPP showed that 5,857 persons were brought to known. hospitals for care and management. The ratio of E Nearly 92% of poisoning were intentional in fatal to non fatal injuries was 1:6 in 2010. nature. E Alcohol was mixed with poisonous products E Highest number of poisoning was registered and consumed thereafter in 8% of non fatal in the age group of 14-29 years (61%) with injuries by men. It was also observed that another ¼ (24%) in 29-44 years. alcohol was consumed prior to the consumption E More number of poisoning cases were seen of products. among women in the age group of 14-29 years and similar pattern was observed among men. E The male to female distribution was almost similar in both genders. E Nearly 85% of poisoning occurred at home and the products used ranged from insecticides / pesticides to OTC drugs. Many easily available drugs like barbiturates, sedatives, anxiolytics and others were used. In almost one third of

Figure 66: Products involved in non-fatal poisoning cases (%)

Mrs. C, 24 year old, is married to Mr. P and stays in a rural area about 40 kms from Bangalore. Their household includes Mr. P’s elderly parents and his 3 younger brothers. Not being educated, Mr P relied on his meager income derived from driving an auto rickshaw. Being a tea-totler, he was soft spoken and in his spare time used to work in his father’s 2 acre agricultural land. Because of the economic situation in the household, P’s 3 brothers had discontinued their schooling and had migrated to Bangalore in search of work. Mr. P and Mrs. C had a 3 year old girl child and were finding it difficult to manage their day to day living. Sensing a opportunity to make some extra money, Mr. P started investing in a chit fund to the extent of Rs. 3000 every month. Because of this, he had stopped giving money to run the household leading to a ever increasing battle of arguments, skirmishes and fights. On one such occasion, in the evening at about 7.30 pm, Mr. P stomped out of the house and went to the shed in the fields. When he did not return for a long time, Mrs. C went after him and found that he was lying on the ground frothing from his mouth. Hearing her shouts for help, neighbors rushed in and took him to the district hospital. He was given immediate first aid by the doctors and then referred to Bangalore for further management. In Bangalore, they were able to revive Mr. P and, he is at present in a semiconscious state. Doctors say he will take a longer time to recover. With no money to buy medicines or get herself a cup of tea in the hospital premises, Mrs P hugs her daughter and cries continuously.

60 BRSIPP 2011 E Once again, the first aid availability was Strategic approaches for prevention extremely poor and many of them had to be taken to nearby hospitals by the family All medicines, chemicals and toxic products members. The interhospital referrals were done (household cleaning materials) should be through ambulances in 1/3 of injuries. kept out of the reach of children and E Majority of the patients were semi conscious vulnerable family members. or unconscious in nature at the time of Pharmacists and chemists should not reaching definitive hospitals. 2% of the patients dispense medicines without an authorised died in the emergency rooms and 3 out of 4 prescription from a physician. ER patients were admitted for further Highly toxic chemicals used in horticulture management. – agriculture and others should be banned from market and should be sold (If Poisoning due to chemicals, drugs and definitely required)only through authorised other household products are a common dealers in both urban and rural areas. cause of deaths and injuries First aid measures like removal of poison should be informed to families. Poison treatment centres should be established in each state to undertake research, advocacy, public education on a continuous basis.

C12. Assault and violence

Violence is a type of intentional injury affecting health E Nearly 80% of violence was registered in 15 to and quality of life of people in a significant way. 44 years. Unfortunately, violence is still not considered as a E Nearly 43% of violence occurred on roads and public health problem in India. The type of violence public places, while nearly half of injuries varies from one extreme of homicides to a variety of among women occurring at home. other acts like violence against women, children, E All injuries were intentional in nature even elderly, sexual violence, and other types of violent though the precise causes were unclear. acts. Violence amongst women, children and elderly E Alcohol was found to be major risk factor, as are extremely under reported for a variety of social, one out of 4 acts of violence occurred under its cultural and economic reasons. Once again, stigma, influence. Every 2 out of 3 persons who was medico legal barriers and lack of research have injured and brought to the hospital were under limited our understanding. Hence, the precise the influence of alcohol. information and characteristics of violence are not E Even though majority of injuries were mild in known in India. nature, the other half was moderate to severe

As per NCRB data of 2009, 32,369 persons died due to homicides in the country. The number of non- fatal injuries due to acts of violence is not known due to complexities in registration systems in the police stations. In Bangalore, 39 persons died due to acts of violence during 2010. In the same year, 8,500 injured persons were brought to the 25 hospitals under the program with a ratio of 1:22.

E The male to female distribution was 4:1 for non fatal injuries.

61 in nature requiring longer periods of quantitative research, focussed qualitative studies hospitalisation. are required for understanding various issues in E Injuries were commonly inflicted to the head violence. and face region (67.8%) with fractures noticed in upper and lower limbs (14% each). Violence is the most common type of injury all E Majority were provided care in the emergency over India, but is still not recognised as a health rooms and referrals and hospitalisations were problem. Victims of violence experience seen in 10% and 28%, respectively. problems all throughout their life. Children exposed to violence and experiencing the same As there are difficulties in obtaining clear in their early days are at a serious risk of understanding of causes – context – situation and developing serious mental health and circumstances through surveillance programs and behavioural problems.

Strategic approaches for prevention

E Interventions for children and adolescents subjected to child maltreatment and/or exposed to intimate partner violence. E School-based training to help children recognize and avoid potentially sexually abusive situations. E School- based programs to prevent dating violence. E Sexual violence prevention programs for school and college populations. E Rape-awareness and knowledge programs for school and college populations. E Education (as opposed to skills training) on self-defence strategies for schools and college populations E Confrontational rape prevention programs. E Empowerment and participatory approaches for addressing gender inequality: Microfinance and gender-equality training. E Empowerment and participatory approaches for addressing gender inequality: Communication and relationship skills training (e.g Stepping stones) E Home-visitation programs with an intimate partner violence component. E Reduce access to and harmful use of alcohol E Change social and cultural gender norms through media awareness campaigns. Source: WHO/LSHTM, 2010 and WHO, 2010b

62 BRSIPP 2011 Section D: Trauma care issues

The availability and affordability of trauma care is Information was available for fatal and non fatal one of the determinants for survival and outcome injuries in both urban and rural areas. In all the from injuries. Global experience has shown that four components, only 4-6% of patients received some 15-25 % of injury deaths can be reduced with efficient type of first aid at the injury site and all the rest had trauma care systems (Mann et al, 1999). Trauma to reach a health care institution for obtaining care care is a continuum of activities starting from the (Figure 67). Most of the injured recieved first aid in injury site till the patient is brought to a state of a nearby hospital. Hence, 30-50% of patients had optimum functioning. It includes a number of recieved first aid prior to reaching a definitive activities in pre hospital /emergency care and acute hospital. More than half of the injured persons did trauma care in hospitals. Several studies in India not receive any first aid after injury. Doctors were have pointed out deficiencies and inadequacies in the primary responsible persons for providing both trauma care systems (Gururaj, 2008d; Joshipura first aid, as well as definitive care. This number was et al, 2003). only different in urban fatal injuries with 62% also

Figure 67: First aid in injury cases prior to reaching a definitive hospital(%) Urban Rural Fatal Non-fatal Fatal Non-fatal

BRSIPP focused on collecting small amounts of reaching the nearby private hospitals or nursing information through a surveillance approach on homes. prehospital care patterns that have a bearing on survival and outcome and of injured patients. The information The mode of transportation was through different collected mainly from ER rooms focused on availability transportation vehicles in both urban and rural areas. of first aid, referral patterns, mode of transportation Majority of them (nearly 85%) reached the hospital and time interval between injury and reaching a through auto rickshaws and private vehicles. In both definitive hospital. Information was collected in both urban and rural areas, ambulances were used urban and rural components of the program. for transportation of 25-30% of injured persons,

63 Figure 68: Mode of transportation in non-fatal injury cases (%) Urban Rural

mainly for inter hospital referals (Figure 68). EMRI hospital within an hour and 1/4th between 1 – 3 – 108 ambulances supported transportation of 11% hours in urban areas. In more than half of injured each of urban and rural injuries. patients the time interval ranged from 3 hours to 24 hours. People from outside could only reach the In both urban and rural areas the referral was mainly hospital after 24 hours due to delays in recognition from government hospital at the respective places. of injury and transportation for long distances Nearly 50-65% of the injured persons reached (Figure 69 & 70). hospitals directly on their own. The major reasons for referral were lack of facilities, minimal time, RRR Place of death of RTIs non affordability of care, and non availability of specialists in individual institutions. Information on place of death was known for urban and rural RTIs. In urban areas, nearly a third died The time interval between injury and reaching at the crash site and about a fifth on the way to hospital was ascertained for cases reaching hospitals hospital. Among rural RTIs, every second death was in urban areas. About 1/5th of patients reached the Figure 71: Place of death (%) Urban Figure 69: Time interval between injury and registration in the hospital for non-fatal injury cases(%)

Figure 70: Time interval between injury and Rural deaths in fatal injuries (%)

64 BRSIPP 2011 at the crash site indicating severity of crashes. About 6% died en route to hospital and nearly half the deaths were in the hospital (Figure 71).

RRR Injury patterns and management

Head and face injuries were frequently seen in all types of injuries. In RTIs, this type of injuries was seen in two thirds of patients, while it varied from 50 - 60% for falls and assaults. Fractures and dislocations in upper and lower limbs were seen among 17% to 38% across different injury causes. It is to be noted that this was primarily provisional diagnosis and could have changed after required investigations. This also indicates the need for hospitals and their teams to be prepared for managing such patients. While facilities have improved in urban areas amidst mounting costs, rural areas are far behind in terms of facilities, quality care and human resources. Further, rural patients have to travel long distances to reach a definitive hospital.

65 Strategies for strengthening trauma care

Improving trauma care services in Bangalore and can easily remember, should be introduced and many other parts of India requires an organized organized in Bangalore Central – East – West and a programmatic approach. As it is an – North – South. interlinked and intersectoral activity requiring Ambulances must be provided free and easy close coordination between different partners, it access, and should not be caught in traffic jams. requires a systematic approach. Triaging should be introduced to refer patients A lead organization should be established based on type and severity of injury to the within the Ministry of health to guide designated hospitals. co-ordinate, implement, monitor and evaluate Hospitals should be in a state of preparedness all trauma care activities at the state and to receive trauma patients and provide city-level. This agency should set up immediate care. Notification to hospitals will appropriate guidelines and standards for be an important step to prepare them for delivery of trauma care. The agency should receiving trauma patients. provide directions for development of suitable Facilities to manage trauma patients should manpower resources at different levels of first be strengthened depending on the type and aid responders, basic first aid care responders level of the hospitals and should be and advanced trauma care personnel along categorized. Larger public sector hospitals in with improving facilities and setting standards. cities, district hospitals and community health Integrated emergency care programs covering centers should be strengthened to deliver all types of emergencies need to be developed, trauma care. as basic principles of emergency and trauma Trauma registries and trauma audits should care remains similar in many situations except be an integral part of larger activities and the type and mode of emergency care. should be introduced in all medical college The concept of first aid responders should be hospitals and larger public and private sector improved with basic first aid training to all hospitals. drivers, police, teachers and other interested Increasing costs of trauma care are often people. These personnel should be able to get prohibitive for poor patients to get care, involved in assisting a victim at the sight of resulting in increasing referrals and injury, call for help, assess safety, help the movements of patients from one hospital to victim and provide immediate assistance. another in a crisis situation. Mechanisms need Basic first aid care providers should be to be developed to address this issue in a joint developed in all institutions with training in manner. trauma care capable of providing minimal To develop implement and strengthen interventions like removing the person, clearing programs, a research input is very much airway, control bleeding and patient essential and all programs need to be well assessment. monitored and evaluated to make future Advanced pre-hospital and trauma care changes. facilities should be available in all hospitals Public awareness programs for public with bed strength of more than 100. participation and involvement are required. All public sector hospitals must be well Despite the presence of the Supreme Court equipped with basic facilities and skilled order, public does not come forward to help personnel to provide appropriate trauma care. injury victim’s at times of need. Despite the Hospitals should be in a state of preparedness presence of a judgment by the Supreme Court to receive trauma patients without time delays. ( Pt. Parmanand Katara vs. Union of India and All doctors and nurses should be trained in others reported in 1989 ACJ 1000: AIR 1989 emergency care and should receive periodical SC 2039: 1989 (3) SCR 997: 1989 (4) SCC training in trauma care. Emergency care should 286), public are not aware and needs to be be a part of basic medical and nursing courses. informed. A well-organized ambulance system is required Public should be provided basic knowledge of in the city, which does not necessarily mean first aid. They should be able to decide on what high-tech expensive ambulances. Safe to do and what not to do in an emergency due transportation should be the criteria at an to injury. affordable cost and with minimum required facilities. A nationwide number, which people

66 BRSIPP 2011 Section E: Road Safety and Injury Prevention & Control

E1. Current scenario

In India, systematic and scientific efforts in injury Despite this dismal scenario, there have been some prevention and control are still not in existence. efforts in recent years to address the problem in the Serious concerns are being raised through media area of road safety. Road traffic injury surveillance and on public platforms with regard to injury in Bangalore and Pune has shown the strengths and prevention and control. Some of the obvious limitations of a surveillance approach to establish questions are related to the loss of young lives due the magnitude and characteristics (Shah B et al, to injuries and accidents, the pain and suffering by 2007). Injury surveillance across trauma care centres the survivors, loss of precious resources, mental in India is under consideration of the Ministry of impact of lifelong disabilities, appropriate Health, Government of India. After nearly 4 years management and care and others, at a time, when of preparatory work, The National Road Safety and there is enough knowledge towards prevention and Traffic Management Board Bill, 2010 (Bill no. 59 of control. Despite a greater concern in recent times, 2010) is under the consideration of parliament and the absence of policies and programs on the ground it is hoped this will be approved soon. Based on the are an indication of the current scenario. Given the Sundar committee report, this bill will be a strong magnitude and burden of injury and violence, the beginning for road safety in India. The National required efforts for prevention, management and Highway Authority of India has recognized road rehabilitation are dismally low in India. safety on national highways as an important component of building highways (www.nhai.org ). In recent years, road safety has received importance The proposal and recent revision of the Indian Motor as road deaths and injuries are eminently Vehicle Act has opened up new roads to change the preventable. Based on experience of many HICs, age old motor vehicles act of India(http:// countries like India are also initiating efforts to www.morth.nic.in index2.asp?langid=2&sublinkid address the problem. Interest by national =460 accesed on 22nd March 2011). The governments, increasing motorisation, attention by compensation for injured has seen an increase and the media, involvement of automobile industry and is expected to be available (!) for the timely concerns from public have brought road safety as treatment of individuals. Many states are beginning an important agenda at national and local levels. to address road safety through their policies along This concern from all has to get converted into action with sporadic awareness programs. The sporadic in the coming days. public education programs and media voices need

67 to become stronger for establishing road safety in individual efforts for violence prevention. Work India. related injuries in both organized and unorganized sectors are yet to receive major attention. The transport development policy (http:// www.urbanindia.nic.in/policies/ Many of the other types of injuries like burns, TransportPolicy.pdf), urban development policy poisoning, drowning, variety of violence are all (www.urbanindia.nic.in), environment policy(http:/ unaddressed problems due to lack of data and /www.envfor.nic.in/nep/nep2006.html) mention knowledge, absence of committed individuals and road safety in their policies and programs. The organisations and lack of professional approaches. Golden Quadrilateral project, Highway expansion Even though media has been making many efforts and improvement projects, infrastructure expansion in bringing the issues of injury and violence to the projects of World Bank, Asian Development Bank common man these have still remained as stories, and other multilateral funding agencies are beginning mostly as sensational stories. to address road safety. Road safety audits are becoming an integral component of road safety This dismal state of affairs, with the consequent effect projects. The National Trauma Care Program by being everyday loss of lives, has been due to absence the Ministry of Health and Family Welfare has been of an integrated and comprehensive National Injury focusing on strengthening trauma care facilities on Prevention and Control program. All the above the Golden Quadrilateral route and other high ways mentioned efforts are isolated efforts by individual (www.mohfw.nic.in). The massive expansion of ministries and organizations. Lack of good quality trauma care by private sector in urban areas has data on injury and violence due to absence of proper helped some, while unaffordable to majority. reporting systems, surveillance and research has been Manpower development programs have got a major barrier. Many components of injury strengthened with the recognition of Emergency prevention programs like policies, managerial Medicine as a speciality area. Other initiatives like approaches, coordination, funding, capacity building, helmet legislation and enforcement, reducing and training of professionals, advocacy activities, drinking and driving, speed control measures, monitoring and evaluation are glaringly absent in pedestrian safety are all being discussed by several India. The involvement of professionals has been experts, but the real impact is yet to be seen. minimal, while political attention is never seen or heard. The scientific approach to the problem through Despite a huge increase in the number of suicides across evidence based interventions is totally missing. In the country there are no systematic programs to address this scenario, India will continue to lose young the problem. The report of the National Commission people due to injuries day after day and year after on Farmers (http://krishakayog.gov.in/), Prevention year. of Domestic Violence Act (Ministry of women and child development, 2010), Prevention of Sexual Harassment of Women at Work Places (National commission for women, 2010) are some recent initiatives to address the problem. Massive subsidies dolled out to farmers has not had an effect as seen by the continuous increase in suicides in different parts of the country. Suicides among young adults, women, elderly and across society have not received attention from government and professionals. An active judiciary and NGO networks are making

68 BRSIPP 2011 E2. RTI / Injury surveillance: Strengths, opportunities, barriers and limitations

The present program adopting surveillance approach (data collection – pooling – analysis – and and in partnership with many organizations used utilisation) are addressed effectively. existing sources and resources to build a Road safety E Most importantly, it is essential to realize that and injury prevention program in an Indian city. The RTI/injury surveillance data provides the details of the program beginning with a feasibility foundation and needs to be supplemented with exercise are available at http:// focused research activities (e.g., expanded www.nimhans.kar.nic.in/epidemiology/ data collection and good analysis) and epidem_who2.htm. As the program completes its multidisciplinary crash investigations to 3rd year, it is essential to understand and learn lessons develop specific and targeted activities at local for strengthening of the program that will be of help levels (Figure 72). in deciding future directions and possible replications to other parts of country. Some issues of relevance of As an example, data of 2008 revealed broad data and surveillance are discussed below. geographical areas of RTI occurrence. In 2009, this was expanded to identify specific crash locations in RRR Strengths the city. It emerged that 10 major areas contribute for 50% of crashes and specific roads in these aereas E Since information on injuries and RTIs is not account for 50% of crashes within these areas. This available regularly due to several limitations, has helped in developing an integrated, area wide Injury surveillance is often the first step in safety program in these areas. understanding injuries. This approach has been implemented in many countries and has been Similarly, the routinely available data on risk factors recommended by WHO and other agencies. was strengthened with additional population based It is well acknowledged in scientific literature observational surveys in 2010 – 11 in the areas of that a well designed and implemented helmets, speeding, drinking and driving, seat surveillance program provides information for belt and others. This approach has helped in recognizing the: comprehensive understanding of the role of risk Magnitude of problem factors and mechanisms to address risk factors with Pattern and profile of injuries both general and specific interventions. Geographical distribution Major/ Selected risk factors, and E Surveillance is one activity which can drive Nature – severity and outcome from number of other activities by providing a injuries. platform for agenda setting, prioritisation of The amount, nature and extent of data that activities, allocation of resources, developing can be collected under a surveillance program policies and programs along with monitoring has to be decided by local ministries, researchers and agencies. Experience of last 3 Figure 72: Pathways of research years in Bangalore has demonstrated that comprehensive information can be developed for road safety and injury prevention and control activities with the cooperation of all partners.

E In a situation where injuries are not recognized as public health or national problems and data is not available for this process, surveillance can be an effective step, if, all components

69 of activities. Information from surveillance are already included in this system. program will help to develop and provide Strengthening and reorganization of data direction for a number of activities. collection mechanisms can effectively be It is seen from the report that data helped in utilized for injury surveillance. developing number of capacity building E Information on characteristics of RTIs and other activities for police, doctors, engineers and injuries can be systematically collected with a media. It was possible to improve focus on getting quality information and not understanding of RTIs and injuries with data mere numbers. The recommended format for collected at the local level. In annual stake data collection In India from police department holder’s consultations and other inter is provided in annexure 1 and 2. This departmental meetings, it was possible to information will be useful to develop next level discuss number of these issues. of activities. The present program has shown E Local data is crucial for local programs. Even that it is possible to collect data on though all agencies collect data regularly, Characteristics of those killed in injury bringing it together through surveillance acts (age, sex, residence, education, provided an opportunity to examine local occupation), situation, activities and develop mechanisms. nature of RTIs (location, road user The data has helped in advocacy activities and category, collision nature, place of death, also making RTIs and injuries as important position in vehicle, manoeuvre), public health problems. As many partners were situation and context of injuries (location involved in information gathering, the program – urban / rural ; highway / non highway; brought together departments and ministries junction./ midblock, etc., ) on a common platform. use of protective equipment like helmets, E It is common to see many agencies collecting seat-belts, mounds of data for their individual Vehicle details in buses ( type and year of requirements. Surveillance can be a binding manufacture), force as data collected by different stakeholders Basic details for other injuries (nature, gets analysed and used for policies and place and intent needs extra effort), programs. Intelligent data applications are Issues related to trauma care (referral, required for surveillance to be effective. Even time interval and mode of transport for though the report highlights an overview, in hospital deaths), and the program, we have used data for specific place of death. activities. E Similarly, information on non-fatal injuries can E Presence of surveillance in a geographical area be collected in hospitals with appropriate can stimulate and be a spring board for number guidelines from health or home ministry. The of research, policy and advocacy activities. In format used for data collection is given in the program, new research activities were annexure 4. Information that can be collected initiated, policy aspects strengthened and include advocacy gained momentum as shown in socio-demographic characteristics (age, earlier sections. sex, place of residence), cause of injury (RTIs, suicides, burns, R Opportunities poisoning, drowning, falls, disasters, Place of injury, E Contrary to the popular belief that surveillance Details of RTIs (location, road user systems need to start from scratch, working category, type of impacting vehicle), with existing systems will be a good choice. use of protective equipment (helmets, There is already a system within police, seat-belts, child restraints), transport and health departments for collecting characteristics of other injuries (situation information on deaths and injuries. RTIs, – context - product responsible), suicides, homicides and other unnatural deaths

70 BRSIPP 2011 trauma care (first-aid, referral, time scope for later changes. On few occasions, interval, transportation mode, type and submission of these records to courts has severity (body parts involved, mild- benefited legal proceedings as all information moderate-severe), and was found to be complete and clear. Hospitals mode of management (admission or have used ETCR to provide medical certificates, referral) and outcome (death or referral leave letters and for other administrative or ER care). activities. E Doctors, nurses, PG students, interns, medical E Injury surveillance can be expanded in a phase- records personnel and others are already wise manner. As health systems have been working in hospitals and can be involved in sensitized on surveillance through IDSP and data collection, depending on availability of NCD risk factor surveillance, ample staff. Participating in injury surveillance will opportunities exist for introducing injury also become a part of their training and will surveillance. The major focus of surveillance equip them with skills to understand injury and should be on RTIs and suicides in medical trauma related issues. college – apex – specialty hospitals – Similarly, with many police stations getting proposed level 1 trauma care centres in computer systems support, the writers ( or other phase 1 and can concentrate on moderate equivalent staff) can be trained in data and severe injuries. Surveillance can also be collection activities. Repeated training facilitated with development of trauma programs are essential to obtain good data. registries in selected institutions. E As many hospitals are in the process of E There is a possibility to develop RTI / Injury computerization and developing Hospital surveillance with only selected major hospitals Information Management Systems (HIMS), as there is no need to include all hospitals in a opportunities exist for including surveillance given area. A representative sample of in existing systems. This will also help in institutions, referred to as sentinel sites, can overcoming problems that exist in paper based be helpful. After initial strengthening of systems. program it can be expanded to larger hospitals. E Hospitals, for varying reasons, maintain If information can be captured from 60 - 70% number of registers like accident register, MLC of institutions in a geographical area and can register, ER register, police intimation register cover nearly 3/4th of injuries, surveillance can and several others. A recent review has revealed be an effective method. that each hospital maintains 6 – 8 registers (few hospitals maintain up to 10 – 12 registers) RRR Barriers on an average in the casualty departments. For medico legal reasons, doctors are compelled It is important to be aware of some major barriers to fill these registers. It is possible to reduce for injury surveillance and methods to overcome the the documentation overload with the same over time. Recognizing these barriers is crucial introduction of an Emergency Trauma Care for ensuring sustainability and effectiveness, as there Record (ETCR) in ERs, which can serve all are no national, state and city based programs as of patient care, administrative and legal purposes. now. A larger injury prevention and control or road The availability and use of the simple ETCR in safety program is yet to make a beginning in a hospitals has reduced workload and brought perceptible way in Bangalore and India. The present uniformity in some of the hospitals under the program is the first of its kind being developed on a program. The present program has attempted scientific approach on an integrated platform with to initiate this process and needs to be built participation of all sectors and professionals in a over a period of time. coordinated manner. E The introduction of ETCR has been welcomed by many and resisted by few. In overall terms, E Despite the enormity of the injury burden and it has made systematic documentation of injury impact, there is no national injury prevention details at the time of hospital entry with no and control - road safety - or suicide prevention

71 policy, program or a plan in India or in as people have resisted change for number of Karnataka or in Bangalore. Hence, there is no silly and genuine reasons. There are several single agency responsible for these activities. perceived and real medico legal hurdles This raises the question of who is responsible prompting doctors not to deviate from existing systems as they are repeatedly called to legal for road safety and injury prevention. Each of corridors as witnesses in investigations. This the sectors work independently on their priorities has made the necessity of continuing with and programs without information, coordination umpteen numbers of registers, police and integration. Even though, there is need for intimations, documenting events and other a central agency or unit or division at national, complicated procedures. state and city levels capable of guiding, E Many of the health care institutions are not coordinating, implementing, monitoring and computerized and manual paper based systems evaluating IPC programs, it is yet to be are still in practice. This is a major barrier established. Till such time, an agency comes and should not be difficult to overcome. Proper up, road safety and injury prevention will be application of Information technology will neglected priorities and injury surveillance will facilitate injury surveillance programs. be accorded less importance. E A major barrier is the change of people (due to E Medico legal status of injuries will continue as frequent transfers or time bound jobs) in all a major barrier, till such times legal and policy departments at frequent and regular intervals. changes come up. Injuries and injury details This is a major impediment for continuity of will continue to be recorded as per legal, programs. criminal, administrative requirements and not from a health perspective. For example, data RRR Limitations on alcohol is not recorded for legal issues and till such time this data is not available, alcohol E Several professionals and policy makers believe will not be recognised as a modifiable risk that surveillance is an end all activity; suffice factor (unless strong hospital and population to mention that it is a beginning of activities. based research develops). Suicides intent and As mentioned earlier, surveillance can show mechanisms will not be clear (currently chronic directions for further research that can lead to stomach-ache is the cause for many suicides) and all unnatural deaths will be a waste basket development of interventions. For example, the due to legal issues. In addition, medico legal BRSIPP data has shown that pedestrian injuries issues will continue to be a barrier in treatment are high in the city, but there is need for further aspects, as many will not like to get entangled research to identify focussed risk factors that with police and courts for their injury. Hence, can be modified through interventions, records will get manipulated and remain programs and policies. Similarly, suicides are incomplete with a possibility for changes at a found to be high in younger age groups and later data. among housewives. What factors are E Nonavailability of directions from Ministry of contributing for this need to be discerned with Health at national or local levels on further research? documenting systematic information in ERs is a E A successful surveillance is only possible with major barrier. Lack of coordination and failure cooperation of all partners. Both public and to use data for programs and policies on earlier private institutions within health sector and occasions by government agencies (volumes of partners from outside health sector need to data are asked from hospitals and no one knows actively participate in data collection, analysis, what happens to them) and others are some major barriers. Police and hospitals collect large pooling and utilisation. As more than 80% of amounts of information from injury deaths and services are provided by private health sector, reported injuries. However, these data remain it is important to enrol them in the process. buried in records, as mechanisms to analyse and E Even though surveillance should happen within examine information in totality are not part of existing systems and available resources, an the system. initial investment by the governments are E “Mindset” of people has been a major barrier crucial in the initial phase of program ( may

72 BRSIPP 2011 be for first 5 years) till mechanisms are nonparticipation. Alternative mechanisms need established. This foundation period is crucial to be developed, keeping in mind that any for long term sustainability of the program. surveillance has to be flexible. Cooperation of With no dedicated resources available for hospitals, doctors and police are crucial to build injury surveillance programs. Training, injury prevention and control at this stage, capacity development, feedback, and data professionals do not know which door to knock. utilization needs to be promoted in a systematic E Sustainability of ongoing data collection, way. analysis, interpretation and application is E Data utilization and application is more crucial crucial for success of injury surveillance program over time. The capacity for the same and vital for injury surveillance and IPC to within police and health sectors, both at the continue and sustain. Professionals from police, local or national level, does not exist and needs health and other sectors would not just like to to be nurtured and developed over a period of collect data or extract data, if their work does time. not result in positive benefits to the community. E It is a fact that in some hospitals, doctors in Each and every opportunity should be effectively casualty / emergency rooms of hospitals used for proper utilisation of data and to (especially public sector hospitals) are develop evidence based programs. overburdened with heavy caseload. This is cited as the commonest reason by doctors for

Ministry of Health and Family Welfare, in Two National Centres for injury information coordination with Ministries of Home Affairs system has to be established and should be and Information Technology should issue supported with manpower, budget and other appropriate directives and guidelines through support facilities by the Ministry of Health and Family welfare, Government of India. These its state health departments to police department centres should work in close collaboration and all medical college hospitals – district with National and State Crime Records hospitals – and apex referral hospitals in both Bureau and academic institutions to establish public and private sector to document minimal quality control mechanisms, analysis and information on all injuries and related deaths interpretation of data and facilitate data inputs in a uniform and standardised format across for policies and programs. the country.

E3. Sustainability issues

For any program to be effective, administrative E There is need for a dedicated agency in the support - programmatic approaches – motivated and city that can drive road safety and injury committed staff - resource availability – necessary prevention programs on a continuous basis. back up services – continuous feedback – and data There is need for a national and state safety utilization / application for policies and programs regulatory authority to give directions. A Road are crucial. Injury surveillance, especially for Road Safety Cell has been established in Karnataka traffic injuries and suicides, should become an to facilitate road safety activity. This agency inbuilt component of injury prevention and control, has to be identified, supported and nurtured to road safety and suicide prevention programs. undertake these activities with resource Feasibility, sustainability and cost effectiveness allocation and capacity strengthening at should be addressed from the beginning. These appropriate levels. At the city level, a central aspects and possible mechanisms have been discussed agency like CCRB, or an experienced unit (an in our previous report and some salient points are injury prevention centre or Community provided below. Medicine department of a medical college) can

73 be given the responsibility of leading data and use of data. The local decision making collection and analysis activities. All programs bodies and respective departments at higher need direction, vision, mission and a passion. levels should utilize and apply data for E As injuries are a health problem, the Ministry development – implementation of interventions of Health and Family Welfare and / or and for larger decision making process as well. Directorate of Health Services should take a The program should be monitored continuously leadership role and inform all major hospitals and evaluated once a year for further for introduction of ETCR on a regular basis. modifications and improvements. Necessary administrative notifications should E People can make or break things. If one can be sent to all partnering health institutions. build roads that are safe, someone can also Apart from surveillance, number of other make bad unsafe roads. For any program to activities like advocacy, capacity building, be successful, wholehearted participation of monitoring and evaluation should be initiated. professionals is required. A program of this All these will be possible, if, the local nature will require cooperation – participation government and state agencies identifies and – support of stake holders, police and transport nominates a focal unit for all injury prevention officials, hospital administrators, nodal officers and control activities. and teams in casualty departments. Inputs to E Capacity strengthening programs for senior and strengthen this component through training mid level policy makers and training programs programs, information sharing, continuous for other staff from police and health sector feedback, using data at individual and hospital should be held at periodical intervals. Injury levels, and joint collaborative programs needs surveillance will ensure monitoring of activities to be promoted. In addition, data leading to along with data inputs for other activities at action will be a source of inspiration for all, different levels. as a method of recognizing and rewarding E All professionals involved in data gathering, one’s work. treatment and care of injured persons in all E Resources are required in the long run for participating institutions (police at mid and continuous running of the surveillance program junior levels, ER staff of selected – participating and this should be part of the larger road safety hospitals- medical record divisions) should be and injury prevention program; not an isolated trained (at least twice in a year) to improve activity on its own. An initial investment is very trauma care and to obtain better cooperation. much required till the program gets established. The required training modules and training The local government or Directorate of Health course contents should be developed jointly for Services or State health division or City Police ensuring uniformity in training. or BBMP should take ownership of the E Variety of communication channels like reports, program. Injury and RTI surveillance is a part fact sheets, websites and other channels should of larger injury prevention and control and road be utilised for sensitisation, awareness building safety activities.

74 BRSIPP 2011 Section F: Activity Profile, 2010

The Bangalore Road Safety and Injury Prevention Government of India, in collaboration with program was started in 2008 to develop systematic ICMR, WHO, Ministry of Road Transport and and scientific activities for prevention and control High Ways and Ministry of Home Affairs held of RTIs and other injuries. The details of the discussions on National Trauma Care Program program are provided in our earlier reports of 2009 and also reviewed the progress of surveillance and 2010 (Gururaj et al, 2008 and 2010) In activities. The Ministry has expanded the injury addition to 2 reports, a set of 10 fact sheets (Injury, surveillance program to trauma care centres Child injury, Injuries among elderly, Road traffic on the highways and is planning to expand the injuries, Two wheelers safety, Pedestrian safety, same to medical colleges and select district Suicides, Falls, Burns and Poisoning), 5 public hospitals in a phased manner. The Bangalore health alerts (Helmets, Seat belts, Drinking and program has been recognised as a model Driving, Speed management and Trauma care) and program for expansion to all medical colleges 4 prevention series (Education, Engineering, and district hospitals. Enforcement and Emergency care) have been published under the program. The data collection E Road safety and injury surveillance will now activities during the period Jan – Dec 2010 are be formally included in the National Trauma presented in earlier sections of this report. In 2010, Care program of the Government of India and the major focus was on strengthening data the official communications are expected soon. collection mechanisms, utilisation of data, inputs Data collection already in progress in rauma for policies and programs, dissemination of care centres. information and number of advocacy activities. E Inputs were provided for ‘Road safety 10 – Details of various activities undertaken during the India project’, an initiative by MOHFW in year are provided below. collaboration with WHO, GRSP. World Bank, JHU, Embarq and supported by Bloomberg R Inputs for National level activities Philanthropies, USA. Specific inputs have been provided for surveillance, risk factor E The Director General of Health Services, identification, interventions and monitoring for Ministry of Health and Family Welfare, the 2 states of Andhra Pradesh and Punjab. The

75 focus of the program is on improving the use X February 2010 of helmets, seat belts, reducing driving under alcohol influence,better speed management E Training programs for CMO’s and nurses of alongwith data collection and management. Vydehi Medical College and Command E Inputs were being provided for National Hospital (Air Force) were conducted on Highway Authority of India under the newly improving data collection mechanisms in ERs. constituted ‘Road Safety Cell’ to develop road At the same time, discussions were held with safety information system, crash analysis and the management by sharing their data and road safety audits as part of highway emphasizing on improving acute trauma care development projects. practices. E Inputs have been provided for National Crime Records Bureau to improve and strengthen data collection components for RTIs and to develop revised formats for data collection at state, city and village levels. It is hoped that the new computerised formats will help in availability of good quality data in the country.

R Activities in Bangalore - 2010

X January 2010

E Data was used for orientation of nearly 500 school teachers on school safety issues in the city. The focus was to inform teachers about comprehensive school safety programs that E Discussions were held with management of include speed management around schools, BMTC to strengthen data collection capacity building of school management teams, mechanisms for developing a safety promotion involvement of local administration and cell. Data was also shared with BMTC drivers teachers training programs. The need to make during the training program on road crashes school environment safer, both inside and in the city and need for speed management. outside schools was emphasised. X March 2010

E The annual Stakeholders consultation meeting was held at NIMHANS with participation of health, police, transport, highways, education, media and other partners. The program reviewed data collected in 2009 and identified specific programs to be taken up during 2010. The various problems encountered by stake holders were also discussed. The burden and impact of road traffic injuries, suicides and other injuries, current initiatives by different sectors and need for scientific approaches to E Data inputs were provided for the training prevention and control were discussed. program of BMTC depot managers on Following this, discussions by the CC members developing safety programs within individual with individual stakeholders continued at depots in the city.

76 BRSIPP 2011 faculty from Orthopaedics, General Surgery and other related departments. E Two rounds of orientation program on

periodical intervals. Several areas have been strengthened in the intervening period. E Two rounds of training programs were conducted for the writers and assistant writers of all 39 police stations in Bangalore on March 13th and 29th May was conducted for the police 23rd and 30th, 2010. The program was team from Hubli – Dharwad city on road safety. facilitated by Mr. Praveen Sood, Additional Nearly 70 traffic police people participated in Commissioner for Traffic and Road Safety in the program in each batch and data from Bangalore. The writers were informed about program was used for this activity. The need to the correct ways of entering information and enforce helmet – drink drive laws in a strict focussed on discussing the appropriate and manner and benefits of such enforcement were inappropriate entries. Data collected in highlighted in the program. previous months was discussed.

X May 2010 X June 2010

E A pilot study on identifying preventable deaths E A training/orientation program for 40 mid based on data from mortuary divisions was level officers from Bangalore City Police was undertaken and was initiated by Dr. Girish conducted in the Traffic Training Institute. All Chandra, Professor of Forensic Medicine, from personnel were oriented about importance of M.S.Ramaiah Medical College. data collection, enforcement of helmet – drink E An orientation program was conducted for driving – seat belt – speed control laws along interns and faculty of Raja Rajeshwari Medical with timely availability of emergency and College and was attended by nearly 100 interns, trauma care.

77 E Visits were made by the CC team to interact E A training program was conducted for 40 and discuss data collection and hospital based police officers from Bangalore City Police on activities in St. Martha’s Hospital, Baptist need and importance of strict enforcement with Hospital, MS Ramaiah Hospital, Colombia regard to helmet – drinking and driving and Asia Hospital and ESI Hospital. speed management issues

E A nodal officers meeting was held to review the progress of activities and identification of E BMTC staffs were trained in a half day training institution based specific activities. program on importance of data collection within the organisation.

E CC staff visited KIMS hospital and reviewed the progress of activities with nodal officer and hospital management.

E A meeting with Heads of Forensic Medicine Departments of 8 medical colleges was held at NIMHANS to explore the possibility of establishing the Bangalore Mortuary Trauma Registry.

X July 2010

E CC staff conducted a training program for nurses and casualty staff of Sagar hospital on improving data collection mechanisms

78 BRSIPP 2011 E Training cum orientation program was in Bangalore City on implementation aspects conducted for the depot managers of Bangalore of enforcement with regard to road safety. Metropolitan Transport Corporation about the importance of management components in Road Safety to reduce BMTC related bus crashes.

E A meeting with HODs, Faculty and Postgraduate students of Forensic Medicine Departments was held to discuss further E Data inputs were provided in the orientation modalities of developing the Bangalore program held with depot managers of 36 Mortuary Trauma Registry. BMTC bus depots in Bangalore to discuss developing safety mechanisms for avoiding bus crashes and training of high risk drivers. Both programs were facilitated by BMTC and MR. Bhaskar Rao, Commissioner for transport, Karnataka state highlighted the role and importance of safe transport systems on a continuous basis.

X August 2010

E Discussions were held with Senior officials of police and transport departments on strengthening of data collection mechanisms, E A training program for all staff of Forensic integration of road safety in training programs Medicine Departments was held at NIMHANS for police officers, training of bus drivers and to explain the methodologies and procedures progress in hospital activities. It was also for data collection mechanisms in the decided to explore possibilities of developing Bangalore Mortuary Trauma Registry. systematic campaigns on helmets, seat belts, drink drive, speed and pedestrian safety with the involvement of corporate agencies. In addition, training of mid level police officers was also discussed. E Inputs were provided to Mr. Manish Kumar from RV College of Engineering to examine the role of road and environmental factors in road crashes in Bangalore under the guidance of Mr. Srihari. E Orientation cum training program was held for nearly 110 newly recruited police constables

79 X September 2010 E The “Adolescents and Road safety” of the transport department of Government of E CC staff visited St.Johns hospital and reviewed Karnataka in collaboration with MS Ramaiah data collection activities; also held discussions Medical College, was supported with data with forensic medicine staff and discussed with inputs from the program. The program has been hospital management expanded to cover more number of institutions E CC staff visited MVJ medical college and in the city. reviewed data collection activities; also held discussions with hospital administrative staff. E CC staff visited Bangalore Medical college and Victoria hospital and reviewed data collection activities; also held discussions with hospital administration authorities. E A meeting was held with Heads of Forensic Medicine departments on progress with regard to mortuary data collection activities E Meeting with Heads of Community Medicine departments took place to review progress of activities and enlisting the cooperation of staff and interns in training and data collection activities.

X October 2010

E Discussions were held with Heads of the Community Medicine Departments of medical colleges in bangalore to seek their involvement in BRSIPP. Training of interns, advocacy activities and strengthening data collection were finalized.

X December 2010

E Meeting with all heads of Forensic medicine departments was held to finalize details of Bangalore mortuary trauma registry. Results of the pilot study were shared with all members and data collection formats were finalized.

80 BRSIPP 2011 R Campaigns and awareness programs scientific meetings. New activities from academic institutions also were encouraged and are in progress. E Data inputs were provided for a documentary by Terravista Films by Sri Amith Mithra entitled “Lives : Lost and Saved”, to highlight the specific R Technical assistance provided to issues of two wheeler drivers and measures for Dissertation projects improving road safety aspects. (done at very E less cost ) Dr Sreedhara, Postgraduate student of Masters in Hospital Administration, Padmashree E In a campaign developed by www.smilingdrivers.org, specific inputs on Institute of Management studies completed a helmet usage, seat belt use and early trauma study on “ Processing of medico legal cases in care have been highlighted with data from the selected hospitals of Bangalore”. E program. Dr. Shilpa R, Post graduate in Community Medicine under the guidance of Dr. Bobby E In a series of day to day news related programs by the print media, data inputs on number of Joseph, Department of Community Medicine, issues have been provided on number of St. John’s Medical College initiated a study on occasions. The print media from different news “Incidence and profile of cccupational injuries paper agencies covered road safety aspects in among residents of villages under the Sarjapur the City with the data available in the program. PHC area Bangalore”. E All partners were also encouraged to write Sri. D’Souza, Joint commissioner for Transport articles in the press. initiated a study on attitudes and risk taking behaviours of drivers for road safety R Academic Activities management. E A study on risk factors for motorcycle injuries and car occupants was initiated by Dr. Yadukul The partners in program also used the data from their respective Institutions (that was made available by of Bangalore Medical College and Research the CC) to present papers in various conferences and Institute.

Annual Stakeholder’s Consultation, 2009. Annual Stakeholder’s Consultation, 2010.

81 Section G: Bangalore Road Safety and Injury Prevention Program - An Evaluation

The Bangalore Road Safety and Injury Prevention Trauma Care and Emergency Record and Wound Program was started in 2007-08. The collaborative Certificate Register. On an average, 4 - 6 registers activity was built on a consensus and participatory are filled for every case in ER. approach in collaboration with 30 hospitals, E Not all institutions considered all injury cases as Bangalore City Police, Bangalore Metropolitan Medico-Legal Cases (MLCs). Assault, Domestic Transport Corporation, Bangalore Mahanagara injuries, Work place injuries, Self injuries, Self Palike and city based NGOs. The regular periodic fall were considered as either MLCs or Non MLCs Nodal officers meetings served as a forum to discuss depending on the circumstances at the time of problems and challenges in implementation. On injury registration in the hospital ER. This points completion of 3 years of the program, a formal to the substantial confusion surrounding the evaluation was undertaken during January - categorization of cases as either MLC or non February 2011. Two separate forms were developed: MLCs. The cases generally considered as MLCs one for Nodal officers (health, police and transport) and Non MLCs are noted below and Heads of Institutions and the other for the CMOs. Key areas of evaluation related to functioning of the X Cases considered as MLC’s BRSIPP, facilities in ERs, data collection methods, RTIs, railway accidents, burns, poisoning, completion of ETCR, feedback, utility of data, future hanging, suicides, assault, domestic programs, status of pre-hospital care and the next injuries, all unknown patients, animal Plan of action. Nearly 50 Nodal Officers and Head bites, brought dead, domestic abuse, work of Institutions and 96 CMOs responded and gave place injuries, head injury with suspicious their detailed comments and suggestions. The major history, homicide, police custody case and highlights of the evaluation exercise were also drowning. discussed at the Nodal Officers' meeting held on 18th February 2011. Some salient findings are presented X Cases not considered as MLC’s below. Skid and fall, minor RTA's, all Minor E Nearly 15 type of registers were maintained in aberrations/Cuts, accidental Injuries, the Casualty / ERs, varying from hospital to agricultural injury, injury to kids, hospital. These include MLC register, Non MLC workplace injuries, MLC done at other register, Drug register, Brought dead register, institutions, self injury, assault, sports Death register, Police intimation book, Referral injuries, self fall, drowning, domestic register, Casualty register, OP/IP register, Monthly injuries. Census Book, Employment injury register, Primary E Most of the institutions had printed their own and Secondary assessment register, RTA Register, forms with their names and logos; however, it

82 BRSIPP 2011 was unfortunately noted that even after 3 years the referral systems for ensuring continuity of of the program 2 of the institutions were still care particularly for those cases coming from making preparatory activities to print the peripheral areas, implementation of the ongoing forms. activity as a national program and availability E The respondents also reported some difficulties of a separate budget. while filling up the forms. Predominantly it E The recommendations to improve road safety included asking information pertaining to included awareness and education activities, education, occupation, alcohol consumption, strict enforcement of the rules and regulations, reason for collision and outcome. Mass casualty, enhancing co-ordination between different busy casualty, non cooperative patients, departments (BBMP, Police and Road ignorant patient attendant, frequent staff engineering, etc.,), training on safety measures turnover and referred cases hindered filling up to the police and improving city and civic of the form. The respondents also suggested infrastructure. for re-formatting of the form to 'give more space' E The recommendations for preventing suicides for details of informant who gives history, included starting counseling services, bringing Identification mark of patient, etc., greater awareness about life skills, warning E With regard to ambulance services, there were signals, etc., and also strengthening legislative 82 working ambulances in the partner provisions. institutions varying between a minimum of 1 E While all were willing to continue with the to a maximum of 8 ambulances. 12 hospitals program, 84% were willing to print the form, had more than 3 ambulances. All of them 75% were ready to make arrangements for data expressed need for better availability and entry, and more than two-thirds (67%) were networking of ambulances. willing to develop their own programs. Major E Majority of the big private institutions reported challenges are being faced in 3 large public that all their doctors were trained in emergency sector hospitals and one private teaching and trauma care, while a lesser proportion medical college hospital (contributing for reported about the training of the nursing staff. nearly 40 % of cases). E Majority of the doctors and nurses in public sector E All of them expressed serious concerns about hospitals expressed need for training in trauma increasing costs of trauma care and strongly care along with improvement of facilities. highlighted the need for developing alternative E Interestingly, nearly 95% of the institutions mechanisms. reported that their ERs were adequately E Majority of them were clear that data collection equipped to handle emergency and trauma should lead to public programs and patients. This needs to be ascertained with interventions. They also expressed that suitable physical audits of ERs across the city. mechanisms for implementing road safety and E Majority of the institutions (87%) reported that injury prevention in the city along with state they were always receiving periodic feedback and national governments should be about progress of activities. established. E Majority of the institutions (40 to 50%) had used the surveillance data for teaching purposes In summary, the activities of the year focussed and to improve administration. A lesser on strengthening of data collection, developing proportion (25%) had used the data for data led programs and beginning of new purposes of research. activities. Most importantly, the program E The respondents also recommended for strengthened linkages and partnerships and improvement in the program in the following there was more interest and committment for areas - education programs to the public, road safety and injury prevention in the city. initiating on-line training programs, improving

83 References

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85 86 BRSIPP 2011 Annexure - 1

Bangalore Road Safety and Injury Prevention Programme Data Capture Format for Fatal Road Deaths (One form to be used for each crash)

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88 BRSIPP 2011 Annexure - 2

1

Bangalore Road Safety and Injury Prevention Programme (One form to be used for each death, EXCEPT RTI’S)

Bangalore VJ$:C%`% Q:R :`V 7 :JR J=%`7 `V0VJ 1QJ `Q$`:IIV ^ JV `Q`I Q GV %VR `Q` V:H. RV: .5 &&' ';_

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90 BRSIPP 2011 Annexure - 3

Bangalore Road Safety and Injury Prevention Programme

BengaluruBangalore Road Safety and Injury Prevention Programme MORTUARY INJURY DATA FORM(Under pilot testing) MORTUARY(Under INJURY pilot testing) DATA FORM

Mortuary Code : ______Autopsy ID : ______

Date of Injury (DD / MM / YY): ______/ ______/ ______Time of Injury (HH: MM): (0 – 24 hrs) ______:______

Date of Admission (DD / MM / YY): ______/ ______/ ______Time of Admission (HH: MM): (0 – 24 hrs) ______:______

Date of death (DD / MM / YY): ______/ ______/ ______Time of Death (HH: MM): (0 – 24 hrs) ______:______

Date of Autopsy (DD / MM / YY): ______/ ______/ ______Time of Autopsy (HH: MM): (0 – 24 hrs) ______:______

Informant:______Name of the Police station :______A. SOCIODEMOGRAFFIC DETAILS

1. Age (in years):______2. Sex: M/F/TG 3. Place of residence:______

4. Education: 1. Illiterate 2. Primary 3. Middle 4. Secondary, high-school & PUC 5. Graduate

6. Post graduate & above

5. Occupation: ______

B. DETAILS OF INJURY (based on records, inquest data and bystander reports) 6.

7. Place of occurrence: 1. Road 2. Home and premise 3. Factory 4. Hospital 5. School/ college campus 6. Railway tracks

7. Office 8. Market/business area 9. Well/lake/pond 10. Religious place 11. Agricultural area

12. Prison/custody etc. ______13. Unknown 14. Others, Specify ______

8. Place of Injury (Name of Area): ______

9. Nature of injury: 1. Road traffic Injury 2. Fall 3. Assault / Violence 4. Burns 5. Electrical injuries 6. Poisoning

7. Drowning 8. Hanging 9. Work Place injury 10. Animal Bite 11.Fall of Object 12. Gun shot injuries

13. Others, Specfy ______

10. Intent: 1. Unintentional 2. Intentional- Suicidal 3. Intentional - Homicidal/Assault 4. Unknown 5. Undetermined

11.1 Alcohol use in the deceased Yes No Unknown Not Applicable

11.2 Alcohol use in counterpart Yes No Unknown

C. TRAUMA CARE DETAILS

12 Whether FIRST AID was given soon after the injury: 1. Yes 2. No 3. Not known

13 Place of death: 1. At injury site 2. During transport to hospital 3. In the hospital 4. After discharge from the hospital

14 Source of referral to the hospital where the death occurred: 1. General Practitioner 2. Pvt. Hospital 3. Govt. Hospital

4. 108 ambulance 5. Other Ambulances 6. Pvt teaching Hospital

15. Mode of transportation: 1. Autorickshaw 2. 108 Ambulance 3. Other Ambulance 4. Private Taxi 5. Personal vehicle

16. Parts of the body Injured: 1. Head 2. Neck 3. Upper limbs 4. Abdomen 5. Lower limbs 6. Face 7. Chest

8. Spine & vert. column 9. Groin 10. Back

17. Apparent Injuries that could have lead to death Primary Cause:

Antecedent Cause:

Associated conditions:

18. In what way this injury could have been prevented

91 D1. ROAD TRAFFIC INJURY 19. Place of Occurrence: 1. City/Municipal roads 2. Highway 3. Rural roads 4. Others,specify Area: ______Street: ______20. Activity at the time of crash 1. Travelling in a vehicle 2. Walking on the road 3. Crossing the road 4. Standing on the road 5. Working on the road 6. Playing on the road 8. Not known 7. Others, Specify______21. Collision between: ______Name and Type of Vehicle: ______22. Road User category of the deceased: 1. Pedestrian 2. Pedal cyclist 3. Two wheeler rider 4. Two wheeler pillion 5. Three wheeler driver 6. Three wheeler occupant 7. Car driver 8. Car occupant 9. Bus/truck driver 10.Bus/truck occupant 11. Other 4-wheeler driver (maxi-cab/tempo, etc) 12. Other 4-weeler occupant 13. Others, specify ______14. Unknown 23. Type of Crash: 1. Pedestrian hit by vehicle 2. Head on Collision 3. Hit vehicle in front 4. Hit from back 5. Hit & run 6. Skid & fall 7. Run off road 8. Overturn 9. Hit a fixed Object (tree median, pole, building, parked vehicle etc), Specify______10. Others, Specify______24. If Two-wheeler rider/pillion, use of helmet: 1. Yes 2. No 3. Not known 4. Not Applicable 25. If Car driver/occupant, use of seat belt: 1. Yes 2. No 3. Not known 4. Not Applicable 26. Use of cell phone by the deceased: 1. Yes 2. No 3. Not known 27. Use of cell phone by the counterpart: 1. Yes 2. No 3. Not known

D2. FALL 28. Nature of Fall: 1. Fall on Same level 2. Fall from height 3. Fall from tree 4. Fall from balcony/compound etc.

29. Approximate height of fall: ______30. Whether using any protective Harness: 1. Yes 2. No 3. Not known

D3. INDUSTRIAL INJURY 31.1 Type of Industry: ______32.1 Method of injury: ______

32.2 Specific injury due to:______32.3 Whether deceased was using safety devices at the time of Injury: 1. Yes 2. No

D4. ANIMAL BITES/ INJURIES 33. Bites/Injuries due to : 1. Snake 2. Dog 3. Scorpion 4. Others

D5. ASSAULT / VIOLENCE 34.1 Nature: 1. Individual 2. Family 3. Group 4. Communal 34.2 Weapon used in Assault:______

35.1 Perpetrator (relationship): 35.2 Method of Assault: ______

D6. SUICIDE 36. Situation of committing suicide: 1. Alone in house 2. In presence of others 3. Outside house 37.1 Method of suicide: 1. Hanging 2. Poisoning 3. Drowning 4. Self-immolation 5. Fall from height 6. Jumping in front of moving vehicle ______7. Others, Specify ______

37.2 If poisoning, product or object causing suicide: 1. Therapeutic drugs 2. Illicit drugs 3. Insecticides / pesticides 4. Household products 5. Not known Specify Name ______D7. ACCIDENTAL POISONING

38. Nature of product: 1. Therapeutic drugs 2. Illicit drugs 3. Insecticides / pesticides 4. Household products 5. Not known Specify Name ______

D8. BURNS 39. Place of Burns: 1. House 2. Kitchen 3. Bathroom 4. Not possible to ascertain 40. Extent of burns (in %):

41. Product causing burns: 1. Kerosene Stove 2. Electrical burns 3. Electrocution 4. Hot liquids 5. Others, Specify ______

43 Special investigations done: 1. Alcohol 2. Toxicology 3. Photography 4. Histology 5. Swabs 6. None

7. Others Specify______8. Results awaited.

Name: Signature:

92 BRSIPP 2011 Annexure - 4

Hospital Name Bangalore Road Safety and Injury Prevention Programme EMERGENCYHospital TRAUMA Name CARE RECORD BANGALORE INJURY & ROAD TRAFFIC INJURY SURVEILLANCE PROGRAMME EMERGENCY TRAUMA CARE RECORD ECR No: ______NAME OF THE CMO ______

Date of Registration on : V / QJ . / V:` 1IV  

: V QJ . V:` 1IV    Date of Injury on

PLACE of OCCURRENCE: 1. Urban 2. Rural 3. Others

A. PERSONAL DETAILS OF THE INJURED

1 NAME: 2 AGE (in years)

3 SEX: 1. Male 2. Female

4 MARITAL STATUS: 1. Married 2. Single 3. Others 4.Not applicable

5 PLACE of RESIDENCE: 1. Urban 2. Rural 3. Others

Address ______B. DETAILS OF INJURY 6 PLACE of INJURY 1. Road 4. Office 7. Public place 10. Unknown 2. Home 5. Agricultural field 8. Railways 11. Others, specify ______3. Factory 6. School 9. Playground 7 Cause 1. Road traffic 4. Burns 7. Attempt at Hanging 10. Animal bites 13. Stab/cut 2.ij Fall 5. Poisoning 8. Sports injury 11. Crush injury 14. Others, specify ______3. Assault 6. Drowning 9. Fall of object 12. Agricultural injury 8 INTENT: 1. Unintentional 3. Intentional (assault) 5. Unknown 2. Self-harm 4. Others, specify _____ Product / object responsible for 9 injury 10 H/o ALCOHOL consumption in the Injured: 1. Yes 2. No 3. Probably yes If Yes, 1. Injured 2. Counterpart 3. Both 4. Not applicable 5. Unknown 11 ACTIVITY AT THE TIME OF INJURY (Use code given below) 1. Traveling in vehicle 4. Playing on road 7. Going/Coming from school 10. Others, specify ______2. Walking on road 5. Sleeping 8. Doing home work

3. Standing on road 6. Working in factory 9. Unspecified

C. DETAILS OF ROAD TRAFFIC INJURY

12 PLACE of OCCURRENCE: 1. City / Municipal roads 2. Highway 3. Rural roads 4. Others

13 Road User category of the injured: 11. Other 4-wheeler driver (maxi-cab/tempo, 1. Pedestrian 6. Three wheeler occupant 2. Pedal cyclist 7. Car driver etc) 12. Other 4-weeler occupant 3. Two wheeler rider 8. Car occupant 4. Two wheeler pillion 9. Bus / truck driver 13. Others, specify _____ 10.Bus / truck occupant 14. Unknown 5. Three wheeler driver

13.1 If Pedestrian, activity (Use code given below) 1. Walking on the road 3. Crossing the road 2. Standing on the road 4. Working on the road

5. Going/Coming school 5. Playing on the road 7. Others, specify______8. Unspecified

1

93 14.1 For Collision between vehicles, how many Vehicles were involved ( Use code given below) 1. Single 2. Two vehicles 3. More than two vehicle ( Use code given below) 14.2 1. Pedestrian 2. Pedal cyclist 3. Two wheeler 4. Three wheeler 5. Car 6. Bus 7. Truck 8. Other 4 wheeler

14.3 TYPE of COLLISION: (Optional) 1. Hit pedestrian 4. Hit from the back 7. Run off road 10. Fall from moving vehicle 2. Hit & run 5. Hit from the side 8. Overturn 11. Others, specify 3. Head on collision 6. Hit a fixed object 9. Skid & fall

15 USE of HELMET (if Two-wheeler rider/pillion): 1. Yes 2. No 3. Not known 4.Not applicable

16 USE of SEAT-BELT (if Car driver/occupant): 1. Yes 2. No 3. Not known 4.Not applicable

17 USE of CHILD RESTRAINT SEATS 1. Yes 2. No 3. Not known 4.Not applicable

D. P REHOSPITAL C ARE DETAILS 18 FIRST AID given before reaching the hospital: 1. Yes 2. No 3. Don’t know ** If yes, where: 1. At injury site 3. Nearby Pvt. Hospital / 4. Medical College 6. Police

2. Nearby Govt. Hospital Nursing Home 5. Pvt. Clinic/ hospital 7. Others, specify _____

19 SOURCE of REFERRAL: 1. Directly on their own 4. Pvt. Hospital / Nursing home 7. Others, specify ______2. General practitioner 5. District hospital 3. Govt. hospital 6. Primary health centre 20 NUMBER of hospital/s visited before reaching this hospital 21 MODE of transportation: 1. Any Ambulance 4. Autorikshaw (3 wheeler) 7. Others, Specify 2. 108 (EMRI) 5. Police vehicle 3. Private vehicle (personal or taxi) 6. Walking E. INJURY M ANAGEMENT & OUTCOME

22 STATUS of the injured at the time of entry: 1. Brought dead 2. Unconscious 3. Semi-conscious 4. Conscious 3. Severe (Direct medical / 1. Mild (Requiring ER 2. Moderate (Requiring 6 hrs SEVERITY of INJURY: surgical / other admission 23 Care) of hospital stay) requiring intensive management) 24 PART of the BODY injured (tick the appropriate part of the body):

Head Neck Upper limbs Abdomen Lower limbs

Face Chest Spine & vert. column Groin Back EXAMINATION/FINDINGS (all injuries to be documented in total)

25.1 TREATMENT: 1. Treated in emergency room & sent home 3. Treated in emergency room & referred to another hospital

2. Admitted for medical / surgical care

25.2 If referred, PLACE of REFERRAL:

Identification marks of patients Name & Signature of CMO

2

94 BRSIPP 2011 It is time to act . . .

Modern 21st century Incredible India is in a few from the many routine examples that race: a race to be an economic superpower. occur. Road crashes, falls, burns, drowning, However, a crucial aspect of people's lives poisoning, suicides, rape, violence are has been heavily compromised - and that is common every day happening in the life of safety. This grim fact stands out amidst the an Indian. numbers and statistics. Every year and, year after year, nearly a million people, majority As countries around the world moved in of them young, die due to injury and economic growth and improved living violence. The dreams – aspirations – and standards, safety on roads, at home, in work, hopes of the million Indians and their in play grounds and in factories received families are shattered due to injury and greater attention. Moving beyond human violence. The numbers are only increasing error and victim blaming, countries and in a steady manner. established and implemented safety standards, mechanisms, policies, Traditionally and for too long, people have programmes and regulations to make been blamed. 'Human error' is the label for people safe in their environments. Safe the colossal loss of lives. People are an roads, safe vehicles, safe work places, safe integral component of the systems in which products and safe play grounds are a result they live, work and carry out all activities: a of this thinking and investment. It fact conveniently overlooked. was based on political commitment by national governments and research by How can a worker working on the 8th floor professionals. of a construction be safe is he is not provided safety harness? How can a family in a slum India needs to develop right policies and be safe if loose electrical wires are passing programmes for saving lives and limbs in the over their roof? How can a young child be years to come. It is time, we in India, safe if the manhole on road is not closed? recognize the value of human lives and How can a woman be safe if her drunken make all efforts to make people safe by husband beats her up everyday? How can a making safety as a component of everyday young driver be safe, when given a vehicle life and provide safe products and safe that can zoom to 120 kms in a minute and be vehicles in a safe environment. We hope that asked not to drive fast? How can a young girl our policy makers, politicians and be safe on the roads if her safety is not professionals take up this challenge and assured and ensured? How can an injured include people's concerns and voices in this person recover, if he does not have access to process. It is time to act . quality and affordable care? These are just a