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otherwise, from others, especially from parts The green papers are especially noteworthy of the world where we do not have Editorial in that the New Labour administration Inj Prev: first published as 10.1136/ip.4.2.162-b on 1 June 1998. Downloaded from REGIONAL Board members. Please send your contribu- explicitly recognises the strong association tions to the editor, Barry Pless. between poverty and poor health and the REPORTS need to tackle the former (as well as lifestyle and behaviour) in the context of a compre- Pedestrian and bicyclist safety in New hensive health promotion strategy. York City For England, 12 year targets will be set to Southern Africa (and beyond) report reduce mortality and morbidity in four prior- Pedestrian and bicyclist safety in New York ity areas: heart disease and stroke, accidents, I am constantly aware that most of my reports City (NYC) has been in the news lately. Mayor cancer, and mental health (suicide). Targets selfishly concentrate on happenings in South- Rudolph Giuliani has raised the ire of NYC do not feature prominently (although they are ern Africa. Occasionally, I am able to glean residents by increasing the fine for jaywalking not ruled out) in the Scottish paper which, in the odd item on what is happening further from $2 to $50, plus making a court appear- addition to the above four areas, flags up a north from news reports, what little there is ance mandatory for paying fines for this number of others, particularly teenage preg- on the internet, or from that outstanding oVence. In addition, the mayor has recently nancy and dental health. monthly, “BBC Africa”. Rather than bore announced that pedestrian barriers which The green papers have been broadly readers with poor excuses for this imbalance, separate pedestrians and vehicles at certain welcomed by public health professionals. may I rather reconfirm that I would welcome intersections will be kept up “indefinitely”. Disappointment has been expressed however news (in any form whatsoever) related to Anyone who has walked or driven the streets of on two main counts. First, no targets have childhood injury in Africa, and inclusion of New York know that its pedestrians are among been set to monitor progress towards reduc- which would allow this column to become the most aggressive in the world. The scene ing the widening socioeconomic inequalities more representative of the entire continent from the Midnight Cowboy in which Dustin in health in the UK. Second, the proposed than it currently is. Those who are kind HoVman screams to an incensed driver, “I’m action seems weak on specific, sustained, and enough to submit news items will be person- walking here!” exaggerates the attitude of the adequately resourced measures designed to ally acknowledged. New York pedestrian, but only a little. make a major impact on the underlying Having got that oV my chest, I am thrilled Pedestrian and bicyclist injuries are a serious social, environmental, and economic causes to report on a fresh and exciting injury and sizeable problem in NYC city. There was of ill health. Moreover, while the poorer prevention campaign that has been hatched a 23% increase in the number of pedestrians health (including injury) record of the Scots in Uganda, thanks to both support and input and bicyclists killed in motor vehicle crashes in is acknowledged, this is not backed up by a of local and international agencies. I am NYC last year, from 249 in 1996 to 302 commitment to mount a proportionately extremely grateful to Dr Olive Kobusingye, according to preliminary police statistics for more vigorous health improvement pro- Director of the Injury Control Centre based 1997, 3700 hospitalizations annually, and an gramme north of the border. at Makerere Medical School in Kampala, for estimated 10 000 pedestrians struck by motor For injury prevention professionals, the providing me with the following information: vehicles but not hospitalized. Between 1994 statements are a mixed blessing. On the posi- “Representatives from Ethiopia, Kenya, and 1996 pedestrian deaths due to motor veh- tive side, “accidents” have held their place as Uganda, Zambia, Zimbabwe, South Africa, icles declined slightly from 223 to 213. In this priority areas in both England and Scotland. and the World Health Organization (WHO) same period motor vehicle occupant deaths Unfortunately, the writers of the green papers met on December 15–17 in Entebbe, Uganda decreased more substantially from 207 to 169. have clung to an outmoded and discredited at the joint WHO/Injury Control Centre Despite the preponderance of pedestrian and terminology, have oVered virtually no new http://injuryprevention.bmj.com/ Uganda (ICC-U) Working Group Meeting on bicyclist deaths, a study by Transportation ideas to address the injury problem, and have Injury Prevention and Control in East and Alternatives, a NYC watchdog group, found proposed targets that are likely to be met in Southern Africa. Participants focused on the that most of the $400 million of New York the absence of any further policy initiatives health sector issues of injury surveillance State and NYC funds earmarked for trans- whatsoever. Cynics might argue that therein emergency medical systems, and health portation safety in the next five years will go to lies the huge political appeal of the target set- professional training in injury epidemiology improve the safety of vehicle occupants rather ting exercise! and trauma care. A set of recommendations than the safety of pedestrians and bicyclists. DAVID STONE was formulated which has the potential to be From a public health perspective, enforce- The PEACH Unit, a milestone for injury prevention in Africa. ment of laws as well as use of physical barriers Department of Child Health, The adoption of a standardized minimum to separate pedestrians and vehicles are Yorkhill Hospital, Glasgow G3 8SJ data set for hospital based injury surveillance perfectly respectable counter measures against Scotland, UK was discussed. A trauma registry form tested pedestrian injuries. Some of the uproar is and used by the ICC-U will be presented to because the least lethal players in the urban injury control workers in participating coun- drama, the pedestrians and bicyclists, feel they tries for input and development of a common are being unfairly and illogically singled out. on October 2, 2021 by guest. Protected copyright. format; it is hoped that this data set will form And, of course, other measures could and LETTERS TO the core of a common trauma registry system should be taken, including enforcement of in these countries. The single page trauma speed limits, use of speed bumps, creation of THE EDITOR registry form includes ICD-9 categories of walking streets in heavily congested areas, and injury, a severity instrument (the Kampala stricter licensing of taxi drivers. But the public ridicule that has been heaped on the Mayor is score), victim and event information, and in- Safety strategies tentionality. Operate definitions for the registry a reminder of the critical role played by the have been written, and the form has already social context in which environmental and behavioral interventions are launched. EDITOR,—Jan Shield is to be commended for been tested in Uganda and Ethiopia. The rallying the troops in favour of “active” safety trauma registry form is suYcient for base line POLLY E BIJUR strategies,1 and most of her arguments in injury measurements while at the same time Kennedy Center, Room 920, favour of education and enforcement would keeping the form short and simple enough for Albert Einstein College of Medicine, undoubtedly be valid in a developed country. a range of health workers to fill out”. 1410 Pelham Parkway South, However I would like to oVer two contrasting Bronx, NY 10461, USA Contact details for ICC-U: Dr Olive viewpoints on the subject which are based Kobusingye, Makerere Medical School, PO primarily on personal observations related to Box 7072, Kampala, Uganda (fax: +256 41 British green papers highlight injury the challenges of traYc safety confronting us 530022; e-mail: [email protected]). prevention in a cash strapped, developing country. DAVID BASS Firstly, in support of passive measures is Department of Paediatric Surgery, In February 1998, the British government the increasing strain placed on the human Red Cross War Memorial Children’s Hospital, published two green papers (consultative and financial resources essential to conceive Rondebosch 7700, South Africa policy statements) for England and Scotland: and sustain education programmes and law Our Healthier Nation and Working Together for enforcement, particularly in developing Editor’s note: While most Regional Reports a Healthier Scotland. These outline a strategic countries. As such, traYc calming measures have come from regular contributors—our approach to public health that build on earlier are likely to be more eVective than nothing— team of Regional Editors—I am always target setting exercises that have met with simply because there is no other aVordable delighted to receive contributions, regular or limited success. solution to undisciplined traYc flow on a 162 Injury Prevention 1998;4:162 particular thoroughfare. Twelve months ago, 1 Shield J. Have we become so accustomed to 1 Pless IB. The challenge of drowning prevention the community in which which I live opted being passive that we’ve forgotten how to be [Editorial]. Inj Prev 1997;3:237–9. Inj Prev: first published as 10.1136/ip.4.2.162-b on 1 June 1998. Downloaded from active? Inj Prev 1997;3:243–4. 2 Murray CJL, Lopez AD. Global health statistics: a for a system of restricted entry through the compendium of incidence, prevalence, and mortality suburb to reduce to number of “rat runners” estimates for over 200 conditions. Volume II. speeding along a particular route during the Challenge of drowning prevention in low Cambridge: Harvard University Press, 1996. 3 Murray CJL, Lopez AD. Mortality by cause for early morning. At the time the system was put and middle income countries the eight regions of the world: Global Burden in place, law enforcement of the system was of Disease Study. Lancet 1997;349:1269–76. EDITOR,—We read the editorial on “The suYciently regular to be taken for granted, 4 Celis A. Home drowning among preschool age challenge of drowning prevention” with great and to ensure an 86% reduction in traYc Mexican children. Inj Prev 1997;3:252–6. interest.1 There is no doubt that drowning is flow. Then, three months ago, the traYc a major but under recognised cause of department underwent severe rationalisation, premature loss of life and disability. This has Injuries in less industrialised countries and overtime for all oYcers was abolished. been borne out by the Global Burden of Dis- Now there is no enforcement of the restricted EDITOR,—I read with interest the report by ease Study which highlights the scale of the entry system and the “rat runners” are back Mohan published in December.1 I agree that problem, by region and by age and sex in force. In retrospect, a passive measure such “Priorities for injury control have to be based characteristics.2 It is worth examining their as closure of the main access road would on intelligent assessments of oYcial statis- findings further. obviously have been the better choice. In tics...”. This is what prompted me to call At a worldwide level, Murray and Lopez South Africa, where formal education is attention to the improper use of the word estimated that drowning was responsible for “rate” as presented in the second paragraph, limping along on a shoestring budget, and law about half a million deaths in 1990 and enforcement (for a multitude of reasons) is where the author writes “....the rate in India ranked 20th as a leading single cause of (8.6) is....” in reference to table 1 “Distribution virtually non-existent in some areas, the mortality, after road traYc accidents (9th), option of passive safety measures must be of deaths as a percentage of regional total”. self inflicted injuries (12th), and violence Rates and proportions (expressed as per- placed high on any agenda—certainly where 3 (17th) as the other injury related causes. centages) are diVerent. A rate is the ratio of traYc safety is concerned. Mortality rates from drowning were highest Against what I have argued above is a word two diVerent quantities (generally symbolised for children under 5 in China, followed by of caution. Just as active measures may fail, so by the equation a/b) while a proportion is the countries belonging to the “other Asia and may the too hasty adoption and construction result of dividing two quantities where the islands” region, and sub-Saharan Africa, with numerator forms part of the denominator of a passive device which is inappropriate for the lowest rates in the “established market the identified purpose. Possibly because envi- (symbolised by the equation a/(a + b)). A economies” (EME).* In this age group, the proportion multiplied by 100 is a percentage. ronmental modification may be the quickest mortality rate ratio between China and the and cheapest solution to an injury hazard—a Rates and proportions are not synonyms. It EME was 13:1 in boys and 22:1 in girls. seems the author meant to say “percentage” form of instant gratification—the device too The large degree of variation between the hastily chosen may fail dismally to counter and not “rate”. This mistake could confuse diVerent regions in the study must belie an those beginning in the field of epidemiology, that hazard simply because of a lack of even greater variation, both between and adequate research into the hazard itself, or prompting them to think that “percentage” within countries, given the diVerent geography and “rate” are synonymous: they are not. failure to consult expert opinion before firing and populations. There is great diversity in the up the cement mixer. Again, in South Africa, circumstances in which drowning occurs in ALFREDO CELIS I notice a growing trend for traYc calming these diVerent areas. Whereas swimming Public Health Department, CUCS, measures to be demanded by community University of Guadalajara, pools, sailing, and water sports may be priority Sierra Mojada #950, groups, often in response to a spate of casual- http://injuryprevention.bmj.com/ areas in the EME, in low income countries Colonia Independencia, Centro Midico, ties in a residential area, or because a attention must need to be paid to drowning in 44242, Guadalajara, particular intersection has been identified as streams, wells, dams, cisterns, and while Jalisco, Mexico a “black spot”. Lay people may go one step fishing.14Clearly there are a huge range of dif- further and put pressure on a municipality to ferent environmental and behavioural circum- 1 Mohan D. Injuries in less industrialised coun- tries: what do we know? Inj Prev 1997;3:241–2. construct a specific kind of device, speed stances. The obvious intervention to keep the humps being particularly popular, although child who cannot swim away from water must by no means a panacea where the hazard may haveadiVerent interpretation in the diVerent be compounded by a complexity of factors of regions. Although swimming pools could be which vehicle speed is only one. Also, fenced in EME countries, the fencing of BOOK REVIEW piecemeal engineering may simply divert a waterways would be impractical in countries hazard elsewhere so that it becomes the where this runs into thousands of kilometres. problem of a neighbouring suburb instead. This is not to say that there are no common The most eVective passive strategies may approaches. As the editorial rightly points out, Target Risk: Dealing with the Danger of simply require forward planning rather than education about the risks, closer supervision, Death, Disease and Damage in Everyday on October 2, 2021 by guest. Protected copyright. hoping vainly that a “finger in the dyke” and training in resuscitation are important first Decisions. By Gerald J S Wilde. (Pp 234.) approach will plug the gaps later on. Resort- steps which could be applied globally. Re- Toronto: PDE Publications, 1994. ISBN ing to an ad hoc solution reflects that town searchers also need to study the circumstances 0-9699-12404. planners eschewed safety considerations from under which drowning occurs and the first aid the outset and the attitude that condones and health care response, within countries and In Target Risk, Professor Gerald Wilde of such blinkered thinking must be discouraged. cross nationally. Data on good practice need to Queen’s University in Ontario, Canada as- There is currently a backlog of over two be collated so that appropriate interventions sembles an impressive body of theory and million subsidised houses in South Africa. which are transferable to other low and middle evidence to support a provocative conclusion: These can be constructed either according to income countries can be easily identified. the only eVective strategy for achieving an inexpensive generic plan which creates lots Whatever the intervention there is an urgent substantial and durable reductions in the rate of accommodation, and many attendant haz- need to get drowning higher on the agenda for of injury in a population is to increase ards, or by careful planning that can ensure policy makers and researchers. people’s desire to be safe and healthy. that safety features are built into the scheme Traditional measures of injury prevention— as a whole, for example suYcient recreational *The Global Burden of Disease Study used the eight global regions identified by the World Bank for engineering, education, and enforcement— space and play areas, shorter streets, re- the World Development Report 1993 with similar are doomed to failure because they do not stricted access for through traYc, etc. In that levels of socioeconomic development, epidemiologi- alter the “target levels of risk” that govern risk eVective, enduring passive safety measures do cal homogeneity, and geographical contiguity: the EME, former socialist economies of Europe, India, taking behaviors. The process of “risk home- indeed require foresight, research, and careful China, other Asia and islands, sub-Saharan Africa, ostasis” will ultimately undermine all non- consideration, these should not be either Latin America and the Caribbean, and the Middle motivational countermeasures, since people resorted to, or denigrated as a “cop out”, or East crescent (which includes North Africa, the will alter behaviors to achieve an equilibrium Middle East, Pakistan, and the Central Asian even worse, as a quick fix. republics of the former Soviet Union). between the overall amount of risk they perceive and their overall desired level of risk. DAVID BASS DINESH SETHI Department of Paediatric Surgery, ANTHONY ZWI The key to success, Wilde argues, is “expec- Red Cross War Memorial Children’s Hospital, Health Policy Unit, tationism”: promoting people’s interest in Rondebosch 7700, South Africa London School of Hygiene and Tropical Medicine, their future wellbeing in order to motivate (e-mail: [email protected]) Keppel Street, London WC1E 7HT,UK adoption of smaller risk targets. Injury Prevention 1998;4:163 163

Wilde is not arguing that people enjoy or examine international diVerences in how seek risk of injury. Like behavioral decision legal systems treat motor vehicle injuries. Inj Prev: first published as 10.1136/ip.4.2.162-b on 1 June 1998. Downloaded from analysts and economists, he postulates that PEDNET PETER JACOBSEN people select or accept risk targets in order to PO Box 712433, achieve other desired ends in life. When safer Los Angeles, highways are built, drivers trade some or all of CA 90071-7433, USA the extra safety for faster travel speeds and One of the strengths of the pedestrian e-mail 1 Lightstone AS, Peek-Asa C, Kraus JF. Relation- more relaxation (and inattention) in driving. network, PEDNET, is the diverse back- ship between driver’s record and automobile When road conditions deteriorate (due to ice versus child pedestrian collisions. Inj Prev ground of the participants. Last month, a 1997;3:262–6. or fog), people sense elevation in risk and physicist, Alan Streater ([email protected]), respond by slowing down and driving with used his analytical skills to examine how more care. Using variations on this adapta- major newspapers covered 42 motor vehicle tion theme, Wilde challenges the eVective- pedestrian deaths. He termed his analysis Correction ness of most mainstream injury prevention “quick and dirty” but it provides insight into We regret that a production error occurred measures: seat belt laws, antilock brakes, traf- the quality of coverage. in the March issue; this resulted in three fic lights, driver training/education, crack- He categorized the wording in the reports addresses being omitted. The missing downs on drinking and driving, highway into neutral, slightly biased against the pedes- addresses are as follows: design improvements, motorcycle helmet trians (for example, pointing out twice that it x Charles Larson (Going international: laws, you name it! Even more provocatively, was dark or that the pedestrian was not on a what are the implications? p 4), Pediatrics, Wilde hints that any long term progress that crosswalk), or very biased against pedestrians Epidemiology and Biostatistics, Montreal might be made in fatal injury could be oVset (for example, “darted out”, “ran out into traf- Children’s Hospital, 2300 Tupper, Mon- by increases in the risk of fatal diseases (since fic”, etc). He found the wording was mostly treal, Quebec H3H 1P3, Canada. people’s overall risk target is maintained). neutral in 26 out of 42 (62%), partially biased x Robert W Platt (ANOVA, tests, and Technical specialists will certainly find in five cases (12%), and clearly biased in 10 t linear regression, p 52), McGill University/ fault with Professor Wilde’s handling of a cases (24%). In six cases (14%) the report Montreal Children’s Hospital, 2300 Tup- variety of complex empirical questions. For provided additional wording to excuse the per, Montreal, Quebec H3H 1P3, Canada. example, I thought his discussion of the driver, such as “it was raining and hard to see”. association between the business cycle and There were no cases in which wording app- x Chester S Jones (Children and personal injury frequencies was fair and insightful, yet eared to exonerate the pedestrian in any way. watercraft: injury characterisics and poten- his assessment of the eVectiveness of safety Alan had a disturbing observation—that tial countermeasures, p 61), Health Sci- belt use laws was highly selective, one sided, newspaper reporters obtain their understand- ences, University of Arkansas, 308 HPER and arguably deceptive. Professor Wilde also ing of the fatality from police reports. He sees Building, Fayetteville, AR 72701, USA. has a tendency to see risk homeostatic expla- the need for a more careful analysis of biased nations behind all empirical anomalies. language in newspaper coverage and, perhaps Again, on safety belt use laws, Wilde notes more importantly, police reports. The conse- that if belts are 50% eVective in saving lives, quences of this bias may be more than just and if belt use rates increased 50 percentage public perception; this bias may also jeopardize points following laws, why didn’t laws cause the prosecution of dangerous drivers. He also CALENDAR an immediate 25% decline in occupant fatal- recommended comparing interregional and ity counts? (Wilde is correct that few jurisdic-

international diVerences in bias. He also http://injuryprevention.bmj.com/ tions have experienced 25% reductions in reported the coverage of charges filed. A driver fatalities after belt laws.) Aha, Wilde asserts, was reported to be charged in only one case 18–22 October 1998. Fourth International maybe drivers oVset the benefit of the safety out of 42 (2%). In all other cases (98%) the Symposium: Rural Health And Safety In A belts by taking more risks. Some alternative police apparently did not even issue a traYc Changing World, Delta Bessborough Hotel, explanations that Wilde ignores are (a) the ticket to the driver at the scene of the crash or Saskatoon, Saskatchewan, Canada. Organized most crash prone drivers (for example, shortly thereafter. In six cases, the crash was by the Centre for Agricultural Medicine, Uni- drunks and young males) may be least likely reported to be still under investigation, imply- versity of Saskatchewan in cooperation with to comply with the law, (b) the 50% increase ing there is still a chance that some of these the Canadian Coalition for Agricultural Safety in use is an exaggeration, and even (c) the drivers might be charged later. Two cases were and Rural Health, Committee on Occupat- 50% eVectiveness number may be biased hit and run, and in one case the driver died. ional Health in Agriculture of the International upward (we once thought belts might be This analysis closely matches Amy Light- Commission on Occupational Health, and 60–90% eVective). stone’s recent analysis of drivers who kill child others. This conference seeks to capture the Yet I would urge specialists to overlook pedestrians. She found that 214 out of 237 emerging science of health, safety, and sustain- Wilde’s handling of detailed technical mat- drivers were not cited (90%).1 Can something ability in agriculture and rural life, and to ters because such focus can cause the reader be done to change this obviously dangerous probe beyond these issues to address the thriv- on October 2, 2021 by guest. Protected copyright. to shortchange Wilde’s overall message. It is a situation? ing and survival issues of the future. In message that the field of injury prevention Again, the diversity of PEDNET partici- addition to abstracts from scientists, health needs to hear. We spend remarkably little pants provides insight into addressing driver care workers and others, abstracts are also eVort on bottom-up approaches to motivat- behavior. Osias Baptista Neto (techtran@ invited from rural people with views on this ing safety (for example, incentives) and inor- ouro.alcance.com.br) reported that Brazil has topic. Further details: Fourth International dinate resources on top-down measures reduced casualties dramatically after a change Symposium: Rural Health and Safety in a aimed at protecting people from their folly in traffic law at the beginning of the year. The Changing World, Centre for Agricultural (for example, helmet laws and speeding con- new laws recognize that vehicular homicide Medicine, RUH, PO Box 120, Saskatoon, trols). A deeper understanding of the motiva- may be unintentional but none the less results Saskatchewan S7N 0W8, Canada (e-mail: tional barriers that frustrate injury prevention from risky behavior. Killing another person in [email protected], web site: www. measures is critical to the advancement of our a traYc crash results in imprisonment for two usask.ca/medicine/agmedicine/symp98.html). field. Professor Wilde makes a lasting contri- to four years, and a suspension or revocation of bution by shedding some light on this the driving license. It increases the penalty by neglected area. half for striking a pedestrian in a crosswalk or Notice to authors: a new section This book has a length of 234 pages. It is onthesidewalk(pavement).Hereportsthatpre- Brief reports comprehensive in topic coverage. The topics liminary data show a 70% drop in casualties in are as follows: the concept of homeostasis, the major cities like Sao Paulo, Belo Hori- All editors would like to publish as many compact theory of risk taking, theory of risk zonte, and Curitiba. His report illustrates the worthy papers as possible, with minimal homeostasis, deductions and data, interven- benefits of global comparisons of injury con- delay. To facilitate this, in future, the jour- tion by education, remedy by engineering, trol eVorts. Injury Prevention connects the nal will include a section entitled “Brief enforcement action, risk homeostasis in the English speaking world, but extra eVort is reports”. These will be peer reviewed and laboratory, individual diVerences, and moti- required to reach beyond the barrier of diVer- when approved, publication will be expe- vating for safety and health. ing language. dited. The barrier is especially significant with Please note:papers being submitted for this JOHN D GRAHAM section should not exceed 1500 words. Harvard School of Public Health, legal terms and concepts. However diYcult to Boston, USA analyze, injury prevention specialists need to