PubL Hlth, Lend. (1978) 92, 237-245
Road Traffic Accidents: A Major Public Health Problem in Nigeria S. E.
Asogwa
M.B.. B.S., M,Sc,. D.T.P.H.
'Faculty of Medicine, .University of Nigeria Teaching Hospital Enugu, Nigeria Analysis of data on road traffic accidents (RTAs) in Nigeria o~er an eight-year period showed a rising trend. To highlight the importance of RTAs in the~country, the number of deaths from RTAs (1967-74) and from major communicable diseases (.1964-74) was reviewed. It ".was found that there were annually more deaths from RTAs than even the cholera epidemic ot" 1971. International comparison of the RTA situalion in Nigeria with that of industrialized countr.~es(United Kingdom, Sweden and Australia) and developing countries ,(Zambia, Tanzania, U,~anda and Kenya) showed that Nigeria had by faz worse mortality and morbidity rates. The importance of the involvemenl of doctors, especially those in the field of public health, in the prevention of RTA using the methodology which has been successfully employed in the control of communicable diseases is stressed.
Introduction Road Traffic Accident (RTA) started to be a health hazard for .mankind with the invention of the first true automobile by N. T. Cugnot in 1769. ~.In Nigeria, RTAs have been a concern to the public and this concern has been growing in recent times as a result of rapid increases in the number o f motor vehicles with the resultant increase in the number of road traffic accidents. There is scarcely a week that passes without one or more accounts of ghastly RTAs appearing in one o f the Nigerian daily newspapers as having occurred somewhere in the country. This has been largely regarded as a social problem of interest to the law enforcement agencies (the police, etc.), the insurance companies and, o f course, the victims and owners of vehicles involved in RTAs. The Nigerian RTA situation has therefore n o t been regarded as a consequence of an agent o f death and disability which in many respects is similar t o communicable diseases. It is the appreciation of this similarity that made several health workers in industrialized countries advocate the recognition of RTA .as a public health problem and the use of epidemiotogical methodology, which has been successfully used in the control of other communicable diseases, to solve the RTA problem.-°. 3. ~ The RTA problem in Nigeria has not received medical attention anywhere comparable to the size o f the problem. There is, o f course, the treatment of the injured victim which often: upsets scheduled work. But research aimed at unravelling the RTA problem from the point of view of the effects---distribution o f injury on the victims, types of injury, etc.--and the cause o f accidents from an epidemiotogical approach is very scanty indeed. The " D o k R a " (1963) s contained a summary o f a symposium on "Accident Prevention" h d d at the U C H in Ibadan. The trend in R T A from 1946-59 was demonstrated and certain conclusions on the causes o f R T A w;ere made, some based on impressions. The age and sex distribution, mode of participation and the injuries sustained by RTA victims treated at the same hospital were studied by Adeloye & Odeku. a This study was limited in O038-3506/78/050Z37-k09 $01.00/0
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scope and did not present the dimension of the RTA problem in the country as a whole. Omitola': and Oyemade * studied the RTA problem in .the then Western State of Nigeria and lbadan with its environs respectively. Both studies, though showing characteris'tics of RTA victims, related to one part of the country and therefore did not present a national picture. This study was intended to look at the RTA problem a~ it affects the country in general and also view it against the background o f other major communicable diseases. This would bring into relief the actual dimensions of the RTA problem. And, to see how the Nigeria sit,ration compared with those of some countries in developing and industrialized countries, international comparisons became mandatory. Materials and Methods The number o f notified deaths due to each of :he I0 important communicable diseases in the country over an eight-year period (1967-74) were obtained from the Statistic Division o f the Federal Ministry of Health. Data on the number o f reported road traffic accidents over a nine-year period (1967-75) were obtained from the office of the Inspector-General o f Police. (They were, therefore, only reported accidents). Information obtained showed the annual total number of accidents and the number of those killed and injured over the period. Using the data, trends in the total anr~ual number o f accidents, the number for persons killed and injured and case fatality rates were calculated. Those "'killed" were RTA victims who died on the spot o r a t any other time or place so long as their death could be traced to the accident. Those "'injured" were other casualties that had injuries o f varying degrees oF severity following RTAs. The case fatality rate for Sweden and the United Kingdom were calculated from W.H.O. 0968) while fatality and injury rates for Nigeria and selected countries in industrialized and developing parts o f the world, over a ]0-year period, were adapted from data by Jacobs & Fouracre. 1~ The developing countries were Tanzania, Kenya, and Zambia; the industrialized countries were Great Britain and Australia. The number of persons killed in selected countries (Uganda, Tanzania, Sweden and Britain) after a period of nine years, and the percentage change in the number ofdeaths during this period were obtained from.Schram n and W.H.O. TM The da~a-for period 1967-9, were ur~derestimations because they pertained to the period of the Nigerian civil war with its attendant incomplete reporting of.cases. Results It can be seen (Table t ) t h a t deaths from RTA (from 1967 to 1974) were higher ~/han f o r any of the seven major diseases and that the figures had been increasing progressively from year t o year. It contributed 38.9 % of all reported deaths in t967 but in 1974 had reached 60-2 %. In 1971 deaths from road traffic accidents exceeded that due to the cholera epidemic of that year with the numbers being 3206 (RTA deaths) and 3085 (cholera deaths). The yearly trends in all categories of accidents on the roads (Table 2) showed a steady rise from 1971 t o 1975. The annuai percentage increase over the preceding year was minimal in 1971 (6-5%) and maximal in 1972 (3l'2~o). The trend for those killed and injured from 1967 to 1975 showed, on the whole, an increase (Table 3). The increase was more marked in the number of those injured. The post-war period, 1970-25, was more representative of the true situation. Table 4 shows the case fatality rate for the period 1967-75. The war years(1967-59) had a peak in 1968. The reduction in 1970 was followed b y a gradual rise during the post-war years. Nineteen-sixty-eight, however, still had the highest figure (228-62) while the mean annual case fatality rate for the entire period (1967-75) of 200.57 per 1000 cases closely resemE.1~d the data for the post-war period (1970-5).
TABLE I. Number of notified deaths due to ten diseases in Nigeria (1964--74) and Road Traffic accidents (1967-74) Diseases Smallpox CerebrosDinal meningitis TuberCulosis Dysemry Pneumonia Measles Tetanus Malaria Infectious hepatitis Chickenpox Whooping Cough Sleeping Sickness Typhoid and paratyphoid Schistosomiasis (all forms) Cholera Septic meningitis goad trame accident (RTA) Total inc|uding RTA RTA as a percentage of toial
1964
1965
1966
1967
1968
1270 353 229 159 1166 i349 348 207 122 54 ~
496 743 175 125 879 792 314 145 92 --58
406 524 102 181 793 806 350 445 73 82
395 225 131 143 830 723 320 369 88 -4I
164 214 274
2079 5344 38.90~
~ 811 323 265 99 29 47
Year 1969 . 459 214 78 9,t4 610 414 413 160 . 30 27
2808 2347 5874 5696 47.80~o 41.0~
1970
1971
. 1077 577 360 18"44 449 639 1109 587
.
.
. -. 195 56
2895 9788 29.6/,, ":
1972
. 88-6 604 257 282 267 179 1814 t458 7:75 495 462 694 6t3 517 208 122 . . . 94 -. . . . . . -65 3085 96
3206 3921 8471 8433 37.8°~ 46.5~
1973 251 236 152 1460 1029 301 517 134 . 22 . . -27
1974
300 182 586 866 459 330 105 59
-43 4248 4537 4922 8666 8167 52.3°/~, 60.2~
*Data on notified deaths from 10 diseases were supplied by the Statistic Division of the Federal Ministry of Health while that for Road Traffic Accident Deaths were from the Fed. Nigeria Police Hcadquarters.
240
S. E. Asogwa
When compared with two industrialized coumries known for their low accident rates (Sweden and the United Kingdom), the Nigerian figure (of 174 deaths per 1000 cases) TABLE 2. Yearly trends in all categories of accidents in Nigeria (1967-75)
No. of accidents Annual rate of increase of accidems over preeedingyear(%)
1967"
1968t
19695
12,950
12,163
12,998 16,666
.
.
.
1970
.
Year 1971
1972
t973
]974
1975
I7,745
23,287
24,844
28,898
32,651
6-47~ 31-23%
6"68% 16-31~ 12-98%
Mean rate of increase over a five-year period (1971-5) was 14-73% p.a. *Data available f o r the country as made of East, West, North and Midwest regions and Lagos Federal Territory. fNo data were available for the War Zone of East Central, Midwest and Rivers Stales. ~Data were available for all the 1! states and part of the Fast Central State.
T^Bt.E 3, Persons -killed and injured in road traffic accidents per million population in Nigeria (1967-75) Year *Population (I.,000,000) Total killed Rale per 1,000,000 population Totalinjured Rate per 1,0019,000 ipopulation
1967
i968
1969
1970
1971
61-5 2079
63"0 2808
64.5 2347
66-2 2895
67'9 3206
34 9478
45 9474
36 8808
44 I3,154
47 14,592
154
150
137
199
215
1972 69-6 3921
1973
1974
1975
71 "3 4537
73"1 4922
74-9 5552
56 64 16,161 18,154
67 18,660
74 20,132
255
269
232
255
*Population estimates based on the 1963 census figures and an estimated compound growth rate of 2-5 ~ per annum.
TABLE4. Case falality rate of RTA victims (1967-75) 1967 No re~orted killed (a) No. reported injured (19) All reported casualties(c) Case fatality rate (a/c) per 1000
1968
1969
2079
2808
2347
9478
9474
8804
1970 2895
Year 1971
1972
1973
3206
3921
4537
14,154 14,592
16,I61
18,660
]974 4922
1975 5552
18,660 20,132
11,557
12,282 11,15t
16,049
17,798 20+082 22,691
23,582
25,684
179.89
228.62
180.38
180.13 195-24 199.94
208'71
216-16
210-47
Mean annual case f a t a l i t y r a t e 1967-75 = 200.57 per 1000 cases
by far exceededthose for Sweden (73 deaths) and the UnitedKingdom (27deaths) (Table 5). In fact, it was more than six times that of the United Kingdom and about two-and-a-half times that of Sweden. The fatality and injury rates over a 10-year period for three African
Road accidents #1 Nigeria
241
countries, Great Britain and Australia showed (Table 6) lhat Nigeria had the highest figures. Fatalities per 10,000 vehicles were 147-40 in 1961 and 175.10 in 197|. The data for the other countries were: Tanzania 71-90 0959) an~t 70-42 (1969); Kenya 38-92 (196t) and 69"14 (1971); Zambia 50.15 (1961) and 76.41 (1971); Great Brilain 6-97 (1961) and 5"I6 (t971) and Australia 8-41 (1961) and 7"17 (1971). The rate for injuries per 10,00O vehicles were similarly highest for Nigeria (1110-69 in 1961 and 796.94 in 1971). Tanzania had TABLE5. Case fatality raies for Nigeria, United Kingdom and Sweden Country Nigeria (Average 1971-5) United Kingdom (Average 1964-6) Sweden (Average 1964-6)
Rale (per I000) ! 74 27 73
Source: Calculated from W;H.O.' TABLE6. Road deaths in selected countries
Country Britain* Sweden* Tanzaniat Ugandat Nigeria
Year and number killed 1965 7952 1965 1313
1973 7406 1973 1177
1960
1968
460 1960 3524 1967 2079
477 1968 4530 1975 5552
Percentage Numberof increase(÷) years or decrease(--) 9
6"7% (--)
9
10-4% ( - )
9
3-7% (+)
9
28-5~ (+)
9
167"0~/ (+)
*Source: W.H.O. i= fSource: Schram.n 754"02 and 679-52 injuries per 10,000 vehicles in 1959 and 1969 respectively. For the other countries the rates were: Kenya 437.78 (196.1) and 498-28 (1971); Zambia 300.17 (1961) and 461.36(1971); Great Britain 346-10 (196i) and 230.98 (1971) and Australia 202.37(1961) and 181-84 (1971). Data on road deaths in Nigeria, two other African countries (Tanzania and Uganda) and two European countries (Britain and Sweden) showed that after a period o f nine years, the European countries all had decreases while the African countries had increases (Table 7). Britain's rgad deaths had decreased by 6-7 ~ and those for Sweden by 10-4yo. Tanzania had increased by 3-7°~i Uganda by 28-5y0 while Nigeria had increased by 167~0!
TABLE7. Fatality and injury rate over a 10-year period for Nigeria and some selected countries
Country Nigeria l'an~ania Kenya Zambia Great Britain Australia
Year
Fatalities
Serious and slight injuries
1961 1971 1959 1969 1961 1971 1961 1971 1961 1971 196t t9~71
1313 3206 277 528 329 1046 273 794 6908 7~696 2524 3590
10,614 14,592 2905 5095 3701 7509 1634 4794 342,859 344,390 60,749 9~,036
*Source; Adapted from Jaeobs & Fouracre t..
Vehicles
Population (thousands)
Vehicles per person
Fatalities per 10,000 persons
Injuries per 10,000 persons
95,$62 i83,100 38,527 74,979 84,540 i 50,697 54,436 103,910 9,906,300 14,910,000 3,001,903 5,006,446
36,200 56,510 9076 12,926 8300 I t,800 3300 4250 52,676 55,910 10,508 t2,730
0.003 0'004 0.004 0.006 0'010 0.013 0.017 0.025 0'189 0.267 0-286 0.394
0'36 0.57 0'31 0.41 0"40 0.89 0'83 1-87 1.31 1'38 2.40 2'82
2'93 2.58 3'20 3.94 4.46 6.36 4'95 11.28 65.09 61,6',9 57'81 71'51
Fatalities Injuries per 10,000 per 10,000 vehicles vehicles I37.40 175.10 71 '90 70.42 38.92 69.41 50'15 76.41 6.97 5.i6 8"41 7'17
1110'69 796.94 754'02 679"52 437.78 498.28 300'17 461.36 346.10 230"98 202.37 18I'84
Road accidents ht Nigeritt
243
.Discussion The available information shows that road traffic accidents constitute a major cause o f morbidity and ntortality in Nigeria. The data for the period o f the civil war and the postwar years x~ere all high. What is distressing is that there is a rising trend from year t o year. When compared with communicable diseases of public health .concern, road traffic accident is clearly of greater importance. It was responsible for more deaths in 1971 .than the cholera epidemic of that y~lr, yet the nation and particularly public health workers, have not shown comparable.concern. Road traffic accidents have been called a new epidemic.~"-It has also been described ason endemic rather than an epidemic disease because it is constantly present in a given country.!3 In the Nigeria situation, RTA is there all the time .and of great magnitude hence one can better describe it as an endemic di~ase with epidemic dimensions. Looking at the RTA data for the country against the data +for other causes o f death and disabilityl-one can appreciate theilmportance of this new disease vis fi ~,is other diseases. Analysis of RTA mortality and morbidity data alone would not present a complete picture. It would be immensely usefti~ to compare the RTA problem in Nigeria with those of other countries t o see how Nigeria fares. International comparison of RTA statistics can be extremely di$cult and unlessfnterpreted with caution can be misleading. For example, lack of international agr~ment on .such a seemingly .straight forward issue as definition of "'person killed" in RTA underliOs the seriousness of the disagreement. Forinstance, in Australia, "person killed" means "killed :outright oi" dying within 24 hours", but in the United Kingdom, it is "killed outright or dying within 30 days',? In Nigeria, no definite time interval is used and one is+deemed as having been killed in a road accident if one's death Cart be traced t o the accident. International agreement designed to make comparison possible hasbeen reached by++certain countries. F o r example, tile member states o f the :United Nations Economic Commission for Europe have adopted "person killed" as "'any person w h o was kiltedoutright+or who died Within 30 days as a result of the accident", a~ The use o f this period is supported by result of research workers. Robertson & Tonge~s found that only 2.8 ~o of 2081 victims in Brisbane and 3-8 ~o of the 775 victims in Adelaide (both in Australia ) survived beyond 30 days after their accidents. Notwithstandingthe shortcomings of international comparison o f R T A statistics, all the data presented showed that the RTA problem in Nigeria is worse not only compared with those of thejndustrialized countries but alsothose 0f other developing countries :of Africa. That road traffic accident is a staggering public health problem in Nigeria-therefore needs no further amplification. Members~of the medical profession, particularly those in the field o f public health, should seen it as such ffhd deal with+it using methods that have been successfully usedS0 the control of similar public health problems with-high morbidity and mortality. It has been stated~+ that-accidents£oilow some of the same biological laws a s d o diseases and that attempts at control or preventmn should involve consideration of the interaction of+agent, host and environment, i.e. the vehicle, the driver, and the highway. Members o f the-medical profession should not 'think+that ~thelr role in road accident .in Nigeria is just. to treat the injured. They sfiouid, as s t a t e d b y Marples, ~: study ways in which accidents can be minimized. This basically,means a study of the pattern o f injuries sustained by RTA victims?a.~9as well as a study' of th~ causative factors ot+r0ad accidents. The former is a hospital'based study, while the latter l o o k s at RTA from the Viewpoint of-its.epidemiology. I n hospitals doctors can contribute to the reduction of road accidents in several ways, including the organization of effective first aid and subsequent management o f RTA Victims, especially those+with head injuries an~ fractures. ~° And while under their care, every opportunity-should be used to preach the gospel o f R T A prevention through a change in the road user's behaviour. This has been recognized as a most important
2,~
S. E. Asogwa
factor, an improvement on which would result in a substantial reduction of accidenLs? Doctors should also be familiar with the medical conditions against which driving is contraindicated. °z' m.-0' Appropriate advice should be .given whenever the opportunity arises. The ultimate solution of RTA problem--a reduction in morbidity and mortality so that RTA is no longer the Number 1 killer in the country--must rest with the application of preventive measures on identified causative factors. Research in this field should be of concern to the medical profession. Initially this will not be easy in the country because o f lack of reliable data on such essential issues as the number of vehicles and the length o f motorable roads to name but a few. The deficiencies in accident statistics in developing countries and the need for action was clearlyrecognized by the then .Director General o f W.H.O., Candau. ~'~In his World Health Message he advised those industrializing countries which did not as yet have statistics to guide them, where legislation was insuffic,ient or not enforced and where the idea that something could be done to prevent accidents was accepted only by a fe~,', to face up to that situation and act quickly, avoid the bitter mista~kes made in the industrialized countries and profit from the knowledge that was then accumulated. Lack of reliable statistics on the number o f vehicles, the length o f available roads (already referred to) and out-dated census figures, makes it impossible to apply a t~rmula developed by Smeed in 1949°e for calculating such statistics as total vehicle-miles, and deaths per population in Nigeria. (The Nigeria census figure of 1963 is still being used with projections based on an estimated compound growth rate of 2.5 % per annum.) Besides, it was found that, due to the fact that the situations in developed countries where 'the data on which the formula was derived differed in many respects from those in developing countries, the application of Smeed's formula would be inappropriate in any developing country. Hence, using Smeed's .work as a basis, a different formula was developed in 1968 based on figures from 32 developing countries that had available data. ~-6 It would appear, therefore, that for the soluli6n o f the RTA problem in the country, the evolution of a reliable mechanism for the collection and collation of data is fundamental. D ~ t o r s in the field of public health and other specialties need t o be involved in every aspect o f the RTA problem~the treatment of the injured, advice on those medical conditions where driving is a contraindication and research on the epidemiology of accidents. It is only by a demonstration of concern by actively Co-operating with others involved, such as highway engineers, the police, vehicle manufacturers, etc., that Nigerian doctors wou!d show their recognition o f this agent o f death and disability as a major public health problem in the country. References I. Baird, J. D. & Flamboe, E. E. (~975). An historical overview o f research in Xraffic accident investigation activities. SAE Paper 75081, p. 14. Society of" Automotive Engineer Inc., Pa., U.S.A. 2. McFarland, R. A. (1962). The epidemiology of motor vehicle accidcnts.Journalofthe American Medical Association 180, 289-300. 3. Norman, L. G. (1962). Road Traffic Accidents--Epidemio]ogy, Control and Prevention. Public Health Papers 12. Geneva: World Health Organisation. 4. Jami~on, K. G. & Tait, I. A. (1966). T~ffic injury in Brisbane: report of a genera! survey. National Health and Medical Research C6uncil Special Report Series 13, p. 317. Brisbane, Australia. 5. DOKITA (1965). Accident prevention: A symposium organized by the Department of Preventive and Social Medicine, University College Hospital, Ibadan, Nigeria. DOKITA 7, 39-42.
Road accidents hi Nigeria
245
6. Adeloye, A. & Odeku, L. E. ,(1970). The pattern of road traffic accidents seen at the University College Hospital, ibadan, Nigeria: A preliminary study. West A~ican Medical Journal 19, 153-7. 7. Omotola, E. L. (1967). Road traffic accidents in the Western stale: Medical Association Symposium on Trauma; lbadan. Quoted b y Oyemade (1973). N(eerian Medical Jtnm~al 3, 174-7. 8. Oyemade, A. (1973). Epidemiology of road traffic accidents in lbadan and its environs. Nigerian Medical Journal 4, i74-Z 9. W.H.O. (1968). World Health Statistics Report 21, 298. Geneva: World Healfl~ Organisation. 10. Jacobs, G. D. & Fouracre, P. R. (1977). Furilier research on road acciden! rates in developing countries. TRRL Supplementary Report 270. Crowthorne, England: Transport and Road Research Laboratory. I1. Schram, R. (i970). The epidemiology o f road traffic accidents in Africa. The Bulletin of the International Epidemiological Association African (Regional Meeting) 20, 105-23. 12. W.H.O. (1975a). Road accidents. IVorM Health October 1975. Geneva: World Health Organisation. 13. W.H.O. (1975b). The epidemiology of road traffic accidents. W.H.O. Regional Publications European Series No. 2, 2. 14. Domino, E. F. & Huelke, D. F. (1975)~ Belts, bags and medicines: Application of a medical treatment and prevention model for automobile occupant protection. S A E Paper 750392. Society o f Automotive Engineers Inc., Pa., U.S.A. 15. Robertson, J. S. & Tong e, J. I. (19fi8). Duration of survival in traffic accident fatalities. ,~ledical Journal of Australia 2, 571-8. 16. McFarland, R. A. & Moseley, A. L. (1954). iIuman Factors in Highway Transport Safety, 12. Havard School of Public Health. 17. Marples, E. 0962). Introduction to Symposium on road acciden!s. The Practitioner 188, 445-6. 18. Jamieson, K. G. (1966). The toll of the road--clinical aspects. Medical Journal of Australia 2~ 157-62.
19. Advani, H. S. & Owings, R. P. (1974)i Evaluation of head i~ury criteria SAE Paper 740083, p. 10. Society of Autorhotive Engineers Inc., Pa., U.S.A. 20. Pacy, H. (1972). Road accidents~ledical Aid: A Guide for il,[edical Practitioners ht~lved at the Scene of Motor Traffic Accidents. Pp. ~36. Edinburgh: Churchill Livingstone. 21. McFarland, R. A. & Moore, R. C. (1957). Human factors in highway safety--~A review and evaluation. New England Journal of Medicine 256, 792-8. 22. American Medical Association (1959). Medical guide for physicians in determining fitness to drive a motor ve|~icle. Journal of the Americah Medical Association 169, 1195-207. 23. Canadian Medical A~sociation (1966). Report o f Medical Committee on the Medical aspecls of Traffic Accidents. CanOdialrAtedical Association Journal 95, 488-90. 24. Medical Commission on Accident Prevention (1971). MedA-hl Aspects of Fitness to Drive: el Guide for Medical Practitioners. Edited by A. Raffle.Great Britain: Holbrook & S o n s Ltd. 25. Candau, M. G. 1'1961)..World Health 14, 14-21. Geneva: World Health Organisation. 26. Jacobs, G. D. & Hutchinson, P . (1973). A study of accident rate in developing countries. TRRL Report LR 546. Crowthorne, England: Transport and Road Research Laboratory.
Road Traffic Accidents: A Major Public Health Problem in Nigeria S. E.
Asogwa
M.B.. B.S., M,Sc,. D.T.P.H.
'Faculty of Medicine, .University of Nigeria Teaching Hospital Enugu, Nigeria Analysis of data on road traffic accidents (RTAs) in Nigeria o~er an eight-year period showed a rising trend. To highlight the importance of RTAs in the~country, the number of deaths from RTAs (1967-74) and from major communicable diseases (.1964-74) was reviewed. It ".was found that there were annually more deaths from RTAs than even the cholera epidemic ot" 1971. International comparison of the RTA situalion in Nigeria with that of industrialized countr.~es(United Kingdom, Sweden and Australia) and developing countries ,(Zambia, Tanzania, U,~anda and Kenya) showed that Nigeria had by faz worse mortality and morbidity rates. The importance of the involvemenl of doctors, especially those in the field of public health, in the prevention of RTA using the methodology which has been successfully employed in the control of communicable diseases is stressed.
Introduction Road Traffic Accident (RTA) started to be a health hazard for .mankind with the invention of the first true automobile by N. T. Cugnot in 1769. ~.In Nigeria, RTAs have been a concern to the public and this concern has been growing in recent times as a result of rapid increases in the number o f motor vehicles with the resultant increase in the number of road traffic accidents. There is scarcely a week that passes without one or more accounts of ghastly RTAs appearing in one o f the Nigerian daily newspapers as having occurred somewhere in the country. This has been largely regarded as a social problem of interest to the law enforcement agencies (the police, etc.), the insurance companies and, o f course, the victims and owners of vehicles involved in RTAs. The Nigerian RTA situation has therefore n o t been regarded as a consequence of an agent o f death and disability which in many respects is similar t o communicable diseases. It is the appreciation of this similarity that made several health workers in industrialized countries advocate the recognition of RTA .as a public health problem and the use of epidemiotogical methodology, which has been successfully used in the control of other communicable diseases, to solve the RTA problem.-°. 3. ~ The RTA problem in Nigeria has not received medical attention anywhere comparable to the size o f the problem. There is, o f course, the treatment of the injured victim which often: upsets scheduled work. But research aimed at unravelling the RTA problem from the point of view of the effects---distribution o f injury on the victims, types of injury, etc.--and the cause o f accidents from an epidemiotogical approach is very scanty indeed. The " D o k R a " (1963) s contained a summary o f a symposium on "Accident Prevention" h d d at the U C H in Ibadan. The trend in R T A from 1946-59 was demonstrated and certain conclusions on the causes o f R T A w;ere made, some based on impressions. The age and sex distribution, mode of participation and the injuries sustained by RTA victims treated at the same hospital were studied by Adeloye & Odeku. a This study was limited in O038-3506/78/050Z37-k09 $01.00/0
~'~ 1978 The Society of Community Medicine
238
S. 23. Asogwa
scope and did not present the dimension of the RTA problem in the country as a whole. Omitola': and Oyemade * studied the RTA problem in .the then Western State of Nigeria and lbadan with its environs respectively. Both studies, though showing characteris'tics of RTA victims, related to one part of the country and therefore did not present a national picture. This study was intended to look at the RTA problem a~ it affects the country in general and also view it against the background o f other major communicable diseases. This would bring into relief the actual dimensions of the RTA problem. And, to see how the Nigeria sit,ration compared with those of some countries in developing and industrialized countries, international comparisons became mandatory. Materials and Methods The number o f notified deaths due to each of :he I0 important communicable diseases in the country over an eight-year period (1967-74) were obtained from the Statistic Division o f the Federal Ministry of Health. Data on the number o f reported road traffic accidents over a nine-year period (1967-75) were obtained from the office of the Inspector-General o f Police. (They were, therefore, only reported accidents). Information obtained showed the annual total number of accidents and the number of those killed and injured over the period. Using the data, trends in the total anr~ual number o f accidents, the number for persons killed and injured and case fatality rates were calculated. Those "'killed" were RTA victims who died on the spot o r a t any other time or place so long as their death could be traced to the accident. Those "'injured" were other casualties that had injuries o f varying degrees oF severity following RTAs. The case fatality rate for Sweden and the United Kingdom were calculated from W.H.O. 0968) while fatality and injury rates for Nigeria and selected countries in industrialized and developing parts o f the world, over a ]0-year period, were adapted from data by Jacobs & Fouracre. 1~ The developing countries were Tanzania, Kenya, and Zambia; the industrialized countries were Great Britain and Australia. The number of persons killed in selected countries (Uganda, Tanzania, Sweden and Britain) after a period of nine years, and the percentage change in the number ofdeaths during this period were obtained from.Schram n and W.H.O. TM The da~a-for period 1967-9, were ur~derestimations because they pertained to the period of the Nigerian civil war with its attendant incomplete reporting of.cases. Results It can be seen (Table t ) t h a t deaths from RTA (from 1967 to 1974) were higher ~/han f o r any of the seven major diseases and that the figures had been increasing progressively from year t o year. It contributed 38.9 % of all reported deaths in t967 but in 1974 had reached 60-2 %. In 1971 deaths from road traffic accidents exceeded that due to the cholera epidemic of that year with the numbers being 3206 (RTA deaths) and 3085 (cholera deaths). The yearly trends in all categories of accidents on the roads (Table 2) showed a steady rise from 1971 t o 1975. The annuai percentage increase over the preceding year was minimal in 1971 (6-5%) and maximal in 1972 (3l'2~o). The trend for those killed and injured from 1967 to 1975 showed, on the whole, an increase (Table 3). The increase was more marked in the number of those injured. The post-war period, 1970-25, was more representative of the true situation. Table 4 shows the case fatality rate for the period 1967-75. The war years(1967-59) had a peak in 1968. The reduction in 1970 was followed b y a gradual rise during the post-war years. Nineteen-sixty-eight, however, still had the highest figure (228-62) while the mean annual case fatality rate for the entire period (1967-75) of 200.57 per 1000 cases closely resemE.1~d the data for the post-war period (1970-5).
TABLE I. Number of notified deaths due to ten diseases in Nigeria (1964--74) and Road Traffic accidents (1967-74) Diseases Smallpox CerebrosDinal meningitis TuberCulosis Dysemry Pneumonia Measles Tetanus Malaria Infectious hepatitis Chickenpox Whooping Cough Sleeping Sickness Typhoid and paratyphoid Schistosomiasis (all forms) Cholera Septic meningitis goad trame accident (RTA) Total inc|uding RTA RTA as a percentage of toial
1964
1965
1966
1967
1968
1270 353 229 159 1166 i349 348 207 122 54 ~
496 743 175 125 879 792 314 145 92 --58
406 524 102 181 793 806 350 445 73 82
395 225 131 143 830 723 320 369 88 -4I
164 214 274
2079 5344 38.90~
~ 811 323 265 99 29 47
Year 1969 . 459 214 78 9,t4 610 414 413 160 . 30 27
2808 2347 5874 5696 47.80~o 41.0~
1970
1971
. 1077 577 360 18"44 449 639 1109 587
.
.
. -. 195 56
2895 9788 29.6/,, ":
1972
. 88-6 604 257 282 267 179 1814 t458 7:75 495 462 694 6t3 517 208 122 . . . 94 -. . . . . . -65 3085 96
3206 3921 8471 8433 37.8°~ 46.5~
1973 251 236 152 1460 1029 301 517 134 . 22 . . -27
1974
300 182 586 866 459 330 105 59
-43 4248 4537 4922 8666 8167 52.3°/~, 60.2~
*Data on notified deaths from 10 diseases were supplied by the Statistic Division of the Federal Ministry of Health while that for Road Traffic Accident Deaths were from the Fed. Nigeria Police Hcadquarters.
240
S. E. Asogwa
When compared with two industrialized coumries known for their low accident rates (Sweden and the United Kingdom), the Nigerian figure (of 174 deaths per 1000 cases) TABLE 2. Yearly trends in all categories of accidents in Nigeria (1967-75)
No. of accidents Annual rate of increase of accidems over preeedingyear(%)
1967"
1968t
19695
12,950
12,163
12,998 16,666
.
.
.
1970
.
Year 1971
1972
t973
]974
1975
I7,745
23,287
24,844
28,898
32,651
6-47~ 31-23%
6"68% 16-31~ 12-98%
Mean rate of increase over a five-year period (1971-5) was 14-73% p.a. *Data available f o r the country as made of East, West, North and Midwest regions and Lagos Federal Territory. fNo data were available for the War Zone of East Central, Midwest and Rivers Stales. ~Data were available for all the 1! states and part of the Fast Central State.
T^Bt.E 3, Persons -killed and injured in road traffic accidents per million population in Nigeria (1967-75) Year *Population (I.,000,000) Total killed Rale per 1,000,000 population Totalinjured Rate per 1,0019,000 ipopulation
1967
i968
1969
1970
1971
61-5 2079
63"0 2808
64.5 2347
66-2 2895
67'9 3206
34 9478
45 9474
36 8808
44 I3,154
47 14,592
154
150
137
199
215
1972 69-6 3921
1973
1974
1975
71 "3 4537
73"1 4922
74-9 5552
56 64 16,161 18,154
67 18,660
74 20,132
255
269
232
255
*Population estimates based on the 1963 census figures and an estimated compound growth rate of 2-5 ~ per annum.
TABLE4. Case falality rate of RTA victims (1967-75) 1967 No re~orted killed (a) No. reported injured (19) All reported casualties(c) Case fatality rate (a/c) per 1000
1968
1969
2079
2808
2347
9478
9474
8804
1970 2895
Year 1971
1972
1973
3206
3921
4537
14,154 14,592
16,I61
18,660
]974 4922
1975 5552
18,660 20,132
11,557
12,282 11,15t
16,049
17,798 20+082 22,691
23,582
25,684
179.89
228.62
180.38
180.13 195-24 199.94
208'71
216-16
210-47
Mean annual case f a t a l i t y r a t e 1967-75 = 200.57 per 1000 cases
by far exceededthose for Sweden (73 deaths) and the UnitedKingdom (27deaths) (Table 5). In fact, it was more than six times that of the United Kingdom and about two-and-a-half times that of Sweden. The fatality and injury rates over a 10-year period for three African
Road accidents #1 Nigeria
241
countries, Great Britain and Australia showed (Table 6) lhat Nigeria had the highest figures. Fatalities per 10,000 vehicles were 147-40 in 1961 and 175.10 in 197|. The data for the other countries were: Tanzania 71-90 0959) an~t 70-42 (1969); Kenya 38-92 (196t) and 69"14 (1971); Zambia 50.15 (1961) and 76.41 (1971); Great Brilain 6-97 (1961) and 5"I6 (t971) and Australia 8-41 (1961) and 7"17 (1971). The rate for injuries per 10,00O vehicles were similarly highest for Nigeria (1110-69 in 1961 and 796.94 in 1971). Tanzania had TABLE5. Case fatality raies for Nigeria, United Kingdom and Sweden Country Nigeria (Average 1971-5) United Kingdom (Average 1964-6) Sweden (Average 1964-6)
Rale (per I000) ! 74 27 73
Source: Calculated from W;H.O.' TABLE6. Road deaths in selected countries
Country Britain* Sweden* Tanzaniat Ugandat Nigeria
Year and number killed 1965 7952 1965 1313
1973 7406 1973 1177
1960
1968
460 1960 3524 1967 2079
477 1968 4530 1975 5552
Percentage Numberof increase(÷) years or decrease(--) 9
6"7% (--)
9
10-4% ( - )
9
3-7% (+)
9
28-5~ (+)
9
167"0~/ (+)
*Source: W.H.O. i= fSource: Schram.n 754"02 and 679-52 injuries per 10,000 vehicles in 1959 and 1969 respectively. For the other countries the rates were: Kenya 437.78 (196.1) and 498-28 (1971); Zambia 300.17 (1961) and 461.36(1971); Great Britain 346-10 (196i) and 230.98 (1971) and Australia 202.37(1961) and 181-84 (1971). Data on road deaths in Nigeria, two other African countries (Tanzania and Uganda) and two European countries (Britain and Sweden) showed that after a period o f nine years, the European countries all had decreases while the African countries had increases (Table 7). Britain's rgad deaths had decreased by 6-7 ~ and those for Sweden by 10-4yo. Tanzania had increased by 3-7°~i Uganda by 28-5y0 while Nigeria had increased by 167~0!
TABLE7. Fatality and injury rate over a 10-year period for Nigeria and some selected countries
Country Nigeria l'an~ania Kenya Zambia Great Britain Australia
Year
Fatalities
Serious and slight injuries
1961 1971 1959 1969 1961 1971 1961 1971 1961 1971 196t t9~71
1313 3206 277 528 329 1046 273 794 6908 7~696 2524 3590
10,614 14,592 2905 5095 3701 7509 1634 4794 342,859 344,390 60,749 9~,036
*Source; Adapted from Jaeobs & Fouracre t..
Vehicles
Population (thousands)
Vehicles per person
Fatalities per 10,000 persons
Injuries per 10,000 persons
95,$62 i83,100 38,527 74,979 84,540 i 50,697 54,436 103,910 9,906,300 14,910,000 3,001,903 5,006,446
36,200 56,510 9076 12,926 8300 I t,800 3300 4250 52,676 55,910 10,508 t2,730
0.003 0'004 0.004 0.006 0'010 0.013 0.017 0.025 0'189 0.267 0-286 0.394
0'36 0.57 0'31 0.41 0"40 0.89 0'83 1-87 1.31 1'38 2.40 2'82
2'93 2.58 3'20 3.94 4.46 6.36 4'95 11.28 65.09 61,6',9 57'81 71'51
Fatalities Injuries per 10,000 per 10,000 vehicles vehicles I37.40 175.10 71 '90 70.42 38.92 69.41 50'15 76.41 6.97 5.i6 8"41 7'17
1110'69 796.94 754'02 679"52 437.78 498.28 300'17 461.36 346.10 230"98 202.37 18I'84
Road accidents ht Nigeritt
243
.Discussion The available information shows that road traffic accidents constitute a major cause o f morbidity and ntortality in Nigeria. The data for the period o f the civil war and the postwar years x~ere all high. What is distressing is that there is a rising trend from year t o year. When compared with communicable diseases of public health .concern, road traffic accident is clearly of greater importance. It was responsible for more deaths in 1971 .than the cholera epidemic of that y~lr, yet the nation and particularly public health workers, have not shown comparable.concern. Road traffic accidents have been called a new epidemic.~"-It has also been described ason endemic rather than an epidemic disease because it is constantly present in a given country.!3 In the Nigeria situation, RTA is there all the time .and of great magnitude hence one can better describe it as an endemic di~ase with epidemic dimensions. Looking at the RTA data for the country against the data +for other causes o f death and disabilityl-one can appreciate theilmportance of this new disease vis fi ~,is other diseases. Analysis of RTA mortality and morbidity data alone would not present a complete picture. It would be immensely usefti~ to compare the RTA problem in Nigeria with those of other countries t o see how Nigeria fares. International comparison of RTA statistics can be extremely di$cult and unlessfnterpreted with caution can be misleading. For example, lack of international agr~ment on .such a seemingly .straight forward issue as definition of "'person killed" in RTA underliOs the seriousness of the disagreement. Forinstance, in Australia, "person killed" means "killed :outright oi" dying within 24 hours", but in the United Kingdom, it is "killed outright or dying within 30 days',? In Nigeria, no definite time interval is used and one is+deemed as having been killed in a road accident if one's death Cart be traced t o the accident. International agreement designed to make comparison possible hasbeen reached by++certain countries. F o r example, tile member states o f the :United Nations Economic Commission for Europe have adopted "person killed" as "'any person w h o was kiltedoutright+or who died Within 30 days as a result of the accident", a~ The use o f this period is supported by result of research workers. Robertson & Tonge~s found that only 2.8 ~o of 2081 victims in Brisbane and 3-8 ~o of the 775 victims in Adelaide (both in Australia ) survived beyond 30 days after their accidents. Notwithstandingthe shortcomings of international comparison o f R T A statistics, all the data presented showed that the RTA problem in Nigeria is worse not only compared with those of thejndustrialized countries but alsothose 0f other developing countries :of Africa. That road traffic accident is a staggering public health problem in Nigeria-therefore needs no further amplification. Members~of the medical profession, particularly those in the field o f public health, should seen it as such ffhd deal with+it using methods that have been successfully usedS0 the control of similar public health problems with-high morbidity and mortality. It has been stated~+ that-accidents£oilow some of the same biological laws a s d o diseases and that attempts at control or preventmn should involve consideration of the interaction of+agent, host and environment, i.e. the vehicle, the driver, and the highway. Members o f the-medical profession should not 'think+that ~thelr role in road accident .in Nigeria is just. to treat the injured. They sfiouid, as s t a t e d b y Marples, ~: study ways in which accidents can be minimized. This basically,means a study of the pattern o f injuries sustained by RTA victims?a.~9as well as a study' of th~ causative factors ot+r0ad accidents. The former is a hospital'based study, while the latter l o o k s at RTA from the Viewpoint of-its.epidemiology. I n hospitals doctors can contribute to the reduction of road accidents in several ways, including the organization of effective first aid and subsequent management o f RTA Victims, especially those+with head injuries an~ fractures. ~° And while under their care, every opportunity-should be used to preach the gospel o f R T A prevention through a change in the road user's behaviour. This has been recognized as a most important
2,~
S. E. Asogwa
factor, an improvement on which would result in a substantial reduction of accidenLs? Doctors should also be familiar with the medical conditions against which driving is contraindicated. °z' m.-0' Appropriate advice should be .given whenever the opportunity arises. The ultimate solution of RTA problem--a reduction in morbidity and mortality so that RTA is no longer the Number 1 killer in the country--must rest with the application of preventive measures on identified causative factors. Research in this field should be of concern to the medical profession. Initially this will not be easy in the country because o f lack of reliable data on such essential issues as the number of vehicles and the length o f motorable roads to name but a few. The deficiencies in accident statistics in developing countries and the need for action was clearlyrecognized by the then .Director General o f W.H.O., Candau. ~'~In his World Health Message he advised those industrializing countries which did not as yet have statistics to guide them, where legislation was insuffic,ient or not enforced and where the idea that something could be done to prevent accidents was accepted only by a fe~,', to face up to that situation and act quickly, avoid the bitter mista~kes made in the industrialized countries and profit from the knowledge that was then accumulated. Lack of reliable statistics on the number o f vehicles, the length o f available roads (already referred to) and out-dated census figures, makes it impossible to apply a t~rmula developed by Smeed in 1949°e for calculating such statistics as total vehicle-miles, and deaths per population in Nigeria. (The Nigeria census figure of 1963 is still being used with projections based on an estimated compound growth rate of 2.5 % per annum.) Besides, it was found that, due to the fact that the situations in developed countries where 'the data on which the formula was derived differed in many respects from those in developing countries, the application of Smeed's formula would be inappropriate in any developing country. Hence, using Smeed's .work as a basis, a different formula was developed in 1968 based on figures from 32 developing countries that had available data. ~-6 It would appear, therefore, that for the soluli6n o f the RTA problem in the country, the evolution of a reliable mechanism for the collection and collation of data is fundamental. D ~ t o r s in the field of public health and other specialties need t o be involved in every aspect o f the RTA problem~the treatment of the injured, advice on those medical conditions where driving is a contraindication and research on the epidemiology of accidents. It is only by a demonstration of concern by actively Co-operating with others involved, such as highway engineers, the police, vehicle manufacturers, etc., that Nigerian doctors wou!d show their recognition o f this agent o f death and disability as a major public health problem in the country. References I. Baird, J. D. & Flamboe, E. E. (~975). An historical overview o f research in Xraffic accident investigation activities. SAE Paper 75081, p. 14. Society of" Automotive Engineer Inc., Pa., U.S.A. 2. McFarland, R. A. (1962). The epidemiology of motor vehicle accidcnts.Journalofthe American Medical Association 180, 289-300. 3. Norman, L. G. (1962). Road Traffic Accidents--Epidemio]ogy, Control and Prevention. Public Health Papers 12. Geneva: World Health Organisation. 4. Jami~on, K. G. & Tait, I. A. (1966). T~ffic injury in Brisbane: report of a genera! survey. National Health and Medical Research C6uncil Special Report Series 13, p. 317. Brisbane, Australia. 5. DOKITA (1965). Accident prevention: A symposium organized by the Department of Preventive and Social Medicine, University College Hospital, Ibadan, Nigeria. DOKITA 7, 39-42.
Road accidents hi Nigeria
245
6. Adeloye, A. & Odeku, L. E. ,(1970). The pattern of road traffic accidents seen at the University College Hospital, ibadan, Nigeria: A preliminary study. West A~ican Medical Journal 19, 153-7. 7. Omotola, E. L. (1967). Road traffic accidents in the Western stale: Medical Association Symposium on Trauma; lbadan. Quoted b y Oyemade (1973). N(eerian Medical Jtnm~al 3, 174-7. 8. Oyemade, A. (1973). Epidemiology of road traffic accidents in lbadan and its environs. Nigerian Medical Journal 4, i74-Z 9. W.H.O. (1968). World Health Statistics Report 21, 298. Geneva: World Healfl~ Organisation. 10. Jacobs, G. D. & Fouracre, P. R. (1977). Furilier research on road acciden! rates in developing countries. TRRL Supplementary Report 270. Crowthorne, England: Transport and Road Research Laboratory. I1. Schram, R. (i970). The epidemiology o f road traffic accidents in Africa. The Bulletin of the International Epidemiological Association African (Regional Meeting) 20, 105-23. 12. W.H.O. (1975a). Road accidents. IVorM Health October 1975. Geneva: World Health Organisation. 13. W.H.O. (1975b). The epidemiology of road traffic accidents. W.H.O. Regional Publications European Series No. 2, 2. 14. Domino, E. F. & Huelke, D. F. (1975)~ Belts, bags and medicines: Application of a medical treatment and prevention model for automobile occupant protection. S A E Paper 750392. Society o f Automotive Engineers Inc., Pa., U.S.A. 15. Robertson, J. S. & Tong e, J. I. (19fi8). Duration of survival in traffic accident fatalities. ,~ledical Journal of Australia 2, 571-8. 16. McFarland, R. A. & Moseley, A. L. (1954). iIuman Factors in Highway Transport Safety, 12. Havard School of Public Health. 17. Marples, E. 0962). Introduction to Symposium on road acciden!s. The Practitioner 188, 445-6. 18. Jamieson, K. G. (1966). The toll of the road--clinical aspects. Medical Journal of Australia 2~ 157-62.
19. Advani, H. S. & Owings, R. P. (1974)i Evaluation of head i~ury criteria SAE Paper 740083, p. 10. Society of Autorhotive Engineers Inc., Pa., U.S.A. 20. Pacy, H. (1972). Road accidents~ledical Aid: A Guide for il,[edical Practitioners ht~lved at the Scene of Motor Traffic Accidents. Pp. ~36. Edinburgh: Churchill Livingstone. 21. McFarland, R. A. & Moore, R. C. (1957). Human factors in highway safety--~A review and evaluation. New England Journal of Medicine 256, 792-8. 22. American Medical Association (1959). Medical guide for physicians in determining fitness to drive a motor ve|~icle. Journal of the Americah Medical Association 169, 1195-207. 23. Canadian Medical A~sociation (1966). Report o f Medical Committee on the Medical aspecls of Traffic Accidents. CanOdialrAtedical Association Journal 95, 488-90. 24. Medical Commission on Accident Prevention (1971). MedA-hl Aspects of Fitness to Drive: el Guide for Medical Practitioners. Edited by A. Raffle.Great Britain: Holbrook & S o n s Ltd. 25. Candau, M. G. 1'1961)..World Health 14, 14-21. Geneva: World Health Organisation. 26. Jacobs, G. D. & Hutchinson, P . (1973). A study of accident rate in developing countries. TRRL Report LR 546. Crowthorne, England: Transport and Road Research Laboratory.
