The world is motorizing rapidly: in China, the number of motor vehicles quadrupled between 1999 and 2002 to more than 55 million, according to the WHO World Report, while in Thailand the number of registered motor vehicles rose from 4.9 million to 17.7 million between 1987 and 1997. In countries where cars and trucks have only recently—in the last decade or two—begun to crowd the streets along with pedestrians, cyclists, and two- and three-wheeled vehicles such as motorized rickshaws and jitneys, conditions are dangerous for drivers and even more dangerous for those on foot. Whereas in high-income countries the majority of crash victims are car occupants, in low- and middle-income countries road traffic fatalities “occur mostly among people who do not own or have access to a car: pedestrians, motorcyclists, cyclists and users of public transport," the report's authors note. In a study of road traffic deaths in African countries, pedestrians' burdens in road collisions ranged from 65% to 89% in the cities of Nairobi, Abidjan, and Addis Ababa.  

With motorization occurring so rapidly in low- and middle-income countries, there has been a lag, not only in building infrastructure that promotes safety for all road users, but in making laws that give traffic safety institutional support and accountability, agencies and procedures for setting and enforcing safety standards for equipment, and institutional commitments to providing appropriate trauma care to crash victims.  

Many countries still lack helmet, seat belt or child restraint laws, as well as minimum standards for roadway designs. Enforcement is often a low priority. In most poorer countries, emergency medical services are unreliable at best and, in some countries, practically nonexistent. According to the WHO report, a Kenya study found that police transported only 5.5 percent of crash survivors to care facilities, and hospital ambulances evacuated only 2.9 percent of survivors. Furthermore, most low- and middle-income countries lack an institution charged with overseeing road safety, and their systems for recording crash data are generally inadequate. In fact, nearly two-thirds of the world’s countries do not report annual statistics on road traffic injuries and deaths. 

Not only do low- and middle-income countries account for a substantial portion of DALYs due to road traffic injury, but the poor are disproportionately affected by road traffic injury because crash victims tend to be vulnerable road users who cannot afford more protective modes of transportation such as cars and trucks.  Furthermore, the economic strain put upon the families of crash victims in poorer countries is likely to exceed the strain felt by families in high-income countries. Worldwide, a high percentage of crash victims are young and male; adults aged 15-44 account for 60 percent of all DALYs due to road traffic injury, while males account for 70 percent of all DALYs lost due to road traffic injury, according to WHO. In poorer countries the loss of a family member in his or her prime working years may have devastating consequences for an entire household. According to the WHO report, in Bangladesh, “Three quarters of all poor families who had lost a member to road traffic death reported a decrease in their standard of living, and 61 percent said that they had to borrow money to cover expenses following their loss.”   

In his report, “Social Cost of Road Traffic Crashes in India,” Dinesh Mohan, a leading safety researcher and advocate in India, writes that analyses of the costs of road traffic crashes in India and other poorer countries fail to take into account many of the material losses suffered by crash victims and their families. Mohan cites “loss of land, personal savings or household goods,” job loss, and the strain put on households when “reallocation of labor” of family members is necessary. Mohan writes that, “Since a very large number of poor households depend on daily wages and temporary jobs, don’t have health insurance, or the assistance of social welfare schemes, a serious injury can result in permanent reduction of income. In cases of prolonged treatment or death of the victim, the family may end up selling most of their assets and land and getting trapped into long-term indebtedness.”  

Programs to address the road safety epidemic in lower-income countries must be shaped by and respond to these elements that give the problem a different cast than what is encountered in the wealthier regions of the world. For example, if governments can quantify the economic and social costs of traffic deaths and injuries, the issue of transportation safety might be more widely incorporated into the public dialog that helps set spending priorities. As it stands, the costs incurred by society as a result of victims' suffering are largely under-reported, and the victims are largely voiceless. 

At the same time, as many of these countries start to embark on a journey towards greater prosperity‚ itself a marker for a period of increased danger for road users, there is an opportunity to shape the new and emerging transportation infrastructure in ways that better protect those who will travel on it.