Road accidents [full issue]

TH HEALTH ORGANIZATION • OCTOBER 1975 • UK 45 p • USA $1 THE MAGAZINE OF • ■;!",4 :4PZ • • f -CV • .• ' ROAD ACCIDENTS 2 WORLD HEALTH ROAD ACCIDENTS Cover hr Peter Davies Contents Avoidable epidemic 3 Death on the road by L.A. Kaprio ... . 4 Autosclerosis by L. Levi. .. . '10 Africa . 14 Kuwait 16 Highway conscience by V. Christensen 18 The Americas 20 No joking matter? by W. Cutter 22 India 26 The economic cost Interview: R. Andreasson . 28 Killed in their prime 30 WHO News in Brief . 32 United Nations: 30th Anniversary 33 Young World Health 34 World Health appears in Arabic, English, French, German, Persian, Portuguese, Rus- sian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. avoidable epidemic n the time it takes you to read this issue of World Health, about 450 men, women and children will have been killed or injured on the world's roads. Road traffic accidents pose grave and extensive public health problems. This was recognized with much concern by the Twenty-seventh World Health Assembly, which expressed the belief that effective solutions in this field, maybe more than in others, require the coordinated efforts of inter- national organizations and agencies, and national, regional and local authorities, as well as those of "world citizenry". The Assembly also declared that wHo has a responsibility to provide leadership, guidance and technical assistance to its Mem- ber States in order to improve road traffic safety. This issue of World Health is aimed at encouraging efforts be- ing made throughout the world to improve traffic safety pro- grammes. If traffic accidents are tackled by methods similar to those used against the great killing diseases, the present epidemic of road deaths could be made to disappear just as plague and smallpox have now been eliminated almost everywhere in the world. The behaviour of the road user, and the psychological, physio- logical and pathological processes that influence him, must be an essential consideration in all attempts to prevent road accidents. Apart from situation reports contributed by World Health staff writers from Africa, the Americas, Asia and Europe, this issue also contains challenging articles on human reactions to traffic problems and the educational value of cartoons. No matter how heavy the economic cost of road accidents may be, says Rune Andreasson, Executive Secretary-General of the International Association for Accident and Traffic Medicine, "no mere cost can ever justly depict the deep, lasting tragedy of traffic accidents". In 1976, the Executive Board of WHO and the World Health Assembly will discuss the latest developments in efforts made to foster increasingly effective educational and other programmes designed "to encourage responsible use of vehicles and roads". Efforts are also being made to promote and coordinate research on human and medical factors involved in traffic accidents, in- cluding the use of alcohol and drugs. ■ 3 ( Photo Len Sirman ©) death on the road The vast numbers of those maimed and killed on the roads are too often accepted fatal- istically as a normal part of modern life. Yet, if traffic accidents are tackled by methods like those used against the great killing diseases, the present epidemic of road deaths can be made to diminish just as epidemics of plague and smallpox have now been almost completely eliminated everywhere in the world BY LEO A. KAPRIO bout 250,000 people or more are killed on the roads of the world each year. In 1974, 50,000 people died in the USA as a result of road traffic accidents. In three countries of Europe, the Federal Republic of Ger- many, Italy and the United Kingdom, nearly 35,000 were killed in 1973 (see table). In one year in France the figure was 16,000, and this was dramatically demonstrated in a French television programme by mock-killing the total population of a town, 16,000 men, wom- en and children. Mankind has always suffered from in- juries, and bonesetters belong to the folklore of any country. People have always been killed in wars, although most war casualties before World War II were due to disease. The growth of modern technology, the use of high- powered machines and high-voltage electricity have caused an increasing number of accidents in the home and at the place of work; but none is so dra- matic and so new as "death on the road". Strictly practical and economic argu- ments strongly reinforce the need for the modern preventive and epidemiological approach to road accidents. Generally speaking, the only official action has been to provide first aid, hospital emergency services and rehabilitation services for accident victims, and in many technically-developed countries these services cannot even keep pace with the annual increase in the number of road casualties. In 1973, there were over 7 million in- jured in road accidents throughout the world. Among those who died, 90,000 were first hospitalized for periods up to 30 days. Many of these were treated in costly intensive care units. Great num- bers of survivors needed, and go on needing, continuous care. This repre- sents a huge drain on hospital, medical and public health resources, not to speak of the human suffering whose magnitude can only be guessed at. Material damage, insurance costs, etc., further swell the huge burden on national economies resulting from road accidents. The fatalistic attitude Our attitude to accidents today rather resembles that of our great-grandfathers to disease before it was believed that vaccination could prevent smallpox, and good sanitation and safe water could banish cholera and typhoid. Ignorance about the true causes of road accidents still appears to be widespread. As recently as 1967, a survey in one Euro- pean country showed that a majority of drivers held views on quite simple as- pects of the problem that were contrary 4 to the facts. Moreover, 44 per cent of the sample carried a St. Christopher charm and 35 per cent strongly believed in its power to protect them from an accident. Here is an obvious field for health educators. Public health authorities must now en- deavour to change the fatalistic attitude to road accidents, which tend to be regarded as inevitable side-effects of a valued facility of modern life—side-eff- ects so severe that they would never be accepted in the case of a drug. In the first year of the oil crisis, when traffic had to be limited and speed limits imposed for economic reasons, there was a sudden drop in both injuries and deaths from traffic accidents. Although the figures are now mounting again, that drop was a great encouragement for those who have kept on insisting year after year that something can and must be done to reduce the number of acci- dents, to level off the upward trend, and The price that society pays for rapid modern transport. A young road-user lies seriously in- jured in hospital. (Photo WHO/P. Almasy) then achieve a yearly decrease of at least mortal and severe accidents. In Europe, before 1974, only Sweden had a real plan designed to achieve a permanent downward trend despite the anticipated growth of traffic density. Two workers in the United States of America, Baker and Haddon, have developed in the last few years what they call "the scientific approach" to reducing injuries and their results. They attack the word "accident" and its con- notations of fate, chance or luck, because, as they quite rightly state, inju- ries can be prevented or their severity reduced. They claim that they are finally not "unexpected" if the problems in- volved are studied using the same tech- niques as are used to prevent disease. The fatalistic approach, however, has mainly prevailed until now, at least in Europe. This does not mean that the problem has not been discussed and analysed. Both the World Health Or- ganization's Regional Committee for Europe and the United Nations Eco- nomic Commission for Europe have for years been sources of information, reports, recommendations and resolu- tions. Some 20 or 30 other national and international bodies, including, for _ex- ample, the World Meteorological Or- ganization, the International Federation of Pedestrians and the International Federation of Senior Police Officers, have declared their interest in the pre- vention and control of road accidents in Europe, and many are active in organiz- ing surveys of research in varied aspects of the problem. As yet none of this well- meaning activity has had any visible im- pact on the accident situation. 5 t . .*.1, : ,ed .40:44:4:0111:iritAiAl:iir c • :#0014:07:tif..4*,.4 4. *A..* gr.* 11."1:44'•• • • 11" 24: 0 rof:Aft0i! ,. 0 0 0 -* L:0:F.1111;f:•:11 • Ili . 4/.. *' •Ai if igy :10 0.10- ' o Er * ft4 ..41., * . :111*0* :110 0.0f.... • • •:•: *044 .414 • fr• • • •-• fio 473i ;4 .•:• 4... •• • • • 00, Ik* Ay • • 410 41 • • * '!1.0 cfd, a • • • • • • Atir.0•• • •• ► • lo io•t** ** ,..• •••••0***** y •••••e$00*** •• e • " . • e ,• •, • AI ,,'. . . Death on the road SA HAR SKA DINA BARN SITTA I BEEN. 1 Those road casualties who survive often need continued care. Rehabilitation represents a huge drain on hospital, medical and public health resources. This patient is learning how to repair watches so he can earn a living when he returns home. (Photo UN) A Swedish road safety poster shows how chil-D dren should sit in a car, at different ages from infancy to school age. Werra 9 man ligti borne i harmaingnitstaen cch gall den tut har i Nem Ng.. Klam fag i . all den intekan rubbas ur Aitt late. Fran 9 mini till 3 -5 Or Barnet her Ct. i en Igkiltvand hamgel Wan ar placerad i tramaatet bilar fir11111 stag aom kan mean.. upp 6116—tire Alder F,,,, I, pi barn,te lanig. Fran 3-5 Oral 7-10 la Maim fulhegt skgki (inns Mg Mr hem gen visit ur bannirden T41111111111 Or tor Hter tar an Forma envende WIMP.. Men en Naha ar said.n cod MC Vartig into en iodkand Phmkey. hjagnt Bak. tut ar givetue end. reg. platen lot deem barn. elver 7-10 or (30 kcj) Nu ken dill ham berje emends INMitri. Men kolla an deter ritt inertat net, OF der g ger tag mg kmpen. Slcydda cig *Ivo& train niirmaste i trafiken. '1'rafikgkerhep, I Many countries have now realized that a more systematic and scientific ap- proach is needed, and have started to develop it. One of the main difficulties is the coordination of potentially preven- tive actions. Take the relatively simple example of the use of safety belts which has been proved to minimize the violent effects of a collision, or that of the pro- tection of pedestrians crossing the road in heavy traffic; both require quite com- plex planning by many authorities and, even more necessary, the understand- ing and cooperation of the public as potential victims or "persons-at-risk". In most countries, there is no coordina- tion of such planning. Effective preven- tive action calls for the cooperation of car manufacturers, road builders, traffic policy makers, etc. Health authorities have their role to play. They may be made responsible for overall coordina- tion of accident prevention, or in any case they need some full-time staff to keep in contact with the coordination body. In the absence of a systematic ap- proach, there have been a large number of fragmented actions, all useful and praiseworthy, but none by itself able to curb the rising trend in the number of accidents. The development of services to deal with accident victims has received the most attention, especially by health au- thorities, but also by national Red Cross organizations and, at an international level, by WHO and the League of Red Cross Societies. Once an accident has ROAD TRAFFIC ACCIDENTS 1965 AND 1973 Country Number killed Number killed or injured 1965 1973 1965 1973 Austria 1 829 2 469 61 816 71 013 Belgium** 1 392 3 072' 100 786 106 528' Czechoslovakia 1 611 2 073 40 326 43 317 Denmark 1 010 1 132 26 077 24 588 Finland 1 049 1 086 16 963 16 945 France** 12 150 16 545' 302 406 388 363 German Dem. Rep. 1 730 2 122 55 217 49 286 Germany, Fed. Rep. of 15 753 16 302 449 243 504 548 Greece 760 1 076 19 835 25 243 Hungary 870 1 831 19 559 27 473 Iceland 202 25 951' 1 242 Ireland" 356 592 5 667 9 362 Italy 8 990 10 728 226 523 276 262 Luxembourg 83 108 2 677 2 943 Malta 11 13 701 839 Netherlands 2 479 3 092 64 361 73 453 Norway 423 511 8 608 11 483 Poland 2 475 4 200 23 175 48 068 Portugal 920 1 312 20 973 26 162 Romania — 18123 — 5 786' Spain 2 802 4 764 71 049 105 321 Sweden 1 313 1 177 24 931 23 728 Switzerland 1 284 1 451 30 842 34 251 Turkey 2 564 — 16 218 — Great Britain 7 952 7 406 397 937 353 738 Yugoslavia 1 737 4 377 28 834 58 209 Total 1965 (25 States) 71 563 2 015 675 Total 1973 (25 States) 89 276 2 288 141 "" Series changed Source: United Nations (1974) Statistics of road traffic accidents in Europe, Vol. XX, 1913. ' 1972 2 1970 3 1971. Footnote: Definition of persons killed and injured may differ some- what from country to country. occurred, first aid treatment, hospital emergency services and then rehabilita- tion services for the victims can save life and limit the results of the injuries. However, this "normal" medical ap- proach does nothing to prevent the con- tinuous increase in the number of fatal or grievous accidents. Efforts have also been made to make roads and vehicles safer, but both require heavy investment either of pub- lic or private funds and thus meet eco- nomic and also psychological obstacles. Especially in Europe, car driving has been regarded as a pleasure involving competition and risk-taking rather than a controlled, safe system of moving from A to B like rail transport or civil aviation. All countries have legislation and highway codes designed for the most part to ensure orderly and accident-free traffic. But the answer to some ques- tions must depend on the results of fur- ther research. Who should be allowed to drive? Is it a human right at all ages? What, if any, medical examinations should drivers undergo? Fitness to drive can be regulated; inexperienced drivers given certain limitations; all drivers and passengers obliged to use safety belts. Speed limits, if adhered to and rational, can "calm" down traffic. Similarly, many details in road construction and vehicle design could be ensured by national legislation. In the opinion of some experts, however, legislation can- not, by itself, bring about safe patterns of driving behaviour. 7

Human behaviour It is rarely possible to attribute the cause of a road accident to a single fac- tor, but there is general agreement among experts that human factors are at the root of most motor-vehicle acci- dents. The behaviour of the road user, and the psychological, physiological and pathological processes that influence it, must be an essential consideration in all attempts to prevent road accidents. Un- fortunately it is an aspect of the prob- lem about which very little is known. One of the difficulties in persuading road users of the importance of factors influencing their behaviour is that, in the mind of any individual, the absolute risk of his being involved in a road acci- dent is low, even though the relative risk may be increased many times. One ex- ample is the case of a driver who has developed a perfectly false feeling of security because he has driven with a high blood-alcohol concentration many times without being involved in an acci- dent. Yet one carefully-controlled survey has demonstrated that a driver with a blood-alcohol concentration in excess of 150 mg/100 ml increases his relative risk of accident involvement 25 times as compared with a sober driver. It is obvious that many traffic acci- dents could be avoided if drivers were medically fit, psychologically alert to the risks involved in driving, and not under the influence of drugs or alcohol. Drivers at maximum risk Peak mortality in road accidents oc- curs between the ages of 15 and 25, after which it appears to fall steadily until late middle age, rising only slightly thereafter. There is some evidence that length of driving experience has little ef- fect on this pattern. Yet, drivers be- tween 15 and 25 are at the peak of their abilities with regard to most of the fac- tors thought to be important for safe driving, for instance speed of reaction, visual acuity, resistance to glare, etc. Oddly enough, this is the minimum-risk age-group for pedestrians. No satisfactory explanation has been advanced for the fact that middle-aged 4 Surveys show that accident involvement per mile driven is highest among young people. Road safety education from an early age can go some way towards "immunizing" children against the risks. These schoolchildren are learning good road habits by moving models about on a magnetic table. (Photo WHO/P. Boucas) Did you know that ? *Nearly 10% of beds in the large hospitals of some countries are occupied by road accident victims. *For every person killed in a road accident, between 10 and 15 persons are seriously injured, and some 30 or 40 receive minor injuries. *It was estimated 10 years ago in the United Kingdom that more than half the chil- dren born will sooner or later be injured in road accidents, and that one in 50 will lose his, or her, life on the roads. The situation is little better today. *Accident surveys have shown that accident invol- vement per mile driven is highest in youth, falls steadily until late middle age, and rises only slightly thereafter. In the USA, dri- vers over 60 have an acci- dent ratio below the aver- age for all ages. * Road accidents are respon- sible for over 30% of all deaths in the 15-25 age- group, although this is the minimum-risk age-group for pedestrians. Males be- tween 15 and 25 are many times more likely to be killed than females . *Serious traffic infringement or careless driving was the cause of 77% of a series of 92,000 accidents result- ing in injuries, according to French police statistics. Of these, 20% were due to excessive speed, 17% to refusal of priority, 11% to driving on the wrong side of the road, 10% to careless driving, and 7% to faults in overtaking. *In all countries, deaths from road accidents are higher in males than in females. drivers, in whom the physical, coordina- tive and psychomotor functions are deteriorating significantly, have a very much better accident record than those aged 15-25. There is no doubt that fur- ther research on this question could contribute to the reduction of road deaths. Attempts have been made in some countries to develop "personality tests" which could differentiate between those more likely to have accidents, the so- called "accident-prone", and those who could be considered "safer" drivers. A WHO Symposium on Human Factors in Road Accidents held in Rome a few years ago considered that the value of such tests was doubtful, at least for private vehicle drivers, while their use in the case of professional drivers required further study. Education As traffic in the city and on roads is part of our everyday life, children should be well prepared to understand its risks and future drivers properly edu- cated. Use of public transport should be encouraged whenever it is a more conve- nient and more economical solution. A private car should only be a tool we use for our transport and not a purpose of life as such. The number of injuries from road traffic accidents per population is enor- mous in the industrialized countries but information from developing countries shows high accident rates per car, and many rapidly industrializing societies experience severe accidents involving overworked, tired drivers, bad roads and a low level of car maintenance. Road traffic accidents constitute a worldwide health problem on the way to becoming rapidly worse if we do not succeed in having coordinated preventive pro- grammes become a part of each coun- try's overall traffic policy. Various activities are now going to take place under WHO's sponsorship and with the support of interested govern- ments. The WHO Regional Office for Eu- rope has a long-term plan of action and is planning to hold a Conference on the Epidemiology of Road Traffic Accidents in Vienna in November 1975. I hope sincerely that national authorities even at the highest level will keep awake to the importance of this health hazard in our societies and take positive action to prevent road accidents as recommended already in 1970 by the voio Regional Committee for Europe and in 1974 by the World Health Assembly. ■ 9 autosclemsis Anxiety, aggression and stress reactions probably helped Stone Age man to survive when confronting a wolf pack but not modern man facing traffic jams BY LENNART LEVI orse power was wonderful when only horses had it. Although ap- pealing to some, this statement is not entirely fair. The develop- ment of transport technology has cer- tainly been of great benefit to modern man, primarily by making possible the integration of urbanized society, since urbanization and industrialisation demand high mobility of people and goods. However, the side effects of this development may also be rather ob- vious. The journey from home to work is often long, traffic jams may occur, and the trip accordingly becomes in- creasingly stressful and tiring. The num- ber of traffic accidents increases. Even when designed on a very large scale, communication facilities are liable to prove insufficient; the diversified ser- vices and benefits offered by the city may turn out to be virtually inaccessible in time and space. This is particularly so for the very young, the very old and the handicapped. Public transport in some large cities even exposes those using it to the risk of bodily harm or robbery. As a result, large population groups tend to switch from public transport to the private automobile. This, in turn, in- creases traffic congestion, "autosclero- sis", which in turn leads to annoyance, stress, loss of valuable time and so forth. Briefly, then, the interaction between man and car driving is very complex in- deed. Let us look at various elements of this interaction as they relate to human health and well-being. This relation is heavily influenced by the fact that the human organism is still made up in much the same way as during the Stone Age in two particular respects. These are its propensity to react, emotionally and physiologically, by preparing for in- tense muscular activity when exposed to a wide variety of environmental changes, challenges, and threats; and the diurnal variation in a great number of its physiological and psychological processes, preparing the organism for activity during the day and sleep and rest during the night. These two genetically determined "psychobiological programmes" com- plicate man's adaptation to modern traffic demands, and contribute to some of the noxious effects of car driving on health and well-being. In general, whenever exposed to envi- ronmental change, the human organism reacts with a set of processes which were presumably adaptive in the dawn of the history of mankind. These processes seem to comprise a preparation for cop- ing with the environment. The non-spe- cific subjective elements of this response may be labelled psychological "arousal" or "activation". From the evolutionary point of view, unpleasant emotional reactions may have been adaptive by promoting the self-preservation of the living organ- ism. Correspondingly, those perceived as predominantly pleasant may have promoted the development of the organ- ism, and the maintenance of the species. Similarly, the physiological concomi- tants of these subjective reactions can be seen as adaptive originally, namely by preparing the organism for muscular ac- tivity, e.g., fight, flight, or sex. This rather non-specific physiological reac- tion pattern in response to almost any type of environmental change is closely 10 related to Professor Hans Selye's stress concept—the notion that we each have our own natural stress level. The past 500,000 years have seen dra- matic changes in the human environ- ment. These changes, however, do not seem to have been accompanied by any substantial modification of man's genet- ically determined "psychobiological programme" and, accordingly, of his basic psychophysiological reaction pat- terns, which have in a sense become "obsolete". Anxiety, aggression, and physiologi- cal stress reactions were probably pro- moting the survival of the individual and of the species when Stone Age man was confronting a wolf pack, but hardly so when modern man is confronting a traffic jam or a provocative and compet- itive driver. Pleasurable emotional reac- tions and their physiological concomi- tants were presumably promoting the development and maintenance of the in- dividual and the species, as when Stone Age man got oral or general satisfaction when ingesting delicious vegetables or animals, but not when modern man in- Bus drivers working for London Transport suffer nearly twice as many heart attacks as their bus conductor colleagues who do not face the strain of city traffic. The potential stresses have not deterred 22-year-old Rosa- mund Viner, London Transport's first woman bus driver. According to statistical studies, women drivers tend to be less frequently in- volved in serious traffic accidents than men. (Photo Publifoto Milan (0) gests alcoholic beverages or narcotic drugs before he takes the driver's seat. Briefly, then, however purposeful these "Stone Age reactions" may have been in the dawn of history of mankind, they do not appear to be appropriate in the adaptation of modern man to vary- ing traffic situations in the large cities and on the motor highways. Stone Age man's stress reactions to environmental changes, challenges and threats included an increased release of adrenal and other stress hormones, fol- lowed by increases in heart rate and re- spiration, mobilization of various "fuels" into the blood and dilatation of the blood vessels to the muscles. These are all very adaptive or even life saving if the threat is a wolf pack but much less so if you are stuck in a city traffic jam or overtaken on a motor highway. The great difference is that in the latter cases no vigorous muscular activity is needed or even possible. The initially adaptive reactions have become maladaptive, potentially leading to ill health or even death. This may occur through two types of processes. In British studies, radio-electrocardio- graph recordings in ordinary people driving their own cars on familiar roads have demonstrated considerable stress reactions in terms of increases in heart rate from the resting level, averaging about 80 beats per minute, up to levels between 110-150 beats per minute. The most marked changes were seen during overtaking. The researchers concluded that, when the driver puts his foot hard down on the accelerator, the body ap- parently responds by injecting more stress hormones into the blood. Has this any adverse health conse- quences (apart from increasing accident proneness, to be considered below)? No 11 one knows for sure, but current data in- dicate that prolonged, intense or often repeated stress reactions do indeed pro- voke subsequent ill health by increasing the "rate of wear and tear" in the body. There is growing evidence to support the assumption that occupational stress in particular is an important factor in triggering off pathogenic mechanisms in the body, eventually leading to in- creased morbidity and mortality in a number of diseases. In a well-known study comparing heart disease as an oc- cupational hazard in bus drivers and in conductors working for London Trans- port, the drivers were found to have both higher blood pressure and choles- terol levels and suffered nearly twice as many heart attacks. Apart from stress mechanisms, car driving can be detrimental to health and well-being by causing over- and under- stimulation. In the case of over-stimula- tion, the driver is exposed to so many simultaneous, competing signals that he is eventually unable to discriminate be- tween important and unimportant ones. A crucial warning sign remains unno- ticed, and another driving accident takes its toll in human life and suffering. Similarly, a low level of sensory input, as in the case of prolonged, monotonous driving on highways as straight as an arrow, can decrease the driver's alert- ness to the extent that he falls asleep or becomes inattentive, again increasing the risk of traffic accidents. A very consider- able proportion of accidents involving private and commercial vehicles have been attributed to the driver being either asleep at the wheel or inattentive. This is particularly so in single-vehicle accidents. Other accident-provoking factors in- clude experiences of recent emotional stresses like marital conflicts, occupa- tional frustrations or economic prob- lems. Such experiences might occupy the mind of the driver to such an extent that he gets inattentive, commits errors of judgement and causes an accident. Peo- ple experiencing emotional stress also have a greater propensity to take to al- coholic beverages. Such influences affect different people to a different degree. Women drivers, so often subjected to scorn, tend to be less frequently involved in serious traffic ac- cidents. The same goes for elderly driv- ers, despite their possible decreases in hearing and sight, and increases in reac- tion time. By contrast, driver character traits like disrespect for authority and the law, or the sort of burning competi- tive desire which makes a race with ev- ery other car on the road an inevitable accompaniment of every journey, all pro- bably lead to increased accident prone- ness in the traffic. In short, traffic acci- dent proneness seems to be a function not only of exposure to environmental stresses and strains but also of the pres- ence of certain personality traits. Cyclic changes over a period of time are a property of all organic life and as such are of great evolutionary impor- tance. A special example of this rhyth- micity is the circadian (circa dies = about 24 hours) rhythm. Generally, the circa- dian rhythms have their maxima during the active part of the 24 hours and mini- ma during the inactive part. A multitude of physiological and psychological func- tions have been shown to exhibit circa- dian rhythms. From the dawn of man- kind's history and until quite recently, these circadian rhythms have been beau- tifully adapted to the environmental demands on man, favouring a variety of life and species-preserving activities dur- ing the day and sleep during the night, allowing the recharging of the batteries. The increasing demand for services and the introduction of extremely expensive modern technology have favoured in- creasing demands for human occupa- tional activity being carried out around the clock. These demands have been met either by assigning some individuals to work exclusively during night time or in shifts around the clock. The same is true for motor vehicle driving. The resulting discrepancy between en- vironmental demands on the one hand and the human organism's abilities and needs on the other has been studied in a series of experiments carried out by the Laboratory for Clinical Stress Research at the Karolinska Institute in Stock- holm, Sweden. We found that, although the endocrine system does indeed adapt to the environmental demands induced by shift-work by "stepping on the gas" to keep awake in night-time and "slow- ing down" in the day to allow for some sleep, the usual one-week cycle does not suffice for a complete adaptation of turning night into day and vice versa. Not even three weeks of continuous night work are enough to cause an in- version of the circadian functions; the original circadian rhythms still persist. In addition, switching from habitual day work to three weeks of night work is accompanied by increases in a number of indices of physiological stress. In another series of studies, normal healthy volunteers of both sexes were exposed to three days and three nights of continuous work. In spite of the strict standardization and equalization of en- vironmental stimuli, the circadian rhythms persisted throughout the vigil, with pronounced decreases in adrenaline excretion, shortfalls in performance and increases in fatigue ratings taking place in the small hours. Shortfalls in perfor- mance were particularly pronounced in the 60-year-old subjects and less so in the younger ones. It is worth noting that the older subjects were often not aware of the decline in their performance. Although these studies were not car- ried out on car drivers in a traffic situa- tion, they have obvious implications for this category as well and find support from a recent field study on truck and bus drivers carried out by Dr William Harris, Dr Robert R. Mackie and oth- ers in the United States. According to this study, prolonged driving, particularly during the night, is another important factor that contrib- utes to driver stress, fatigue or both, and consequently to increases in the risk of traffic accidents. After only three hours of driving, the level of psycho-physio- logical arousal decreases and driver per- formance errors increase. After about seven hours of driving, the frequency of accidents increases disproportionately. True, such unfavourable effects are usually counteracted by rest breaks, but only up to a certain point. A break after the first three hours on the highway cer- tainly recharges the batteries and reduces driver errors. A second break after six hours does so to a much lesser extent; but with a third rest break after about nine hours of driving, there was not only no recovery but a further decline in psycho-physiological arousal followed the break. Older drivers generally showed an earlier decline in arousal and an earlier increase in errors of driving perfor- mance. They also had proportionately more of their accidents after five hours on the road than did the younger driv- ers, despite the higher absolute accident rate of the younger drivers. Performance levels were further in- fluenced by the time of the day, perfor- mance minima being found in the early morning hours, when most biological processes experience a slow-down. The deterioration in driver performance pro- voked by night driving in drivers who are used to sleep during the night is fur- ther augmented if the circadian effect and the fatigue effect coincide, namely when a long run ends during the early morning hours. Although relatively well known, results such as these are often disregard- ed when working schedules are planned for professional and private car drivers. In the former case, economic reward 12 • • I • • I it ' 1 ,Yrip z. kftwargt .111P 40 • ".* . Ott' 't4S kijk 411e.1.1fitibNI 1/01/"011111;' . ; rlt'i•i,z7,tn' • ., 4 ok. $ - 4;:t,h,-, . till"'F''t- ..!' :`""..-..0,111"—_-.4*-....i'‘\ ".•,. . 1 lkok .4 '41 ' ,mi -,, joys ,... ' .N. ' 4 ..,'}'.■ % t 44,4', ' 'n ..-",*• -41:1`. . • ' ._ • •'' 4 • f . • . , I ... do, ' v' „. 164 ,, i may even be used to counteract the driv- er's instinct of self-preservation. Many drivers are paid in direct proportion to the number of their runs or to the amount of time spent on the highway. In this way, the adjustment between man and his traffic environment is fur- ther impaired, the stress and fatigue reactions are increased and accident risk is augmented. There is reason to consider some recommendations put forward by Dr Harris and Dr Mackie, who con- clude from their extensive safety of op- erations study that : Very long runs which require the driv- er to be on duty in excess of nine hours, Radar checks and police supervision help to keep motorway driving speeds within limits, and thus reduce accidents. But some motorists say that monotonous straight stretches of highway and strict speed limits make journeys more fatiguing. The answer is for motorists to take frequent breaks to "recharge their bat- teries". (Photo Len Sirman ) including rest breaks, should be discou- raged, particularly in the case of drivers over 45 years of age. Drivers should not be permitted to drive more than three hours without taking a break of sufficient duration to ensure recovery of physiological and performance functions. The duration of the break should probably be longer as the hours on duty increase. Attention should be paid to the sche- duling of runs, so that drivers have not been on the road for a long number of hours in the early morning. The com- bined effects on arousal level of the time of day and prolonged driving probably increase the risk of the driver having an accident. The road transport industry should be encouraged to compensate drivers on some basis other than the distance covered, so that drivers who are ap- proaching their limits of endurance will not feel compelled to continue driving for economic reasons. • 13 AFRICA a social scourge Africa's young nations realize that responsibility for preventing accidents rests not just with police or local authorities but with the whole community raffle accidents in the youthful nations of Africa amount to a social scourge. Even a cursory survey of a handful of these coun- tries shows that all too often the victims of such accidents are young Africans, whose rising earning power has enabled them to invest in a motorcycle or a car. Yet it is just this group of promising youngsters whose social and economic contribution Africa can least afford to lose. Several national reports on road acci- dents say they amount to epidemic pro- portions, and conclude that it is much more dangerous to travel on African roads than on roads in countries with much denser populations. Statistics often lend themselves to various interpretations. But one report originating in Kenya expresses the situa- tion succinctly by contrasting the num- ber of road deaths per 100 million pas- senger miles in different countries : United States 6 United Kingdom 13 Kenya 55 Uganda 65 In several countries, road accidents over a ten year period have increased at the alarming rate of between 85 and 100 per cent. One curious finding emerged from Dahomey, where the greatest num- ber of accidents proved to occur on Thursdays, Saturdays and Sundays, and most of them between 3 p.m. and 6 p.m. 14 At the same time it has to be borne in mind that the accident figures, high though they are, represent only a small proportion of the total deaths in African --frOur KEEP IT M CHEEK 16111¢11Al Ce11111771F to, WM, SART Ovanoorecl raraIlLS Traffic accidents in Africa's youthful nations amount to a social scourge, despite posters like this, aimed at drivers with a roving eye. A moment's distraction is enough ... countries. In Kenya, for example, road deaths account for only a half of one per cent of the total. As in other parts of the world, human error is the most common cause of acci- dents. Drivers fail to obey the rules of the road, they drive too fast or under the influence of alcohol, they are impa- tient and overload their vehicle, or they neglect it until it is no longer roadwor- thy. Other causes include the poor state of the roads, inadequate traffic signs, the indiscipline of pedestrians (who pay a heavy toll for their lack of caution), and the carelessness of cyclists. All the countries concerned have traf- fic police to ensure that the highway code is respected, but their numbers are often insufficient as traffic grows ever denser, particularly in towns and cities. Few nations have a proper accident pre- vention service capable of informing and educating both drivers and the pub- lic. However, some steps are being taken to fill this gap, and efforts are being made to convey the right message by posters, radio or television broadcasts, illustrated brochures and so on. In the last analysis, accident prevention should not rest solely in the hands of the local authorities or the police, but should be actively undertaken by the whole com- munity. Some countries have sought the ad- vice of special consultants on simple and practical ways of improving the sit- uation. Others, such as the Central Afri- can Republic, have created an official road accident prevention body under the aegis of the Ministry of Public Works. This body is responsible for im- proving road and traffic signs, carrying out regular checks on the roadworthi- ness of vehicles, and reducing the human factor in accidents by ensuring that all drivers have passed a medical examina- tion and know how to read and write. ■ Two wheels or four wheels — in this case the outcome was the same. Both the car driver and the scooter driver were taken to hospital. (Photo WHO) :"Atr` Altgr KUWAIT epidemic on wheels Oil has brought the little Persian Gulf state of Kuwait great wealth -and 13,000 traffic accidents a year. Most of them are a result of human error traffic jam in Kuwait is a good place to contemplate what has come to be known as the "miracle of Kuwait". Appropriately enough, since the miracle was engendered by the world's richest pool of oil, down- town Kuwait glitters with late model internal-combustion-driven vehicles packed three abreast and polluting the atmosphere with carbon monox- ide gas. Fifteen years ago, fewer than 300,000 people lived in Kuwait and cars were no problem. Today the population has soared to about 860,000 and there is one car for ev- ery five people. Despite the gradual enforcement of road safety mea- sures, traffic accidents are running at more than 13,000 a year. The very oil-derived wealth that has put every fifth Kuwaiti at the wheel of a car has, at the same time, given the tiny Gulf state a host of traffic hazards, about which many of the newcomers who boost its soaring population have no forewarning. Significantly enough, Kuwait has one of the highest motor vehicle ac- cident rates among the economically developed countries, with a death rate of 21.4 per 100,000 people— roughly halfway between the USA. (26.2) and the UK (14.3), according to 1971 figures. The increase in road- traffic density has brought with it, over the past ten-odd years, a three- fold increase in the number of such With a three-fold increase in road accidents in ten years, Kuwait is campaigning hard to educate drivers and pedestrians alike. The poster above shows a carefree girl playing in the road with a ball. Right — a giant effigy of a traffic policeman urges caution, night and day. (Photos WHO/P. Almasy) accidents in Kuwait, and twice as many fatalities as in the early sixties. Since, according to a local joke, affluent Kuwaitis get rid of their cars as soon as the ash-trays are full, few motor vehicle accidents are related to mechanical failure or car defects. Similarly, very few accidents are be- ing caused by road conditions alone. The human factor remains by far the most important cause of traffic acci- dents, according to road casualty reports for the past ten years. Faced with this situation, Kuwait's road safety authorities are conducting a running battle against accidents, investigating every means of reducing casualties. Legislation covering all road users is being en- forced, traffic safety campaigns have been launched, warning signs and safety posters are displayed at major crossroads. Kuwait is also one of the few Mid- dle East countries to have intro- duced an advanced system of first aid treatment, involving an efficient accident casualty service complete with ambulances, emergency surgical teams and post-operative rehabilita- tion units. ■ 16

highway conscience The energy crisis had a brighter side in Europe: petrol prices and heavy fines for exceeding new speed limits helped to cut accidents by one-third BY VIGGO CHRISTENSEN I f in any country it was announced that next week and for several weeks to come at least 80 people would die of poliomyelitis, and that ten times that number would be seriously paralysed, we can easily imagine how that country would be galvanized into action. Advice, legislation and money would pour in from all quarters—and rightly so. But what happens when we are facing one of our greatest killers—death on the road? Traffic experts estimate that within a very few years the annual global number of deaths in road traffic accidents could reach a quarter of a million, and that the number of injured will exceed 10 million. Until recently, the main counter-mea- sures have been directed towards deve- loping first aid posts on the roads, emergency services, hospital treatment and rehabilitation of traffic victims The severity of injuries has in many cases been reduced through insistence upon safer motor cars, and the use of safety harnesses or crash helmets. But actual accident prevention still lags behind. Propaganda in all its various forms is only one of the obvious means of in- fluencing driving behaviour, and of alerting other road users to exercise care in traffic. For many years information and propaganda campaigns aimed at road accident prevention have been car- ried out in most of the developed coun- tries and in many developing coun- tries—with qualified success, as the in- stigators of these campaigns themselves would be ready to admit. During the early stages of road safety information campaigns, when money was scarce and experience even scarcer, the emphasis was generally placed mere- ly upon the do's and don't's in traffic situations. Such modest efforts were only too often outweighed by the well- known tendency of advertising and en- tertainment to glamourize the unsafe as- pects of driving; the hero and his girl in Road safety posters are an important means of educating the general public. Above — a graphic Dutch poster shows a child's scooter abandoned in the road and reminds the read- er: Your blood can save a life. the fast sports car, octane-boosted petrol advertisements and the performance fanfares by motor car manufacturers suggesting—as indeed they still do—that acceleration and speed are all-impor- tant. Today, the road safety people have developed a more direct and often quite sophisticated approach. We find their posters and pictorial presentations on street corners, in schools and public places, and along the highways—coerc- ing, cajoling, and fortunately often com- pelling us to try to develop a highway conscience : to observe speed limits, show consideration and thoughtfulness towards other road users, refrain from overtaking in dangerous spots, use seat belts, wear crash helmets, and drive only when sober. Humour, as well as the shock-treat- ment approach, is often used in road safety propaganda, with varying results. Varying because humour is rarely univ- ersally uniform, and does not easily cross borders. A joke or a pun can easi- ly defeat its own purpose. Horror pos- ters, originally very popular with the designers, soon proved to have only lim- ited popularity with the public, and there is little evidence that they had pos- itive reactions and effects. We can, therefore, probably conclude that a terse and straightforward presentation is the most effective; when the do's and don't's are emphasized, they should em- body an element of positive motivation. A brighter side of the energy crisis was to bring about a new situation, such 18 Var radd cicj och kirk( )stet. 6 timmar tar det att"hii av mcd"2 groggar. ten nAlan etter CU grogg kan ki irkrrtet aka. sysTr,11101,AGEF , K5 C HAP K KI.1111,,,,RHET Hall till hoger di ni mots I Goteborgs stalls gatukontor Goteborgs trafiksakerhetsbrening 19 on as the road safety experts could hardly have dreamt of. In many European countries the new position made the year 1974 epoch-making in the history of safety on the roads. Crippling petrol prices, increased taxation, closer police surveillance and heavy fines for speeding beyond the new limits decreased the number of victims of road accidents by up to one-third. These startling results should not, and have not, made the Road Safety Asso- ciations feel that they can now sit back and relax for a while. On the contrary, the immediate effects of the restrictions have been to encourage a number of leg- islations to introduce new highway codes, and new rules and regulations for safe driving behaviour and for driver- pedestrian relations. These should give the Road Safety Associations a new and wider scope for their activities, enabling them at the same time to improve and extend a number of activities already in preparation or under way. Posters, leaflets, films, radio and tele- vision presentations, advertisements and special campaigns will no doubt remain an integral part of road safety activities. But the Associations can be expected to concern themselves more directly with the behaviour of drivers and other road users, and to deal more whole-heartedly than before with education. Safety edu- cation will start, as it already does in many countries, with the very young, generally in cooperation with schools. Children need to be taught how to behave as pedestrians or cyclists in the road traffic of today. As children reach the age when they themselves may ex- pect to be sitting behind the wheel of a motor car, it is not enough to teach them the usual technical driving skills and traffic regulations. Driving lessons should include education in safe driving habits, and should seek to develop in the pupil an attitude of concern for the safety of others. The imparting of such basic knowl- edge, with its appeal to the conscience and to the public responsibility of driv- ers, should substantially help towards slowing down the slaughter on our streets, roads and highways. ■ <Swedish posters warn motorists that even one alcoholic drink can cost them their driving licence (above), and that not only drivers but pedestrians too should be disciplined (below). THE AMERICAS road sense Latin America's problems are aggravated by the migration to cities of countrydwellers unused to city traffic, and by unplanned urban growth raffic accidents are the Number One cause of death among "young adults" in at least four countries of the Western Hemi- sphere : Chile, Costa Rica, the United States and Venezuela. Although the relevant statistics are in- complete in some parts of the region, it is clear that in most countries in the Americas traffic accidents are among the first ten causes of death for all age groups. Because of the alarming nature of these figures, the Directing Council of the Pan American Health Organization (PAHO) drew up a programme of ac- tion, one of whose first results was a series of seminars on road accidents, held in Mexico and Venezuela in 1972, and in Jamaica in 1973. Representatives from all the countries of the region at- tended the seminars, generally those of- ficials responsible for health, road en- gineering, police or other aspects of the problem. On each occasion, there was unani- mous agreement about the importance of undertaking epidemiological studies of traffic accidents so as to arrive at the right basis for taking preventive action. It was also agreed that national traffic accident prevention councils were needed—multi-disciplinary bodies re- sponsible for coordinating and promot- ing interest in tackling the problem. Such councils would be able to make recommendations to governments about road safety education, provision of first aid, and the role of alcohol and drug consumption in causing accidents. The need was also recognized for technical advisory services and trained personnel. El trago del estribo El alcohol a nula su capacidad pare conducir One for the road. This Chilean poster dra- matically conveys the message that alcohol and driving don't mix. From this first round of seminars developed a further round of six national seminars arranged in the coun- tries with the highest accident rates: Argentina, Brazil, Chile, Colombia, Mexico and Peru. From these discussions it became clear that Latin America, like the major- ity of developing countries, has a higher incidence of traffic accidents involving pedestrians than drivers alone. Among the causes are lack of instruction in the use of roads and vehicles; pedestrian ig- norance of road signs; the lack of spe- cial school transport; the poor condi- tion of public transport vehicles and the carelessness of drivers in ensuring the safety of their passengers; and the abuse of alcohol and other intoxicants by both drivers and pedestrians. The problems are aggravated by the migration to cities of rural populations unused to heavy city traffic and by the urban disorganization caused by the un- planned growth of these populations. Particular stress is now placed on the need for intensified road education pro- grammes to be organized directly by Ministries of Education and Health and indirectly through voluntary agencies. This will ensure that they reach the en- tire population, particularly those at risk, such as drivers of public and pri- vate vehicles, schoolchildren and so forth. In addition, several countries have run short training courses in first aid for the police and the general public, have produced booklets and other au- dio-visual aids to training, and have in- troduced special courses for drivers and school road safety programmes. Now the countries of the region are anxiously waiting to see whether these various intensive activities will result in checking or even reversing the previous steady increase in the grim toll on the roads. ■ A nine-year-old boy and this little girl were sharing a ride on a bicycle when it was hit by a truck. The boy was killed outright. Drench- ed in his blood, she is lifted into the ambu- lance, while a policeman stands by to cover her with a blanket. The scene is New York, but it could happen — it is happening — all over the world. (Photo Len Sirman (0) 20

no joking mailer? Driving is a stress activity. In the long history of mankind, people at times of greatest stress have tended to make jokes about their situation BY WALTER CUTTER here might be a tendency on the part of some in considering this subject to change its title to "An Enquiry into the History, Sym- bolism, Relevance and Effects of Car- toons, plus some Reflections upon Graf- fiti and Primitive Wall Paintings". This tendency, we will resist: Car- toons are various, but they are seldom ponderous. The cartoon laughs at others and causes us to laugh at ourselves. It punctures shame, hypocrisy, arrogance and other distasteful traits by showing the emperor to have no clothes. It con- veys lessons without being didactic. The cartoon, therefore, should be treated with warmth. The cartoonist should have a high place in the pantheon of "people to be valued". He is not only an accomplished commentator; he is indis- pensable. Consider an example from the New Yorker. There are innumerable groups and individuals all over the world ex- pecting Armageddon, or at the least the overturn of the established order, and the defeat of the establishment, whatev- er that is or may be. Ponderous tomes, and papers and articles have appeared to frighten us and to cause us to gather rosebuds while we may. In one penetrat- ing picture, with words, the New Yorker cartoonist captured the whole spirit of chaos. The scene : a Victorian drawing room. A guest, a lady, is sitting ramrod straight on a sofa and holding a teacup. Her hostess is moving towards the but- ler's bell-pull. Turning to her guest, she says, "My son, Reginald, is such a radi- cal. He says that some day I will pull this and no one will come." No one will come! How much longer it took Spen- gler in The Decline of the West to say the same thing. The difficulty is that the traffic car- toon has become a cliché. With so many millions of drivers and so many car- toonists and what is really a limited number of basic situations, even exten- sions of permutations and combinations cannot furnish us with much novelty. Driving situations are international. Drivers' excuses fall into categories whether it be Scandinavia, France or England. The wicked police, the cranky judge exist in every country. "Why are you out here bothering drivers when you ought to be chasing lawbreakers?" If this question has not been asked wherever there are motor vehicles and motor police, I would be surprised. Officer : "Sir, you are driving on a one-way street" (the wrong way, of course). Motorist : "Well I'm only driving one way, aren't I?" Officer : "Madam, you are driving at 60 miles per hour in a 40-mile zone." Madam : "That can't be. I haven't been out an hour." 22 Officer : "You are driving well above the posted speed limit." Driver : "I was not. I couldn't have been going more than 40, than 30, than 20 miles per hour." Officer : "Stop! You'll be backing into the car following you." And one, which is peculiarly Ameri- can, yet familiar to people all over the world who are familiar with Western motion pictures with their bows and ar- rows, is this: Officer to drunk who is driving the wrong way on a one-way street: "Didn't you see the arrow?" Drunk: "Arrow? I didn't even see the Indian." And so on and on. Everyone can recall some favourite cartoons involving drivers and police, drivers and other drivers, or drivers and judges. The question which must be faced, particularly in a journal of health, is The motorist today faces whole batteries of road signs which he is required to read, under- stand and obey in a split second. Perhaps there are less solemn ways of communicating the message that speed kills? (Photo Len Sirman ) does the cartoon help or hinder traffic safety? No definite answer can be made, but the question is well worth consider- ing. It is a fact that in the long history of mankind people at moments of greatest stress have tended to laugh at them- selves, make jokes about their plight, or draw cartoons highlighting some facet of their experience. Driving is a stress activity. Many drivers undoubtedly drive in a state of fear, fear of the ac- tions of other drivers, fearful that their own abilities may not be adequate when emergency conditions arise. Such drivers might never admit this, might even deny it indignantly. Thus we have a situation where familiarity with the act of driving not only breeds contempt, but can actu- ally enhance danger. What cartoon can portray this condition? Some related observations are in or- der. The subject of the first cartoon mentioned is "Why are you bothering drivers when you should be chasing law- breakers?" The implication, shared by far too many, is that the offending driv- er is not a lawbreaker. The truth is that the offending driver is a lawbreaker and, worse, his lawbreaking carries the threat of danger to life and limb to himself and innocent people. Is there a cartoon for this? Some years before my retirement, I was invited to submit an article to the company magazine of a large company. With the invitation came the title, "Let's Stop Coddling our Killers." I didn't like the title and said so, but I was per- suaded to write the article. Imagine my 23 astonishment when I found myself writ- ing: "The driver who drives in a reckless or dangerous manner must be presumed to intend killing or injuring someone." This is strong medicine. A lawyer might say, "Pfui. There is no mens rea or guil- ty intent, therefore no such presumption can be made." Such a lawyer might be forgetting that strong circumstantial evi- dence, in the absence of direct observa- tion of a criminal act, is sufficient to convict. So, isn't society free to assume an intent when socially undesirable ef- fects follow upon the socially disap- proved actions of a driver? It is worth remembering that in the United States, more people are killed in vehicle crashes than die by murder. Do the cartoons show this? The drinker and the obvious drunk have long been figures of fun. Hundreds of cartoons have portrayed their words and actions. These words and actions, their attempts to walk in a straight line, have provoked smiles and laughter. The ordinarily quiet man or woman becomes the life of the party. At the wheel of a vehicle we can all too frequently strike out the word life and substitute the word death. Driving after or while drinking displays not only a lack of re- sponsibility towards other drivers and oneself, but a profound ignorance of the effects of alcohol. Too many continue to think of alcohol as a stimulant whereas, in truth, it is a depressant. The psychic monitors are deadened and actions and words not ordinarily characteristic of the person emerge into consciousness. The person feels a capacity for actions and words far above his usual norm, while simultaneously decreasing his ability to respond. This is bad enough in a social situation. On the street or high- way this condition can be lethal. Does the cartoon show this? Have you ever seen an inebriated per- son start to fight? He aims a blow at someone. In his muddled condition he feels the strength of Hercules and the blow he is aiming will have the effect that a European prizefighter called the "Hammer of Thor". But, the blow rare- ly lands on the intended victim. Either an innocent bystander is struck, or the drunk ends by hitting himself, or spin- ning until he falls. How many drivers now lying peace- fully in cemeteries (arriving long before their allotted time) believed up to the last moment that a couple of drinks steadied them, or increased their ability to drive? The cartoon cannot show this mistaken belief, only the crash and the funeral. A personal experience will serve as an illustration. Many years ago I attended a dance in a city about 25 miles from the city in which I lived. My car was filled with friends. The evening was hot so that a punchbowl of cool liquid was visited frequently. I didn't learn until we started homewards that this cooling punch was one-half gin. Everything went well for a while until I spied some lights coming towards us, as I thought. I remarked that the oncoming truck had very wide headlights. When we came up to it, I discovered that I had been look- ing at the lights of a petrol station. Im- mediately I pulled to the side of the road and surrendered the wheel to a non-drinking passenger. Like the aero- plane pilots, I prefer both a safe takeoff and a safe landing. This road had many turns and I didn't want to perish trying to straighten the curves. A very amusing cartoon might have been made of this episode, but I might never have seen it. Better a live coward than a dead drunk. If there is one category of cartoons that contains thousands of entries, it is the interplay of police and drivers. As many drivers regard the traffic police as natural enemies, any cartoon showing the police at even a slight disadvantage is viewed with great joy. The men at the cafe, the pub, the bistro, the saloon are regaled with the pungent remarks made by the driver and how he told off the policeman, the gendarme, the offizier or the highway patrolman. Even the dear ladies will recount the words and wiles they used to escape receiving a sum- mons. This writer has known hundreds of traffic police and it is only truthful to say that a good-looking woman, as at- tested by many cartoons, has a measura- bly better chance of escaping retribution than a man. This feeling about the police is of course stupid. These men are more in- terested in protecting the safety of all drivers than in writing traffic tickets. In this case, there have been cartoons showing traffic police in their role as protectors. The work of police has been described as an effort to protect fools from their folly. There are, unhappily, more cartoons of the negative sort, so that the real work of the police becomes blurred. Cartoons extolling the con- structive work of traffic police are in or- der. They may not be funny, but they will save lives. 24 Years ago, I was made aware of a very significant suggestion in the field of industrial safety. For years, posters had been created showing accident produc- ing actions and physical situations. The suggestion was that the effect of such posters was incomplete, that right beside the negative picture there should be the positive picture showing the action or condition that would have prevented in- jury or property damage. Obviously such a plan would have little appeal to the cartoonist who might consider that his pithy or amusing comment was be- ing turned into a sermon. Yet the sug- gestion merits consideration. The clever cartoonist can be instructive without be- ing didactic. Earlier in this article, the question was raised, "Does the cartoon help or hinder traffic safety?" Any convincing answer must depend upon how the car- toon is viewed. With the incredible vari- ety of human reactions, plus the variety of types of cartoons and "messages", anything like a consensus is not pos- sible. Exact data are not possible. To collect the subjective reactions of view- ers in respect of particular cartoons is a possibility, but it would leave the larger question unanswered. In a broad sense, the traffic accident problem is a substantial part of the in- ternational health problem. And it must be asserted that there is nothing funny about traffic deaths and injuries. Some millions of people have been killed, tens of millions injured, some permanently, with incalculable familial and societal disruption. Hospitals and rehabilitation centres have thousands of patients fight- ing their way back to some degree of physical and social adequacy. In view of these actualities, whatever is said or done about the problems of traffic safety must be viewed in terms of its possible positive or negative effects. If we could be certain that viewers of cartoons could be admonished or in- structed by what a cartoon suggests rather than what it shows, the role of cartoons might be adjudged construc- tive. And there will be those who will say, "Oh, come now, why be so serious and solemn about amusing cartoons? Didn't you say that mankind in stress situations needs to laugh at himself and others?" True. What is suggested, however, is that we do not stop at the laughter, that we look through it and learn how to avoid the frequent dangers that the cartoons suggest. Thus, we can have laughter, we can seek learning, we can improve practice and, voila, we can enhance our chances of dying peacefully in bed. ■ 25 INDIA a lack of discipline With over two million motor vehicles on India's roads, its cities suffer a road death toll ten to fifteen times greater than in the UK or the USA urning a little button on the dashboard made our police si- ren wail and helped clear a path through the crowded streets. It helped, but only a little. Traffic in a country like India is rather special. Where else do you have to dodge bullock carts loaded with steel gird- ers, scooter rickshaws, battered taxis, huge trucks loaded with gravel, passenger cars, and thou- sands of bicycles, not to mention a thick flood of unconcerned pedes- trians? Perhaps it isn't fair to call the pedestrians unconcerned; they are just more concerned with getting where they want to go than watching out for traffic. Almost 50 per cent of the traffic fatalities in Delhi are pedestrians. The police sergeant was asked about accidents : "What do you do if you find someone injured?" "Some of the officers have first aid training and we have this box of emergency supplies. But the main thing we do is get the injured to hos- pital." Looking at the small dusty box and its meagre contents I could easily see why that was a good idea. We had been called to Ring Road, a large highway that runs around Delhi. A huge lorry was lying on its side with its contents of logs strewn over the embankment. It looked like a large helpless bug. No one was hurt and the driver was still at the site. "Often drivers run away, especially when someone is hurt", explained the sergeant. Perhaps no school lesson will have more direct bearing on these children's lives than this one. An older girl shows her schoolmates how drivers are warned when they approach a school: but the sign is not an invitation to play "last across". (Photo WHO/A. Kochar) "Don't they forfeit their licences?" "They do in this State. But they can just cross the river or go into another State and start driving trucks again. There is no national system of licence registration." "What do you think caused this accident?" "Can't tell for sure. Maybe over- loading, maybe he was forced off the road by another truck. And the oth- er driver may have been drunk. Did you know that we ran a spot check last week for trucks entering Delhi and found one in four of the drivers were drunk?" "Did you fine them or suspend licences ?" "Unfortunately, the law is a bit vague. Drunkenness is defined in the law as being unable to drive. That is hard to prove. We don't have any breathalyzers and unless the law is changed it remains almost impos- sible to charge anyone with drunken driving." Next day there was a hit-and-run victim, lying still and small on the pavement. No identification, so the police had the body taken away in an ambulance and the newspapers next day ran photos and asked if anyone could recognize this young man. 26 The Head of the Traffic Division, Dr N.S. Srinivasan, outlined some of the problems. "Attempts are being made to divide cycle traffic from vehicular and pedestrian traffic, but discipline is lacking and enforcement spotty and understaffed." When asked what was the major cause of accidents in India, he re- plied straightaway : "Human error." In the case of Delhi, a 1970 study showed that the fault of the driver of the motor vehicle accounted for 96 per cent of the accidents! Another study has shown that the majority of the drivers involved in severe injury and fatal accidents had defective eyesight. Developing countries have, in ad- dition to all the problems of most industrialized countries, special problems of their own. This helps explain why the fatality rate per 10,000 vehicles in Indian cities is about 10 to 15 times that of the USA or UK. The high rate of urbanization in the countries of Asia and the Far East has been accompanied by an in- crease in the number of motor vehi- cles in and around urban areas, resulting in an alarming increase in traffic congestion and in the number of road accidents. In many cities, while the annual increase in popula- tion is about 4 to 6 per cent, there is an increase of some 15 per cent in motor vehicles—there are now more than two million—and an increase of about 15 to 20 per cent in road acci- dents. On average, eight persons are killed in road accidents for every 1,000 vehicles, which compares to a far lower figure of about one per thousand in industrialized countries. Fatal accidents run as high as one or two a day in Delhi, and many of these may involve motor-cyclists and scooterists. Significantly, drivers and their pillion-riders are not obliged by law to wear helmets. ■ A police spot-check found that one in four of the truck drivers entering Delhi was drunk. Hardly surprising, then, that the mangled remains of a lorry make a commonplace sight at the roadside. All too often there are blood- stains too. (Photo WHO/A. Kochar) 27 tip the economic tgs ------ ..... orb mg+, ea MO ...... ••••-•• ■■■•■•••• ■••., ■•■•••■•••■•■•••• 11111 ••• ..... II • • - .11 mu VII 11111 lee .411 1 •••• • • 11/11" 1 1 1811M' 1 111 wig eve -1111 irs gift ...me 4 ∎ .11111111/11,1 1111 4••• ••• MD t 4617 111%". WI/ OM aka 004 No mere cost can ever justly depict the deep, lasting tragedy of traffic accidents INTERVIEW WITH RUNE ANDR EASSON WH: Is it possible to assess the economic cost of road accidents? RA : The costs of injuries and property damage resulting from traffic accidents are borne not only by society as a whole, but also by such groups as the insurance indus- try as well as by the private individual and his relatives. Some of these costs are direct, out-of-pocket expenses that can readily be identified. Other costs, however, are diffi- cult to specify and quantify. Calculated costs of traffic injuries and property damage are therefore highly imprecise and cannot be used as bases for determining compensation. WH: What is the practical purpose of such calculations? RA : They are probably sufficient for a gen- eral elucidation of the economic conse- quences of traffic accidents, although the uncertainties present in the cost estimates do not allow a perfect cost benefit analysis. The very size of the costs, though, should stimu- late measures aimed at reducing the mortali- ty and morbidity frequency of traffic acci- dents. WH: What are the costs to society? RA : They comprise direct expenses or reduced income : costs for medical care, medicine and transport, administrative ef- forts in conjunction with police investiga- tions and judicial processes, social-welfare payments to accident victims and their fami- lies, reduced tax revenues, and so forth. In Sweden, for example, where we have a pop- ulation of 8 million, it is estimated that the cost to society of traffic accidents which oc- curred in 1970 amounted to 230 million Swedish crowns, medical-care costs account- ed for 180 million crowns and the net loss of tax revenues was 30 million crowns. (1 US dollar is worth approximately 4 Swedish crowns.) The total for that one year was 440 million crowns or US $110 million. WH: It must be easier for insurance compa- nies to come up with precise figures. RA: Yes, traffic-accident costs borne by the road-traffic insurance system are easy to determine as long as they refer to sums paid out for objective injuries and damage, loss of income, and medical care. However, dis- cretionary judgements often based on sub- jective claims for compensation—form the basis of so-called general or non-material damages, such as physical and/or mental suffering and relatives' grief and suffering as a result of injuries and death. WH: Are personal costs included? RA : Costs or reduced income resulting from traffic-accident damages and injury to the victim himself or his family certainly amount to significant sums, but these are not included in estimates of traffic-accident costs. Altered income circumstances result- ing from a traffic accident, for example, can mean a reduction in the future standard of living as well as additional financial prob- lems for those affected. WH: How do statisticians define a traffic ac- cident? RA : It is difficult to separate motor-vehicle accidents whose cause is directly related to the vehicle and its use from traffic accidents arising from other causes. This difficulty can lead to traffic-accident-cost figures that are higher than they really ought to be. Acci- dents can have other causes apart from nor- mal road-use. These include cases in which a driver dies of a disease condition, such as cerebral haemorrhage, heart attack, or diabetic coma prior to involvement of the motor vehicle in an accident. WH: Can you think of more examples? RA: Yes, in one case a loaded firearm was being carried in a motor vehicle in motion, and it accidently fired, causing injury and damage. In such an event, motion is not considered to be the primary contributing factor; therefore the event is not a motor- vehicle accident. Another example : a driver kills himself by purposely driving a motor vehicle against a fixed object or another car; or he commits a similar deliberate act while driving, and this intent is verified in some manner. Such intentional events are not 28 motor-vehicle accidents. Nor is it an acci- dent when a vehicle is used intentionally to kill or injure others. More stringent demands than hitherto must therefore be imposed on the statistical bases upon which motor-vehicle-accident costs are computed. WH: Are wage losses a major item in calcu- lating the economic cost of accidents? RA : Yes, they often amount to as much as one third of the total sum. They are wage losses due to temporary inability to work, lower wages after returning to work due to permanent impairment, and present value of future earnings lost by those incapacitated or killed. In such calculations, a future eco- nomic situation featuring full employment and maximum use of labour is assumed. But no such economic situation now prevails in any industrialized nation. On the contrary, the tendency is toward unemployment, shor- ter working hours, longer vacations, and earlier retirement. Such factors markedly af- fect cost calculations and hence reduce the amount of the putative costs. WH: What about lost taxation? RA : The estimate of lost taxation income to society is based on the assumption that the "tax strength" of the injured or killed victim would have remained unchanged in the future. In fact, the tax-loss estimate should always be reduced to reflect taxes on life- annuities and so forth. We must remember, A society with a high standard of living has to maintain a high state of medical-care prepar- edness and in all cases of need must be capable of taking care of every injured and ill person. Photograph shows Moscow's newly built and busy Kalinin Prospekt. (Photo Len Sirman (c ) ) however, that this kind of reasoning about losses of productivity and taxation can be applied to practically every disease or cause of death. When these fallacious costs are rather unfairly included in traffic-injury costs, the impression can easily be created that accident- and injury-preventive mea- sures are motivated more by economic con- siderations than by humanitarian ones. WH: What about medical-care costs? RA : The basis for calculating medical-care costs resulting from traffic accidents makes fairly precise estimates possible. In Sweden, with approximately 23,000 persons injured and killed in traffic accidents annually, med- ical-care costs amount to between 180 and 225 million crowns each year, over 80 per cent of this sum representing in-patient care. Half of those registered as traffic fatalities receive an average of about six days of host- pital care before they die. The medical-care cost per 24-hour day for this category amounts to approximately 450 crowns. The average hospital stay for injured in-patients is about 180 days at a cost per care-day of approximately 300 crowns. WH: Are these costs calculated separately in Sweden? RA : No, to present the medical-care for traffic victims separately would be, accord- ing to Sweden's National Board of Health and Welfare, to depart from the principles applying to society's medical care. A society with a high standard of living has to main- tain a high state of medical-care prepared- ness and in all cases of need must be capable of taking care of every injured and ill person regardless of what has caused his injury or illness. A separate presentation of traffic victims' medical-care costs would immediately bring up the same principle of medical-care cost responsibility attributable to railroads, air- lines, industry, and so forth: in other words, to every sector of society in which a risk of injury and consequent need for medical care can be regarded as being present. WH: Would charging fees for medical care of persons injured in traffic contribute to greater caution in traffic and thus constitute an accident-reducing factor? RA: Maybe. But, in the words of Dr Franz Bauhofer (Director of Health Services, wHo, Copenhagen), "the human right to health carries with it responsibilities which are not always accepted. Lifestyles often defy pre- ventive measures". ■ 29 killed in their prime Here are the photographs of just a few famous people who were killed in the prime of life as a result of traffic accidents. Readers of World Health throughout the world will no doubt think of others Queen Astrid of Belgium was 30 years old when she died in a car crash while on holiday at Kiissnacht, Switzerland, in 1935. (Photo Len Simian ©) James Dean, world famous American film star, was 24 years of age when he died in a car crash near Salinas, California, in 1955. (Photo Len Sirman ©) Pierre Curie, French Nobel Prize winner for Physics in 1903, was run down and killed by a lorry in Paris in 1906, when he was 47 years old. (Photo Len Simian c ) 30 "TO YOUR HEALTH" (Above left) Albert Camus, French author and 1957 Nobel Prize winner for Literature, was 47 when he died in a car crash in the south of France, in 1960. (Photo Len Sirman c ) (Above right) Dr Mohamed Taieb Hachicha (1913-1973), of Tunisia, was posthumously awarded the Shousha Foundation medal and prize by the Twenty-seventh World Health Assem- bly in 1974 for outstanding achievements in international public health. He died in a car crash while on duty travel. (Photo WHO) Isadora Duncan, the legendary American dancer ( 1877-1927), was strangled to death by a long scarf which caught in a wheel of a roofless car on the French Riviera. She is pictured here with her two children, Patrick (left) and Deirdre. Not long after this poignant picture was taken, the two children and their governess were drowned in the Seine, near Paris, when their car plunged off the road. (Photo Len Sirman ©) *At WHO Film The best-selling film in WHO's com- prehensive catalogue is a ten-minute cartoon on alcoholism called "To Your Health" ("Le Verre a la Main"), which has already been issued in 12 languages. The film describes graphically how alcoholic drinks work on the human body. Carried in the bloodstream to the brain, the alcohol acts as an anaesthetic and interferes, in turn, with reasoning power, inhibition, memory, vision, speech and hearing. Eventually mus- cular coordination is affected and a sufficiently large dose can be fatal. The commentary points out that very few people die from taking too much alcohol at one time, but adds: "There are other dangers." A cheerful drunk lurches into his car and succeeds, after several botched attempts, in fitting his key in the ignition. He drives off at speed and a moment later, off-screen, comes the detonation of a car crash. The cartoon is concerned primarily with showing the downward spiral of the alcoholic; what begins as an agreeable social custom can end in addiction, degradation and self-torture. But the vignette of the drunken driver suffices to show that alcohol adds a horrific new dimension to the problem of making road travel safe. "To Your Health" has been made in Danish, English, Finnish, French, Ger- man, Greenlandic, Hungarian, Italian, Japanese, Russian, Spanish and Swe- dish. Directed by Philip Stapp and produced in Technicolour for 35 mm and 16 mm projection by Halas and Batchelor Limited of London, the film may be obtained from The Film Officer, WHO, 1211 Geneva 27, Switzerland. 31 NEWS IN BRIEF Vision and Road Safety The First International Congress on Vision and Road Safety, held earlier this year in Paris, brought together 78 spe- cialists from all over the world to con- sider the mass of evidence indicating that a direct correlation exists between road accidents and poor visual percep- tion. Held under the auspices of WHO and the Prevention Routiere Internationale (PRI), the Congress recommended more intensive research into this correlation, with the object of identifying specific visual performance measures to be used in screening driving licence applicants, and of determining the minimum capability an individual should have for driving safely. This research, it suggest- ed, ought to concentrate on the relation- ship between driving safety and dynamic aspects of visual performance (including dynamic visual acuity, perception of motion, eye movement and fixation capability), overall visual performance under low levels of illumination, and overall visual performance in the pres- ence of glare. As an interim measure, the Congress recommended that, in countries where no control of the visual capacities of driving licence applicants exists, tests should be initiated for visual acuity, visual field, night vision and colour vision. Where weaknesses are con- firmed, the applicants should be directed to see competent eye specialists. Where such controls are already obli- gatory, the practical means of checking on driver vision should be still further perfected, and studies should be carried out into the best ways of checking on night vision. The Congress discussed the quality of road lighting, especially at major cross- roads or where traffic is very busy, the use of white lines or other markings to show road widths, the need for efficient non-glare headlights and signal lights, UKINYVVA POMBE USIENDESHE GARI From Kenya comes this health education pos- ter in Swahili. It says "If you drink pombe (a local beer) do not drive your car". particularly on heavy vehicles, and the design of vehicles so as to permit the driver the best possible field of vision. Individual speakers introduced such topics for discussion as the fact that one-eyed drivers are particularly at risk when overtaking, the need for routine visual screening of older drivers, the ten- dency of older cars and trucks to have scratched windscreens which substan- tially reduce the driver's vision, and the special problems of colour-blind drivers. First Aid: pressing need for mass training Perhaps as many as one in five lives lost on the roads could be saved by sim- ple and effective first aid measures, taken within the first few minutes after the accident. Dr George Blikra, head of the Accident Unit at the Akershus Cen- tral Hospital, Norway, also considers that many injured survivors could make a speedier recovery or have a more suc- cessful rehabilitation if correct first aid could be given in time. Dr Blikra underlined the pressing need for mass training of the general public in lifesaving first aid, during the First International Workshop on First Aid at the Scene of an Accident, held in April at WHO Headquarters in Geneva. The Workshop was arranged by the In- ternational Association for Accident and Traffic Medicine (IAATM) and the League of Red Cross Societies (LRCS). He said : "The great challenge ... is to teach very large segments of the entire population such basic lifesaving mea- sures as opening a victim's airway, per- forming mouth-to-mouth resuscitation, controlling external bleeding, and plac- ing unconscious victims who are breathing in the 'stable side position'. If we could teach all drivers to master these simple procedures, and if we could prepare them mentally for the role of the rescuer in the accident situation, many fatalities in road accidents and in other everyday-life could be avoided." Mr George Bolton, First Aid Adviser with the LRCS, said the priorities taught were: first—breathing: use mouth-to-mouth resuscitation. External cardiac compression should be practised only by properly trained personnel. Second—bleeding: this should be con- trolled by improvised methods if there is no kit available. Improvisation is a vital part of the training given. Finally— treatment for shock : this consists main- ly of carrying out the first two proce- dures and protecting the injured in every way possible, while also reassuring him to allay his fear. The Workshop members heard detailed accounts of the best methods of giving mouth-to-mouth resuscitation, checking bleeding, keeping a person in shock warm and dry, and equipping the ideal first aid kit for all motorists to carry as a matter of routine. As one speaker said : "Who is the modern Good Samaritan? The answer is—You are." 32 UNITED NATIONS: 30TH ANNIVERSARY "May the world of tomorrow be an enjoyable place to live for all peoples of the planet. These aspirations are not unrealistic. It is up to you, it is up to us, to pave the way for a new and better world." UN Secretary-General Kurt Waldheim I hirty years ago this month, out of the chaos of the Second World War, the United Nations was born. Universally acclaimed as a ray of hope for a prosperous and peaceful future, it began life in a mood of euphoria and optimism. Three decades later cynicism has all too often replaced opti- mism as one conflict has suc- ceeded another and little pro- gress has been made in the efforts to improve the lot of large proportions of the world's citizens. Nevertheless, this is no occa- sion to start writing the obituary of the United Nations. Together with its agencies, the UN con- tinues to contribute positively and valuably to a vast num- ber of enterprises around the globe—enterprises which re- flect the most fundamental aims of the UN Charter, namely, to promote higher living stan- dards, to solve the most serious international problems, and to foster universal respect for human rights and fundamental freedoms. Many of the tasks under- taken in the name of the UN, though of intrinsic importance in themselves, are not particu- larly eyecatching and all too often go unnoticed. In keeping with the theme of this month's issue of World Health, we spotlight the work of the Inland Transport Committee of the United Nations Economic Com- mission for Europe (ECE). Greater safety on the roads through international coopera- tion is one of the prime aims of the Committee. Under inter- national agreements adopted by the Committee, road signs, signals and markings have been standardized throughout Europe. ECE regulations have made possible the uniform approval—and international re- cognition of approval—of ve- hicle equipment and parts, including those which have a vital role in safety : lighting and braking systems, direction indi- Dr Kurt Waldheim cators, door latches and hinges, steering mechanisms, seat safety belts, protective helmets and head restraints. Other ECE regulations lay down inter- national requirements for the safe transport of dangerous goods by road. An ECE agreement on the work of crews of vehicles in international road transport— already being applied in many countries—will formally come into force at the beginning of 1976. It governs such questions as driving and rest periods and the minimum age for drivers. Another ECE agreement sets out minimum requirements for the issuing and validity of driv- ing permits, and their inter- national recognition. The Inland Transport Com- mittee is making comparative international studies of the education and behaviour of road users. These studies include the instruction of drivers and road traffic educa- tion in schools. The Committee is also engaged in promoting uniform general speed limits for various types of vehicle and categories of road. ECE is the main source of region-wide information on the European transport situation, and publishes statistics on such subjects as road accidents, and traffic censuses on the inter- national network of E-roads. The Inland Transport Commit- tee's studies, based on ECE statistics, give guidance to those areas where action to reduce road accidents is most urgently neded. ECE's work keeps pace with the transport revolution. The Committee regularly reviews agreements, issues new regula- tions and launches studies to deal with the problems created by the increasing motorization of long-haul transport, the specialization of vehicles and equipment, and the spectacular expansion of private motor traffic. The Committee collaborates closely with a number of other international organiza- tions in the transport field. WHO is associated with ECE in lay- ing down minimum medical standards for drivers, determin- ing the positioning of controls inside vehicles, protecting the occupants in case of collision, and defining acceptable limits of motor vehicle noise and pollution. ■ WORLD HEALTH A bus crash like this in Paris was almost a nine days' wonder back in 1912. Today there are more buses, more cars and lorries, more two- wheelers, more pedestrians even. Traffic moves faster too, except in traffic jams, and the crashes tend to be all the more catastrophic. (Photos Viollet ©) ACCIDENTAL DEATH-THE RAVAGES OF A MODERN PLAGUE Violent death is the outcome of many untoward events—genocide, war, and murder come to mind immediately, not to speak of accidents. We shall confine ourselves here only to the latter, particularly as there are still too many causes, some of which would be amusing if they were not bound with tragedy. Hans Christian Andersen (1805-1875), the great Danish storyteller, suffered a serious injury falling from his bed. The Italian writer Pietro Bacci (Aretino) (1492-1 556), a penetrating observer of his period, was killed when the chair in which he was sitting fell backwards! In the contemporary world, such causes are insign- ificant compared with road accidents, the plague of the 20th cen- tury. It is of course true that the horse and carriage have always been sources of accidents but these resulted in the death or disability of only a single rider or of a few travellers when a horse-drawn carriage overturned. The advent of steam brought with it slaughter on a much larger scale, mainly owing to the striving for speed— a new form of addiction that has been described as the eighth deadly sin. On 8 May 1842, a train on the Paris-Versailles line was derailed and a fire followed; more than 150 passengers were killed. By a strange twist of fate, the French navigator Dumont d'Urville, who had just returned from perilous explorations in the South Seas, was among those burned alive. No country was spared by such disasters and public opinion naturally became seriously aroused. Its concern and indeed consternation were reflected in the strident and often violent demands for adequate safety measures. The invention of the automatic airbrake in 1869 by the American engineer George Westinghouse eliminated one of the basic causes of rail accidents. Goaded on by public clamour, train designers and builders, railway companies and governments succeeded by the end of the 19th century in making trains what they still remain today, the safest means of transport. For steam- driven stage-coaches, the reaction was even more violent. In 1834, one of these vehicles exploded on a Scottish country road, killing fivcy passengers. The outcome was no less than a total ban on these contraptions! Our forefathers had a deep-seated horror of accidents, a feeling the French writer Jean Cocteau has so well described in the following terms: "The horror aroused by an acci- dent that one encounters on the road derives from its image of immobilized speed and a scream transformed into silence". With the replacement of steam by petrol, our 20th century has undergone profound changes, but it is not certain that we know the precise significance of these changes. There is however one new feature characteristic of accidents today: for the driver at the wheel accidents are individual, as at the time when the horse was the basic means of transport, and yet they also strike on a mass scale (if one considers the overall toll exacted by road accidents) —as at the time of the first railways. What has changed is the sum total of human lives lost, for the locomotive never killed anything like the number of persons who now die as a result of road traffic accidents every year. The total world figure is now in excess of 250,000! It has been said that the 20th century is up to the ankles in blood; at any rate it bears the responsibility for causing a calamity worse than the most terrible epidemics of the Middle Ages. And the veritable novelty is the manner in which public opinion accepts the slaughter as if it were due to a natural disaster, like a cyclone or an earthquake! One takes the road fully aware that, for thousands of other motorists, there will be no homeward journey... Just like the soldier who summons up his courage before the attack by repeating to himself that he personally will emerge unscathed from the hail of bullets, we all assume that it is others who will be involved in accidents, never ourselves. It would seem that the horror evoked by Cocteau is easily sur- mounted since the authorities encounter devious forms of resistance to the safety measures they introduce. And the mass of the public attend imperturbably to their affairs while the individual accepts that "something has to be left to Destiny". On the grounds of pure sanity alone, no one would accept this form of apathy that is so contrary to the deepest elements of human nature. What we should attempt to do is to revive the far more appropriate reactions of earlier times and bring about the reversal of attitudes that Dante (author of that eternal masterpiece, The Divine Comedy) in another context termed "the great refusal" (ii gran rifiuto). The health services have their role to play in this return to common sense. They will of course not succeed in eliminating accidents any more than they have eliminated death. But by further improving studies on the circumstances and causes of accidents and by developing preventive measures, including the information and the education of the public, they will contribute to reducing the role of fate in violent death to the low share that is its due. R. Bouissou Before the days of the "horseless carriage", journals and newspapers could rely on a train crash to horrify their readers. This was an artist's impression of an encounter between two trains near Arras, France, in 1864. 34 VAN LEEUWENHOEK (1632-1723) I I ANTONJ VAN LEEUWENHOEK'S WORK IN DELFT, HOLLAND, ON MICROSCOPIC LENSES STRONG ENOUGH TO ENABLE HIM TO SEE AND DESCRIBE TINY ORGANISMS EVENTUALLY MADE HIM FAMOUS; HE SENT 26 MICROSCOPES TO LONDON, AND IN 1680 BECAME A FELLOW OF THE ROYAL SOCIETY. THE DIRECTORS OF THE EAST INDIA COMPANY SENT HIM SPECIMENS TO STUDY. BUT PERHAPS THE PROUDEST MOMENT OF HIS LONG LIFE HE WAS AGED 91 WHEN HE DIED—OCCURRED IN 1689 WHEN THE TSAR, PETER THE GREAT OF RUSSIA, WHO WAS PROFOUNDLY INTERESTED IN THE "NEW SCIENCES", CAME IN PERSON TO VISIT HIS COLLEC- TION OF MICROSCOPES, LENSES AND DETAILED SKETCHES. Authors of the month Dr LEO A. KAPRIO is Director of wHo's Regional Office for Europe in Copenhagen. Dr LENNART LEVI is Director of the wuo Psychosocial Centre at the Karolinska Institute in Stockholm. Mr VIGGO CHRISTENSEN is a Danish free-lance journalist. Dr WALTER A. Cui ihR was formerly Director of the Center for Safety at New York University, and is Profes- sor Emeritus of Education and of Traffic Program Management. Mr RUNE ANDREASSON is Executive Secretary-General of the Interna- tional Association for Accident and Traffic Medicine (IAATM), Stock- holm. Dr R. Bouissou is a French Navy physician and author of "A History of Medicine" SCIENTISTS KEPT FINDING NEW TECHNIQUES FOR IMPROVING LENSES AND MOUNTING THEM IN TUBES, USUALLY OF BRASS. THE ALL-BRASS INSTRUMENT PICTURED HERE WAS MADE BY WILLIAM CARY (1759-1825) WHO STARTED AN OPTICAL BUSINESS IN LONDON. IT HAS A TRIPLE SYSTEM OF LENSES FOR THE EYEPIECE MOVED BY A SMALL WHEEL FOR ACCURATE POSITIONING, WHILE THE LEGS AND STAND FOLD UP SO THE INSTRUMENT CAN BE PACKED INTO A FLAT BOX. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: IN 1927, HANS BUSCH OF GERMANY SHOWED THAT ELECTRONS CHAR- GED PARTICLES—IN A MAGNETIC FIELD CAN BE ARRANGED LIKE A LENS SO AS TO DIFFRACT LIGHT JUST AS A LENS OF GLASS DOES. BY 1940 AN ELECTRON MICROSCOPE HAD BEEN PUT ON COMMERCIAL SALE IN THE USA, THE BEST ORDINARY MICROSCOPE IS USELESS FOR OB- JECTS SMALLER THAN ONE-THOUS- ANDTH OF A MILLIMETRE. BUT THE ELECTRON MICROSCOPE CAN IN THEORY GIVE A MAGNIFICATION OF MORE THAN 100,000, THAT IS, 10,000 TIMES MORE THAN THE "LIGHT" MICROSCOPE. TODAY SCIENTISTS CAN ACTUALLY WATCH, FOR EX- AMPLE, THE ACTIVITIES OF TINY ORGANISMS CALLED BACTERIO- PHAGES, VIRUSES WHICH CAUSE FATAL "DISEASES" TO BACTERIA. US$* £ • Swir.* One year 8.75 3.75 25.- Two years 15.75 6.75 45.- Three years 21.— 9.— 60.— One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland 35 ie s R eu ni e s S. A . La u sa n ne S w itz er la n d Att ki:ira med hjalm är att kiira med insidan av huvudet. Calculated to startle the public, this Swedish road safety poster says: A driver who wears a helmet is using his brain wisely. 41I N ° 39 16 October 1975 Chess Club A course for beginners, organized by the WHO Chess Club, will start on 29 October and run for 8 weeks. A course will be held each Wednesday at 5.15 p.m. and lectures on all aspects of chess will be given with the aid of a chess demonstration board, together with practical advice on actual playing situations. The cost of the whole course is Fr. 10.- and if you would like to attend, please send your name to Ms D.A. Fresle, President, WHO Chess Club, Office 4165. Petit Palais Museum The management of the Petit Palais museum at Geneva is offering to international civil servants a "group" entry card entitling them to an unlimited number of visits during the year at a price of lOfr. per card. WHO staff members who would like to obtain this group entry card for 1976 (valid from this autumn) are requested to enrol and pay for the card at the Staff Association Secretariat, office E-111, not later than 31 October 1975, between 10 - 12 and 2 - 3 p.m. only. Ralph J. Bunche Residential Centre at Bianco (Calabria, Italy) We have received new documentation on the layout of the project for international civil servants at Reggio (Calabria, Italy). This can be consulted at the Staff Association Secretariat, office E-111. English Week at the Restaurant The restaurant has asked us to announce that an English Week will be organized at the Restaurant francais, Self-Service and Cafeteria from 20 to 24 October 1975. T.S.V.P. STAFF ASSOCIATION ASSOCIATION DU PERSONNEL 41/t4/000 No 39 16 octobre 1975 Club d'Echecs Le Club d'echecs organise un cours pour debutants, des le 29 octobre, pour une duree de 8 semaines. Les cours auront lieu chaque mercredi a 17 h.15 et des exposes sur les echecs seront donnes a l'aide dun echiquier de demonstration, ainsi que des conseils pratiques sur des situations concretes du jeu. Le prix du cours complet est de Fr. 10.-. Les personnes interessees voudront bien envoyer leur inscription a Mlle D. A. Fresle, Presidente du Club d'echecs, bureau 4165. Musee du Petit Palais La Direction du Musee du "Petit Palais" a Geneve offre aux fonctionnaires internationaux la carte d'entree "de groupe" donnant droit a un nombre illimite de visites durant l'annee, au prix de Fr. 10.- par carte. Les membres du personnel de l'OMS qui desireraient obtenir cette carte d'entree de groupe pour 1976 (valable des cet automne) sont pries de s'inscrire jusqu'au 31 octobre 1975 et de payer le prix de la carte au Secretariat de 1'Asso- ciation du Personnel, bureau E-111, exclusivement de 10 a 12 heures et de 14 a 15 heures. Centre residentiel Ralph J. Bunche (Calabre/Italie) Nous avons recu une nouvelle documentation sur le projet de lotissement pour fonctionnaires internationaux a Reggio (Calabre, Italie). Elle peut etre consultee au Secretariat de l'Association du Personnel, bureau E-111. Semaine anglaise au Restaurant Le restaurant nous prie de communiquer qu i ll organise au Restaurant francais, au self-service et a la cafeteria une semaine anglaise du 20 au 24 octobre 1975. P.T.O. STAFF ASSOCIATION ASSOCIATION DU PERSONNEL