Road traffic deaths in sub-Saharan Africa are predicted to rise by 80% by 2020, according to a World Bank report, which found the region to have the highest number of accidents, but the fewest vehicles on the road.
An estimated 24.1 people per 100,000 are killed in traffic accidents every year, according to the bank. Younger and poorer people are disproportionately vulnerable: accidents on the road are expected to become the biggest killer of children between five and 15 by 2015, outstripping malaria and Aids.
“The poorest communities often live alongside the fastest roads, their children may need to negotiate the most dangerous routes to school and they may have poorer outcomes from injuries, due to limited access to post-crash emergency healthcare,” the report says.
Aside from the obvious distress caused by accidents, sub-Saharan Africa’s high-risk roads have a significant economic impact too. Crashes are estimated to cost African countries between 1 and 3% of their GNP each year, the report finds.
Roads and disease: common ground
While there are a “whole bundle of different drivers” behind the rise in road accidents and NCDs, some of the causes show remarkable parallels, Dr Jill Farrington, the former Europe co-ordinator for the World Health Organisation’s NCD programme and the report’s co-author, says.
The shift towards urbanisation is a case in point. City residents typically take less exercise, triggering diabetes and cardiovascular problems. Rising incomes are driving demand for processed foods that are higher in sugar, fat and salt. The same factors result in increased car use and ownership, and more traffic accidents.
Alcohol consumption links the two. Though seven in 10 adults abstain from drinking alcohol in sub-Saharan Africa, those who do have the highest prevalence of heavy episodic drinking globally, the report says.
A lack of data makes it difficult to determine the extent to which traffic accidents are caused by alcohol. However, a study of police reports in Nigeria between 1996 and 2000 found that half of all car crashes involved drink-driving.
There is growing awareness of NCDs. Between 2001 and 2008, funding for cancer, heart disease and diabetes in developing countries grew sixfold. In 2011, the UN held a major summit on the theme. Even so, programmes to combat NCDs comprise less than 3% of global development assistance.
The lion’s share of public health spending and health-related donor aid goes to infectious diseases, particularly malaria, tuberculosis, and HIV and Aids. Policies and intervention to tackle these “big three” diseases are typically managed through separate “vertical” systems. The authors of the World Bank report argue that this silo approach is often counterproductive and co-ordinated health programmes are needed.
The logic of a more holistic healthcare system is compelling, says Farrington: “If cars get faster on the roads and it’s unsafe, it will actually reduce walking and cycling, which will then have consequences for the development of obesity.”
There are practical arguments for a more integrated approach to disease interventions too. Many African countries have agreed to continent-wide commitments to combat NCDs, but they lack the resources to tackle each individually.
With the financial downturn, additional aid is unlikely, Farrington says. “The concern would be that if these [commitments] are all implemented separately, it would need resources and capacity beyond what is available.”
The report flags up early examples of where integrated, or “horizontal”, thinking is emerging. In Botswana, for example, health facilities set up for patients with HIV and Aids are being used to carry out screening and vaccinations for the human papilloma virus.
South Africa has developed a similar approach. Eight of the top 10 diagnoses in primary care are respiratory conditions. These relate as much to NCDs such as acute bronchitis or asthma as they do to infectious diseases such as TB and HIV. As a result, nurses are being trained to adopt a people-centred, rather than a disease-focused, approach to diagnosis.
“We wouldn’t be able to run a health system in the UK or any other so-called developed country that has these vertical programmes running right through it,” Dr Kalipso Chalkidou, international director at the London-based National Institute for Health and Care Excellence, says.
The aid sector’s obsession with targets is seen as a reason for the persistence of disease-specific policies; it is easier to measure vaccinations than calculate how many people have access to healthcare, Chalkidou says.
“Those who champion this individual approach to diseases and conditions should try and think more laterally,” she says. “It [integrated health provision] is going to happen, but how it’s going to happen and whether everyone involved is keen to make it happen is another question.”