Increasing motor vehicle use is now a major threat to the quality of urban life in many parts of the world. Motor vehicles kill thousands of pedestrians and cyclists daily, disabling tens of thousands more. With rising road danger, everyday walking and cycling is declining in popularity and this may be a factor in the obesity epidemic, particularly in the Western world. Against this backdrop, it would seem appropriate that public health and health services are judged against the criterion not only of improving well-being but also of reducing inequality and preventing environmental degradation.
Trauma is a disease of poverty. Although anyone can be the victim of a violent attack or a road traffic accident, the risk is much higher for the most disadvantaged. In the UK, children in the lowest social class are 20 times more likely to be injured as pedestrians than those in the highest social class1. The strong link between road trauma and poverty is also seen in low- and middle-income countries, where people who will never own a car represent the majority of traffic victims2. The injuries sustained can be a cause of poverty as well as a consequence. A study in Bangladesh found that many households were made destitute by the death or injury of a family member in a road traffic crash. Medical costs, funeral costs and the loss of family income can lead to decreased food consumption, a fall in living standards and increased indebtedness3.
Ensuring that walking and cycling are the safest, most enjoyable and most convenient modes of urban transport is critical for improving health, reducing inequality and ensuring ecological sustainability. Meeting greenhouse gas emission targets in the transport sector requires substantial increases in walking and cycling with corresponding reductions in car use. Based on the evidence linking physical activity and health, it is estimated that the necessary increases in walking and cycling would dramatically cut rates of chronic disease, with around 10–20 per cent less heart disease and stroke, 12–18 per cent less breast cancer and 8 per cent less dementia4. Sustainable transport would also improve mental health with an estimated 6 per cent less depression. Reducing the speed and volume of traffic in urban areas is the cornerstone of reducing danger on the roads. Doctors can play an important advocacy role by working with victim organizations in calling for road danger reduction5.
The evidence base for the prevention of road traffic accidents is strong and the major obstacles to prevention are largely political. When it comes to providing effective healthcare for trauma victims, however, the evidence base is weak and we cannot be sure that even current treatment protocols do more good than harm6. The Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) 2 trial7 recently showed that providing reliable evidence about the effectiveness of emergency trauma care is possible. This study recruited 20 211 patients from 274 hospitals in 40 countries and demonstrated that tranexamic acid safely reduced mortality. If given promptly, this inexpensive treatment can reduce the risk of bleeding to death by about a third8. Economic analysis showed that tranexamic acid administration was highly cost-effective in high-, middle- or low-income countries9. If all injured patients with significant bleeding around the world were given tranexamic acid, this could avoid more than 100 000 premature deaths each year. On the basis of the results of the CRASH-2 trial, tranexamic acid has been included on the World Health Organization's list of essential medicines. Its benefits to human health have clearly outlived patent protection. Indeed, because strong scientific arguments can be made that it could also improve outcomes in other types of bleeding, further clinical trials are either planned or under way in life-threatening postpartum, gastrointestinal and intracranial bleeding.
The identification of a highly cost-effective treatment for traumatic bleeding could and should benefit some of the most disadvantaged people in the world. Regardless of impact on economic growth, the ability to avoid premature death from traumatic injury clearly adds to human development. These benefits will not be realized, however, without concerted efforts to ensure that results are disseminated and the drug is freely available. At the same time, in settings where global economic injustice imposes major resource constraints, it must be acknowledged that if a larger health gain can be achieved through a different use of the same resources then, all other things being equal, the alternative use should be prioritized10.
There are some important threats to evidence-based trauma care. The increasing off-label use of recombinant activated factor VII (rFVIIa) is a shameful example of how patient interest is poorly served by unreliable evidence and unethical marketing. There is no evidence from randomized controlled trials that rFVIIa improves survival of injured patients with significant haemorrhage11. There is evidence, however, that rFVIIa increases the risk of arterial thrombosis12. Despite the lack of proven efficacy, serious safety concerns and the high cost, extensive marketing through the medical literature has resulted in rising off-label use13, 14. At the same time, tranexamic acid, which is safe, effective and inexpensive, is hardly used outside specialist trauma centres. These facts show clearly that the availability of reliable evidence is necessary but not always sufficient to reduce the burden of suffering from trauma and that ensuring medical knowledge is used for the benefit of patients requires the ongoing commitment of trauma care professionals around the world.