Leveraging the surgeon’s role in health policy to address global road traffic injury

Given its staggering health and economic burden, road traffic injury (RTI) prevention is one of the top public health and surgical disease priorities worldwide.¹ According to the World Health Organization (WHO), road traffic collisions (RTC) account for approximately 1.35 million fatalities around the world every year, are the leading cause of death for children and young adults ages five to 29 years old, and are the eighth leading cause of death for people of all ages. Furthermore, the WHO estimated in 2018 that 20 to 50 million additional people sustain nonfatal injuries annually, causing substantial disability. Such injuries result in massive economic losses not only for the individual and their family, but also for their communities and nations in terms of treatment costs, loss of wages, and decreased productivity. In total, the WHO estimates that RTC and RTI cost most countries a staggering 3 percent of their annual gross domestic product.²

Because victims of RTI consistently rely on surgical assessment and intervention, who better than surgeons to advocate for these patients and the health care system in which we operate every day? Surgeons have the opportunity to play a valuable role in addressing the burden of RTI, as 38 percent of surgically treatable disease is related to trauma.1 We have an intimate understanding of the injury mechanisms, trauma patterns, and associated clinical outcomes and are, therefore, well-equipped to advocate for prevention and enhancing health care systems policies. Certainly, we provide the distinct perspective of witnessing the direct impact of policymaking on our patient population. However, the added familiarity of how policy also affects health care management and practice environments places the surgeon in an ideal position to address misaligned policy from disconnected political actors.³ In addition, surgeons function within a team-forward health care system on a daily basis and, therefore, are experienced in the multidisciplinary and intersectional approach needed to develop health policy. Because surgeons advocate not only on behalf of our patients and communities, but also on behalf of the medical profession (specifically in the cases of billing and payment reform), many health care professionals consider it their duty to leverage this unique position to translate practice into policy.

An evidence-based approach

After having navigated the academic surgical training paradigm, most surgeons are familiar with the necessary research, dissemination, and implementation process that drives an evidence-based approach to policy development. One example of a surgeon-driven, evidence-based methodology is the widespread use of trauma registries. In both local and global settings, these registries have proven to be critical sources of information for burden assessment, resource allocation, quality improvement, and injury prevention.^4-6 The development and operation of trauma registries highlights an example of how surgeons can use the surveillance of trends and assessment of local trauma burden to inform RTI prevention policy.

For instance, a typical trauma registry captures epidemiological data, including mechanism of injury, presence of alcohol or other substances, and whether safety devices (such as helmets, seat restraints, and so on) were used.⁷ In some cases, time and location of the traumatic event, and length of time from event to treatment, may be recorded and can provide insight into systematic delays in access to care. Exploration of these variables in combination with clinical data, such as injury severity and complications, draws attention to associations that can inspire actionable, multidisciplinary, public health programs. The surgeon-advocate is endowed with the requisite skills and experience to direct the implementation of trauma registries and to extrapolate the findings to support a meaningful, evidence-based approach to policymaking.

Injury prevention and control

In recognition of road safety as a priority in the Sustainable Development Goals, the United Nations General Assembly and WHO launched the Decade of Action for Road Safety in 2011.⁸ The initiative targeted five areas in which improvement was theorized to reduce the burden of RTI and deaths using methods of injury prevention and control: health care services, management of road safety, road network safety, vehicular safety, and road safety legislation. This collaboration was intended to standardize and enforce traffic rules and prevention measures internationally, while providing the framework for policy, practice, and advocacy. The Decade of Action for Road Safety 2011–2020 set the foundation for the WHO to publish recommendations for global stakeholders to adopt legislation that addresses key road safety risk factors: speeding, driving while intoxicated, helmet use, safety restraint use, and distracted driving.² Shortly thereafter, the Lancet Commission on Global Surgery (LCoGS) reiterated the growing burden of surgical disease and proposed a number of health system metrics for addressing the crucial worldwide need.⁹ The 2015 LCoGS report called on surgeons to commit to the research of, investment in, and advocacy for, policy that would prioritize universal access to safe, timely, affordable surgical care, including treatment required for severe RTI.

Keeping in line with the agenda put forth by the Decade of Action, the WHO recommendations for RTI prevention and control, and the LCoGS’s call to action for global surgeons, the American College of Surgeons (ACS) continues to advocate for universal helmet laws in the U.S. In response to the 1966 Highway Safety Act, universal motorcycle helmet laws were initially adopted by up to 47 states. However, many states slowly repealed these universal mandates over the last four decades as federal policy shifted. The ACS has consistently opposed legislation to repeal these laws, noting the impact of helmets in reducing injury severity and mortality for our patients, and in decreasing economic burden in terms of lost wages and productivity, as well as the cost of uncompensated care.¹⁰

On the global stage, while motorization (and subsequently, RTI) of low- and middle-income countries (LMICs) expanded exponentially over the last few decades, corresponding improvements in road safety and prevention strategies and acute trauma care lagged behind. Spurred on by the Decade of Action, LMIC stakeholders and global surgeon-advocates were encouraged to accelerate the adoption of effective policy regarding road safety. As one example, mandatory helmet laws in India previously exempted women from required helmet use on motorized two-wheelers. After persistent evidence-based advocacy from public health officials and surgeon-advocates, notably citing the fatal consequences of gender bias, the government announced plans to withdraw the exemption in 2020.^11,12

The surgeon’s specialized experience in triaging and treating traumatic injuries qualifies us to promote and advocate for proven injury control interventions to inform policy change. For instance, it has been projected that bystander first aid has the potential to increase survival from RTC, on the order of 1,000–2,000 possible lives saved annually in the U.S. alone.¹³ Specifically, studies have reported that the use of prehospital tourniquets is associated with decreases in blood transfusions, limb complications, and mortality from hemorrhagic shock.^14-15 For this reason, the ACS Committee on Trauma developed the STOP THE BLEED^® campaign, a comprehensive program designed to teach the civilian population how to provide crucial initial response to stop uncontrolled bleeding in traumatic emergency situations. Although initially developed as part of the Hartford Consensus with mass shooter incidents in mind, the STOP THE BLEED^® program is considered to be beneficial in any traumatic emergency situation where uncontrolled bleeding may occur, including RTC.^16,17

As part of the effort to eliminate preventable death from bleeding, the ACS has publicly endorsed legislation to provide states with grant funding for training workshops and widely available bleeding control kits.18,19 A layperson armed with the knowledge, preparation, and tools to stop uncontrolled bleeding could result in lifesaving action at the scene of RTC, before emergency medical services even arrive.¹³ In this scenario, the experience of the surgeon-advocate allowed for the identification of both a point of intervention and evidence-based support for legislation.

Strengthening surgical systems

As LCoGS noted, the disproportionate burden of surgical disease is borne by LMICs, yet these countries have the lowest operative volumes, and most of their populations lack access to basic surgical care.⁹ Despite the efficacy of many local and global RTI prevention strategies, the success of such policy is limited unless deficiencies in the health care system also are addressed.20,21 While standardizing traffic laws, helmet mandates, and basic requirements for road infrastructure do aid in reducing the overall burden of RTI, these prevention strategies have little impact on injury control efficacy (that is, whether the injured patient has access to timely, effective, and affordable surgical treatment). In this light, it is evident that policy must also work to strengthen health systems with respect to improving prehospital care, addressing barriers to accessing timely and adequate surgical services, and building surgical workforce capacity.

Around the world, injured patients often lack access to hospitals with adequate surgical capacities and, therefore, frequently experience significant and sometimes fatal delays in care. Depending on the mode of transportation (in many LMICs, patients rely on fractured ambulance systems or inconsistent public transportation), the closest facility with the appropriate level of specialized surgical care can be several hours or even days away.²² Once an injured patient has arrived at the nearest hospital, they still may not be guaranteed adequate surgical care for their injuries and may be transferred to yet another facility.

The 2015 LCoGS analysis of the WHO Emergency and Essential Surgical Care Situational Analysis Tool database demonstrated that the proportion of first-level hospitals that could provide appropriate surgical treatment for open fracture was a mere 40 percent.9 Although many facilities in resource-limited settings may employ the appropriate number of surgery and anesthesia providers, they continue to be plagued by structural deficits—unreliable electricity, variable supplies of oxygen and running water, limited access to blood banks—that render the ability to provide safe and timely surgical care inadequate.⁹

Surgeons’ intimate experience with such systemic shortfalls places them in an ideal position to contribute to policy change that will address inadequacies for injured patients. For instance, the College of Surgeons of East, Central and Southern Africa (COSECSA) Strategic Plan for 2021–2025 highlights the importance of including surgeon-advocates in policymaking that addresses matters of surgical care, systems strengthening, and national surgical plans. The COSECSA plan to improve quality in surgical care notes that surgeons have the ability to make meaningful contributions to policymaking platforms because of evidence-based research and practical insights.²³

ACS takes on universal challenge

Though LMICs face significant challenges, insufficient access to surgical care is a universal problem. Within the U.S., a growing shortage of general surgeons in rural areas is a critical component of our nation’s health care workforce shortage. For instance, a patient with severe RTI in a remote area often requires transfer to another region or state to access the specialized surgical services required to treat their injuries. Such transport, often by air, results in increased costs and use of resources, delays in treatment, and, consequently, suboptimal outcomes for the patient. In light of the increasing evidence of these disparities in surgical care for the rural U.S., the ACS continues to advocate for legislation to address this crucial need. Surgeon-advocates have publicly endorsed the Ensuring Access to General Surgery Act of 2019, H.R. 1841/S. 2859, which calls for research to explore workforce data in order to accurately define surgical shortage areas and thereby inform policy to better address the deficiency.²⁴ In addition, the ACS worked with the House Ways and Means Committee Health Task Force on Rural and Underserved Communities in 2019 to educate policymakers on the challenges of surgical shortages and trauma care in rural America.²⁵ Previously, health care professional shortage areas have not been designated based solely on regional shortages of surgical capabilities and, therefore, the contribution of surgeon-advocates to the conversation has made access to surgical care a vital part of local health care systems strengthening policy.

Conclusion

The global burden of RTI is a pressing public health and surgical disease priority. With the requisite experience in multidisciplinary, intersectoral, and evidence-led approaches, surgeons are well-suited to function as public health professionals in advocating for prevention and intervention strategies aimed at reducing the economic and health impacts of RTI for our patients. Surgeons also should seek to incorporate a multidimensional approach to health and specifically strengthening health systems to ensure that victims of RTC can experience the best possible outcome. Because patients with severe RTI rely on access to safe, timely, and affordable surgical care, surgeon-advocates must leverage our unique position to inform the translation of practice to meaningful policy change to achieve those standards universally.

References

1. Jamison DT, Breman JG, Measham AR, et al. Disease Control Priorities in Developing Countries (Second Edition). Washington, DC: The International Bank for Reconstruction and Development/The World Bank; New York: Oxford University Press; 2006.
2. World Health Organization. Global status report on road safety 2018. Available at: www.who.int/publications/i/item/9789241565684. Accessed July 27, 2021.
3. Khatana SA, Patton EW, Sanghavi DM. Public policy and physician involvement: Removing barriers, enhancing impact. Am J Med. 2017;130(1):8-10.
4. Mitchell R, Williamson A, Curtis K. What is the potential of trauma registry data to be used for road traffic injury surveillance and informing road safety policy? J Safety Res. 2011;42(5):345-350.
5. Rosenkrantz L, Schuurman N, Hameed M. Trauma registry implementation and operation in low and middle income countries: A scoping review. Glob Public Health. 2019;14(12):1884-1897.
6. Cameron PA, Gabbe BJ, McNeil JJ, et al. The trauma registry as a statewide quality improvement tool. J Trauma. 2005;59(6):1469-1476.
7. American College of Surgeons Committee on Trauma. National Trauma Data Bank: NTDB Research Data Set User Manual and Variable Description List; 2018. Available at: www.facs.org/~/media/files/quality-programs/trauma/ntdb/ntdb-rds-user-manual-all-years.ashx. Accessed June 24, 2021.
8. United Nations General Assembly. Resolution adopted by the General Assembly: 64/255: Improving global road safety. New York: United Nations, 2010.
9. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
10. American College of Surgeons. Statement in Support of Motorcycle Helmet Laws, 2015. Available at: https://bulletin.facs.org/2015/05/statement-in-support-of-motorcycle-helmet-laws/. Accessed June 27, 2021.
11. Swaroop M, Marie Siddiqui S, Sagar S, Crandall ML. The problem of the pillion rider: India’s helmet law and New Delhi’s exemption. J Surg Res. 2014;188(1):64-68.
12. Gupta A, Jaipuria J, Bagdia A, et al. Motorised two-wheeler crash and helmets: Injury patterns, severity, mortality and the consequence of gender bias. World J Surg. 2014;38(1):215-221.
13. Ross EM, Redman TT, Mapp JG, et al. Stop the Bleed: The effect of hemorrhage control education on laypersons’ willingness to respond during a traumatic medical emergency. Prehosp Disaster Med. 2018;33(2):127-132.
14. Smith AA, Ochoa JE, Wong S, et al. Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications. J Trauma Acute Care Surg. 2019;86(1):43-51.
15. Teixeira PGR, Brown CVR, Emigh B, et al. Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury. J Am Coll Surg. 2018;226(5):769-776.
16. Jacobs LM, Jr. Joint Committee to create a national policy to enhance survivability from mass casualty shooting events: Hartford Consensus II. J Am Coll Surg. 2014;218(3):476-478.
17. Jacobs LM, McSwain NE, Jr., Rotondo MF, et al. Improving survival from active shooter events: The Hartford Consensus. J Trauma Acute Care Surg. 2013;74(6):1399-1400.
18. Hoyt DB. ACS letter of support for the Prevent Blood Loss with Emergency Equipment Devices (BLEEDing) Act of 2020. Available at: www.facs.org/-/media/files/advocacy/federal/prevent_bleeding_support_letter_senate_021920.ashx. Accessed June 24, 2021.
19. Jacobs L, Burns KJ. The Hartford Consensus to improve survivability in mass casualty events: Process to policy. Am J Disaster Med. 2014;9(1):67-71.
20. Hung YC, Bababekov YJ, Stapleton SM, et al. Reducing road traffic deaths: Where should we focus global health initiatives? J Surg Res. 2018;229:337-344.
21. Moroz PJ, Spiegel DA. The World Health Organization’s action plan on the road traffic injury pandemic: Is there any action for orthopaedic trauma surgeons? J Orthop Trauma. 2014;28 (Suppl 1):S11-S14.
22. Nielsen K, Mock C, Joshipura M, et al. Assessment of the status of prehospital care in 13 low- and middle-income countries. Prehosp Emerg Care. 2012;16(3):381-389.
23. College of Surgeons of East, Central and Southern Africa. COSECSA Strategic Plan 2021–2025. Arusha, Tanzania, 2021. Available at: www.cosecsa.org/wp-content/uploads/2021/01/COSECSA-Strategic-Plan-2021-2025-1.pdf. Accessed June 24, 2021.
24. Hoyt DB. ACS Letter of support for the Ensuring Access to General Surgery Act, 2019. Available at: www.facs.org/-/media/files/advocacy/federal/ensuring_access_general_surgery_act_2019_support_letter_house.ashx. Accessed June 24, 2021.
25. Hoyt DB. ACS response to the Rural Health Request for Information, 2019. Available at: www.facs.org/-/media/files/advocacy/federal/rfi_rural_health_response_letter.ashx. Accessed June 24, 2021.