A bit of a bump on the head

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A few years back I visited Vietnam with my brother for a long weekend break. Never been before. First impressions all good…airport clean and organised well set up for tourists and we left to get the taxi to our modestly priced hotel and there was a shock.

Thousands upon thousands of motorbikes and scooters. And every single person, driver and passenger, was wearing a helmet. Every. Single. Person. There were no exceptions and in the days we spent there I never saw anybody on a scooter or motorbike not wearing a helmet. The few cyclists wore them as well.

The helmet revolution started with Resolution 32 in 2007 when the government decreed that all riders of scooters and motorbikes wear a helmet in an effort to reduce the spiraling numbers of injuries and fatalities resulting from what for the most part were low-speed and low-impact accidents. The new law was not popular, but was enforced nationally and fatalities dropped quickly and have stayed low. This requires some serious maintenance on the part of the government, with public awareness raising campaigns and consistent application of swingeing penalties for serial offenders.

Low and middle-income countries suffer 90 percent of the world’s road traffic fatalities, in large part because so many road users rely on two-wheeled vehicles. As of August 2008, there were more than 26 million registered vehicles in Viet Nam, and 95% were motorised two-wheelers. There were almost 9000 new motorcycles on the road each day. An estimated 60% of all road traffic fatalities occurred among motorcycle drivers and passengers. It is worth noting that in 2017 the government planned to ban all two-wheeled transport from Hanoi, the capital city, by 2030.

Pakistan, present day. In the family section of the house lies my sister-in-law. She is a senior community health worker managing primary health care delivery in a remote and under-resourced part of Cholistan. She often goes to work riding the back of one of the many motorbikes that ply between Feroza and her home village. The bike got back-ended in a low-speed low-impact accident. She came off, injuring her knees and hands. And banging her head on the road. Sans helmet. She has not been recovering as quickly as might be expected and we are awaiting the results of an MRI scan as all is not well in her head. She feels it and the doctors are uneasy.

Legislation requiring the wearing of helmets in Pakistan came into force a little over two years ago. People mocked the new law, and the media was littered with pictures of motorcyclists with saucepans and other kitchenware on their heads. Helmet shops inflated their prices and the traffic police who were responsible for enforcement were briefed nationwide as to their responsibilities – which were clearly beyond their capacity everywhere in terms of enforcement, and they said so.

Two years ago a dear friend died as the result again of a low speed and low impact crash. Sister Violet, Mother Superior of the Dominican Convent in Bahawalpur was sidesaddle on a bike in Karachi, caught in an accident and thrown off. Her only injuries were to her head and were so severe that she never regained consciousness. Doctors were clear – had she worn a helmet she would have survived, probably with minimal injury. A good woman died needlessly.

Cut to academia. I make no apology for quoting at length from the most recent study I could find, based on data collected in Karachi between January 2007 and September 2013. Please read carefully – ‘We estimated likelihoods of death and severe injury in riders wearing helmets compared to those not wearing them. Results: Only 6% (n = 6,092) of the 109 210 riders wore helmets. Helmet wearing was about 1% in pillion riders, women, and children. About 2% of riders died (n = 1,949) and 15% (n = 16,051) were hospitalized. About a third of riders (n = 37,439, 34%) suffered from head injuries, 30% (n = 33,130) had facial injuries, 46% (n = 50,264) had extremity injuries, and 61% (n = 67,094) had external body injuries. Those wearing helmets were less likely to die (adjusted odds ratio [aOR] = 0.37, 95% confidence interval [CI] = 0.28–0.50) or sustain a severe head injury (aOR = 0.70, 95% CI = 0.55–0.89) than others. The preventive effects however disappeared in high-impact collisions, e.g. heavy vehicles, head-on. Conclusion: Helmets effectively reduced the likelihood of deaths and serious head injuries in the injured motorcyclists in Pakistan. Improving legislation and enforcement could help further prevent deaths and serious head injuries in Pakistan.’ This was published in the journal ‘Cogent Medicine’ in 2018.

Up against this body of evidence is a powerful and thus far dominant force – kismet. Fate. It is written. What will be will be. The national sense of fatalism that runs through the population, beating common-sense and objective research into hapless submission. A silent and elemental force that trumps all arguments. An acceptance of a daily cull of dead and injured, with the injured representing an incalculable on-cost in terms of lost livelihood and dependence in the case of severe incapacity, the unvoiced price of a monstrous folly.

It is possible to lay American attitudes to guns and the thousands that die yearly as a result, a madness that is held collectively and the body count the price of ‘freedom’ – and the not dissimilar circumstance of Pakistan and its perverse aversion to life-saving helmets. This is not playing with false equivalencies; there is a willful blindness to reality in both cases. And a national acceptance of countless thousands dying each year. Pakistan is comfortable with its pile of dead no less than is America with its. In neither country is there the slightest indication of a shift in public attitudes and behaviours.

And will my own family, hearing my pleas, protect themselves? Almost certainly not.