London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England
Child injury is a broad category and so I will limit my response to the problem of traffic injury, the problem with which I am most familiar. I became obsessed with this issue while working as a paediatrician on an intensive care unit. I once anaesthetized a ten-year-old girl, the victim of a high-speed road crash, so that she could be taken for urgent surgery to stop her internal bleeding. When she arrived at the hospital she was awake but deathly pale. I reassured her that she would be fine. She never woke up. I worked nights on the unit where the mother of a brain-dead two-year-old wailed desperately all night long. Her daughter's head had been squashed under the wheels of a car. Her child had the same name and was the same age as my own daughter. These experiences scratched grooves in my memory, which later became conduits, directing strong emotion to an issue that many people treat with indifference.
I had several questions that demanded answers. Why do some health problems become public issues demanding societal solutions, whereas road trauma, a leading cause of child death worldwide is trivialized, remaining a matter for personal responsibility? Why is the death of a child following child abuse taken as clear evidence of the failure of our collective efforts to protect children, whereas a child pedestrian death represents only the failure of an individual child to take care while crossing the road? Why did President Nixon "declare war" on cancer and not road trauma, when more children died on the roads that year than died from cancer? Why did an insidious proliferation of cells take on the violent metaphor of war, instead of road trauma with its twisted limbs and torn flesh? It seems to me now that some deaths are more acceptable than others and that the distinction is an ideological one. In other words, I agree with Dr Pless: injury is a political issue. Governments blame the victims in road traffic injury and take no real preventive action because it serves the economic interests of the world's most powerful companies to have it that way. It is better for profits to blame victims than to take real action to make the world a safer place.
The global economy revolves around resources, factories and markets. Raw materials are transported to factories where workers produce manufactured goods. These goods are then transported to markets where consumers can buy them. If consumers are willing to pay more for the goods than it cost to produce them, the company will make a profit. And making a profit is what business is about. Cheap transport is good for profits because it reduces the costs of production and enables companies to take advantage of the lower wages of workers in poor countries. It is more profitable to set up factories in low-income countries where wages are low than in wealthier countries where workers enjoy decent wages and standards of living. But poor people cannot afford to buy expensive manufactured goods and so the goods have to be transported back to markets in high-income countries. Road deaths and injuries, physical inactivity and climate change are part of the real social and environmental costs of road transport, but these costs are borne by other people and not by those who profit from the use of motor vehicles.1,2 If a truck kills a child, the family suffers the loss, not the truck owners. The greenhouse gases produced by vehicles in rich countries, contributes to the global warming that is causing malnutrition and disease in poor countries. Economists call these spill-over costs "externalities" but, having treated children seriously injured in road traffic crashes, their suffering seems to me an ethical human justice issue, rather than an accounting problem. Keeping transport costs low for business means that the suffering and environmental destruction that road transport causes is kept out of the limelight.3 However, we are coming to the end of the road. Climate change now threatens our survival as a species. Unless we radically restructure how our economy works, it will be the end of us all.4 We must value things differently and re-orientate the economy towards increasing human development rather than increasing gross national product. And a world that valued human development would not tolerate the fact that every year some 300 000 children are killed on the roads.
Competing interests: None declared.
1. Roberts I. Injury and globalisation. Inj Prev 2004;10:65-6. PMID:15066964 doi:10.1136/ip.2004.005140
2. Mohan D, Roberts I. Global road safety and the contribution of big business. BMJ 2001;323:648. PMID:11566817 doi:10.1136/bmj.323.7314.648
3. Roberts I. Corporate capture and Coca Cola. Lancet 2008;372:1934-5. PMID:19059037 doi:10.1016/S0140-6736(08)61825-5
4. McMichael AJ, Woodruf RE, Hales S. Climate change and human health: present and future risks. Lancet 2006;367:859-69. PMID:16530580 doi:10.1016/S0140-6736(06)68079-3