Trauma and the consequences thereof remain a scourge on the health status of lower- and middle-income countries (LMIC), with up to 90% of the world trauma mortality occurring in such places.\[[@ref1]\] The challenges are numerous from a lack of emergency medical services with prehospital care training to inadequate emergency departments staffed by nonspecialists or without access to imaging and laboratory services. There may be a shortage of specialist surgeons and orthopedists to provide definitive care, limited access to intensive care resources, and finally, there may be largely absent or deficient rehabilitation services. Coupled with this is a financially resource-constrained community without liberal access to funded medical care.\[[@ref2]\] This latter group comprises largely the population of vulnerable road users (VRU) that the WHO Decade of Action is aiming to address.\[[@ref3]\]

With this background, it is important to start somewhere in defining the burden of disease of LMIC and to use this to either design trauma systems relevant to the local region or to use this data overtime to assess the impact of a fledgling trauma system on the outcome, after trauma, in a particular environment.

In this issue of JETS, Dr. Angeline Radjou and her team in Puducherry, Tamil Nadu\[[@ref4]\] report on VRU mortality over 18 months for patients presenting to their center alive but demising before discharge. The included 193 patients interestingly found that elderly patients had the highest incidence and that pillion riders of two-wheel powered vehicles and pedestrians had similar numbers of deaths whereas it was much lower among cyclists.

Most cases were inter-hospital transfers and the devil of distance played a part in the delays to arrival at the referral facility. The most common injury pattern leading to mortality was brain injury, expected in a resource-limited situation, most of these being early deaths. It was interesting that the incidence of major torso trauma was low compared to other studies from Africa,\[[@ref5][@ref6]\] suggesting either these patients demised before reaching hospital or that the injury patterns indeed differ in the specific population under review.

They assess the issue of early death as a need for emphasis on prevention although the development of community first response to provide basic first aid\[[@ref7]\] and development of rapid prehospital transport systems with designated receiving facilities will also potentially reduce the early mortality -- the latter being the great challenge in LMIC trauma systems.

Similar studies examining the overall disease burden and rapid triage systems have been described with the spectrum of injury similar to that in the index article, namely, a preponderance of nonfour-wheel vehicle-related injury, both from India\[[@ref8]\] and Africa.\[[@ref9]\]

Designing trauma systems that meet the needs of the regional population are essential to ensure the best outcomes for the majority of patients. As such knowing the type of injury, place and timing of death enable planning for prevention, the establishment of EMS services, and the improvement of initial care to ensure salvageable cases do not die in the early phase of care. This does not detract from the need for access to definitive care, including neurosurgical intervention, this itself a challenge in the LMIC scenario.

This paper adds to our knowledge base of emergency care in the LMIC scenario and is important to stimulate further research on the impact of prevention strategies, the impact of systems interventions, and the outcome of timely treatment plans on the most severely injured VRU; however, previously showing pedestrians to be the most vulnerable. This new paper sheds new light on the risks to pillion riders and the elderly. Change should happen and this requires leadership. Leadership crosses disciplines and this is illustrated in the discussion highlighting the role of engineering and enforcement in addition to health care. For systems to benefit the population, all these aspects should work in concert.
