all causes of death are equal in as much as they cause death . but some are less equal 
 than others by being more overlooked , more taken for granted or more accepted as an 
 inevitable part of life than others , which are more scandalising . road traffic injuries ( rtis ) must be counted among the less equal .
their global health 
 burden of causing more than 1.2 million deaths per year , corresponding to 2.4% of all 
 global deaths , establishes them as a major global health threat , in a similar league 
 with tuberculosis .
however , until recently the response of the international health 
 community appeared strangely muted .
the  combined effort of the global community towards 
 funding road safety is roughly estimated to be between us$1025 million per year , a 
 fraction of the sums spent on other public health issues of comparable 
 significance . 
 
international health organisations have never attempted eradication , have 
 invested only few research funds and have , in fact , only discovered the issue about 
 fifteen years ago although it had been around for decades .
cars stand for a way of life which existed as the uncontested goal of all economic 
 development for decades and for which alternatives continue to have a difficult time 
 competing .
cars have therefore possessed a powerful significance as both signs and 
 preconditions of supposed modernisation , progress and development . however , from the 
 beginning , rtis as a destructive side - effect of the motorisation of society has 
 threatened this image .
the spread of cars and rtis as a public health issue has been 
 accompanied by a parallel story of efforts to prevent , limit or control rti morbidity 
 and mortality , their tangible reality as well as their public image .
in fact , in many 
 ways , the rise of a car culture depended on the construction of an acceptable rti 
 narrative . as cars spread from industrialised countries to the rest of the world rti 
 narratives inevitably became part of the global development and modernisation discourse . 
 in the process
, discussions on rtis have been both a reflection of and a contribution to 
 the international construction of the costs and benefits of a key element of 
 development . 
critics see it as an imperialist policy by which high - income countries have 
 fortified their economic superiority and their political control over low - income and 
 often formerly colonised countries . 
 
they call attention to the dramatically growing economic inequalities between 
 high- and low - income countries despite  or because of ? 
development 
 efforts allegedly designed to mitigate such disparity . meanwhile , other scholars point 
 to perceived successes of 
development , measured in health or social indicators such as 
 life expectancy , infant mortality , gender equality or literacy rather than purely 
 monetary data . 
 
other concepts do not easily lend themselves to this type of tally at all , 
 notably amartya sen s view of  development as freedom or herman daly s insistence on 
  development as a strictly qualitative notion , to be distinguished from economic 
 growth . 
 
development in a non - judgmental sense as an expression of the notion 
 policy makers , stakeholders or the general public have had about the direction their 
 country , other countries or the world at large should take and for which they seek to 
 make decisions accordingly .
both high - income and low - income countries develop in the 
 sense that they evolve over time and concepts about desirable socio - economic conditions , 
 viewed as the target of 
concepts differ according 
 to their perceived benefits and drawbacks at specific times and places , and this paper 
 argues that rtis have been an important element of the perceived advantages and 
 disadvantages of motorised transport and the socio - economic system it represents . at the 
 same time , the construction of rtis has been affected by the perceived benefits of 
 motorised transport and , in a larger sense , by the perceived benefits of the specific 
 type of development which prevailed at the time when rtis became an issue in the early 
 twentieth century .
modernisation , was marked 
 by mechanisation , motorisation , increased provision with material goods , increased 
 urbanisation , increased need for and ways of travel and life at an accelerating pace . 

these changes resulted from industrialisation in europe and north america , a complex 
 social transformation based on changing modes of production and consumption , changing 
 power structures , changing forms of rural and urban living , and changes in medicine , 
 food and technology .
these changes relied heavily on the exploitation of fossil fuels , 
 coal and increasingly oil , which made an unprecedented amount of energy available for a 
 broad range of activities , especially for heavy industry used for warfare and 
 transportation .
transport increased exponentially because railways and steamships 
 provided the means and because intensified migration , trade and military campaigns 
 created the need .
the process entailed benefits and disadvantages for various groups of 
 people at different times and places in volatile and sometimes contradictory ways .
it 
 improved nutrition , medical care , housing and opportunities for social mobility and 
 political freedom for some and exacerbated it for others , within but especially between 
 countries . 
 
for the first time in world history , societies in europe and north america were 
 tangibly wealthier , more powerful and apparently healthier ( though the reality was more 
 complicated ) than people in other parts of the world , many of whom , notably in asia , had 
 enjoyed similar or higher living standards than their european counterparts only a few 
 generations earlier . 
 
development in the sense of 
 undergoing the combination of processes which encompassed a european - type 
 industrialisation .
after 1945 , the countries in europe and north america which were 
 industrialised in this way were regarded as 
developed , others were believed to be in 
 need of such  development and therefore became categorised as  developing countries. 
 generally , 
development was perceived as an economic concern and was placed under the 
 responsibility of economists . 
 
thereby , it often came to be seen as synonymous with economic growth , defined as 
 an increase in gross national product ( gnp ) , a concept , which had just been 
 invented . 
  since this entire process appeared to go hand in hand with increased wealth , 
 power and welfare it became widely accepted as a desirable process , or indeed the 
 natural and only process towards improving well - being .
this view was held by the vast 
 majority of actors both in  developed and 
developing countries , although motives 
 ranged from the altruistic to the self - serving , and it is still held by leading 
 economists today . 
 
considerations about how much of this process depended on finite fossil fuels 
 and of making use of other regions resources through imperialism were voiced repeatedly 
 but generally marginalised or excluded from the mainstream discourse on  modernisation , 
 thus glossing over the fact that this process would be impossible to repeat on a global 
 scale .
while the deaths of people who die on the 
 road are real enough , the concept of rtis is no less of a construction than that of 
 
development. rtis are the result of a complex interplay of a series of components , 
 including various traffic participants , vehicles , roads , the spatial , legal and logistic 
 organisation of road traffic and medical care .
accordingly , rtis can be constructed as 
 the result of individual misbehaviour , corporate irresponsibility , lack of 
 administrative regulation or control , insufficient public maintenance and medical 
 services , misguided transportation arrangements , poverty , fundamentally flawed working 
 and living configurations or just bad luck .
these constructions are not trivial since 
 they determine which rti prevention strategies are chosen , placing the financial and 
 political responsibility on some actors while relieving others .
they determine how much 
 money is spent where and for whom , or even if any money is spent at all .
depending on 
 how well those respective constructions reflect the reality of deaths on the road , they 
 also determine how many people die or stay alive .
using discourse analysis , this paper explores how rtis have been constructed in ways 
 that have served local , regional and global development agendas and how 
development 
 has been ( re-)negotiated through the discourse of rtis and vice versa . for this purpose ,
the paper analyses a selection of key publications of organisations in 
 charge of international health or transport and contextualises them within ( a ) the 
 surrounding scientific discussion of the period and ( b ) relevant data regarding rti 
 mortality , development funding , and road and other transport infrastructure .
1910 and 1950 cars were concentrated 
 in the usa , between 1950 and 1975 they became widespread in europe and from 1960 onwards 
 in the rest of the world , especially in asia . in the process , the number of cars , trucks 
 and motorbikes exploded from roughly one million cars in 1910 to 50 million ( 1930 ) , 100 
 million ( 1955 ) , 500 million ( 1985 ) and 777 million in 1997 .
in addition , average driving distances expanded , further increasing overall 
 traffic exposure . 
 
the modern automobile , driven by a combustion engine , was developed and first used in 
 france and germany , but it was in the usa that it first became part of everyday 
 life . 
 
two deaths due to motor 
 vehicles were registered in great britain in 1896 and one in the usa in 1899 . 
  indeed , initially it did not seem that cars would spread beyond a small group of 
 eccentrics .
early drivers in the usa were wealthy sportsmen who used cars to demonstrate 
  conspicuous leisure. their attitude outraged many americans , some of whom reacted with 
  intense anger , and even acts of violence  often tinged with class hostility. 
  part of this resentment reflected the frustration of the have - nots watching the 
 haves flouting their riches , but another part resulted from the experience that speeding 
 motorists were becoming a danger to other street users .
the number of cars grew , and 
 stories of children being run over by reckless drivers or 
they presented 
 a more difficult problem than railway traffic , which had also caused new dangers to 
 which travellers were unaccustomed , but where a strict separation of railway lines from 
 the rest of the traffic , notably from pedestrians , had proved successful at reducing 
 victims . 
 
such a separation was not practical for motorised cars and the question involved 
 a renegotiation of space .
the issue was less acute in the countryside where other road 
 users were few and where the car was often the only means of rapid transportation and 
 its advantages were obvious .
it was here that the car , in the form of an affordable and 
 unpretentious model - t ford , turned from a symbol of aggressive luxury to one of the 
 social success of the hard - working man .
country doctors , who had the most need for fast 
 and reliable transportation , often served as promoters of cars as respectable 
 products . 
 
mass production brought the car within reach of most americans , and between 1909 
 and 1920 the number of registered cars increased by 2750% . 
  in the cities , which often had efficient means of public transportation already , cars 
 had fewer obvious benefits and were more of a nuisance . throughout the 1910s and 1920s , 

an angry animosity greeted cars , as traditional street users resented drivers who were 
 perceived as disturbing the public order and as endangering people s lives .
in marked contrast to 
 later times , early observers blamed motorists for their deaths , not children who had 
 played on the streets or parents who had failed to watch them .
they portrayed drivers as a 
 persecuted minority deserving protection and succeeded in redefining the issue away from 
 one of injuries and death to one of freedom .
any restriction of the use of the car was 
 constructed as inhibiting the people s rights to choose their preferred means of 
 transport and of street use . 
  in the process
, they effectively reconstructed a street from a place of public 
 service to a 
marketplace for transportation demands , an expression of a more modern 
 economic outlook . 
  in a deliberate campaign
the car lobby ridiculed pedestrians as  jaywalkers and 
 thereby as less legitimate users of street space . 
  by the 1930s ,
years before cars became majority traffic participants , most 
 people had accepted that streets were primarily for them . 
 
in addition to determined lobby activities , the democratisation of car ownership 
 changed attitudes .
people bought their first cars , not just because they 
 were useful as well as fun , but because their self - respect demanded it. 
  but the spread of motorised individual transportation was more than the sum of private 
 decisions .
everywhere , governmental planning and the construction of an extensive system 
 of overland roads preceded mass ownership of cars which could make use of it . in the 
 usa
, president wilson signed the first large - scale highway building programme into law 
 in 1916 with the federal aid road act , at a time when less than 4% of the population 
 owned any type of motorised vehicle . 
  in europe ,
widespread motorisation did not begin until the 1950s or even later 
 but various measures spurred and anticipated future needs .
the italian government similarly initiated a high - profile programme of highway 
 building years before there were sizable numbers of drivers but discontinued the scheme 
 during the economic depression . 
  in great britain and france ,
car ownership was no longer restricted to the most 
 privileged class by 1938 . 
 
the increase in cars went hand in hand with an increase in the burden of road traffic 
 accidents . 
  in the usa
the number of rti deaths increased drastically , both in absolute and 
 relative terms between the first world war and the 1930s . while rates declined slightly 
 and remained relatively stable afterwards , the absolute number of rti deaths decreased 
 only during the years of war and then continued to climb until more than 50 000 people 
 were killed in 1970 ( table  1 ) . in great britain , 

rti fatalities surpassed 7000 in 1930 , 1933 and 1934 , corresponding to a rate of 
 approximately 15 per 100 000 .
this compared to a total of 9000 deaths caused by all 
 types of traditional accidents ( falls , drowning , burning etc . ) in 1900 .
unlike the usa , 
 where rti deaths receded during the second world war , the british situation initially 
 became more critical after 1939 , when war - time blackouts exacerbated the pre - existing 
 dangers of the road : 8000 people died on british roads in 1939 , roughly 8,500 in 1940 
 and 9000 in 1941 , approaching 18.8 per 100 000 .
the numbers subsided afterwards , due to 
 a drastic reduction of car ownership and available fuel . 
 
although these numbers were well below the rates experiences in the usa at the 
 time , they were impressive when road casualties were compared to war casualties : 370 000 
 people were killed and wounded during the war , while 588 000 people were killed and 
 injured on the roads during the same period . 
 
sources : us bureau of census , the 
 statistical history of the united states , introduction by ben j. 
 wattenberg ( new york : basic books , 1976 ) , series q 208209 , p. 719 ; us bureau 
 of census , table 1103 , http://www.census.gov/compendia/statab/2012/tables/12s1103.pdf.(a ) usa 19131970yearnumberrate per 100 000 pop . 

( age - adjusted , base 1940)average of 1913176 7007.0average of 19182212 50012.3average of 1923730 90026.4average of 1928221 70019.6average of 1933736 31329.3194323 82317.7194424 28218.3194633 41124.0194931 70121.5195034 76323.3195237 79425.0195538 42624.6196038 13722.4196549 16326.5197054 63325.3(b ) usa 19902009yearnumberrate per 100 000 pop.199044 60017.9199541 80015.9200041 90014.9200543
sources : us bureau of census , the 
 statistical history of the united states , introduction by ben j. 
 wattenberg ( new york : basic books , 1976 ) , series q 208209 , p. 719 ; us bureau 
 of census , table 1103 , http://www.census.gov/compendia/statab/2012/tables/12s1103.pdf .
after 1950 , mass motorisation took root in europe , and widespread car ownership formed 
 part of a series of massive socio - economic transformations , based on cheap fossil fuels . 

within one generation , patterns of housing , shopping , work and leisure time all 
 reflected a society that relied increasingly on cars .
rising rti numbers were part of 
 this development , and they changed shape in the process . while initially accidents had 
 primarily involved one vehicle and fixed objects or pedestrians , the rising presence of 
 cars on the streets meant that collisions increasingly engaged several vehicles . in the 
 uk , crashes involving three or more vehicles represented a mere 1.5% in 19367 but 4.7% 
 in 1953 . in the usa , deaths resulting from collisions of vehicles with fixed objects 
 increased by 80% from 720 in 1930 to 1300 in 1952 but during the same period deaths 
 resulting from collisions between two or more vehicles increased by 140% from 5880 to 
 14.100 . in the usa , as the number of cars increased , death rates in proportion to vehicles 
 decreased , as did the proportion of victims resulting from collisions with pedestrians 
 first in relative and eventually in absolute terms . from 1950
onwards , more people died 
 in collisions between two motorised vehicles than in accidents involving vehicles and 
 pedestrians .
similarly , the number of pedestrian deaths per registered motor vehicle 
 roughly fell by half in switzerland , sweden , the uk and ireland between 1947 and 
 1953 . 
 
these changes led to a shift of concern about rtis from pedestrians to drivers but also 
 to an increasing acceptance of cars and rtis .
even in pre - war great britain , pro - car and 
 pro - pedestrian associations had competed for dominance while government policies tended 
 to favour the affluent , i.e. car drivers . 
 
after the second world war , the widespread perception that the expanding car 
 industry was instrumental to economic reconstruction as well as to social recovery 
 provided automobiles with a positive connotation . this existing pro - car bias and the 
 growing democratisation of car ownership complicated a perspective which focused on cars 
 as the culprits of rti mortality . instead , discussions were muted and concentrated on 
  the human factor. in great britain , the discourse focused on pedestrian behaviour and 
 pedestrians accepted that it was primarily up to them to adapt to an increasingly 
 motorised environment .
this discourse was complemented by a new perspective of speedy 
 cars no longer as the source of road dangers but as a proud sign of modernity , which 
 required similarly modern road systems . 
 
automobile 
 associations and insurance companies organised driver education courses , designed to 
 turn car users into
 safe drivers , while local administrations established and police 
 enforced regulations which should ensure that driver behaviour was conducive to road 
 safety . 
 
rtis were perceived as a form of dysfunction , caused by individual traffic 
 participants who were insufficiently adapted to the demands of modern life .
remarkably , during the first half of the twentieth century rtis never appeared as an 
 international public health issue .
the league of nations , which pioneered data 
 collection and assessments of the state of public health around the world , completely 
 ignored rtis . 
 
it was only in the 1950s , after the usa had recorded its millionth rti death ( in 
 1951 ) that the international community began to take note . 
  the united nations ( un ) economic commission for europe began publishing detailed 
 annual road traffic statistics ( the statistics of road traffic accidents in 
 europe ) for eighteen european countries . 
 
in 1957 , the first international congress of traffic police , held in eindhoven , 
 discussed road safety measures . in line with prevailing attitudes , its recommendations 
 focused on the weakest of potential victims , calling for better education of pedestrian 
 road users , especially of children . 
 
meanwhile , the world health organisation ( who ) discovered rtis as a health issue and 
 began defining it in those terms . as a start , it carried out a survey regarding motor 
 vehicle accidents .
forty - seven member states returned questionnaires : between them they 
 had recorded 102 552 deaths that year ( 79 810 of them males ) out of a population of 650 
 million people , and numbers were rising .
no records existed regarding the much larger 
 number of people who were injured , often seriously .
it became clear that rtis affected 
 predominantly young males and children where they took a staggering toll :  in canada , the united states , austria , the netherlands , australia , and new 
 zealand , deaths from motor vehicle accidents in males in 1958 exceeded those due 
 to tuberculosis ( all forms ) , acute poliomyelitis , typhoid fever , diphtheria , and 
 diabetes mellitus added together . among females in these countries fatal road 
 traffic accidents were fewer but were still prominent among the causes of 
 death . 
 
 in canada , the united states , austria , the netherlands , australia , and new 
 zealand , deaths from motor vehicle accidents in males in 1958 exceeded those due 
 to tuberculosis ( all forms ) , acute poliomyelitis , typhoid fever , diphtheria , and 
 diabetes mellitus added together . among females in these countries
fatal road 
 traffic accidents were fewer but were still prominent among the causes of 
 death . 
  in the uk ,
rtis killed fifteen times as many children as poliomyelitis in 1956 , and 
 twice as many as during the worst polio epidemic after 1945 . in a complaint that was to 
 be repeated many times during the following decades , the author of a study observed that 
 these numbers aroused a fraction of the interest of that directed at other 
 epidemics . 
 
the who tried to raise the awareness of this invisible health issue , dedicating 
 its 1961 world health day to the theme of  accidents and their prevention. 
  it also commissioned a study on road traffic accidents .
this report , written by the chief medical officer of the london transport executive , was 
 published by the who in 1962 under the sub - title of  epidemiology , control , and 
 prevention and declared that rtis constituted  a public health problem of the first 
 magnitude. 
  but comparisons between countries , and , indeed , an assessment of the burden , 
 were difficult since definitions varied widely . in belgium , for instance , road traffic 
 deaths described deaths which occurred at the site of the accident only , while in 
 england , deaths occurring up to 30 days after the accident entered into the 
 statistics . 
  what was clear , however , was that there were gender- and age - specific 
 differences regarding rti risks .
the most striking element then  as later - was the 
 gender gap . in all participating countries ,
the ratio of male to female road traffic 
 deaths ranged between three and five and , the author of the 1962 who study observed , 
 resembled a  biological or sociological law , so far little understood . 
 
the age distribution differed between traffic participants . among pedestrians , 
 children between roughly 1 and 10 were particularly at risk ; prevalence then declined 
 and rose again from age 65 onwards .
the increase in old age resulted in part from the 
 high probability of elderly people dying from injuries from which younger people 
 recovered . 
 
however , within the age bracket of young adults , rtis represented a major cause 
 of death , causing  a serious economic loss to the community. 
  while rtis , therefore , slowed down economic development in tangible , although 
 unquantified ways , the essential role of the motorisation industry for economic growth 
 was obvious .
the report commented that evidently rtis took an increasing part of 
 national mortality as a country became  more highly developed and therefore more highly 
 motorised. 
  the connection between development and motorisation appeared too obvious even to 
 suggest a cost  benefit analysis . despite his urgent calls to address rtis as a public 
 health threat , the author was ready to accept a certain level of rtis as an inevitable 
 side - effect of modernisation , and he merely suggested that  a balance between man and 
 the new element in his environment , the motor vehicle , is being reached , and that a 
 mortality of roundly 20 per 100 000 per annum is the price of introducing the motor 
 vehicle on a large scale. 
  thus , in the early 1960s , a cost of 20 lives lost for every 100 000 people 
 seemed an acceptable price for the benefit of modernisation , a rate reached in the usa 
 during the late 1930s and then briefly again in 1948 , but which had consistently been 
 surpassed since .
meanwhile , the perception of rtis as a public health issue remained concentrated in 
 north america and europe where it gradually changed its character . in the late 1950s ,
a 
 diverse group of public health experts , politicians , lawyers and social activists began 
 arguing that 50 000 rti victims annually were unacceptable and that car designs , which 
 did not prioritise safety , bore a large part of the responsibility for the number of 
 casualties .
they argued that getting drivers to act more responsibly was clearly not 
 succeeding while making cars  crashworthy by supplying them with padded dashboards and 
 stronger door locks would have instant effects .
the political climate of social 
 discussions and the civil rights movement of the time were propitious for the argument 
 that people s well - being went beyond the control of the individual .
the public was 
 introduced to the new arguments through congressional hearings and , above all , in ralph 
 nader s book unsafe at any speed , published in 1965 .
the car industry , 
 fearing expensive construction changes and liability claims , tried to portray the issue 
 as one of personal freedom .
this strategy remained unsuccessful in part , because 
 insurance companies could be drawn over to the other side of the argument . 
 
one year later , lyndon johnson signed into law two bills raising safety 
 standards in cars and roads , and established a new federal agency , the national highway 
 safety bureau ( nhsb ) , in charge of rti control . 
 
these events marked an important shift in how the causes for rtis were defined , with 
 ambivalent effects .
on the one hand , it weakened a perspective which blamed rti victims 
 for their fate .
thus , shifting attention to cars can be seen as a correction to a 
 situation where the industry had largely been exempt from any accountability . on the 
 other hand ,
this new reductionist view of the problem became obvious during the more recent 
 controversy regarding airbags , which became mandatory in the usa and whose overall 
 benefits remained unclear .
this development has been blamed for a neglect of behavioural 
 factors and , ultimately , for a relatively less positive development in the usa , compared 
 to other industrialised countries . 
 
the change of perspective paved the way for a view of economic development not as a 
 cause of rtis , i.e. the problem , but as its solution . and eventually , the focus on 
 vehicles established the view of drivers being the primary victim of rtis deserving 
 protection .
no similar technical considerations were directed at protecting pedestrians , 
 who , by that time , had been driven out of large part of public spaces .
implicitly , this 
 was criticised by william haddon , an american epidemiologist who developed a systemic 
 approach to rtis which integrated considerations of infrastructural factors with 
 vehicles and users in the pre - crash , the crash and post - crash stages relevant to road 
 traffic accidents . 
 
haddon matrix was criticised but spurred a shift towards a more 
 comprehensive perspective of traffic and rtis in the 1970s and would re - emerge in a 
 transformed shape in the late 1990s . as urban centres in industrialised countries experienced an increasing burden of traffic 
 congestion with its economic , environmental and social costs as well as ever - increasing 
 rtis , many cities took measures designed to reduce the motorised traffic on their 
 territory .
a study of the organisation for economic cooperation and development ( oecd ) 
 of twelve cities in as many countries revealed that , by the mid-1970s , eleven had 
 restricted parking in their centres , eight had increased the frequency of public 
 transportation services , ten had provided preferential treatment for public services 
 ( such as bus lanes etc . ) , ten had established pedestrian zones and five had made 
 provisions for cyclists .
thus , nagoya reduced rtis by 61% and rti mortality by 59% in its central 
 business district within a few years .
even paris , which saw its overall rti rate go up 
 by 52% , enjoyed a reduction of rti mortality by 24% . in ottawa ,
where overall rtis 
 increased by 19% , the rti rate decreased by 40% in those areas where measures to reduce 
 transit traffic had been put in place . 
 
these changes could not gloss over the fact that private cars were still 
 considered  the predominant mode of personal travel in north america and were gaining 
 ground in many areas of europe and japan . 
  nevertheless , in a curiously contradictory development , the number of cars kept 
 increasing while cars were no longer automatically considered the best or the most 
 modern means of transportation everywhere in high - income countries , and pedestrians 
 regained some of the urban ground from which they had been evicted some decades before . at about that time , the who began addressing rtis more seriously . in 1974 ,
the world 
 health assembly acknowledged the  extensive and serious individual and public health 
 problems resulting from road traffic accidents and urged national health authorities to 
 provide leadership in the issue . in its proposals of tangible measures
the resolution 
 remained well within the paradigm of the last decades , calling for  improved driver 
 licensing standards and traffic safety education programmes and the application of 
  safety principles in the development of new types of vehicles. 
  the regional office for europe was made responsible for the who programme on 
 road traffic accidents . 
 
however , probably this office observed more than they caused the substantial rti 
 decline which was unfolding around them . between 1975 and 1998 ,
rti mortality decreased 
 drastically in virtually all high - income countries : by 63.4% in canada , by 58.3% in 
 sweden and by 27.2% in the usa . 
  in 1987 , a public health expert stated that a 200-fold increase of cars had been 
 accompanied by an only twenty - fold increase in rti deaths and that the rti death rate 
 was lower in 1985 than at any time during the preceding sixty years except in 1948 . 

the epidemic of road traffic deaths may be most remarkable for 
 the way it has been controlled. 
  unfortunately , this assessment overlooked the majority of global regions and people . in 
 fact , rtis were fast developing into a global issue with an immense public health burden 
 concentrated in middle - income countries . between 1975 and 1998 ,
rti deaths increased by 
 237.1% in colombia , by 243% in china and by 383.8% in botswana . in 1990 , rti assumed 
 place nine in contributors to the global burden of disease . globally , road traffic 
 deaths increased from ca .
990 000 per year in 1990 to nearly 1.2 million in 2002 . 
  in the late 1980s ,
international organisations gradually became aware of the extent of 
 the evolving problem and of the need to address it .
given that north america and europe 
 looked back on decades of experience and that rtis appeared to show a positive downward 
 trend , there was a natural tendency to apply lessons learned in the 
had rti 
 rates declined because of better drivers , more stringent regulations , safer vehicles , 
 better protection for cyclists and pedestrians , more alternatives to travelling by car , 
 medical progress or simply because the sheer number of cars provided the majority of 
 traffic participants with a protective frame , so that cars served as both protection 
 against and as threats to other cars and their passengers ? or any combination of those 
 factors ? and which of these findings were applicable to the rest of the world , to whose 
 benefit and at what price ?
discussions evolved around competing claims to historical 
 analysis and their conclusions for development policies in those countries where car 
 traffic was still low but rising . in many ways ,
the situation in low - income countries at the end of the twentieth century 
 resembled that of countries in europe and north america at its beginning : rti victims 
 were primarily pedestrians and cyclists , vulnerable traffic participants who competed 
 with an increasing number of motorised vehicles for road space .
researchers listed a fateful combination of reasons for the rising 
 rti burden , including a  traffic mix of incompatible users ( pedestrians , cyclists , 
 motorbikes , cars , and trucks ) with , for example , communities living within the vicinity 
 of roads or the lack of pavement along large urban streets. 
  passengers in africa and asia usually rode in multi - passenger vehicles such as 
 overloaded mini - buses or taxis , so that individual accidents involved more people than 
 the typical accident in a high - income country , which had usually affected the driver(s ) 
 of one or several cars involved . comparing rtis in different parts of the world in 2000 , 

this difference was exacerbated by the lack of effective first aid and emergency medical 
 care in low - income countries . according to a harvard study 10 000 crashes resulted in 66 
 deaths in the us , but 1786 in kenya and 3181 in vietnam . 
 
given the 
 complex nature of rtis , they could not but become part of the tension between different 
 international health agendas . by the 1980s ,
a new major player was the world bank , which had been alerted 
 by who efforts at the conference of alma - ata in 1978 to connect public health policies 
 to demands for increased global economic equality and regulations , while growing 
 neoliberal tendencies among key members , notably the usa , called for further economic 
 deregulations . during the 1980s and 1990s , the world bank steadily increased its role in 
 the international health scene . through substantial investment in health projects and 
 the generation of health - related data it integrated health into its overall programme of 
 fostering a market - driven form of economic development . 
 
part of this strategy was to identify poverty reduction through economic growth 
 as the primary means of improving public health in low - income countries , and research 
 programmes were designed accordingly . 
 
this situation gave rise to the global burden of disease project , which the 
 world bank launched in preparation of its 1993 world development report 
 investing in health , which successfully established the work of the 
 world bank as a reference point for global health . 
 
the global burden of disease project introduced disability adjusted life years 
 ( dalys ) as new measurement unit , which combined mortality , morbidity and injury into a 
 single number .
road traffic accidents ranked ninth among the leading causes of dalys , 
 accounting for 2.4% of the total . 
 
road traffic 
 accidents were the second leading cause of dalys for men between 15 and 44 year of age 
 in high as well as in low income countries . 
 
these data prompted a growing number of research publications dedicated to rtis 
 in the following years .
in line with the perspective begun in the 1962 who report , 
 publications constructed rtis in medical terms as a  neglected epidemic , 
  a  global epidemic , 
  a  global road trauma pandemic 
  or compared rtis to aids , insisting that one epidemic provided lessons for 
 fighting the other . 
  some publications invoked warfare , describing rtis as  vehicular 
 manslaughter 
  or a  war on the roads. 
  however , this health discourse had a hard time competing against the entrenched view of 
 roads and road traffic as essential economic infrastructure .
the 1994 world bank world 
 development report on infrastructure for development was a case in 
 point .
it acknowledged that rtis were a leading cause of death in low - income countries 
 and accorded governmental 
regulation to preserve safety standards in infrastructure 
 service provision and delivery an important priority . 
 
another paragraph observed the  very low rates of traffic accidents which the 
 brazilian city of curitiba had achieved through  carefully designed public transport 
 routes. 
  however , those were the only references to road crashes and could easily be 
 overlooked in the midst of a report which , otherwise , overwhelmingly discussed the need 
 for optimal cost - effectiveness of infrastructure services , ideally through 
 privatisation .
ironically , this preference for market solutions for development 
 challenges should have provided grounds for the world bank to favour investments in 
 railway lines and other forms of collective transport rather than roads .
railways , bus 
 services , subways etc . could easily be supplied by private operators or under 
 concessions , working under conditions of competition and , therefore , supposedly more 
 efficiently and cost - effectively .
the privatisation of roads was sometimes possible as 
 toll roads , but in general roads would necessarily remain public spaces . 
 
but these theoretical considerations clearly had little effect on real lending 
 decisions . since the 1970s
, world bank commitments for transportation infrastructure had 
 increasingly concentrated on highway building , which effectively dwarfed the sums spent 
 on railway lines .
investment in urban transport were non - existent or a fraction of those 
 for highways and also consisted largely of road constructions .
this tendency would 
 continue and even intensify in the beginning of the twenty - first century .
the sums 
 invested in rural and urban roads amounted to 80% of all infrastructure lending 
 ( figure  1(a ) and ( b ) ) .
the world bank was not 
 the only source of global investments in transportation infrastructure but its 
 distribution of funds was reflected in the development of road and railway lines in many 
 countries , including el salvador , malawi , brazil and india .
invariably , the length of paved roads increased 
 substantially , sometimes dramatically , between 1960 and 2000 while that of railway lines 
 stagnated .
if any funds were spent on infrastructure supporting non - motorised 
 transportation , such as buses , trams , subway or even secure sidewalks or bicycle lanes , 
 they were considered too insignificant to be mentioned in world bank publications . 

clearly , although a large part of the population in low - income countries had no chance 
 of ever owning cars , motorised road traffic had become the accepted model for transport 
 development .
a precise 
 understanding of the situation was difficult since data were  and still are  often 
 patchy or simply non - existent , but those that were available were impressive enough . 

examples included el salvador and mauritius , both of whom experienced rapidly rising 
 rtis mortality rates even though the length of paved roads in mauritius expanded only 
 slightly from 1593 to 1699 km between 1970 and 1990 . 
 
figure  1:ibrd and ida commitments : ( a ) millions of current us dollars . source : world 
 bank , infrastructure for development , world development report 
 1994 ( oxford and new york : oxford university press , 1994 ) , 149 ; ( b ) millions of 
 us dollars .
source : world bank evaluation group , a decade of action in 
 transport ( washington dc : world bank , 2007 ) , 23 .
source : world 
 bank , infrastructure for development , world development report 
 1994 ( oxford and new york : oxford university press , 1994 ) , 149 ; ( b ) millions of 
 us dollars .
source : world bank evaluation group , a decade of action in 
 transport ( washington dc : world bank , 2007 ) , 23 .
 general 
 transport corresponded to  urban transport and consisted predominantly of 
 roads . 

figure  2:railways tracks and paved roads in kilometres : ( a ) el salvador and malawi ; ( b ) 
 brazil and india . source : world bank , infrastructure for 
 development , world development report 1994 ( oxford and new york : 
 oxford university press , 1994 ) , 140145 ; cia world factbook , https://www.cia.gov/library/publications/the-world-factbook/fields/2085.html#182 . 

international road federation , world road statistics 2007 , data 20002005 , 
 geneva 2007 . 
 
railways tracks and paved roads in kilometres : ( a ) el salvador and malawi ; ( b ) 
 brazil and india . source : world bank , infrastructure for 
 development , world development report 1994 ( oxford and new york : 
 oxford university press , 1994 ) , 140145 ; cia world factbook , https://www.cia.gov/library/publications/the-world-factbook/fields/2085.html#182 . 

international road federation , world road statistics 2007 , data 20002005 , 
 geneva 2007 . 

figure  3:the crude death rate due to motor vehicle traffic accidents : el salvador and 
 mauritius .
source : who mortality database . 
  the crude death rate due to motor vehicle traffic accidents : el salvador and 
 mauritius .
the international federation of red cross and red crescent societies presented 
 warnings about the seriousness of rtis as a  hidden global epidemic in its world 
 disaster report . 
  in response , the world bank established the global road safety partnership 
 ( grsp ) , a network of representatives of business , civil society and government 
 organisations .
its membership read like the who s who of the international car and oil 
 industry , including general motors , honda , bp , daimlerchrysler ag , michelin , renault , 
 shell , total and toyota .
the group was hosted by the international red cross , 
 which provided contacts and credibility , and it was overseen by a steering 
 committee . 
  within some years it supported practical road safety projects in several 
 countries around the world .
activities ranged from targeting drunk - driving and speeding 
 to promoting the use of helmets and seat - belts to separating motorised and non - motorised 
 traffic or promoting public transportation . 
  however , the main focus was on the behaviour of potential victims , portrayed as 
 those most responsible for rti deaths .
children , particularly , were described as lacking 
 sufficient skills and knowledge to cope with complex road traffic situations .
this line 
 of argument had formed part of the conventional wisdom in high - income countries since 
 approximately the 1940s , but it was quickly becoming outdated .
a 2002 meta - study of 
 controlled trials of pedestrian education programmes in high - income countries showed no 
 evidence that such programmes reduced the risk of road accidents involving child 
 pedestrians .
no similar studies existed for low - income countries . 
  including representatives of the automobile industry in this group brought technical 
 expertise and assured close contact with those actors whose actions inevitably formed an 
 important component of any road safety programme .
but obviously their presence also 
 precluded solution strategies which questioned motorisation in principle . in 2002 ,
the 
 secretariat for the steering committee was shifted to the task force for global health , 
 an institution which had been founded to coordinate international activities of primary 
 health care after 1978 , when the world bank succeeded in shifting the health for 
 all approach of the alma - ata conference from a political strategy aimed at 
 increasing economic equality to technical programmes of oral rehydration , breastfeeding 
 and immunisation . 
  a similar strategy to define the issue as a technical problem appeared underway 
 with regard to rtis .
however , even this met little response in the car industry , as the 
 european enhanced vehicle safety committee ( eevc ) realised .
its proposals regarding 
 changes to the fronts of vehicles designed to make them less dangerous to pedestrians 
 were not on the agenda of car manufacturers in 2002 . 

at the end of the twentieth century , discussions on rtis evolved into a more fundamental 
 debate about global development .
the kuznets curve went back to a theory presented by simon 
 kuznets in 1955 . drawing on historical data of industrialised countries he maintained 
 that social inequality increased in the early phase of modernisation but decreased from 
 a turning point onward as national income continued to grow .
the relation between social 
 inequality and economic growth evolved , therefore , along a curve the shape of an 
 inverted u. 
  in the 1990s , the model received a second life as a description of the 
 relationship between economic growth and some pollutants , notably \documentclass[12pt]{minimal } 
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 } { } $ { \mathrm{so } } _ { 2 } $ \end{document } and smoke , and became known as the environmental kuznets curve .
this 
 finding provided a welcome defence against accusations that the existing growth - oriented 
 economic system was responsible for large - scale environmental destruction , and it was 
 readily accepted by advocates of the contemporary economic system . in 1992 ,
the world 
 bank incorporated it into its world development report on the environment . 
  in the following years
, further research challenged the curve : similar 
 developments could not be reproduced for other forms of environmental burden . besides , 
 it was doubtful to what extent the effect resulted from the transfer of polluting 
 industries to low - income countries , a strategy which could obviously not be imitated on 
 a global scale . 
  in 2000 , van beeck et al .  appear to have been the first to 
 observe a kuznets curve of rtis in relation to 
prosperity levels. economic growth , 
 they argued , was  not only associated with growing numbers of motor vehicles in the 
 population , but also seems to stimulate adaptation mechanisms , such as improvements in 
 the traffic infrastructure and trauma care. 
  this view suggested that economic growth would in itself lead to a reduction of 
 rtis , making a rise in gross domestic product ( gdp ) the best strategy to reduce the 
 health burden of widespread motorisation .
it also implied that rtis as a health problem 
 were largely solved in high - income countries .
the world bank development research 
 group on infrastructure and environment issued a policy research working paper on 
 traffic fatalities and economic growth . 
 
analysing vehicles per person ( v / p ) and fatalities per vehicle ( fn ) data from 
 eighty - eight countries for the period 196399 , they found a confirmation of the kuznets 
 curve with a turning point at a per capita gnp of $ 8600 in 1985 international dollars . 
 on the basis of these data and of prognoses of population and income growths
, they 
 projected that it would take many years for developing countries to achieve the low rti 
 fatality rate of existing high - income countries .
rtis in india , for instance , which had 
 a per capita income of only $ 2900 in 2000 , would only begin to decline in 2042 after a 
 peak of at least twenty - four fatalities per 100 000 persons , or thirty - four when 
 adjusted for estimated underreporting .
peak in 2032 and would 
 experience an rti mortality rate of twenty - six deaths per 100 000 persons as late as 
 2050 , compared to a rate of around eleven enjoyed by high - income countries in 2000 . only 
 on the last page
did the text mention , almost in passing , that these projections were 
 based on a continuity of ongoing policies , while measures such as mandatory helmet 
 wearing or effective traffic separation might lower those numbers . 
 
its projections 
 led nitin garg and adnan hyder to urge that countries like india should take active 
 steps to curb rtis along who recommendations well before the theoretical economic 
 threshold . 
 
other researchers accepted and confirmed a kuznets curve behaviour of rtis as 
 the statistical representation of a development whereby increasing national income would 
 allow investments in safer roads and vehicles . 
  in an analysis of data from forty - one countries from the years 19926 david 
 bishai et al
.  found that in low - income countries a ten per cent 
 increase in gdp increased rtis by 4.7% and rti deaths by 3.1% .
by contrast , gdp 
 increases in high - income countries reduced the number of deaths , although not of crashes 
 or injuries .
the turning point appeared to be between $ 1500 and $ 8000 per capita 
 income . 
 
other projects were more clearly tied to corporate interests . in a study that 
 was financially supported by the automobile industry , walter mcmanus of the university 
 of michigan transportation research institute calculated the lives that would be saved 
 by lowering either vehicles per capita or the fatalities by vehicle .
both would save 
 lives but , he concluded :  reducing motorisation ( vehicles per capita ) is unlikely to be 
 used as a policy to reduce fatalities because it is inextricably linked to economic 
 growth .
consequently , the focus should be on reducing fatalities per vehicle. 
  clearly , this approach limited anti - rti strategies to those not harmful to the 
 large sector of the global economy which depended in some way on the construction or use 
 of motorised vehicles .
it also portrayed rtis as a regrettable but temporary side - effect 
 of modernisation .
one sign of changing attitudes appeared 
 in a debate about terminology . in 1987 ,
a group of intensive care specialists in new 
 zealand proposed to change  the discourse on road traffic injuries by rejecting the 
 concept of  accidents  . 
  in a widely publicised campaign they succeeded in changing the choice of words 
 in the media .
the editor of the prestigious 
 british medical journal ( bmj ) adopted the same attitude , arguing that numerous injuries , 
 including rtis , were not accidental and , therefore , should not be called 
maybe the expression of 
  traffic accident was too deeply ingrained in the general vocabulary , maybe bmj was 
 insufficiently influential or maybe people were unconvinced by the idea that 
accident 
 should be reserved for those rare events which involved no human responsibility at all . 

eight years later ,  accident continued to be widely used , including in articles 
 published by the bmj . in reaction ,
bmj , in its self - proclaimed position as  a leading 
 communicator in medicine with a responsibility  to establish or follow standards in 
 language banned the  inappropriate use of 
when the psychologist alan steward 
 ( university of georgia ) and social worker janice lord , former national director of 
 victim services of mothers against drunk driving , argued against 
 
accidents since crashes  caused by intoxicated , speeding , distracted , or careless 
 drivers were no accidents and that such misnaming might create extra stress for crash 
 victims and impede their recovery , several colleagues disagreed . 
 
indeed , prior studies had suggested the opposite effect : patients who blamed 
 themselves for car accidents recovered more rapidly than those who blamed others . 
 
nevertheless , the new terminology was adopted by many researchers and was also 
 in who publications .
some authors clearly considered this change an important move , 
 which they took pains to explain . 
 
meanwhile , the current classification of causes of death and disease , icd-10 
 kept 
it did 
 underscore that rtis resulted from preventable causes rather than fate and thereby 
 contradicted a view of rtis as inevitable consequence of development .
but the new 
 wording offered no new perspective as long as it continued to refer to well - rehearsed 
 factors such as child restraints or driver behaviour , which stayed well within the 
 conventional discourse .
other initiatives had more far - reaching consequences . in 1999 , kre rumar , professor at 
 the swedish road and transport research institute , insisted that , despite falling rti 
 rates in europe , the problem was far from solved . to illustrate its continued 
 significance he pointed out that in most european countries one out of three citizens 
 would need hospital treatment after a road traffic accident sometime in their lives and 
 that one in twenty people would be killed or injured in a road accident . 
 
he urged a systemic approach . in what appeared like an expanded form of the 
 haddon matrix he described a web of factors , including age , gender , traffic regulations , 
 road maintenance , attitudes to safety policies , intelligent control systems , unclear 
 distribution of responsibilities , etc .
overall , his explanations aimed at a change of 
 perspective . instead of accepting the need for motorised traffic as a given and focusing 
 on ways to reduce its health price , intelligent strategies should begin with the 
 underlying purpose of traffic ( transportation and mobility ) and the biological 
 vulnerability of the human body to external shock , and then search for ways to combine 
 highest benefits with least sacrifice on that basis . as a vastly underestimated measure 
 he singled out reducing the exposure of traffic participants to the risks of motorised 
 transportation : [ t]raffic
the fact is that presently the number of cars is increasing faster than the 
 number of persons on this planet . 
 
[ t]raffic exposure is increasing faster than the reduction of crash and injury 
 risk .
the fact is that presently the number of cars is increasing faster than the 
 number of persons on this planet . 
 
this approach was taken up by the who , which was initiating a five - year - strategy . 
 
a first result was a study on the  global road safety crisis , issued in 2003 , 
 which incorporated input from various un bodies .
the report advocated integrating rti 
 consideration into a broader vision of urban development and transportation planning , 
 which also included alternative modes of transport .
a one - sided concentration on a 
 car - based system of traffic was portrayed as aggravating social inequality since it 
 invested  increasing resources in the building and maintenance of an infrastructure for 
 private motorised transport , while overlooking the public transport needs of the larger 
 part of the population. 
  it also contributed to further health problems since in  many high - income 
 countries , increasing use of cars has led to a general decline in walking and an 
 increase in sedentary lifestyles , which in turn has had adverse consequences in terms of 
 increasing obesity and cardiovascular health problems. 
  effective strategies to reduce rtis were said to require a 
systems approach , 
 aimed at identifying and addressing all relevant factors . successful strategies of 
 high - income countries could serve as orientation , but policies in low - income countries 
 would have to be adapted or even newly created according to local circumstances . while 
 these explanations promised a new approach , the list of relevant determinants ( speeding , 
 alcohol , helmets , safety devices , trauma care , road safety standards , traffic safety 
 regulations , vehicle safety ) appeared remarkably conventional and addressed , again , to a 
 large extent the behaviour of road users . 
  nevertheless , the text appears to have been the first time that a high - level 
 international report on rtis welcomed  and by implication recommended  a cutback of 
 the use of cars as one strategy to reduce the rti burden .
systems approach was further elaborated in a world report on 
 road traffic injury prevention , a who report , published in 2004 in 
 collaboration with the world bank , which presented a wealth of data and analysis . 
 despite a reality of more than 1.2 million rti deaths , twenty to fifty million
people 
 injured and rising numbers the report insisted that rtis had to  be considered alongside 
 heart disease , cancer and stroke as a preventable public health problem which responded 
  well to targeted interventions. 
  the report recommended and discussed in considerable detail a series of 
 well - known practical measures such as speed control , the use of seat - belts and adequate 
 child restraints as well as helmets for two - wheeler users , the enforcement of alcohol 
 limits , good road design , improved vehicle standards and efficient post - crash medical 
 care .
other , less 
 frequently cited but relevant strategies included reducing the deprivation of 
 underprivileged social groups , the separation of different types of traffic in clearly 
 marked separate roads with different speed limits , mandatory daytime running lights , 
 intelligent seat - belt reminders , traffic calming measures such roundabouts , road 
 narrowings , chicanes or road humps , or crash - protective roadsides . 
  and even these points were merely tactical elements in a far more comprehensive 
 approach , designed not primarily to make motorised traffic safer but to provide living 
 conditions which would satisfy human needs for food , household items , work and leisure 
 activities in intelligent ways . this task might entail measures to reduce the need for travel by  [ l]and - use planning 
 practices and  smart growth  land - use policies  development of high - density , compact 
 buildings with easily accessible services and amenities or the  creation of clustered , 
 mixed - use community services or encouraging the use of electronic mail for 
 communication . 
 
if moving from one place to another could not be totally prevented , it could be 
 organised in safer ways than through private cars .
calculations for the european union 
 regarding the risk of death in relation to distances travelled listed motorised 
 two - wheeler users as running twenty times the risk of car occupants , who were seven to 
 nine times safer than cyclists or pedestrians but ten times less safe than bus and train 
 occupants .
thus , travelling by public transportation was by far the safest means of 
 transportation , creating good reason to encourage it . 
  reducing the need to travel in general and to travel by car in particular was 
 also considered a very positive step since , as studies from high - income countries 
 indicated that  under certain conditions , for each 1% reduction in motor vehicle 
 distance travelled there was  a corresponding 1.41.8% reduction in the incidence of 
 crashes. 
  besides
, such measures could have tangible health benefits in addition to 
 reducing rtis , such as increasing healthier life - styles through more walking and 
 cycling , and reducing noise and air pollution . 
 
however , as the report acknowledged , many of the road safety measures would not be 
 applicable in developing countries , where the need to act was greatest .
since the large 
 majority of global rti victims were pedestrians and cyclists in low- and middle - income 
 countries and since in the foreseeable future most people in those countries would 
 continue to be walking , cycling and using public transportation , their needs would have 
 to be the priority concern . 
  in the absence of facilities for pedestrian and cyclists
these services , often in obsolete overloaded 
 vehicles , driven by overworked drivers and owned by businessmen , who bribed traffic 
 enforcement authorities , created substantial risks to occupants as well as other traffic 
 participants . among other measures ,
strategies had to be found that would simultaneously 
 address the  safety of road users , the labour rights of drivers and the economic 
 interests of the vehicle owners. 

  such a traffic pattern with its mix of dangerous motorised vehicles sharing road 
 space with large numbers of vulnerable road users had never been experienced by 
 high - income countries and therefore lessons from north america and europe were of only 
 limited use in the rest of the world . 
 
in addition , the report showed a more complex connection between rtis and 
 development by citing estimated global costs of the rti burden of us$518 billion per 
 annum and $ 100 billion in developing countries  twice the annual amount of development 
 assistance to developing countries. 
  in this perspective , rtis did not appear as a temporary price paid for a 
 generally beneficial economic development but as a powerful impediment to development .
this who report was the most detailed study on rtis as a global health problem to that 
 date , and was meant to become the central reference point for further research .
notably its 
 numbers regarding present and estimated future rti victims became the standard 
 components of virtually all following studies .
questioning the connection between motorised transport and 
 modern economic development by decentralising residential areas or by making use of 
 online communication means challenged the logic of the traditional view of development , 
 more so than the various traffic reduction measures begun in oecd urban areas during the 
 1970s . while pedestrian zones restricted traffic locally , adopting a reduction of the 
 need to travel as a goal of intelligent housing and work plans could potentially change 
 the concept of development as people knew it .
the structure of recommendations underlined the comprehensive nature of the report , 
 listing what governments , policy , legislation and enforcement , the public , vehicle 
 manufacturers , donors , communities , civil society groups and individuals could do . 
 clearly , preventing or reducing rtis
was considered everybody s responsibility . however , 
 the very comprehensiveness of the report obscured its radical components in the midst of 
 a multitude of more conventional ideas .
indeed , the large number of recommended measures 
 allowed adopting a broad approach that nevertheless could leave out individual onerous 
 ideas . in the summary ,
only two recommendations out of forty - seven called for the 
 establishment of public transportation and none explicitly mentioned the inclusion of 
 traffic - reduction objectives in land use plans . 
 
the un instituted the united nations road safety collaboration , designed to implement 
 the recommendations of the world report .
the group consisted of 
 regional and global international organisations , including the world bank and unicef , 
 and a variety of other national and international bodies ( governments , non - governmental 
 organisations , donors , research agencies and the private sector ) where the who held a 
 coordinating role .
this strand has also led the un general assembly in march 2010 to 
 proclaim the period 201120 as the decade of action for road 
 safety . 
 
thus , there has been a real effort on the part of the un to construct rtis as a 
 global issue and to assume responsibility for it .
each referred to the 2004 
 world report , and provided its own interpretation in line with its 
 own outlook . in subtle ways
, they carried out a competition of concepts : one designed to 
 safeguard motorised transport by making it safer through technical , legal and 
 administrative modifications , another designed to modify the entire system of transport 
 by questioning the prioritisation of its motorised form .
a report by who europe , which 
 also came out in 2004 , was among the latter .
it emphasised the synergistic value of 
 various anti - rti measures and the environmental component of overall anti - rti policies . 
 in the process
, it portrayed finding ways to reduce rtis as part of a strategy for 
 sustainable development : a sustainable transport system is one that ( i ) provides for safe , economically 
 viable and socially acceptable access to people , places , goods and services ; ( ii ) 
 meets generally accepted objectives for health and environmental quality  ; ( iii ) 
 protects ecosystems by avoiding exceedance of critical loads and levels for 
 ecosystems integrity  and ( iv ) does not aggravate adverse global phenomena , 
 including climate change , stratospheric ozone depletion , and the spread of 
 persistent organic pollutants . 
 
a sustainable transport system is one that ( i ) provides for safe , economically 
 viable and socially acceptable access to people , places , goods and services ; ( ii ) 
 meets generally accepted objectives for health and environmental quality  ; ( iii ) 
 protects ecosystems by avoiding exceedance of critical loads and levels for 
 ecosystems integrity  and ( iv ) does not aggravate adverse global phenomena , 
 including climate change , stratospheric ozone depletion , and the spread of 
 persistent organic pollutants . 
  the same objective of  sustainable development was echoed in the title of make 
 roads safe : a new priority for sustainable development , published by the 
 commission for global road safety in 2006 .
the commission was created by the fia 
 foundation for the automobile and society in 2005 with former nato secretary - general 
 lord robertson as chairman .
its advisory board included prominent people connected with 
 the automobile sector , but also members of the who , the world bank and the oecd . 
  the campaign 
make roads safe has been supported by a number of celebrities and 
 world leaders such as british prime minister tony blair and archbishop desmond 
 tutu . 
 
cooperation and overlap of personnel and website space with the grsp was such that it 
 was questionable to what extent these were distinct bodies .
the grsp website included a 
 link from which the 2004 world report on road traffic injury prevention 
 could be downloaded and it issued guidelines for the implementation of its 
 recommendations . 
 
however , below the surface of agreement to behavioural , technological and administrative 
 changes , underlying differences about where transport policies in particular and 
 socio - economic development in general should be heading were played out .
make 
 roads safe : a new priority for sustainable development focused attention on 
 road improvements while referring to developmental challenges . 
 
the report argued that low - income countries could and should learn from the 
 experiences of high - income countries but without having to imitate every step . instead 
 of repeating the kuznets curve relation between economic growth and rtis , found in 
 europe and north america in the 1960s , low - income countries should use additional 
 measures as a form of shortcut to lower rtis . 
  rather than aiming at a  system s approach , like the 2004 world 
 report
this combination of pre - crash , crash and post - crash measures 
 for people , vehicle and environment made the approach appear comprehensive , while 
 accepting motorised transport as a given and narrowing  environment to the technical 
 qualities of a road : its design , markings , maintenance , protection , pedestrians 
 crossing and rescue facilities . 
  improving the safety of vehicles held little promise in low - income countries , 
 the report argued , since few people could afford modern cars and the variety of vehicles 
 used prevented a quick effect . ruling out an emphasis on people as a way of  blaming the 
 victim the report focused on roads as central elements .
this strategy was not limited 
 to low - income countries since ,  [ a]mongst the best performing industrialised nations , 
 improved road infrastructure remains the major source of expected future contributions 
 to casualty reduction targets. 
  nevertheless , the development of low - income countries , formed a central argument 
 using the millennium development goals ( mdgs ) as points of reference .
the report 
 criticised the mdgs for ignoring rtis and insisted on the central importance of roads 
 for achieving these goals in a long - term , 
thus , according to the report , the aim could not be development without roads 
 but development with lots of roads of good quality . a central recommendations , 
 therefore , was that  at a minimum 10% of all road infrastructure projects should be 
 committed to road safety and that this principle should be rigorously and consistently 
 applied by all bilateral and multilateral donors. 
  thereby , the report reconfigured rtis from a development to a 
 development - assistance - programme issue .
three years later , the who issued a global status report on road 
 safety , which sought to provide an overview over the state of rti related 
 conditions in all countries worldwide . based mainly on information gathered in a 
 questionnaire , the report addressed a broad range of factors : institutional settings , 
 the quality of data , vehicle and infrastructure standards , legislation on some of the 
 main behavioural risk factors , medical care and exposure to risk .
while the behavioural 
 factors ( speeding , drink - driving , use of motorcycle helmets , use of seat - belts and child 
 restraints ) received relatively most attention in terms of pages , the exposure to the 
 risk , defined as  the existence of policies to encourage non - motorised modes of 
 transport and public transport and strategies to achieve these , and levels of 
 motorization were also addressed and related questions were included in the 
 questionnaire . 
 
the results reflected years of prioritising transport by car : forty - four per 
 cent of all countries worldwide had no policy , national or local , that encouraged public 
 transport , and sixty - eight per cent had no policy that encouraged walking or cycling as 
 an alternative to motorised transport . in an obvious attempt to produce an inspiring 
 model , the report presented positive examples from bogot , sweden , delhi and lagos , 
 where policies of this type had tangibly reduced rti numbers . 
 
in addition , the need for such policies was addressed in the first of five 
 central recommendations , although it was framed as an issue of  road design and 
 infrastructure , land use planning and transport services , understating its systemic 
 nature . 
 
the world bank had cooperated with both the commission for global road safety and with 
 the who , and in many ways its position has been the most interesting and possibly the 
 most important , given its financial clout and its influential voice in the development 
 debate .
a 2007 report , issued by the in - house independent evaluation group of the world 
 bank , painted the picture of an institution in search of a position regarding a rapidly 
 evolving issue .
huge expansion 
 of the global automobile market , based on the motorisation of china and india , which 
 predicted that  over the next 20 years , more cars may be built than in the 110-year 
 history of the industry. 
  clearly , decisions in this issue involved lots of money , and a huge private 
 market , in which the bank and its investors could hardly remain disinterested , 
 especially since those two countries had absorbed almost half of all world bank lending 
 in the transport sector since 2000 . 
  however , the evaluation group also recognised that the pressure of a three per 
 cent annual growth rate of cars on global roads increasingly created environmental and 
 health problems  and thereby eventually economic burdens . 
 
times were changing and the bank risked becoming outdated unless it changed , 
 too .
the report regarded the dominance of road building in the present world bank 
 transport portfolio as a threat to its long - term relevance .
while highway construction 
 would remain important , other  transport modes and themes were also becoming 
 significant and it was  essential to see transport opportunities with a multimodal 
 setting of integrated urban and rural concerns. 
  given the importance of the  poor in urban and rural areas of developing 
 countries and the bad condition of non - motorised transport facilities open to them , 
 which had been neglected , including by world bank activities , the report strongly 
 recommended that the bank begin funding related projects despite  the lack of or very 
 low revenue - generation nature of such projects. 
  after all , holistic road safety approaches were increasingly being pursued  in 
 all regions. 
  presumably , the world bank would be well advised to recognise these tendencies , 
 their demands and opportunities at an early stage . in other words : [ p]ast bank experience , with its relatively narrow , albeit successful , primary 
 focus on roads , will be insufficient to provide for the bank s future response to 
 these emerging challenges . 
overall , the sector is at a crossroads , where it has a 
 good window of opportunity to attain a higher level of relevance and offer a 
 better level of support to its clients . 
 
[ p]ast bank experience , with its relatively narrow , albeit successful , primary 
 focus on roads , will be insufficient to provide for the bank s future response to 
 these emerging challenges .
 overall , the sector is at a crossroads , where it has a 
 good window of opportunity to attain a higher level of relevance and offer a 
 better level of support to its clients . 

in 2012 , the history of rtis as part of the development discourse is far from finished . 

the upcoming years and decades will clearly bring changes in the number of rti deaths , 
 in rti discussions and in their perceived relation to development .
all stakeholders will 
 be able to choose from a broad range of approaches which have been endorsed by different 
 actors at different times in the twentieth century ( tables  2 and 3 ) .
this paper 
 identifies eight approaches each involving different elements , rti reduction strategies , 
 responsible agents and interpretive frameworks . while addressing the behaviour of 
 traffic participants
has been the preferred approach , all the others have been chosen as 
 well at some point or another , depending on world views and interests .
implicitly and , 
 increasingly , explicitly development played an important role in these choices . 

table  2:matrix of rti constructions.factorselementsstrategies of rti reductionresponsibleinterpretive frameworkpeople behaviourdrivers of motor vehicles bicycle 
 riders , passengers , pedestriansadapt behaviour ( alcohol , speeding , 
 distraction , helmet , traffic education)traffic participants ; legislatures ; 
 policelegal , psychologicalvehiclescars , buses , trucks , motor - bikes , 
 bicycleshighlight safety during productionindustry ; legislaturestechnological ; legalroadssize , surface , markings , signs andprovide safe driving environmentadministrationtechnologicalmaintenancemedical careambulances , hospitals , staff 
 trained in rti treatmentcreate and maintain adequate 
 medical caremedical servicesadministrativeorganisation : existence and enforcement of 
 regulationscreate and enforce regulationslegislatures ; policelegal , administrativeinstitutionagency with clear mandate , budget 
 andcentralise and coordinate all 
 rti - relatedgovernmentpolitical ( national)programme in charge of rti 
 preventionknowledge and initiativesnon - motorised transportpedestrian areas , cycle paths , 
 public transportationbuild infrastructure for 
 non - motorised and public transport ; separate road usersadministration ; private enterprisepolitical ( local and national ) , 
 economicsystemcommunication with work place ; 
 location of shops and places of leisure and social activitiesmodify living and working 
 conditions so as to reduce mobility needsgovernment , societysystemic , societal 
  matrix of rti constructions . 

abbreviations : hic  high - income 
 country ; mic  middle - income country ; lic  low - income country ; nmt  
 non - motorised  traffic.periodtransport development : eventsrtis : eventspublicationsrtis : discourse : prioritised 
 factors ( table 5)transport development : 
 discourse190045motorised vehicles spread mostly 
 in usa ; highway building programmes in usa ( 1916 ) and germany and italy 
 ( 1930s)rti mortality in usa rise from 
 7/100 000 ( 1910s ) to over 29/100 000 ( 1930s ) ; gb : rise to 18/100 000 
 ( 1939 ) ; collisions mostly involve only one motorised vehiclepeople s behaviourroad turns from space for 
 pedestrians to space for cars ; modernisation in high - income countries \documentclass[12pt]{minimal } 
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 } { } $ = $ \end{document }  motorisation194570motorised vehicles spread in 
 europemore people die of rtis than of 
 major epidemic diseases in hics ; most collisions involve several 
 motorised vehicles in hics1962 who : road traffic 
 accidents 
 people s behaviour ; organisationrtis \documentclass[12pt]{minimal } 
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 } { } $ = $ \end{document }  serious public health concern but also a necessary 
 price for modernisationralph nader : unsafe at 
 any speed ( 1962)vehiclesrtis result from 
 safety - neglecting ( underdeveloped ) car designs ( blame : 
 manufacturers)1968 : william haddon jr ,  the 
 changing approach to the epidemiologypeople s behaviour ; vehicles ; 
 roadssystemic approach to crashes197098urbanisation in lics and mics ; 
 large - scale investment in road buildingmeasures to reduce motorised 
 traffic in hic cities ; decline of rti deaths in hics , dramatic increase 
 of rti deaths in mics and on global scale , involving predominantly one 
 motorised vehicle and other traffic participantsorganisationdoubts about growth - oriented 
 economic system in hics ( 1970s ) , rise of neoliberalism ( 1980s ) ; debate 
 about  sustainable development ; excessive car traffic is considered a 
 burden on urban life in hics1994 world bank world development 
 reportorganisationcost - effective transport is 
 essential for development ; rtis are a secondary concern1996 : world bank / who : global 
 burden of disease projectmedical carertis \documentclass[12pt]{minimal } 
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 \begin{document } 
 } { } $ = $ \end{document }  major burden on global health and development , 
 especially in mics1998 : red cross : world disaster 
 report / global road safety partnershippeople s behaviour1999today2003 : world bank :  traffic 
 fatalities and
economic growtheconomic growth is essential to 
 reduce rti rate ( kuznets curve)2004 : who / world bank : 
 world report on road traffic injury prevention 
 institution ; people s behaviour ; 
 non - motorised transport ; systemdevelopment should serve 
 ( transport ) health , not vice versa.2006 : commission for global road 
 safety : make roads safe 
 roadsgood roads are essential to 
 development and to rti reduction2007 world bank : global 
 status report on road safety 
 organisation ; non - motorised 
 transport 
  matrix of events - discourse correlation .
abbreviations : hic  high - income 
 country ; mic  middle - income country ; lic  low - income country ; nmt  
 non - motorised  traffic . from the beginning , rtis have formed part of the spread of motorised traffic .
first in 
 north america and then in europe , rising numbers of cars lead to a rising number of 
 rtis , which caused concern . in the 1970s
, rtis numbers were brought to an acceptable  
 or accepted  level by a combination of regulations , affecting a broad range of traffic 
 components , and by some measures , which upgraded non - motorised relative to motorised 
 traffic in urban areas .
after the 1970s , the number of cars rose in other parts of the 
 world , causing an increase in rtis in those countries as well . by 2000 , the rti 
 situation was recognised as critical .
this paper argues that current difficulties arise in part from a selected transfer of 
 development models , derived from pre-1945 high - income countries to post-1945 low - income 
 societies . in order to be less lethal ,
the transfer of individualised motorised 
 transport as the principal transport model would have required a physical , legal and 
 administrative infrastructure , which low - income countries clearly did not have . on a 
 large scale ,
the process was similar to the policy of the baby food companies in the 
 1970s when they sold infant formula to people in low - income countries who did not have a 
 reliable infrastructure of clean water and sterilisation technology necessary for a safe 
 administration of formula . 
 
although the export of motorised transport is more complex than that of baby 
 formula the underlying logic is comparable : a mixture of profit - driven interests , a 
 eurocentric view of  modernisation and  development , and a lack of infrastructure such 
 as helmets , speed limit regulations , police enforcement , modern cars , road maintenance , 
 etc . in both cases ,
further policies depend on the extent to which the health discourse 
 can affect the underlying development discourse .
so far , rtis have been recognised as an important element of the larger 
 transport / development discourse , but a number of factors prevent their prioritisation : 
 the economic interests of stake - holders of motorised traffic , above all the 
 automobile industry;the traditional conception of  modernity as motorisation , deeply ingrained in 
 the collective consciousness in high- as well as in low - income countries;the path dependency of existing material infrastructures , which privileges 
 motorised vehicles and , on the other side , the scarcity or absence of a 
 material infrastructure for safer modes of travelling , especially in low - income 
 countries;the class difference separating the car drivers and the non - drivers in 
 low - income countries and thereby those who are most like to survive collisions 
 unharmed and those who are most likely to die .
this difference also effectively 
 excludes the potential victims , who would benefit most from policy changes , 
 from political decision - making processes in their countries . 

the deceptive assurance of a kuznets curve like concept that promises a 
 solution of the specific problems of low - income countries once they cease to be 
 low income.the sheer extent of reconceptualisation necessary to separate motorisation from 
 economic development .
the economic interests of stake - holders of motorised traffic , above all the 
 automobile industry ; the traditional conception of  modernity as motorisation , deeply ingrained in 
 the collective consciousness in high- as well as in low - income countries ; the path dependency of existing material infrastructures , which privileges 
 motorised vehicles and , on the other side , the scarcity or absence of a 
 material infrastructure for safer modes of travelling , especially in low - income 
 countries ; the class difference separating the car drivers and the non - drivers in 
 low - income countries and thereby those who are most like to survive collisions 
 unharmed and those who are most likely to die .
this difference also effectively 
 excludes the potential victims , who would benefit most from policy changes , 
 from political decision - making processes in their countries . 
  the deceptive assurance of a kuznets curve like concept that promises a 
 solution of the specific problems of low - income countries once they cease to be 
 low income .
catching up , of imitating step by step 
 the development taken in high - income countries , which most stands in the way of novel 
 systemic approaches .
this concept ignores the fact that it is not possible to extend the 
 car density , the level of fossil fuel consumption and the culture of suburban spread of 
 europe and north america to the rest of the world . on the basis of present - day knowledge 
 about the physical state of our planet ,
a global repetition of the motorisation 
 experience in high - income countries is simply not possible and is therefore not a useful 
 development model . nor is it necessary for an intelligent modernisation .
the mobile 
 phone is one example that a modern means of communication can be extended globally 
 without spreading its europe - centred predecessor ( in this case networks of landline 
 cables ) first .
there is no reason to assume nothing similar could happen in the field of 
 mobility and transportation , given the political will and economic prospects .
promoting non - motorised transport would reduce rtis in high - income countries and even 
 more so in low - income countries .
since , by broad consensus , development in high- as well 
 as low - income countries is meant to improve public health , the need to reduce rtis may 
 eventually serve as a powerful argument to search for intelligent transport solutions .
so discourse is 
 important  and it must be heard . in this context , the promotion of a medical doctor 
 with a history of health promotion in low - income countries to the post of world bank 
 director is an interesting development .
 in the course of the twentieth century road traffic injuries ( rtis ) became a major 
 public health burden . 
 rti deaths first increased in high - income countries and 
 declined after the 1970s , and they soared in low- and middle - income countries from 
 the 1980s onwards . as motorisation took off in north america and then spread to 
 europe and to the rest of the world discussions on rtis have reflected and influenced 
 international interpretations of the costs and benefits of  
 development , as 
 conventionally understood . 
 using discourse analysis , this paper explores how rtis 
 have been constructed in ways that have served regional and global development 
 agendas and how  
 development has been ( re-)negotiated through the discourse of rtis 
 and vice versa . for this purpose , this paper analyses a selection of 
 key publications of organisations in charge of international health or transport and 
 places them in the context of ( a ) the surrounding scientific discussion of the period 
 and ( b ) of relevant data regarding rti mortality , development funding , and road and 
 other transport infrastructure . 
 findings suggest that constructions of rtis have 
 shifted from being a necessary price to be paid for development to being a sign of 
 development at an early stage or of an insufficiently coordinated development . in 
 recent years 
 , rti discussions have raised questions about development being 
 misdirected and in need of fundamental rethinking . at present , 
 discussions are 
 believed to be at a crossroads between different evaluations of developmental 
 conceptualisations for the future . 
Introduction
The Early Years of RTIs
The Construction of a Public Health Issue
The Competition of Development Concepts
Conclusions