"A car wrecked in an accident in Jeddah is being towed to a junkyard. Police say reckless driving is the cause of about 60 percent of accidents in the country, while speeding through a red light causes 34 percent of accidents." Arab News
This post--and the metaphor in the title--were inspired by the following most impressive video:
Street Terrorism إرهاب الشوارع MctoomMediaMovies Ala'a Al Maktoum
The video is by an Architecture graduate of KFUPM, Ala'a Al Maktoum, who is also a "designer, musician, amateur photographer, obsessed with multimedia and movies". The video has spread via Twitter and blogs. It is so good that it anticipated my balking at the use of the metaphor of terrorism, addressed it directly; and, despite my reservations, convinced me it was apt and not overblown. I left this comment on Asmaa's Chapter One post "إرهاب الشوارع ", where I first saw the video; and on Qusay's Qusay Today post "Ala'a McToom: Street Terror", where I saw it very soon after:
Very impressive public service/safety message!
When I see car accident injury statistics I wonder how many are head injuries, with long term neuro-psychiatric consequences. I also wonder how many of those are children, especially since seatbelts are not customary, making children especially projectile objects in a car accident.
A Moroccan child psychiatrist told me a few years ago that the single highest dx they saw in a major city university hospital clinic was neuro-psychiatric disorders secondary to head injuries in car accidents.
Since Saudi is taking gold medals in this field of car accident deaths and injuries, I wonder what the child and adult neuro-psychiatric clinics are like there.
Neuro-psychiatric disorders are elusive and expensive to treat. They result in the types of dysfunction that impede learning, work, and social integration.
So...you all don't need me to tell you anything, but I heartily second Al-Maktoum's message, and applaud his talent in conveying it!I remained struck by the video, and so did some follow-up research from a medical perspective. As expected, the Ministry of Health, public health specialists, and surgeons (trauma and neuro) are actively engaged in research on this problem, and in finding, proposing, and enacting solutions. More surprising to me was the involvement of engineers. However, on reflection, this is part of their domain, especially civil engineers, and perhaps materials engineers. Judging by the costs, financial engineers and economists should be more active in this domain too. Certainly hospital administrators have huge cost and bed usage (1/3 of all hospital beds are occupied by victims of road accidents) problems.
Part of my interest derives from my experiences in Morocco, as reflected in my comment; and, part in other blog discussions with Saudi commentators who confirmed similar issues in Saudi. To a Westerner Moroccan traffic looks like bad imitation French driving. The phenomenon that frightens me the most is what I call the "family moped', ie father driving, mother behind, toddler in handle bars, baby on mother's back, child behind mother. This occurs often at night with no lights, in villages with no streetlights. The phenomenon speaks to income levels, and lack of infrastructure, but convinces me that I could never negotiate the pot holes and the darkness, and miss hitting the family, that I just barely make out as we are passing by in a car.
The other phenomenon that strikes me is the "right of way by virtue of car prestige". This means that the most expensive, prestigious car has the right of way, even going the wrong way on a one way street, in a residential area of a major city. There is a code which I used to know better, but basically a large Mercedes trumps all.
Highways may dwindle to one unpaved lane only to widen to 4 lane superstructures with mega-lighting and decoration when they arrive at the home village of a dignitary, then return to one paltry gravelly (but not really a gravel road) dusty strip again after leaving the village.
Since it is a Muslim country, but a moderate one, alcohol and drugs both are frowned on, but available. Unfortunately, as a Moroccan psychiatrist pointed out, there is a lot of denial about the extent to which these are social problems, because of a preference to believe that Muslims don't drink or use drugs to excess. Still, there are impaired drivers on mopeds, motorcycles, and in cars.
Pedestrian behaviour was a mystery to me. Whereas I cross at intersections, stop, look both ways before crossing, and sprint the last metre or two if startled, Moroccans cross wherever, whenever, seemingly without looking at all, and would never sprint in such an undignified manner. It was explained to me that this is part of a fatalistic "Inshallah" attitude. I am not convinced entirely, because in fact they have looked, though more discretely and do calculate time to the opposite curb accurately. I have learned how to do it better myself--if only not to embarrass companions.
This is not to condemn or over generalize, but merely to share my experiences from which I try to understand the Saudi phenomenon. After doing some research, the issues in Saudi are similar, but unique.
The primary problem is, simply, the drivers. Saudi drivers are responsible for half the accidents and non-Saudi drivers responsible for the other half. Saudis have more trouble in the cities and at intersections with traffic lights (particularly on right-angle turns), whereas non-Saudis have more trouble outside the major cities and where there are no traffic lights. While accidents and injuries are highest in the city and fatalities highest outside (due to speed), disabilities happen everywhere.
Saudis don't like to obey the signals. They like to run red lights (34% of traffic fatalities) and make illegal U turns (18%). It seems that the "who has the most expensive car" rule of the right of way prevails. Bentleys seem to be the most prestigious. However, the advent of 4 wheel drive vehicles has resulted in a marked increase in head injuries from MVAs.
Whereas in Morocco the vast majority of the drivers are Moroccans, a high proportion of drivers in Saudi are non-Saudi, and are on contracts, coming from South Asian, East Asian, and African countries. These are the same countries where it is easy to "arrange" a driver's license, and where poor driving habits, poor enforcement of existing laws, low use of seatbelts and child safety seats, and the resulting accidents and their sequellae are also rampant. To extend Al-Maktoum's metaphor, these countries are Olympic finalists in the MVA, RTA, Car Accident/ Fatalities/ Injuries events. Now, in Saudi, their contenders have better training opportunities.
The most traffic accidents are caused by male drivers 15-25. This is no surprise, given that women aren't allowed to drive, and this is the age group the world over which leads the pack in accidents, fatalities, and injuries. Neuroscience research has proven what many suspected: the brain doesn't fully mature until age 25. Before that impulse control, judgment, and the ability to project long term consequences are poor, and poorest in men, as opposed to women.
In Saudi "bored teens with cars" takes on proportions reminiscent of the 1950's drag racing phenomenon in the USA. This makes for interesting films like Rebel Without A Cause, and entertaining ones like Grease, but also for accidents, injuries, fatalities, and disabilities. In Saudi the phenomenon takes the form of cruising the city in cars, acting like idiots with other cars and passengers, and "skating"--gliding on the pavement hanging on to a car.
Many a blogger has written about the school run, with their own risk-taking driver and that of others, but also of the children in the front or back seats unbelted and playing, fighting, bouncing around. This makes for children potentially bounced throughout the car, through the windshield, or through the doors in the case of an accident. Being thrown from the car is the single greatest factor in fatalities, and the reason for seat belts in the first place.
Children have a disproportionate number of head injuries, and a disproportionate number of fatalities from those head injuries. Most often these injuries are the result of being hit by a car when they are pedestrians. There is no match between a child and a car. There is also no match between an adult without a motorcycle helmet and the road. Or between a motorcycle and a car. These are the greatest causes in Saudi and elsewhere of MVA fatalities for adult men.
Given who drives, most injuries happen to the head of the household, compromising not only his health, but the livelihood of the family. Time off work at the time of the accident, at intervals from sequellae like chronic pain, or limited function and therefore limited job abilities all inhibit the head of the household's earning power, opportunities for promotion, career path.
Given who doesn't drive, fatalities are selectively high for women school teachers. Not only do these female teachers have a 50% greater chance of dieing in a traffic accident than the average Saudi, but the numbers are increasing. Women, facing limited career options, often accept teaching positions in remote areas. They spend many hours commuting and carpooling with chauffeurs on rural roads with little traffic regulation and at high speeds, resulting not only in accidents but in fatalities. As detailed in the excellent 2008 article from AP Female teachers dying on Saudi Arabia roads: Long commutes to remote schools taking heavy toll on women, a number of other factors are at play.
Women are not free to live without a mahrem (or at least his permission), and it is culturally inappropriate to do so anyway, especially in conservative rural villages. Landlords won't rent to them, and government attempts at building houses for them have failed. Women live in their family homes and commute 1-3 or more hours each way, daily, sometimes starting at 3am. The distances may not be as great as implied, between 30 and 108 miles for example, but road conditions increase the length of time it takes to travel, and increase the risks of accidents and fatalities.
Unpaved roads, winding roads, potholes, and roads in generally poor condition are common, as is speeding. The vehicles themselves, especially the vans and buses for carpooling, are often old and poorly maintained, which makes them subject to break downs and non-responsiveness that increase the risk of accidents. Most accidents happen in remote areas with no cell phone coverage, so emergency services are slow to be called and slow to arrive. Ar-Riyadh reported on the death of a woman who wasn't reached by EMTs for 2.5 hours.
While there are other factors, as mentioned the primary factor in Saudi road accident statistics seems to be the drivers. Many are unlicensed, few have formal driver training, some are (very) underage, and some are on their first drive through the city in late childhood, because they are the only available driver for the family. A factor I haven't seen mentioned much, but wonder about is alcohol and drug impairment of drivers. While one study specifically mentions that the drivers were not intoxicated, it is common in Muslim countries to underplay alcohol and drug use because they are forbidden by Islam. However, it is also common to find that rates are higher than many would like to believe, or admit, and the consequences more broad.
Another factor which I haven't seen mentioned, but which I would like to hypothesize, is that of seemingly tiny rebellions with huge consequences. In a highly codified setting small acts of rebellion give a sense of freedom and agency. Smoking in non-smoking areas, wearing your tie askew, hemming your uniform a centimetre too short, writing in peacock blue ink (well it's blue, isn't it?), wearing red lingerie to work (well no one sees it, do they?), etc.
Perhaps disobeying traffic signals is a seemingly tiny bit of freedom, which has, unlike the other examples given here, huge consequences. Or maybe it is a Y-chromosome, machismo, honour, dignity, face saving issue. A little like the Gallic standoff when 2 cars think they have the right of way--not pretty. But then, who wants to be upstaged by a lesser "car".
So where are the neuro-psychiatric disorders I was worried about in my comments on other blogs? Disabilities are not always obviously physical but just as incapacitating if not identified and dealt with. Some are still with the surgeons, some in rehab, some hidden at home, and some probably undiagnosed. On the neurological side, spinal cord injuries are most frequently caused by MVAs and are most often of the dorsal (mid-back) spine. Car collisions with camels also produce spinal injuries in significant numbers, most often of the cervical (neck) spine. These injuries often result in death or severe incapacitation physically with the attendant psychological, familial, and societal strains.
People being people the solutions are similar the world over. These include massive public awareness campaigns via the media and schools to sensitize people to the need to obey traffic laws, and to teach children pedestrian safety. Seat belts for all passengers front and back are important. Saudi law currently requires them for adult front passengers only. Infants need to be in rear facing infant seats, and toddlers in booster child seats. Older children should be in child safety seats until they reach a weight of ~80lbs such that they won't be as likely to be thrown from adult seat belts. Children are not only light weight but they are top heavy as their heads are normally proportionally large for their bodies. This makes them even better projectiles and more likely to fall head first.
Greater attention needs to be paid to driver training and licensing, and ensuring that all drivers are licensed by rigorous examination. Minimum ages for licensing, and graduated licenses as the person has shown safe driving have worked well in other places, where 16-18 is often the minimum age and the first 2 years involve driving in city traffic only, with restrictions on the number of passengers. Licensing women is a separate but related issue, as it would change the dynamics on the road. Women are generally safer (not necessarily better) drivers than men, and have lower accident rates. However, as of today, women drivers would be such a novelty that a lot of staring accidents might happen. This needs to be addressed comprehensively and introduced appropriately.
If an adult woman could be the family driver, the male child wouldn't have to be. Children driving are normally stopped and prohibited from continuing their journey in other countries. A lawyer I know defended an 8 year old charged with driving around town. He was a reserve Native Canadian, and went into town to look for his mother. He was stopped, and in a bit of overkill by local police (could it be because he was Native?) was taken to the station and charged. The judged dismissed the case after the child said his mother hadn't come back from town and he was worried about her.
While there are appropriate traffic laws in Saudi, better enforcement is required, with appropriate consequences regardless of status, nationality, wasta, reshwa etc (yes, Utopian, I know, but improvements could be made). Saudi has introduced a system of radar and photo imaging of offenders' cars so that tickets, fines, and punishments can be meted out with non-negotiable proofs, and more violators can be caught than the police has manpower for. The system is called Suher, or Suhir.
Again, as I said in my original comment on the video, it is hardly my place to tell Saudis what to do. These assessments of the problems and recommendations for solutions have all been made by Saudis themselves: engineers, doctors, pediatricians, surgeons, public health specialists, researchers, ministers, health administrators, and journalists. The list of readings includes a sampling. Hopefully their words will prevail to improve the health and safety of Saudis.
Epidemiology of road traffic accidents in Al-Ahssaa Governorate, Saudi Arabia, EMRO, Eastern Mediterranean Health Journal Volume 4, Issue 3, 1998, Page 513-519
Trauma care systems in Saudi Arabia: an agenda for action. Al-Naami MY, Arafah MA, Al-Ibrahim FS. Ann Saudi Med [serial online] 2010 [cited 2010 May 17];30:50-8.
Seat belt utilization in Saudi Arabia and its impact on road accident injuries. Salaheddine Bendak, Department of Industrial Engineering, King Saud University, Accident Analysis & Prevention Volume 37, Issue 2, March 2005, Pages 367-371
Pediatric thoracic trauma. Stanley J. Crankson, James D. Fiscjer, Abullah A. Al-Rabeeah, Saud A. Al-Jaddan, Saudi Medical Journal.
Dorsal spine injuries in Saudi Arabia—an unusual cause. Sohail A Ansari, M.D. (F.R.C.S.), Mohammed Mandoorah, M.D. (F.A.F.R.M.), Mahamed Abdalrahim, M.D. (F.R.C.S.), Khalaf R Al Moutaery, M.D. (F.R.C.S.) Surgical Neurology. Volume 56, Issue 3, Pages 181-184 (September 2001)
19 die daily in road accidents in Kingdom by Muhammad Humaidan, Arab News Monday 14 December 2009
16 killed daily, 275,000 injured yearly in road accidents By P.K. ABDUL GHAFOUR , ARAB NEWS Published: Apr 22, 2010 00:33 Updated: Apr 22, 2010 02:24
Saudi Drivers Top the World in Road Deaths All Headline News, March 14, 2010.
Gulf states urged to end road death carnage, by Mazen Mahdi, Foreign Correspondent, Last Updated: April 21. 2010 10:28PM UAE / April 21. 2010 6:28PM GMT
Female teachers dying on Saudi Arabia roads: Long commutes to remote schools taking heavy toll on women AP updated 2:08 p.m. ET, Tues., April 29, 2008.
What harrowing traffic experiences have you had, inside or outside Saudi?
What do you think of my right of way hypothesis?
What do you think of my "tiny acts of rebellion with huge consequences" hypothesis?
What type of licensing is in force where you are?
What type of seatbelt, infant seat, child seat laws exist?
What is your impression of the efforts being made currently to improve Saudi road safety?
What else should be done?
Any other comments, thoughts, experiences?