**2. Incidence, mortality and economic impact of traffic accidents**

Before 1970, there are recorded health statistics only from 1958. And they recorded all accidental fatalities together regardless the cause, although the vast majority comes from road traffic accidents (table 1).

According to official reports, there are 10,000 car accidents a year in Cuba (Graph 1). Most of them happen in Havana, followed in descending order by Santiago de Cuba and Holguin (Graph 2), which happens to be the more populated cities in the country with population of 2 147 539, 1 048 377 and 1 036 504 respectively (Oficina Nacional de Estadísticas [ONE], 2010; DNE, 2010).

Each year, injuries account for more than 1.3 million deaths globally, and more than 90 per cent of these deaths occurred in low and middles income countries. The Word Health Statistics 2008 Report predicts that road traffic injuries will be one of the most rapidly growing public health concerns over the next 25 years, primarily owing to increased motor vehicle ownership and use associated with economic growth in low and middle income countries (WHO, 2008). According to this report, in 2004 traffic accidents constituted the ninth cause of death of the world population. In 2030 it is expected that it would be the fifth cause of death, displacing infectious and tumor diseases, with countries with low-to-middle income rates having the bigger share (Peden et al., 2002; WHO, 2010).

In Cuba, from seventies of last century, accidents in general have constituted between the fourth and fifth cause of mortality, preceded by the cardiovascular disease, stroke, cancer and influenza and pneumonia. The traffic accidents together with the accidental falls constitute a fundamental cause of deaths for accidents. (DNE, 2010).

Source: ONE, 2010.

To the first clunker cars manufactured in North America, more vehicles were added predominantly from the United States, which in turn dictated the characteristics of the vehicle inventory. After 1959 vehicles coming from the extinct Soviet Union and others European countries were added to the stock. Starting 1990, there is an economical crisis the country must face against, resulting in important changes in the Cuban society, which in turn changed the way vehicles were employed due to fuel shortages. As an alternative transportation mean, bicycles are started to be used massively by the population to run their usual chores as well as to go to workplaces. At the same time animal-hauled vehicles, especially those using horses are starting to show up in cities throughout the country, less

To remedy the shortcomings of the capital city's public transportation system, alternatives are sought as well, basically employing trucks and tractors without the required safety standards. Along this period, due to the same financial crisis which affected the public transportation system, the pavement of the city's thoroughfares began to deteriorate as well, along with the transit signals. All these factors increase the risks of car crashes and the

Regarding the increased use of bicycles it should be stated that the modifications needed in the traffic system in order to protect bicycle riders -- as dedicated lanes or mandatory use of

However since the beginnings of the XXI century, the number of bicycles has dwindled significantly, which today circulates simultaneously to old built vehicles in North America in the fifties (e.g. Chevrolet, Chrisler), with others of European origin built in seventies (e.g. Lada, Moskvichs, Polski) and other more modern vehicles (e.g. Peugeot, Mercedes Benz, Toyota).

Before 1970, there are recorded health statistics only from 1958. And they recorded all accidental fatalities together regardless the cause, although the vast majority comes from

According to official reports, there are 10,000 car accidents a year in Cuba (Graph 1). Most of them happen in Havana, followed in descending order by Santiago de Cuba and Holguin (Graph 2), which happens to be the more populated cities in the country with population of 2 147 539, 1 048 377 and 1 036 504 respectively (Oficina Nacional de Estadísticas [ONE],

Each year, injuries account for more than 1.3 million deaths globally, and more than 90 per cent of these deaths occurred in low and middles income countries. The Word Health Statistics 2008 Report predicts that road traffic injuries will be one of the most rapidly growing public health concerns over the next 25 years, primarily owing to increased motor vehicle ownership and use associated with economic growth in low and middle income countries (WHO, 2008). According to this report, in 2004 traffic accidents constituted the ninth cause of death of the world population. In 2030 it is expected that it would be the fifth cause of death, displacing infectious and tumor diseases, with countries with low-to-middle income rates having the

In Cuba, from seventies of last century, accidents in general have constituted between the fourth and fifth cause of mortality, preceded by the cardiovascular disease, stroke, cancer and influenza and pneumonia. The traffic accidents together with the accidental falls

constitute a fundamental cause of deaths for accidents. (DNE, 2010).

**2. Incidence, mortality and economic impact of traffic accidents** 

often in the nation's capital.

injuries and casualties' toll.

road traffic accidents (table 1).

2010; DNE, 2010).

helmets -- were not immediately adopted.

bigger share (Peden et al., 2002; WHO, 2010).

Fig. 1. Traffic accidents. Cuba 2004-2009

Source: ONE, 2010

Fig. 2. Traffic accidents in cuban counties (2009)

Traffic accidents mortality had an increasing trend in the 1970 to 1989 period as can be seen in fig.3, in which it soared up to 24.1 deaths by 100,000 habitants (Asamblea Nacional del Poder Popular, 1987; Ministerio de Salud Pública, 2010). Afterward it became evident its decrease down to 7.8 in 2008, which is related to changes in the national prevention strategy as it is reflected in the 60 Act, which includes:


Epidemiology and Prevention of Traffic Accidents in Cuba 185

In national reports there is no evidence of the relative impact of the employment of bicycles as a mean of transportation in the traffic accident's mortality notwithstanding the primary role this vehicle had as such. In 2009 bicycle related accidents yielded the 6.5% of all fatalities (DNE, 2010). A study conducted in Cienfuegos, province located amid Island, the mortality rate related to bicycles was 6.44 by 100,000 habitants, mainly from the 15 – 44 age groups, males (Jorge et al., 2010). Vulnerability of bicycle-riders circulating in thoroughfares

Traumatism due to traffic accidents occupied the ninth place in the 2009 worldwide as morbidity and lesions agents, considering their share in years of life potentially lost due to incapacity. It forecast for 2020 is the third place, getting the lion share countries among low-

In Cuba, traffic accidents were the fourth cause of years of life potentially lost, behind cardiovascular diseases, stroke and cancer, which should be considered when it comes to evaluate its impact on society (DNE, 2010). According to evaluations in Villa Clara, in 2003, the years-of-life potentially lost rate was 11.58 by 1000 habitants, with males yielding 14.46

The impact of traffic accidents in healthcare system could be evaluated be means of use of emergency services for healthcare of injuries, admission in hospital and rehabilitation of patients to survive. Detailed information about this it is not included in the official statistics in Cuba and few published articles in national biomedical journal and in Infomed, the national medical web, refers to this topic. A descriptive study of patients admitted in the main rehabilitation center in Cuba, Hospital Julio Díaz, show that neurologic injured and amputated patient, as consequence of traffic accidents, are the major cause of admission, displacing other previous causes of disability as infectious

**10.6**

**0 5 10 15 20 25 30 35 40**

Fig. 5. Rates of potential life years lost (per 1000 habitants) according selectec causes of

Studies dealing with the economic impact of traffic accidents are scarce in Cuban literature, and the existing ones do not analyze the problem integrally, as they do not

**11.5**

**5.7**

**34.5**

**rates**

**29**

is a world class problem (WHO, 2004).

to-middle GDP (WHO 2009).

diseases (Berbes VL, no date).

**Cardiovascular**

Source: DNE, 2010

death. Cuba 2009.

**Cancer**

**Stroke**

**Neumonia**

**Accidents**

and females 8.35.

Source: Dirección Nacional de Registros Médicos y Estadísticas de Salud, 2010.

Fig. 3. Traffic accidents adjusted mortality rate (by 100 000 hab), Cuba, 1970 -2009.

An element strongly related to traffic accidents mortality's incidence, starting from the 90 decade, was the massive introduction of bicycles on the streets as a mean of transportation. This related with economic problems that reduced in an important way the use of vehicles that use fuel. Although the number of bicycles have since decreased significantly, in 2009 the bicycle related accidents accounted for the 6.5% of the traffic fatalities.

To the death casualties should be added, as an additional burden, the lesions and injuries, with figures that, as a whole, soar to a staggering 7000 a year. According to Graph 4 there is a dominance of male individuals at productive age (fig 4) (DNE 2010). In 2009 the accident mortality rate in Cuba was 14.5 by 100,000 habitants (male) and 3.4 by 100,000 habitants (female) (ONE, 2010). Similar outcome was observed at the Villa Clara Project, where 65% of fatalities and 70% of injuries were male individuals (Guanche, 2008).

Source: ONE, 2010

Fig. 4. Proportional distribution of deaths and injuries in traffic accidents according age. Cuba 2009.

Source: ONE, 2010

Cuba 2009.

**proportion**

**morta;ity rate (por 100 000** 

**inhab)**

**Mortality rate (per 100 000 inhab)**

**1970**

**1972**

**1974**

**1976**

**1978**

**1980**

**1982**

Source: Dirección Nacional de Registros Médicos y Estadísticas de Salud, 2010.

bicycle related accidents accounted for the 6.5% of the traffic fatalities.

fatalities and 70% of injuries were male individuals (Guanche, 2008).

**1984**

Fig. 3. Traffic accidents adjusted mortality rate (by 100 000 hab), Cuba, 1970 -2009.

**1986**

**1988**

An element strongly related to traffic accidents mortality's incidence, starting from the 90 decade, was the massive introduction of bicycles on the streets as a mean of transportation. This related with economic problems that reduced in an important way the use of vehicles that use fuel. Although the number of bicycles have since decreased significantly, in 2009 the

To the death casualties should be added, as an additional burden, the lesions and injuries, with figures that, as a whole, soar to a staggering 7000 a year. According to Graph 4 there is a dominance of male individuals at productive age (fig 4) (DNE 2010). In 2009 the accident mortality rate in Cuba was 14.5 by 100,000 habitants (male) and 3.4 by 100,000 habitants (female) (ONE, 2010). Similar outcome was observed at the Villa Clara Project, where 65% of

> **0 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 > 70 age (in years)**

Fig. 4. Proportional distribution of deaths and injuries in traffic accidents according age.

**1990**

**years**

**1992**

**1994**

**1996**

**1998**

**2000**

**2002**

**2004**

**deaths injuries**

**2006**

**2008**

**rates**

In national reports there is no evidence of the relative impact of the employment of bicycles as a mean of transportation in the traffic accident's mortality notwithstanding the primary role this vehicle had as such. In 2009 bicycle related accidents yielded the 6.5% of all fatalities (DNE, 2010). A study conducted in Cienfuegos, province located amid Island, the mortality rate related to bicycles was 6.44 by 100,000 habitants, mainly from the 15 – 44 age groups, males (Jorge et al., 2010). Vulnerability of bicycle-riders circulating in thoroughfares is a world class problem (WHO, 2004).

Traumatism due to traffic accidents occupied the ninth place in the 2009 worldwide as morbidity and lesions agents, considering their share in years of life potentially lost due to incapacity. It forecast for 2020 is the third place, getting the lion share countries among lowto-middle GDP (WHO 2009).

In Cuba, traffic accidents were the fourth cause of years of life potentially lost, behind cardiovascular diseases, stroke and cancer, which should be considered when it comes to evaluate its impact on society (DNE, 2010). According to evaluations in Villa Clara, in 2003, the years-of-life potentially lost rate was 11.58 by 1000 habitants, with males yielding 14.46 and females 8.35.

The impact of traffic accidents in healthcare system could be evaluated be means of use of emergency services for healthcare of injuries, admission in hospital and rehabilitation of patients to survive. Detailed information about this it is not included in the official statistics in Cuba and few published articles in national biomedical journal and in Infomed, the national medical web, refers to this topic. A descriptive study of patients admitted in the main rehabilitation center in Cuba, Hospital Julio Díaz, show that neurologic injured and amputated patient, as consequence of traffic accidents, are the major cause of admission, displacing other previous causes of disability as infectious diseases (Berbes VL, no date).

Source: DNE, 2010

Fig. 5. Rates of potential life years lost (per 1000 habitants) according selectec causes of death. Cuba 2009.

Studies dealing with the economic impact of traffic accidents are scarce in Cuban literature, and the existing ones do not analyze the problem integrally, as they do not

Epidemiology and Prevention of Traffic Accidents in Cuba 187

Fig. 6. Antique and modern vehicles in urban roads and risk of accidents

Table 2. Government vehicles and passengers transported. Cuba 2004 – 2009.

and solutions to signaling deficiencies (Salgado, 2010).

Related with quality of road infrastructure, was evident an important deterioration in the nineties, that included physical damage of roads and deficiencies in signalings (horizontal and vertical). The construction activities and maintenance of roads net is responsibility of state entities. Recently, in correspondence with the economic recovery, a program of improvement of roads has been developed, included the construction of asphalt factories

Is important consider that in national road infrastructure they are few alternatives to protect pedestrians, elevated bridges for traffic of vehicles in the cities and others, partly determined by financial possibilities for their implementation. Also, the employment of exclusive roads for the circulation of bicycles that was used during the nineties, has decreased in a significant way, although its circulations continues in urban and rural roads, which increased vulnerability to occurrence of traffic accidents. WHO Report of Road Safety (WHO, 2009) define as vulnerable road user to pedestrians, cyclist and user of motorized of

Goverment vehicles

Passenger transported (million of passenger)

Source: ONE, 2010

two wheelers.

variables 2004 2005 2006 2007 2008 2009

Ómnibus 11.491 10.561 11.319 10.460 11.979 12.194 Taxi 3.306 3.544 4.280 4.243 4.310 3.015 Trucks 12.510 15.014 11.658 11.893 10.249 11.326

Ómnibus 647,5 679,5 697,9 755,6 898,1 922,6 Taxi 40,4 41,3 40,2 43,7 45,6 46,7

account the direct and indirect costs involved, as should be considered medical assistance and rehabilitation. Main biomedical publications deal fundamentally with clinical aspects, centering on the description of injuries (Scielo Cuba, 2011). A study in the province of Villa Clara which is one with a high incidence of traffic accidents, first semester of 2009, described the use of hospital services by traffic injuries patient (Guanche, 2008). About 25% of patients were admitted to critical care units, 30% underwent major surgery and 31.3% were prescribed antibiotics. Rough estimates using the abovementioned information give that traffic accidents in Cuba account for some 50 million pesos a year.

According to the National Statistic Office (ONE, 2010), damages caused by traffic accidents to public or private property amounted to 5 978,2 million of pesos in 2008 and 4 390,4 million of pesos in 2009. The global economic loses due to road traffic injuries are estimated to be US\$ 518 billion with a particular impact in low and middle income countries (WHO, 2009).
