Crisis Response Podcast Episode 10 - Road Traffic Injuries in Bangladesh TraumaLink

Episode #10: Road Traffic Injuries in Bangladesh | TraumaLink

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Episode Transcript

This transcript was compiled using automated software — spelling and punctuation errors are possible.

Jason: Hello, Jon, and welcome to the show.

Jon: Thanks for having me, Jason.

Jason: A real pleasure to have you. So you are the founder and executive director of TraumaLink, and your focus is on road traffic injuries in Bangladesh. I’m wondering if you could share how did you get started with this? Where did the idea for this come about and what were your first steps?

Jon: Sure, absolutely. So I traveled to Bangladesh for the first time in 2013. I was working on my Masters of Public Health degree, and I was there for my practicum. My background is as an emergency physician. So I went there thinking that I would do something related to disaster preparedness. But shortly after arriving there and getting to know the country a little bit better, I saw that there was an ongoing crisis on the roads, and I was lucky enough to meet some other people who were interested in road safety while I was there.

So we started putting our heads together, trying to create a community based solution for the lack of first aid services for these traffic injury victims. And when we started, we reached out to a number of different Bangladeshi organizations involved in road safety and volunteerism. We spoke with local community members, police, fire services, religious leaders, local hospital staff and we used those meetings to help guide us towards a model that would be relevant to Bangladesh.

So the model that we developed was one in which we find interesting community members. We give them training on basic trauma, first aid, mass casualty triage, and we provide them with first aid supplies that we keep in locations that are available 24 hours a day.

We also set up a call center that’s available through a dedicated emergency hotline number. And when somebody calls the service, the operator first collects information on where the crash occurred and how many patients have been injured. And we have a customized graphic user interface that will automatically dispatch volunteers based on their proximity to the crash scene by sending text messages to their mobile phones.

So on the way to the crash scene, they’ll collect their first aid supplies. And once they’ve treated patients at the scene, our graphic user interface also provides guidance on where to take the patients based on not only where they’re located, but also how badly injured they are. And, you know, will dispatch police and fire services if we need their assistance and we make use of local transportation networks like police vehicles, fire service, ambulances, local bystanders, vehicles for hire to get the patients to the hospital rapidly. And we also provide a heads up to the hospitals when we have patients on the way.

Jason: Fantastic work you’re doing and it’s really building a system from scratch. I’m wondering for the listeners who are not familiar with the state of emergency medical services in low- and middle-income countries, if you could share a little bit about what was the EMS response system like before TraumaLink got started?

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Jon: Yeah, there are actually very few services in place. There are no formal services. So it tended to be a system in which it was an informal system in which people were primarily relying on bystanders for care. Sometimes police would respond and sometimes fire services. Most people don’t get to the hospital by ambulance. It’s usually by passersby. So it was a very informal service.

And what we found is that there was a lot of goodwill in Bangladesh where people wanted to help, but because they didn’t have equipment or training, they could frequently cause additional injuries through improper handling of patients. And there were also multiple levels of delays in getting people to the crash scene and getting people to the hospital. And because trauma is so exquisitely time sensitive, that resulted in a lot of unnecessary deaths and permanent injuries.

Jason: So when you started this, you obviously had to do, as you mentioned, a lot of community building or you had to get a lot of people involved in your collaboration. How did you go about recruiting partners and did you face any pushback or run into any obstacles?

Jon: Well, I’ll say that one benefit of not having any services in places is that we didn’t have a system that we had to work against. So the way we set this up was by reaching out to as many different people as we could, getting their input and making them partners very, very early on in the process.

And we found that by working early on to create these strong, respectful, honest, open relationships, that actually helped us out quite a bit and got our ongoing support for the program. Also, by rolling in all of that feedback that we got, we were able to create something that was appropriate for the local conditions, acceptable to the communities and something that they felt like they were part of.

Jason: And you mentioned the fire department was involved. You know, in the United States, a lot of times the fire department is delivering emergency medical services and we can’t take it for granted that fire departments are involved in this. But I’m wondering, what was their take on it when you approached them about being involved, were they already involved in road traffic injury response or was this something new to them?

Jon: When we first started working there, the vast majority of calls, the vast majority of responses were the result of calls from bystanders. And a lot of people didn’t have access to the phone numbers for police or fire services. So it was often the case that somebody would get in a vehicle and drive to the station, let them know about the incident, and then they would mobilize a response.

So there were very significant delays. Fire services get some first aid training. They don’t really have a formal process for dispatching fire services to crash scenes. And police would sometimes help injured victims, but their mandate was really to create a legal case. And that was their primary responsibility.

Jason: What kind of numbers are you dealing with now in terms or responders, response vehicles, incidents, and so forth?

Jon: When we started our pilot, it was on 14 kilometers on one national highway. And at this point, we’ve expanded that to 205 kilometers on three national highways. We’ll have another expansion next week, actually, where we’ll be adding another 22 kilometers to the service. And right now we have 828 volunteers. We’ll add another 88 volunteers with our next expansion.

Jason: And how many responses do they have per month?


Well, we’ve responded to just over 2500 crashes. We usually get one or two calls per day on average. You know, it varies as you understand. But yeah, a little over 2500 crashes where we’re approaching 4800 patients. And what’s remarkable about this is that we’ve never missed a call. The volunteers have a 100% response rate. And because it’s a hyperlocal emergency response system where we have about four volunteers per kilometer, we get very rapid response times.

So about 90% of the time we have somebody there within 5 minutes. And about 80% of the time, we have somebody at the hospital within 30 minutes of the crash.

Jason: Wow!

Jon: Yeah. It’s a vast improvement.

Jason: Hats off, That’s fantastic. How do you communicate with the public about your services, that they can call you for certain things? This can get tricky because on the one hand you want to make your services accessible to everybody, but on the other hand you have limited resources. And the second you start taking calls from everywhere, response times go way up and people lose faith in your service.

Jon: Yeah, that’s been a challenge, you know, in terms of getting the word out as widely as we need to, but also not getting inappropriate calls or calls from areas that we’re not covering. So what we do is before we start working with the community, we arrange a number of events locally where we discuss traffic injuries, possible solutions, and we start using those as a tool for recruiting volunteers before we launch the service, we have a launching event within the community where we have the new volunteers as teams members of the community, and we bring them together to educate people on the service.

And also during those launching events, we have the volunteers take an oath to provide service to anybody in need without any compensation, financial compensation. And we advertise our hotline number locally through billboards, pamphlets. The volunteers will go out and talk to people in marketplaces to have them preprogram the number into their phones. We also use local cable networks.

But certainly confining the messaging to a specific community has certainly been a challenge for us.

Jason: The training that you provide, you said, was basic first aid or basic life support, level of training. And how long how does that training go? What is the length of it? And how do you recruit for it?

Jon: Yeah, absolutely. That’s something that we’ve refined over the years. What we do these days is before we start working, we’ll canvass the section of highway that we’re going to expand to. Our area coordinators will actually just work their way down the entire section of highway, going to local businesses, to marketplaces, talking to people. And they do that to find out who in the community is already doing this sort of work.

Because we work on the national highways, there are a lot of incidents that are happening there. And what we’ve found is that there’s often a self-selecting group of people who will go out and respond to these crashes when something is happening. So we like finding our way to those people. We also speak with community leaders to help get suggestions for people who might be good volunteers and then also to vet people so that we know that we’re getting quality individuals.

We’ve been lucky enough where at these recruitment events we have many more volunteers than we actually have positions available. So our local staff will interview them, you know, find out where they live, how available they are, how invested they are in the community, what their experiences with treating traffic injury victims, if they have any personal experience with traffic injuries, basically just to find good people that we know are going to be available and also aren’t going to be going elsewhere.

When we first started working, we actually wound up working with a number of students, but we found that that was not a good use of our resources because once they completed their education, they moved on and they had to be replaced. So we’ve refined the process of selecting the volunteers over time, and that’s actually been really successful for us.

We’ve got overall a 94% retention rate among our volunteers, and most of them left during the early phases of the program when we were still learning about who we should be recruiting. But, you know, another really important part of that retention is that we maintain very close ties with the volunteers. You know, we’ve had a number of them tell us that after they got recruited and trained, they fully expected that that would be the last they ever heard of us, and they would sort of be on their own.

But we maintain very close ties with them through social media, through telephone calls, through visiting our service areas. And, you know, they really appreciate the support that they get. And we in turn appreciate how invested they are in what we’re doing. One of the ways that this has played out really nicely was during the early stages of the pandemic. In March of 2020, we developed infection control protocols. And because a lot of our volunteers are not literate, we called all of them individually to go over the infection control protocols, but also to offer them a leave of absence. Basically, we said we understand this is a unique situation and if you don’t feel comfortable working, we understand that and, you know, you’ll be welcome back. No questions asked and not a single one of them accepted that offer. They all told us basically, you know, if we don’t do this, who else is going to do this? So they felt very invested in continuing to work. And actually a lot of them restocked their own first aid boxes so that our staff would not have to travel during periods of lockdown.

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Jason: I feel like there would be EMS managers across many, many countries who would like to learn from you how you’ve managed that attrition. What are the incentives that you’re offering them? That community engagement, that they have a role to play, is that it? I mean, that’s a lot. But, you know, we run into groups who have a really hard time retaining their staff, particularly when its volunteer based. And one of the big purposes of this podcast is to go from aspiration to activation in a field like this. So, what are the other incentives, if any, that you are providing them?

Jon: Yeah, a lot of it is just being able to perform service for our community. We also make them feel like they’re part of a family. We provide them with a lot of support. And you know, one important thing that I didn’t mention is that we work pretty hard to make sure that we’re steering them from emotional trauma from this work.

So very early on in the program, we would hold monthly meetings with all of the volunteers and also our paid staff, and we would use those as opportunities for people to talk about their experiences. As you understand, a lot of first responders find it very difficult to talk to other people, including their family members or friends, about the experiences they have had. They find it most helpful and also easiest to speak with people who have had similar experiences. So we found that forum was really helpful not only for helping them to process what they had been through, but that was also a mechanism for us to get really honest feedback about how the program was going. So we were able to improve things based on that.

But to get to your question more directly, you know, it is this improved social capital. You know, these people become heroes. They become well-known in their communities, and people recognize the good work that they’re doing. We’ve also found that for a lot of small business owners, they have improved patronage because people know that they’re doing this good work for their communities. So they will frequent their businesses more often as a way of supporting them in their work.

But we don’t offer any sort of financial or non-financial incentives, and we actually have one in our policy where, like I said, we have them take an oath that they will not accept any financial or other type of compensation for their work.

We do pay them in full for any transport expenses or food expenses. You know, if they’re taking somebody to the hospital, a lot of times this is a multiple hour process, you know, between taking somebody, they’re helping support them at the hospital, advocating for them so they’re compensated for all of that. But we wanted to be very sure that there were no perverse incentives for people doing this work, and we didn’t want to create any in formal barriers to patients getting care by virtue of these volunteers expecting to get some sort of compensation, we have not had anybody have to leave the service for violating those policies.

Jason: It’s phenomenal. It’s just so impressive. You know, volunteer groups struggle in so many ways retaining their responders, especially, like you said, you know, paid or not paid, it can be a very traumatic job. I mean, it’s based on trauma and those experiences can be harrowing. So a real testament to your work, that’s just phenomenal.

You mentioned the hospitals, and I’m wondering in our experience working in a range of countries, we’ve had very different experiences with the hospitals. And I’m wondering if you could talk about your relationship with the hospitals and how that works. And maybe put it in a little bit more of the context of how the health care system in Bangladesh operate, you know, are they private versus public versus NGO run hospitals or how does that work?

Jon: Yeah, there are public and private hospitals. One of the things that we learned when we did our initial needs assessment was that a lot of private hospitals will turn away trauma patients because they’re concerned about their ability to pay. A lot of our victims are, you know, economically disadvantaged, and also have severe injuries that will require a lot of money to treat.

So for that reason, we found that people were being turned away and that was creating even further delays in their getting care. So we will we’ve defaulted to bringing patients to public hospitals in terms of our relationship with them. We involved them in the process early on. If we’re going to be moving into a new area, we make ourselves known to the staff, the administrators at the local hospital. We let them know what sort of work we’re doing, who we are, what our experiences have been, and we will give them a heads up when we have patients on the way to the hospital. So we actually have really good relationships with them. There aren’t really any formal emergency services in Bangladesh, especially in the more rural areas that we work. You’ll find some trauma centers in the capital of Dhaka, but outside of doctors there are very few resources available.

The hospital staff are not really proficient with trauma management and that has been an issue for us. One of the things that we’ve started working on more recently is training the hospital staff as well. So they at least have that basic skill set.

And as you know, a lot of this is just stabilizing patients and treating things like bleeding. So we were providing those skills as well.

Jason: That’s a wonderful segway into my next question, because trauma care is often a chicken or the egg problem. What we’ve run into is people would say to us, the hospitals can’t handle trauma, so why are you bothering with a prehospital care system? And there’s a valid argument to that, right? I mean, if you’re bringing patients to, you know, in a fully equipped ambulance and you bring them to the hospital and there’s no capacity in the hospital, well, what good is that?

But we also say the converse is true, that you could have the most sophisticated advanced trauma center in the world, but if everybody showing up to your doorstep is on their last breath, that’s not going to be a very efficient use of your resources. The outcomes are going to be pretty terrible. And so, I mean, at what point did you determine that, okay, now we want to get involved in the hospitals and start training them up in trauma skills?

Jon: Yeah, I think when we first started out, because the trauma services were so poor at the receiving hospitals, we felt like our resources were best spent in the pre-hospital arena. You know, if you can get to patients quickly, our experiences is that most of these saves that we have are just through bleeding control. That’s what we hear from our patients. That’s what we hear from hospital staff. These are generally young, healthy patients. About two thirds of our patients are men between 21 and 40. So these are eminently salvageable patients, if you can get to them early. So our feeling was that the lowest hanging fruit was just to get the volunteers there absolutely as quickly as possible to perform bleeding control to properly handle and transport the patients in a way you didn’t cause additional injuries and then to rapidly get them to the hospital.

We’ve only started working with the hospital staff as part of a broader project that we’ve entered into with the World Health Organization and the Ministry of Health to expand the program more broadly. So they’ve based this program on our model, but now we’re also training police and fire services and staff in the receiving hospitals with the same skill sets that we’ve given to our volunteers.

Jason: It’s wonderful that you’ve got an involvement with the World Health Organization and the Ministry of Health. I was going to ask that too now. You know, how does the government respond to this? What’s their take on all of it? How has the Bangladeshi Ministry of Health gone about this?

Jon: You know, it’s been a process over multiple years of educating them and just bringing as many organizations into the fold as we could to try to create a unified front, pushing for an organized, post-crash response. We’ve worked pretty closely with the World Health Organization over the last two or three years advocating for a broader expansion of the program. W.H.O. in Bangladesh has very close ties with the Ministry of Health, and we were lucky enough for the W.H.O. to get enough funding to launch a broader program. So once we had their support and once they were ponying up, you know, the Ministry of Health was you know, they were very much on board. And, you know, we’ve been lucky because the W.H.O. is well respected.

The Ministry of Health has been able to bring in all of the other relevant government organizations like the Roads and Highways Department. We’ve also been able to bring in some of the larger NGOs like the Red Crescent Society, BRAC, and now we’ve got a partnership that involves about 20 government and non-governmental organizations that are all working together in a coordinated way, specifically on post-crash response.

So we’ve been really pleased with the results of this, but it’s been a multi-year process to get that sort of support, and it’s been a lot of work on our end to kind of get everybody on board. But it’s bearing fruit now in a way that makes us really optimistic about the future of this program.

Jason: I don’t doubt that it’s taken a lot of work and a long time. These are truly systems. And you said 20 governmental and non-governmental partners. I’m sure it’s taken a lot of sit downs and discussions with each and every one of them independently. But that’s just a real testament to the work you’re doing. The police department, you said that you’re now beginning to train them. Is that correct?

Jon: That’s right.

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Jason: And what has their response been? Have they been eager to do this, or is this something that, you know, kind of we’ve seen it with fire departments. Some fire departments say, yes, absolutely. We get cars, we get called to car accidents all the time for extrication. It would be great if we had skills to stop the bleeding.

And we’ve had other fire departments say we fight fires. You know, we’re not medical personnel. And I suspect, I know with police, it’s the same thing that both arguments can be made. How has it been in Bangladesh? What has their participation been like?

Jon: The police were kind of a unique challenge for us when we first started doing our needs assessment. We heard from multiple members of the community that the police were actually a significant barrier to people getting care at the crash scene. We heard multiple anecdotal stories about, you know, good Samaritans being accused of having caused the crash or trying to steal from the victims. And they could potentially be at risk from bystander violence of being taken into custody by the police or being called upon to be witnesses. And like I said, you know, the police mandate is to create a legal case. So their focus is on collecting information from bystanders, surveying the crash scene. Filing their paperwork. It’s not treating injury victims.

So there are actually multiple disincentives to people getting care. And when we were first developing this model where this is strictly a volunteer run service, we recognized early on that that was a potentially fatal flaw in the model. So the way we addressed that was by approaching a very senior level police administration. We worked with the second highest level officer in the country and basically sat down with her. We explained who we were. Educated her on the importance of early treatment for traffic injury victims and worked with her to find a way where we could both do our work in parallel with the crash scene. And once we got her support, we worked our way down the chain of command each step and basically had the same conversation, you know, educating them on what we were doing and then also letting them know that their supervisor was also supportive of this.

So we worked our way down the chain of command to local and regional police departments, and we maintained close and ongoing ties with them. There’s a lot of turnover within the police departments, you know, constantly new officers coming in. So our staff will meet with them roughly once a month just to check in with them. Talk about how the service is going.

We actually give them data on where crashes are occurring, which they find helpful. And, you know, we have strong support from the police because of the work that we’ve put into maintaining these relationships with them. So because of those close ties, they’ve been very receptive to getting the training.

Jason: You’ve hit upon a lot of important points that I think people overlook, especially when we’re talking about road traffic injuries. And that’s the importance of legislation and policy. And what you’ve discussed right now about the role of law enforcement and their traditional role versus what they may be asked to do. Have you been involved in any legislative efforts to make it more amenable to a community-based trauma response program? Things that come to mind is like Good Samaritan laws, right? Or just some kind of immunity against people who are trying to help. Does that exist already in Bangladesh or if not, are these kinds of things that you’re working on as well?

Jon: There’s no Good Samaritan law in Bangladesh. And honestly, we haven’t been involved and there are other organizations that are working on that. But on a pragmatic level, because we’ve been so closely involved with these communities and have such good ties with them, we’ve never had an incident. We’ve never had an instance of either police harassment or harassment from members of the community. So we haven’t really had to worry about it, which is not to say that it’s not important. It’s just, you know, we have limited resources of limited time and we haven’t run into that directly as a problem. So we haven’t really gotten involved with that.

Jason: Yeah, that makes sense. You mentioned about data, I’m wondering response times, obviously the number one data point and you also mentioned hotspots, right? Locations where road traffic injuries or collisions are happening regularly. What other data are you collecting or are your funders asking for to really demonstrate impact?

Jon: We collect pretty comprehensive data on all of our responses. So we have information on where the crash occurred, the time of day, the vehicles that were involved, the number of injured patients. We have basic information on the types of injuries. We have demographic information on gender, age. And, you know, it’s been interesting, one of the criticisms of the program is that it’s more reactive. You know, we’re only responding to these crashes after they occur. And people want to know why we’re not focusing on prevention. I think that’s fair. You know, my answer to that is that no prevention efforts are ever going to be perfect. And until they are, there were always people who were going to be getting injured. So somebody has to take care of them.

But the flip side of that is that, you know, because we learn about pretty much every crash with injuries that’s occurring in our service areas, we’re actually getting very, very comprehensive data on the way that data are generally collected in Bangladeshis by the police. The police have a mandate to report fatal crashes, but not other crashes.

So if you look at the data that’s collected, there is vast undercounting and it’s very heavily skewed towards fatal incidents happening on national highways and more urban areas. So in crashes where the injuries are not as severe, that are happening in more remote areas frequently don’t get counted. And as a result of that, when you look at the national numbers, you know, because the numbers are generally probably five or six fold below what’s actually happening that results in under prioritization of traffic injuries as a health care priority.

Jon: If you’re trying to allocate those resources based on the number of people affected, you know, if the data says you’ve only got 4000 fatalities a year when it’s actually more like 25,000, you’re not going to be appropriately directing resources. So, you know, because we collect this comprehensive data, we’re hoping that actually this is going to lend itself more towards better prevention efforts as well.

We already look at where these incidents are clustering. Our experience is that it’s probably about a third of the highway where all of these incidents are occurring. I mean, there are large areas where we’ve seen no incidents at all. There are other areas where we see very high numbers of incidents.

And our hope is that by identifying those, you know, we can do some directed mitigation efforts. And also, this is an avenue for once we expand this to a national scale, you know, Bangladesh would be pioneering, would be a pioneer in having a really robust data on what’s happening on their roads.

I mean, it’s as you know, it’s a pervasive problem in developing countries that makes it very difficult to carry out any sort of directed mitigation efforts. So you need good information to direct good policy.

Jason: Well, pioneering is certainly a word I would use to describe your program. I mean, we see efforts like this all the time in all sorts of countries, but for one reason or another, they don’t ever get to take off. And you certainly are well beyond take off. And now you just mentioned scaling nationally. And so I guess the next question is what are your plans? Is it to scale nationally or is it to stay only on road traffic injuries on the highways or something else?

Jon: Well, we’re hoping to scale up the program in a couple of different ways. We want to do this geographically so, you know, expand it to a national program focusing on the national highways and then eventually to all of the roads. But what we also want to see is that this is the basis for a broader of services available in the pre-hospital arena.

As you know, this was how the American EMS system got built. It was initially a response to traffic injuries. And then over time, it’s evolved to provide a full complement of services. The next step, I think, in what we’re doing is going to be providing blast training. And the reason that’s so important is because drowning is actually about as big a killer in Bangladesh as traffic injuries are so blast training is highly relevant for drowning victims.

So we’re hoping to add that. But, you know, there are a number of possibilities, including responding to obstetric emergencies, you know, getting people connected with possible blood donors. I think that over time this will evolve so that we can provide more services in the pre-hospital arena. What I’d also like to see is that, you know, once we’ve built this program in Bangladesh, it can serve as a model for other developing countries.

There are about 5 billion people in the world that don’t have any access to emergency services and especially on the roads. A lot of the factors are true. You know, throughout the developing world. So I think if we can successfully build this in Bangladesh, then we can adjust the model to suit local conditions and a number of other developing countries.

Jason: Well, you are well on your way and it’s really an inspiration to see all that you’re doing and just been so glad to be able to follow it over the years, just as a last question here for other groups, I just mentioned there are lots of programs around the world that pop up and are trying to do what you’re doing and for one reason or another are not able to overcome the many, many obstacles that they face.

I’m wondering if you could maybe share from your own experience a little advice on how did you get to where you are? What’s the thing that sticks out to you? Most know the ability or the skill that you need or that you relied on most to keep this going and to keep it growing.

Jon: I think our biggest strength has been our close ties with the local communities. The advice that I give to my students is to never underestimate the power that’s already present within these communities. If you’re coming in as an outsider, you’re never going to understand the place as well as the people who live there. So, you know, be humble, ask a lot of questions and really listen to what people are telling you.

And, you know, sometimes that feedback is uncomfortable, but it’s important to be honest with yourself and honest with your aspirations and the conditions you’re working with. And, you know, like I said, those respectful relationships will get you very far.

Jason: Very well-earned wisdom. Thank you very much, Jon. Really a pleasure. And just hats off to you and your entire team. Such fantastic work and a real inspiration to everybody. Thank you so much for joining us.

Jon: Thanks, Jason. It’s great to be with you.

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