The principal explanation for the socioeconomic gradient is the greater exposure of people in deprived areas to various hazards coupled with poorer access to health services consequent to accidents in these deprived areas rather than on a purely behavioral explanation (Nantulya and Muli-Musiime, 2001
). Behavioral factors may provide an understanding of direct causality but not an explanation of the gradient. A behavioral explanation lacks the factual basis for emphasizing social responsibility for safety as a requirement of justice. The determinants of RTID are not only individual knowledge and skills, but also the socioeconomic environment in which a crash takes place. Socioeconomic position not only shapes choice of means of transport, but determines injury outcomes and access to life-saving solutions when an injury occurs. The existence of a gradient calls for a theory of justice that explains why social factors that determine vulnerability to RTID are just or unjust.
To address social inequalities and design health policy, Madison Powers and Ruth Faden develop a non-ideal theory because inequalities provide a real-world context to address issues of justice. Their approach to justice goes beyond issues of distributive justice to embrace the well-being of people in social communities and groups because distributive principles cannot address RTID and serve as foundations for safety policy in isolation from larger issues of social justice (2006
Powers’ and Faden's account of social justice as well being is helpful in clarifying how the problem of road accidents in Kenya is a matter of social justice. Faden and Powers are less concerned with how one individual fares in comparison to others than with how a group of people is doing. Hence, the realm of social policy central to human well-being becomes an important locus for safety promotion. Here, the question of justice arises from the operation of the totality of social institutions, practices, and policies that both independently and in combination have the potential for a profound and pervasive impact on human well-being (2006: 5). An analysis of social policy based on well-being is almost always concerned with whether a group affected by a given policy is being treated fairly.
Their approach is concerned with human flourishing which can be understood as including many dimensions each of which represents something of independent moral significance (2006: 6). Each dimension of well-being provides prisms through which the justice of political structures, social practices, and individual behavior can be understood and assessed. This approach shows how differences in exposure across populations can be understood as resulting from the lack of important dimensions of well-being in the population at risk. The lack of some dimensions of well-being prevents the underprivileged from having what is needed to avoid injuries or deaths. Respect, education, health, safety, and participation are fundamental dimensions of human well-being which are important for road safety. Justice requires that every citizen be provided, in one way or another, with the possibility of having a sufficient amount of each of the essential dimensions of well-being. By emphasizing well-being in our approach to justice, we seek to improve human well-being by promoting the public's health and placing the concerns of the most vulnerable at the center of public policy dealing with road safety. Our commitment to justice attaches a special moral urgency to remediating the conditions of those who are more vulnerable to crashes because they lack multiples dimensions of well-being.
Respect means treating others as dignified moral beings deserving of equal moral concerns. In other words, respect for others requires an ability to see others as independent sources of moral worth (Power and Faden, 2006
: 22). Our respect for others is grounded in our shared humanity and does not simply refer to the freedom to leave the other person alone, but to the necessity of providing each member of society with what is needed to live a dignified life. Kant's understanding of respect for person provides the ground for the categorical imperative which he formulated in five different ways (Kant, 1785
). Kant challenges everyone to act so that one treats humanity whether in one's own person or in that of another, always as an end and never as a means only. When Kant talks about autonomy, he does not imply that one should act according to one's own desires, unconstrained by a balanced consideration of one's situation as a being-among-others (Gillett, 2008
). Instead, he refers to the dignity of humans who are capable of making for themselves and others universal law. The categorical imperative is more than just viewing respect as simply not harming others; Kantian autonomy is applied to actions performed when the will is freed from any selfish determination. When humans treat each other as subjects and never merely as means for an end, there arises a systematic union of rational beings under common objective laws. On the societal level, respect for others requires the provision of social arrangements and institutions that protect freedom and equality. This very foundation of our shared humanity is at stake when people, living in a state of abject poverty and enduring the hardships imposed on them by an unfair ruling of the country, bear disproportionately the burden of injury. The link between social conditions and risk of injury shows that differentials in risk for road crashes engage all the dimensions of well-being, but perhaps most importantly the dimension of respect.
The claim of justice comes from the fact that every human being is, in him/herself, a certain ‘ought’ with respect to his or her fellow human being (Hollenbach, 1977
: 211). The principle of humanity challenges both the focus on individual behavior and the contextual blindness often seen in road safety policy by recognizing road crashes not merely as the result of driver or pedestrian behavior but also as the contribution of institutional arrangements and prevailing structures of socioeconomic power. These, in turn, result in differential vulnerabilities to road crashes. Therefore, respect for others forces us to shift the strategic question from examining the best ways to influence crash-related behaviors for RTID prevention to exploring the socioeconomic roots and social relationships that increase vulnerability among marginalized population groups. As an important dimension of human well-being, respect should bring about an acute sensitivity to conditions that diminish agency and perpetuate social discrimination. The basic anthropology that sustains this analysis understands the individual as nested within the social environment. Accordingly, the focus is not on the individual as the endpoint of causal processes and actions, but on the behavioral tendencies of individuals and groups as an outcome of causal relationships with people and the environment. RTID is thus viewed in relational terms, and preventive measures involve public policy.
Our understanding of health focuses on the biological or organic functioning of the human body. It allows us to differentiate between health and other dimensions of well-being. Health has an important moral significance in that it is crucial in sustaining human functioning and well-being across the lifespan. Health conflates with many elements which are important characteristics of public health and biomedicine (Power and Faden, 2006
: 17). Some of these elements are important for injury prevention and management since they include premature mortality, preventable morbidity and disability, loss of mobility, and the social and biological basis of human behavior.
Matatus are small-scale, unsafe public transport vehicles in Kenya. Matatu drivers often violate traffic regulations; for example, they may work long hours because of their poor wages; they may often be sleep deprived and not have any outlet for their stress because their time is taken up by their job. They may also drive under the influence of emotional stress which may lead to depression or substance abuse including alcohol or drug dependency. These factors (sleep deprivation, emotional stress, and substance dependency) may alter their ability to anticipate and prevent a crash and might contribute to an increased risk for RTID. Similarly, most materially deprived individuals who are the most vulnerable to RTID are often poorly nourished or work in blue collar jobs or in unsafe environments which expose them to harmful chemicals, irritants or pollutants. Exposures to these harmful chemicals and/or poor nourishment may weaken these individuals’ immune systems, which are important for post-trauma recovery. Furthermore, most of those who are vulnerable to road injury may not go to a physician for regular health check-ups since they cannot afford to take time from work to schedule a visit, or they may not be able to afford basic preventive healthcare. As a result, these individuals may have undiagnosed conditions that may increase their vulnerability to RTID. For example, undiagnosed diabetes may lead to coma when blood sugar elevations are high and symptoms of undiagnosed heart disease may include syncope. If either of these symptoms occurs while a person is driving a vehicle, the consequences could be fatal.
Even though access to healthcare is a right in Kenya, access to quality healthcare depends on one's ability to pay and one's geographical location. The healthcare system discriminates between poor and rich as well as between urban and rural areas. This systemic discrimination further explains the high mortality due to RTID among the urban poor and people living in rural areas. In large part, this is due to unfair distribution of trauma care services in the country and income differentials between population groups (Nantulya and Muli-Musiime, 2001
). However, social discrimination alone cannot fully account for injury risk and mortality differentials between individuals and population groups but also the lack of public leadership. Poor public leadership is also to be faulted. Poor leadership goes hand in hand with the inadequacy of health infrastructures. Compared to private and faith-based hospitals, government run hospitals are the least prepared to treat trauma cases. In 1999, only 40% of public, faith-based, and private hospitals were prepared to treat trauma cases from traffic crashes, with 74% of the least-prepared being public health facilities (Nantulya and Muli-Musiime, 2001
). Most of the material needed to manage trauma is usually found in private hospitals, whereas government health facilities rarely had the material to treat trauma. Access to trauma care is related to the question of respect since inability to access the needed care is an important dimension of well-being which, when lacking, interferes with other dimensions of well-being. The underprivileged use public health services the most, not because these services provide them with quality care but rather because they cannot afford care in private clinics. Society's obligation to ensure universal access to healthcare (including trauma care) rests not only on the effects of access on health but also on what justice requires with regard to what is necessary for being respected as being endowed with a dignity that cannot be violated (Power and Faden, 2006
Socioeconomic exclusion and political marginalization of disenfranchised groups cause harms in other dimensions of well-being including education, participation in society's affairs, health, and respect. Social exclusion and marginalization function as a threat to people's physical and psychological integrity no matter who they are. Every human being has a right to safety, including road safety (Montreal Declaration, 2002
). The violation of this right, through political inaction and discrimination and socioeconomic exclusion by the very people and public institutions entrusted with the duty to protect and implement it, creates a state in which hazards and conditions leading to physical, psychological or material harm are not controlled. Consequently, unnecessary injuries and preventable deaths may occur. When a local government fails in its regulatory role to protect vulnerable groups, individuals’ interactions among themselves and with their environment become hazardous. The Kenyan government cannot eliminate all road traffic risks, but, it can, at least, control these risks in order to promote public safety.
The importance of education in providing opportunities to achieve well-being is simply indisputable. Education can be acquired by schooling or by means of nurturing human reasoning. Education can provide the skills and abilities both theoretical and practical that increase an individual's capacity to function. As it relates to RTID, education should provide individuals with the ability to read road signs. Of importance also is the fact that education can improve an individual's socioeconomic status by increasing his/her chances of finding a better-paying job, which in turn, allows him/her to use a less risky means of transport, to have adequate nutrition that may boost the quality of the immune response to any health challenge, to live in a better environment with well-lit and properly designed roads, and to have access to medical services. Such access may prevent or remediate any preexisting conditions that might increase fatality when injury occurs. Epidemiological studies have shown that education is an important determinant of risk for RTID and for health in general (Lynch et al
). The value of education and the fact that the right to education is a fundamental right challenge us to argue that the right to education should be part of the body of laws ensuring a citizen's right to it. Universal access to primary education is one the greatest achievements of President Mwai Kibaki's regime. Since 2003, every Kenyan child can access free primary education. However, access to primary education may not significantly reduce risks for injury among the underprivileged because epidemiological evidence shows that completion of, at least, secondary education tends to have a protective effect against road injury (Peden et al
). Thus, equal access and opportunity to primary and secondary education should be provided to all. To avoid discrimination, educational institutions and programs must be accessible to everyone, especially the most vulnerable, in law, and in fact, within the jurisdiction of the State party (United Nations, 1999
The democracy supports and calls for social participation in the decision-making processes and requires that people be empowered to directly or indirectly participate in making society a livable place for all. Democracy presupposes fair procedures in decision-making and transparent institutions that promote well-being and political equity. Since the socioeconomic gradient in RTID is related to the lack of social equity, the first step in setting up long term prevention strategies is essentially political. The quest for social equity is always linked to issues of governance, which include accountability and broad representation of all social groups in road safety decision-making processes. The involvement of local communities and the civil society in road safety may create a forum of discussion within which the concerns of those who are most at risk are brought to the table. People's participation in developing safety policy is an important dimension of well-being because it leads to the improvement of individual and collective agency. Neglecting this dimension of well-being can have important implications on other dimensions of human life because the lack of participation might lead to the development of unjust policies and social institutions that compromise human well-being.
As a political concept, participation presupposes the recognition of the substantive and instrumental roles of freedom, the need of empowering disenfranchised populations and the necessity of supporting social relations and political arrangements required to sustain and expand that empowerment (Hofrichter, 2003
). In rural areas, for example, local communities have been working to provide people with the public necessities for their lives. Social activism within these communities provides a basis for envisioning and actualizing multilateral cooperation in programs and policies which ensure access to basic social goods and favor participation in decision making.
The social dimension of injury needs to be taken into account if progress in a certain level of road security has to be achieved. Road security does not happen by accident (Khayesi, 2005b
). Instead, it is the result of deliberate and concerted efforts by many sectors of society, both governmental and non-governmental, that recognize safety as a public good that can only be achieved if adequate policies and programs are developed to promote it. Partnership composed of stakeholders both inside and outside the Kenyan government offers a promising basis for policy discussion which goes beyond government control. It can be a real policy forum that presents the prospect of making decisions that conform to public interests rather than interests of political opportunists. A consensual manner of decision-making in such a forum provides the opportunity for everyone's voice to be heard.
Human rights, distribution of social/public goods, and socioeconomic inclusion
RTID is a critical public health challenge located within social, political, economic and historical contexts. The connection between RTID and these dimensions of social life emphasizes the need for a population-based approach to tackle the underlying causes of the disproportionate distribution of crashes, injuries, and deaths across the population groups. Education, safety, participation, and health are considered important human rights by the international community (United Nations, 1948
). The rights to education, health, and safety have a population-based orientation because they belong to the realm of socioeconomic and cultural rights. This is true even though their realization depends upon the government's willingness and ability to provide what is needed to fulfill these rights. This governmental obligation rests not only on the health benefits of universal access to healthcare but also on the fundamental basis of respect for a human being. A liberal approach to these rights will not properly address the social inequities which are at the roots of the disproportionate distribution of RTID. The mainstream human rights movement considers socioeconomic and cultural rights as the preconditions for civil and political rights and well-being and also as a framework for analysis and direct societal response to social determinants of health (Evans, 2002
). A moderate-communitarian reconstruction of human rights is needed to balance the needs of the individual and to serve the public's health. Safety, education, and trauma care services are goods of public importance. An individualistic understanding to these goods could potentially conflict with public well-being, whereas, if rights are vested in a group, public health benefits are easily viewed as consonant with a (group) rights argument. Even though the individual is the subject of these rights, it is always important to highlight the need to deliver the necessary services in response to the claim of right in the context of the community by governments (London, 2006
The Kenyan government does not respect, protect, and fulfill these rights since road safety measures are not enforced and the basic conditions to avoid injury are not ensured. Vulnerability to road traffic crashes reflects the extent to which people are, or are not, capable of protecting their dignity, assuring their own safety, having access to education and healthcare, and participating in policy-making processes. A social justice approach to RTID challenges policy makers to create conditions for just social relationships, guarantee the basic material necessities for individual dignity, and promote society's economic progress. The fact that the underprivileged are the most affected by RTID demonstrates that social relationships within the country are not conducive to solidarity. The lack of basic institutional solidarity transforms the public space into a hierarchical sphere where the privilege, political prestige, and socioeconomic position are the major distributive principles. Following the late 1980s implementation of Structural Adjustment Plans, as in many other developing countries, Kenya adopted economic liberalization of a public policy framework. These adjustment plans focused essentially on individual ability to participate in the market so as to improve market competition. The reduction of government spending on public infrastructures resulted in the exclusion of poor people from mainstream economy and the increase in social inequities.
In the public health community, distributive justice is often understood as providing the practical means to promote a healthy society and to ensure the public's health. Distributive justice provides the practical tools to reduce the magnitude of RTID and to challenge discriminatory practices that sustain social inequities. The distributive role of governments consists of investing in public goods, designing welfare programs, and supporting community-based initiatives to provide an acceptable baseline for all citizens. Justice requires an equitable distribution of social goods such as well-designed roads, social institutions that promote road safety, police presence, education, road surveillance system, access to hospitals and trauma services, and other goods and services necessary for road safety and treatment of injuries. The distributive aspect of justice specifies the claim that all persons have some share in those goods which are essentially public or social since all members of society are at least indirectly involved in their production through their membership in public society (Hofrichter, 2003
). The criterion for distribution should focus not solely on economic efficiency and gain, but also on the nature of the good to be distributed and the type of society that such a distribution can create. It is within this approach to justice which promotes mutuality and interdependence, subsidiary and participation, accountability and honesty, solidarity and care for less fortunate, local and international contribution that the state can effectively play its distributive and regulatory role.