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Health: Redefine risk to help fatal subtraction

BACK home I would never get in the car without a seat belt, much less ride a motorcycle (or even bicycle) without a helmet. There’s something about being here that makes me more relaxed about this stuff. It’s not just knowing that I won’t cop a massive fine or demerit points on my license, or that I’ll get pulled over anyway. It goes deeper than this.

Take alcohol as an example. Many an expat has told me they never drink like this back home. There are many other examples linked to the debaucheries of the Penh, but the key question is why we compromise our own beliefs, principles and practice when we set foot somewhere else. Or even more fundamentally, what is the influence of our environment on our behaviour?

Influential economist John Maynard Keynes, in response to accusations of inconsistency, is reported to have said: “When the facts change, I change my mind. What do you do, sir?” On the surface, it’s beyond logic. Of course, if the facts change one should change one’s mind. But it’s not as easy as that – at least in my experience.

Take traffic accidents. Cambodia has the highest per capita accident death rate of all the ASEAN nations, more than double the toll in most developed nations. And there are many non-fatal injuries from traffic accidents. In 2009 across Cambodia, there were more than 21,000 casualties  reported, including 7,000 people severely injured and 1,700 deaths. This is double the number of fatalities compared with 2005, while the population has itself only increased by 6 percent and the number of vehicles by 50 percent in that time. Interestingly, the proportion of minor injuries has decreased over recent years, with a shift towards severe injuries and fatalities.

Cambodia, and ASEAN countries, are not alone. Turns out that 90 percent of the world’s more than 1 million annual traffic fatalities occur in countries with low and middle incomes. Around 50 million people are injured annually, with 10 percent disabled for life. It is a relatively recent phenomenon globally, once confined to the West. Between 1975 and 1998, mortality attributed to traffic accidents increased by 79 percent in India, 237 percent in Colombia, 243 percent in China and 384 percent in Botswana.

The vast majority of deaths are among male moto riders – mostly likely aged between 20 and 24. And most happen at night. No doubt alcohol is a contributor, though we don’t know to what extent.

Avoid the roads? A start but not entirely possible. Wear a helmet? Well over 75 percent of moto accident fatalities involve head trauma and major hospitals reported a reduction in head injuries this year following the introduction of helmets. Seatbelt? Yes, but these don’t help completely (where’s the airbag in a tuk tuk?). As always it’s a combination of factors. Reduction of risk is all we can do.

Risky environment is a hot topic in the HIV world. It’s all about the fact that when sensible individuals (and some not so) get placed in a dangerous environment, they get influenced by it and may not always abide by behaviour which reduces their risk of acquiring HIV. For example, they may share syringes or not use condoms. An extreme example maybe, but Cambodia is a risky environment from a health point of view.

Unfortunately the same paradigm which emphasises the importance of the risky environment as the determinant of human behaviour advocates for environmental change to reduce risk (i.e. having appropriate HIV prevention interventions available at hand).  Great idea, but not always possible.

You may not know it, but a concept called anchoring affects our thinking every day. This holds that when making decisions, we place too much emphasis on one piece of information or event rather than the overall picture. First impressions are a prime example. In one experiment, United States college graduates were told to write down the last two digits of their social security number before bidding for an item in an auction. Individuals were more likely than not to bid at a similar price to the last two digits of their social security number. Logical? No. Happens all the time? Yes. The extension of this argument is that we’re heavily influenced by what we see around us – no matter what we believe in.

Unfortunately we have little control over our environment. Although one would hope that our environment would have little control over us, at the individual level this is not so true. Culturally though, we are certainly in control. The power of cultural practices to modify a risky environment is significant. If none of your friends drinks too much, chances are you won’t either – even if others do. Are we more likely to wear a seatbelt if none, one or all of the other passengers are wearing one? Organisational culture is a good example of the power a sub-cultural environment can possess.

So don’t be fooled by the risks that others take – particularly on the roads. The figures would suggest that even greater caution is needed in Cambodia compared with home or even other countries in the region. To paraphrase Keynes: “These are the facts, now what will you do?”

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