Mandate for Change

I want to tell you a story, but first I have to paint you a picture.

Imagine, if you will, an upwardly country with a population of 86 million. 90% of the road traffic in this country consists of motorbikes. Every day in this country, 38 people die as a result of traffic accidents – mostly due to head trauma following motorbike accidents. Many more become permanently disabled — everyday -- because of motorbike accidents. Everyone is aware of the problem -- it’s hard to spend any time on the roads here without coming across the scene of an accident. If you ask folks, almost everyone knows someone who has died or has been disabled following a motorbike accident. Yet almost no one wears a helmet.

Over the years, the government, the World Health Organization, and various NGOs have weighed in on this on-going catastrophe. Studies were done. Inexpensive, light-weight helmets -- suitable for use in this country’s tropical climate -- were designed. One NGO even built a factory in order to produce helmets. An American president (Bill Clinton) was enlisted to kick off a program to provide free helmets for school children. Certain roads were designated as “helmet roads” and nominal fines were imposed on bare-headed riders.

Still, up until 15 December 2007, less than 5 percent of motorbike riders wore helmets.

OK, here comes the story:

My husband and I arrived in Vietnam in 2005 to serve as short-term volunteers at a rehabilitation center in Da Nang. Many of the patients that we saw in this rehab center were brain-injured -- mostly due to motorbike accidents. Every day, after work, we would go out to dinner and, often, we saw motorbike accidents. These were low-speed accidents, not the grisly sort of carnage that you might imagine. Often, in fact, the only injury was to the head, as the rider flipped over his handlebars or fell backwards off the bike. Unfortunately, that head injury was often sufficient to cause death or permanent disability due to intra-cranial bleeding. Had the rider been wearing a helmet, he would have walked away from the accident. Yet nobody, not even the Vietnamese physical therapists and physicians who worked with these head-injured patients every day, wore helmets.

It occurred to us that helmets, though inexpensive from an American point of view, were pricey by Vietnamese standards. Also, it was clear that nobody wanted to stand out by being the only one to wear a helmet. Towards the end of our volunteer stint, my husband and I decided to address both of those issues by providing free helmets for all the employees of the rehabilitation center. The employees appeared delighted and the director of the facility spontaneously announced that, hereafter, he would require all employees to wear helmets when travelling to and from the center. We handed out booklets that we’d assembled from internet articles and had had translated into Vietnamese in order to help these rehabilitation specialists better articulate to the general population “Why We Wear Helmets.” For the remainder of our stay, those employees wore their helmets. We thought that we had found the key to tipping the balance on helmet use in Vietnam: just give helmets, talking points and a little peer support to people who have first hand knowledge of the tragedy of head trauma.

We returned to that same facility in Da Nang one year later. Do you know how many of those sixty employees were wearing helmets? Zero. Absolutely zero – not even the director was wearing one. What happened, I asked? Where were the helmets? Back at home, they said – we only use them when we travel on Route 1, where helmet use is mandated.

Well, that was certainly disappointing.

By the beginning of 2007, we had established a working relationship with a different rehabilitation hospital -- this one under the auspices of the Da Nang Department of Health. Coincidentally, 2007 was also designated as the Year of Traffic Safety in Vietnam. Going about my work of mentoring Vietnamese physical therapists and physical therapy students in this second rehabilitation hospital, it was hard to overlook the fact that over half of the patients were there as a result of motorbike accidents, many of them having suffered severe traumatic brain injuries. I love the challenge of treating neurological patients, but it was overwhelmingly obvious that I and the fledgling corps of Vietnamese physical therapists were never going to catch up with the on-going deluge of new head trauma patients flooding Vietnamese hospitals every day. We decided to take another stab at the helmet situation.

This time we approached the Da Nang Health Department with the proposition that our organization, Steady Footsteps, would provide every employee of the Da Nang Health Department with a free helmet if the Department of Health mandated their use. They agreed. With a great deal of fanfare, and three television crews filming, my translator and I addressed an assembly of 80 DOH administrators. We talked about the ongoing tragedy of head trauma in Vietnam. We told them that their leadership was essential to ensure the safety of their employees. And we talked about the potential for their helmet-wearing employees to serve as positive examples for the general population.

Well, it worked – up to a point. All 3401 employees received their pale green tropical motorbike helmets with the DOH logo emblazoned on the sides. Guards at the gates of each of the 26 DOH facilities in Da Nang prevented any employee from entering or leaving the facility without wearing their helmet. The employees wore their helmets—even to the market. And because of television coverage, including interviews with the workers themselves, and the identifiable logos on the helmets, they were a recognizable and respectable group of helmet wearers. However, helmet wearing still did not spread into the general population.

Later that same year, however, the prime minister issued an edict mandating helmet use throughout the country. (Groups like the Asia Injury Prevention Foundation had been promoting this idea for years, so I certainly claim no credit for this breakthrough.) Helmet wearing would be mandated on the main provincial roads as of the first day of November and implementation of a law requiring universal helmet usage -- city streets included -- was scheduled for 15 December 2007. Television stations aired public service announcements consisting of poignant stories and graphic footage, urging people to protect themselves by wearing helmets. As soon as the law took effect on the provincial roads, nightly news prominently featured footage of police road blocks and interviews with people who had just been caught and fined and – if they didn’t have their vehicle registration papers on them—had their motorbikes impounded. It caught people’s attention. Overnight, people started wearing helmets whenever they set off to travel out of town. Still, however, only the DOH workers and out-of-towners wore their helmets in the city. You had to respect the efficacy of the police in enforcing the helmet law on the few main out-lying roads, but it was still hard to imagine how they could convince city folks to comply with the law.

But they did. On 14 December 2007, less than 5% of motorbike riders in the city were wearing helmets. On the morning of 15 December 2007, over 95% were. Those who “forgot” to wear their helmets were readily caught up in the multiple traffic stops set up about town.

Now, over a month later, police are no longer working overtime and the news has turned to other things. But people are still wearing their helmets. Whereas helmet-wearing was previously seen as an aberration worthy of derision, it’s now “normal.” Someone without a helmet is now perceived as a “risk-taker”. New incidents of head trauma are less common, but out-patient clinics are gaining a new kind of customer—guys who fall off their bikes with their helmets in place. Instead of lying in the morgue or a head trauma unit, they are now being treated for “whiplash”—a diagnosis with an altogether more favorable prognosis.

What’s the point of this story? Simply this: large-scale behavioral changes require large-scale coordinated efforts, even if there is no organized opposition. There were no big corporations in Vietnam who stood to benefit either way from universal helmet use. There were no economic forces pushing the government either way. Medical care in Vietnam is pay as you go and the government provides no significant financial support for families affected by death or disability due to traffic accidents. The reality of head trauma was available for all to see, and yet people could not bring themselves to do something as simple as wearing a helmet. It took the combined forces of political leadership, police enforcement, the media, and earlier groundwork laid by an NGO willing to invest in designing and producing helmets when there was no market for them. It took all that to produce this “over-night” success. But the important thing to realize here is that there was NO organized resistance to helmet-wearing or to helmet laws – and it was still incredibly difficult to bring this change about.

What chance would we have had if there had been a powerful and well-connected opposition to our efforts?

In America, the large-scale option is not open to those who would have our society move in a more progressive direction. American media and government conspire to marginalize or even render invisible potential agents for change. So be it. Let’s be “sub-versive” in the truest sense: let’s turn society from underneath. Let’s begin the hard work of building caring friendships, supportive communities, local food networks and mutual aid societies that will protect and enfold us as our oil-powered, credit-dependent, imperialistic, corporate-run government becomes increasingly irrelevant to our lives.