I met Dr Richard Cash when I was a student at Harvard T.H. Chan School of Public Health working towards my masters in public health in 2011. In Richard’s classes and in our private conversations I learned important lessons about the real world practice of global health. Because he was never one to boast about it, in my own studies I also learned more about Richard and the work that made him a beloved and heroic figure in Bangladesh.

In the 1960s he worked with American physiologist Dr. David Nalin to conduct the first clinical trials of oral rehydration therapy (ORT) for diarrheal diseases like cholera, a leading killer worldwide. They translated this research into a broad public health initiative by advising the Bangladesh Rural Advancement Committee (BRAC) and bringing rigorous scientific inquiry and analytics to a programme that became thoroughly integrated into affected communities nationwide.

Training the trainers

Using a model of training the trainers, BRAC was able to educate 13 million people, mostly mothers and other caretakers, to prepare for ORT. This simple solution – a pinch of salt and a handful of sugar in a glass of water – proved to be highly effective. It has become an intervention used across the globe, saving tens of millions of lives, and is widely recognized as one of the most important medical advances of the 20th century.

I first visited Bangladesh on a winter session trip in January 2013, organized in part by Richard, to seek out a research project for my degree. At that time Bangladesh, like many low- and middle-income countries (LMICs), lacked formal prehospital medical services, but had some of the most dangerous roads in the world.

Victims injured in crashes were left without access to care when it could be most effective in preventing death and disability. Most crash victims in Bangladesh are young and otherwise healthy men – often family breadwinners – and the majority of traffic fatalities in Bangladesh are due to uncontrolled bleeding prior to arrival at the hospital.

I was already a practicing emergency physician, and in 2010 had lost my father to a traffic crash that occurred just a mile from my childhood home in Cape Cod, MA. I still had fresh memories of the suffering that my father and family had endured, and seeing these tragically preventable deaths occurring on a daily basis in Bangladesh became a call to action.

Worldwide, road traffic injuries claim roughly 1.2 million lives annually and are the leading cause of death among people aged 5-29 globally. This burden is borne disproportionately by low- and middle-income countries in part because less than half the world’s population has access to formal prehospital care.

We began developing a programme that would be appropriate for the challenges and resources in Bangladesh, but also with an eye towards creating a model that could be adopted by other developing nations.

Following Richard’s example, our team has sought to address this more modern scourge by harnessing the power of communities to reduce preventable deaths. In developing the service model we held numerous meetings with Bangladeshi organizations involved in road safety and volunteerism and spoke with academic researchers and local community members including government officials, police, fire services, public hospital staff, and religious leaders.

These conversations were invaluable in creating and refining the operational model. The open, trusting, and respectful relationships developed in the process were also essential in strengthening widespread and lasting support.

TraumaLink

In November 2014, we launched the first pilot of TraumaLink on a section of the busiest and most dangerous highway in Bangladesh. In our service model, community members are recruited and trained to act as volunteer first responders treating traffic injury victims at the crash scene, free of charge. There are no minimum literacy or educational requirements for volunteers. We designed the training curriculum to teach simple lifesaving skills that people with any level of education and no prior medical background can learn and perform.

Emergency response teams learn first aid techniques. Photo: TraumaLink

When a bystander calls the hotline number, the nearest available first responders are dispatched to the crash scene through mobile phone text messages. Victims who require further care at a hospital are rapidly transported using local networks that include fire services, police, vehicles for hire, and bystanders.

The program has been remarkably successful, with service expansions to multiple communities along three national highways. We have treated thousands of patients, with a 100% response rate for all calls and volunteers at the scene within five minutes of the crash 90% of the time. Rapidly providing basic first aid treatment to control bleeding and stabilize injured victims is often life-saving. This allows patients to return to healthy and productive lives, and prevents devastating and multigenerational consequences for their families and communities.

In 2022, the Bangladesh government adopted the TraumaLink model by establishing an official post-crash response programme under the Ministry of Health & Family Welfare, with TraumaLink as the implementing partner and the World Health Organization providing financial and technical support.

The evolution of this grassroots initiative in Bangladesh offers a model for other nations seeking to better address the crisis of road traffic injuries. It also provides insights into the vital importance of the collaborative process in creating broad support for the development and sustenance of such national programmes. While technology is often seen as the remedy for all our problems, the success of such community-based programmes is an important reminder to focus first on people, using technology as a tool, not as an end in itself.

By his example Richard also demonstrated that one of the most important and powerful things we can do in development work is to show people what is possible by drawing on the talents and goodwill of the communities we serve, working hand-in-hand to develop tools to improve their lives.

(The writer an emergency physician who also holds a master’s in public health, is the Primary Founder of TraumaLink (www.traumalink.org) in Bangladesh, and preceptor, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. By special arrangement with Sapan)