The Moscow and Brasilia Declarations on road safety – a parallel between two moments in health

Two high-level multisectoral global conferences on road traffic safety (Moscow, 2009 and Brasilia, 2015), held under the auspices of the United Nations, adopted formal declarations on both occasions. Given the potential of these documents to establish positions, propose guidelines, policies and legal frameworks, this paper compares these charters, in order to identify the emphases, expectations and horizons indicated at each moment, highlighting their health-related items. We describe the WHO’s involvement with road safety, considering the ways this relationship signaled the health sector’s connection with the theme. We present both conferences and their respective declarations, comparing health issues addressed. We conclude that Brasilia reinforces Moscow and, in addition to contributions expected from the health sector (data, notification, post-trauma care), the implications of the sector have increased, particularly with regard to health promotion, the call for intersectoral collaboration, equity and sustainability aspects, influenced by the United Nations 2030 Agenda.


Introduction
Globally, two multi-sectoral meetings under the auspices of the UN gathered government officials, international agencies, private sector and civil society at large on road safety.The first event took place in Moscow, the Russian Federation, on November 19-20, 2009; and the second in Brasilia, Brazil, on November 18-19, 2015.Both were held by governments of host countries jointly with the World Health Organization (WHO), which in 2004 was mandated by the UN to coordinate efforts on road safety within the United Nations system.As is customary in such events, both the First Global Ministerial Conference on Road Safety and the Second Global High-Level Conference on Road Safety -titles given to their respective meetings -finalized their work with adherence to the Declaration of Moscow and Declaration of Brasilia, formalizing projections and aspirations reflecting in each event.
Charters and declarations, among other texts proclaimed at the end of conferences and summits and other large gatherings make up the set of reference documents to reflect the collective construction of basic concepts, understanding of issues related to the subject and recommendations resulting thereof.This is the case, in order to stay in public health, of milestones such as Alma-Ata (1978) and Ottawa (1986).Thus, given the significant impact of road traffic morbidity and mortality on public health and appropriateness of Moscow and Brasilia Declarations to firm positions, to propose guidelines, signal agendas, policies and legal frameworks, we propose, by choosing more directly health-related matters, to compare these two documents in order to identify their development, which emphases were borrowed and prospects pointed at all times.First, however, we report briefly the history of the WHO's involvement with the issue of road safety, taking into account how this relationship signaled the way the health sector, largely, was involved as a topic.We then present the conferences and their implemented declarations thereof and we compare the addressed health issues.We summarized these in a schematic table, preceding a discussion and closing remarks.

Participation of the health sector through the WHO
While road traffic deaths and injuries were already of concern with the advent of motor vehicles in the late nineteenth century, the problem would gain remarkable proportions by the middle of last century.This is when the first movements emerge within the WHO, identifying the issue of traumas acquired in such events commonly referred to as "road traffic accidents" as a striking problem in the health sector.In 1962, London's transport management agency chief physician at the time Leslie G. Norman developed a report for the WHO 1 , using the basis of epidemiology to analyze road traffic dynamics, proposing elements of the ecological triad, namely, "host-agent-environment" as if they were similar to road users, vehicles and the road traffic environment.Interestingly, while epidemiological explanatory models underwent revisions in the following decades, with the ecological triad questioned in its potential to understand the complex chain of causation of accidents and injuries, the "man-via-vehicle" tripod still enjoys ascendancy in the ranks of road safety.A decade after the Norman initiative, and following notes at the World Health Assembly 2 and the Executive Board of the World Health Organization 3 , WHO 4 views road traffic traumas as a serious public health issue.However, in the 2000s, the Organization would give greater emphasis to the subject, given the remarkable escalation of road traffic injuries in previous decades, in line with increased motorization rates, particularly in developing countries.
In March 2000, WHO's Department of Injury and Violence Prevention would publish a 5-year WHO strategy for road traffic injury prevention 5  and, in 2003, in  The World Report released by the WHO in 2004 was proposed as a base document to guide a global action and based on different assumptions from those adopted at the time of its first forays into road safety.The document assumes in its foundations aspects such as the multi-sectoral nature and social equity dimension underlying the issue of road traffic traumas, due to the disproportionate representation of most affected segments.Since one of its objectives is to inform a wider audience than intended by the 1960s studies, the report points out from the outset the changes in the perception of road traffic injuries prevention, summarized in a series of principles.Among these, we highlight the emphasis on predictability of road traffic trauma-generating events, the resulting need for rational analysis of this dynamic and the vulnerability of the human body as a key parameter for preventive action.This reference document was followed by UN and WHO resolutions and reports, triggering events, campaigns, projects, publications, demonstrations, cooperation and strategic meetings such as Moscow and Brasilia conferences.Progressively, both within WHO and at regional and local levels, the health sector starts to play a leading role in initiatives traditionally restricted to the public security and engineering sectors, highlighting contributions of epidemiology and with emphasis on intersectoral approach to the problem, influenced by health promotion views.

Moscow and Brasília Conferences
The 2009 Moscow Conference held under the slogan "Time for Action" was characterized by a pioneering spirit and aspirations of a meeting of global unprecedented proportions on road safety issues, whose key recommendation urged the UN to declare a "Decade of Action on Road Safety 2011-2020", which would be readily accepted by the UNGA 10 .
If, on the one hand, uniqueness characterized the first conference, the second event held in Brasilia mirrored a moment of evaluation and review of commitments made, not only in Russia but also in the guidelines of the Decade of Action proclaimed, which in 2015 was exactly halfway there.It was also marked by the analysis of the progress of the recommendations of Resolutions issued in the interregnum 2009-2015.As in Moscow figures of the Global Status Report On Road Safety 2009 11 were considered, the event in Brazil occurred soon after the release of this same report for the year 2015 12 , and since the latter evidenced an overall stabilization of road traffic deaths, but way too far from the desired target, the motto of Brasilia was, as if in response to Moscow, "Time for results".
Also noteworthy is the synchronicity of the Conference and the Declaration of Brasilia with the Sustainable Development Goals (SDG), 2030 Agenda for Sustainable Development.Although the Moscow event was held, in turn, under the 2000 Millennium Development Goals (MDGs), it is a fact that these contoured, rather than addressed road safety, whereas those of the ODS, which have been negotiated in parallel with the organization of the meeting in Brasilia and were announced one month before the Brazilian meeting are unprecedented and explicitly mention road safety.Indeed, since the first meetings to define the second conference's outlines, the proximity of the event in Brasilia with the release of SDGs occupied much of the negotiations because, while it longed to imprint uniqueness to the road safety conference and to commitments of the Decade of Action for 2020, one could not ignore the scale of the 2030 Agenda.In the end, the incorporation of road traffic issues into the goals of SDGs and the proximity of events proved to be appropriate, but mainly complementary.More so, they would guide the Brasilia Declaration.

A parallel between Declarations
With regard to developments of Declarations, the consultation process for the text of Brasilia was more complex than Moscow, also resulting in a more extensive and detailed document.In its general structure, the introductory paragraphs of the Moscow document consisted of more than 60% of the text, while proportion of preamble (PPs) and operational (OPs) items in the Brasilia document was 50-50.Both documents note annual global figures estimated at about 1.2 million deaths and 50 million road traffic injuries, attesting to the plateau maintained in the interim between the Declarations.Both documents also mention the fact that 90% of victims belong to low-and middle-income countries, but it should be noted that while in Moscow road traffic injuries/traumas are already proclaimed as a public health issue, in Brasilia, this mention is repeated and preceded by deem-ing the problem as a "a major development issue (...)" (PP3).
Brasilia reaffirms Moscow by reminding that road traffic injuries and deaths are the leading cause of death for children and young people aged 15 to 29 years, but also highlights the fact that 2/3 of victims are male, suggesting the need to guide actions.The Declaration of Brasilia updates Moscow with regard to the economic impact of road traffic deaths and injuries: of the estimated annual costs of US$ 65 billion reported in 2009 (end of 1990s data), equivalent to about 1-1.5% of national GDPs, Brasilia's text informs costs of US$ 1.850 trillion a year from other studies 13 .The Brasilia document recalls recommendations of the gloomy forecasts for 2020 in the Russian Conference, by not addressing firmly the issue and, recognizing the distance of coveted goals, while in the middle of Decade of Action, assumes that there is much to do.
The Declaration of Moscow pointed out the main risk/protection factors associated with road traffic injuries and deaths: speeding; drink and drive; and use of safety belt, restraint systems for children and helmets.It also refers to old vehicles without proper maintenance or safety devices; infrastructures that do not protect pedestrians; the lack of or insufficient monitoring; and trauma care and rehabilitation.The Declaration of Brasilia shall address all of these factors in more detail, and more, such as the use of smartphones, not so popular at the time in Moscow.
On the other hand, if the error to blame recurrently victims -something warned in the 2004 WHO report -is not noticeable in the Declaration of the first conference, in Brasilia, this aspect gains a highlighted paragraph (PP13), which claims that it is "( ...) inappropriate and insufficient to focus only on roads' users as culprits of traffic accidents".More than that, Brasilia recalls that many of the causes of road traffic deaths and injuries "(...) are linked to social determinants."In this regard, the role of government is pointed out in Moscow and reinforced in Brasília (PP15), and the latter venue attributes "primary responsibility' , rather than "leadership" to governments regarding road traffic issues.
We can outline a parallel between various items, comparing how each of the charters addresses, for example, public transport, legislation, mobility and urban development, sustainability, multisectoriality and labor aspects.However, for the purposes of this text, we focused on points more directly related to health, although others, as noted above, somehow also are.Thus, we chose risk, referring to a familiar concept in epidemiology; vulnerability, from both physical and socioeconomic standpoint, insofar as it alludes to road traffic morbidity and mortality overrepresented segments, and, in necessary correlation with these aspects, equity and inclusion.Targets and indicators, given the need to design and monitor progress; skills training and education, taking into account the training of professionals; and people sensitization processes and an assessment of the most direct references to road traffic with health finalize the analysis of these highlights.In the end, Chart 1 summarizes schematically the parallel outlined.
Risk: the term appears once in the Declaration of Moscow and eleven times in the Declaration of Brasilia, eight of which as "risk factors".In the latter, in addition to road traffic risk/protection factors, there were other factors not expressed in the Moscow document, such as "medical conditions and medications that affect safe driving; fatigue; use of narcotics, psychotropic drugs and psychoactive substances; cell phones and other electronic and text messages devices" (PP22).The Brasilia document also mentions visual distractions on the roads and electronic and text messaging devices, taking into account that these aspects have become relevant.Risk mitigation is also addressed when countries are encouraged to introduce new intelligent traffic management and transport technologies.
Vulnerability: the subject of the most vulnerable road users such as pedestrians, cyclists, motorcyclists and unsafe public passenger transport are reported in two passages of the Moscow Document: when asserting the representativeness of these segments in low-and middle-income countries, while referring to infrastructure; and where policies and infrastructure to protect them are called for.In the Brasilia Document, the term appears four times, and the condition of vulnerability refers not only to physical frailty, but also to the fact that many vulnerable people, not coincidentally, are exponents of the poorest layers.In addition to the vulnerable status of children and the elderly mentioned in Moscow, Brasilia adds women in public transport, while welcoming the inclusion of the goal regarding the ODS 11 issue of the 2030 Agenda.This is reinforced where it is recommended "(...) to fully integrate the gender perspective in all decision-making processes and policy implementation related to mobility and road safety, especially in roads, traffic environments and public transport" (OP18).Urging safety of vulnerable people is further de-tailed in OP16, where States are called on "(...) to promote, adapt and implement road safety policies for the protection of vulnerable people", also referring to relevant United Nations legal in-Chart 1. Parallel between points of the Moscow and Brasilia Declarations.

Understanding of the traffic morbidity and mortality issue
Annual estimated costs of accidents mentioned:

Equity Moscow Declaration
-Public health problem.
-Word mentioned once.
-Presents the main risk / protection factors: speed; drinking and driving, seat belt, children restraint systems; helmets.
-Old vehicles without maintenance or safety devices; infrastructures that do not protect pedestrians; lack of or insufficient supervision and attention to trauma.
-Mention representation in middle-and low-income countries and the importance of infrastructure.
-Mentions child and elderly vulnerability.
-Points impacts on most significant segments in less developed countries, but does not directly mention equity.

Brasília Declaration
-Development and public health issue.
-Causes of road traffic deaths and injuries linked to social determinants.
-Governments and their leaders have "primary responsibility".
-It is inappropriate and insufficient to focus only road users as the sole cause of road traffic accidents.
-Added to factors mentioned in Moscow: medical conditions and medications that affect safe driving; fatigue; use of narcotics, psychotropic drugs and psychoactive substances; cell phones and other electronic and text messaging devices; visual distractions on the roads.
-Vulnerability is physical and socioeconomic.
-Women added to child and the elderly in public transport.
-States urged to promote, adapt and implement road safety policies to protect vulnerable population.
-Mentions UN legal instruments for the theme.
-Specific mention to motorcyclists in developing countries.
- -Invites the WHO to strengthen the standardization of definitions, indicators and reporting and recording practices.
-Encourages the WHO, employees and stakeholders concerned to facilitate the development of national, regional and global goals and definition / use of indicators for road traffic-related ODS.
-Need for countries to establish and / or strengthen monitoring of serious road traffic injuries.
it continues cific paragraph in the Brasilia Declaration, given the size of the problem in regions such as the Americas, where a 15% to 20% increase in the proportion of motorcycle fatalities in three years 2010-2013 12 was reported.In the OP19, States are urged to develop and implement legislation and "(...) comprehensive policies on the use of motorcycles, including education and training, driver license, vehicle registration, working conditions and use of helmets and personal protection equipment (...)".Attention is particularly drawn to the case of developing countries.

Moscow Declaration
-Road traffic injuries referred to as major public health problem.
-Health is part of a crosscutting issue.
-Mention to timely access to emergency care.

Brasília Declaration
-Specific paragraph for the subject.
-Refers to the reduction of road traffic deaths / injuries and improved health results.
-Refers to the role of health and universal coverage systems.
-Mentions prehospital, hospital, posthospital comprehensive care and reintegration of road traffic accidents victims; -Mentions the positive impacts on public health resulting from Investments in road safety.
-Correlates protection and promotion, safety of pedestrians and cyclists mobility with the broad improvement of health, in particular, non-communicable diseases and injuries.
-Refers health at work on road safety issues, with particular attention to professional drivers.
-Refers to outpatient and hospital guidelines, appropriate legislation and qualification of access to comprehensive health care.
-Highlights paragraph for timely rehabilitation and social reintegration, including world of work and providing Support to victims / families.
-Claims means of environmentally sound transport, especially public and nonmotorized transport for public health.
-Healthy lifestyle referenced in the emphasis on its interrelationship with road safety.
-Health services directly related to improving the quality of systematic and consolidated data collection.
-Invites the WHO to strengthen the standardization of definitions, indicators and reporting and recording practices, including on road traffic-related deaths, injuries and risk factors, in order to produce comparable information.
Equity and inclusion: the highlights and detailed references on the subject of the most vulnerable in Brasilia refer to one of the characterizing points of the Declaration of the Second Global Conference: equity -a point highlighted by the 2004 landmark-report as central to the review of the road safety paradigms of the 1960s.Although the Moscow Declaration has had this same 2004 reference, its text touches the issue of equity, pointing out the impact on the relatively least developed countries and their poorest segments without, however, being explicit as Brasilia.In the latter, the term equity and one of its variations (equitative), which were missing in the first Declaration, appear three times.In fact, in PP18, the disproportionate condition that the most vulnerable segments are "exposed to road traffic risks and injuries and deaths, which can lead to a cycle of poverty exacerbated by the loss of income (...)" is verbalized.
The term "equality" in the equity concept sphere appears in a context that refers to inclusion, insofar that ensuring people with disabilities and other users with reduced mobility access to road traffic environment and transport in urban and rural areas is claimed.The concern is already present in Moscow, when there are claims for infrastructure for all, with emphasis on vulnerable people (there including unsafe public transport), but in Brasilia, this is strengthened in OP14, with the following: "(...) the purpose of road safety policies must be to ensure protection for all road users."The mention to all users still appears in the speed approach, noting the condition of those outside the vehicle.Brasilia also refers to the participation of employers and workers in developing public policies to reduce work-related traffic accidents.
Goals, indicators and their monitoring thereof: given the number of commitments that begin in 2009 and scale-up, they become more detailed and bolder in the Decade of Action (especially for ODS); the term "goals", previously quoted in the 2009 Declaration, also occurs in 2015.Moscow merely recommends "ambitious, but feasible" goals.On the other hand, Brasilia invites the WHO to "(...) enhance standardization of definitions, indicators and reporting and recording practices" (OP7), as well as encourages the Organization and employees, along with all stakeholders, to facilitate the development of national, regional and global goals and the definition and use of indicators for road traffic-related ODS.However, goals and indicators require verification.Thus, the Declaration of Brasilia recognizes "(...) the need for countries to develop or improve and strengthen arrangements for the monitoring of serious road traffic-derived injuries" (PP10) in order to achieve aspirations set for 2020.
Skills training and Education: much in the same way as the Moscow document mentions support to training, by recognizing sources of funding, the Brasilia document also does it, by understanding that training should be integrated into development strategies for transport, and while referring to post-accident professionals, it also refers to international cooperation and encouraging governments and agencies to qualify people.However, while training appears in both documents, only the Brasilia version evidences that the risk factors approach's address is recommended through raising awareness, advocacy, campaigns, social marketing, educational and training programs, lessons sharing, best practices and knowledge transfer (OP19; PP23; OP23; OP24; OP27).References to education, training and raising awareness in Brasilia, by the way, indicate change with regard to an apparent eloquent skepticism or omission of these mechanisms, in earlier times.The following is explained: "(...) a context of continuing education, with regular testing to encourage responsible behavior of all road users, in order to create a peaceful circulation and social environment, as well as raising awareness on risk factors" (OP23).However, in the same paragraph, it is reminded that initiatives should occur in "comprehensive, inclusive and evidence-based educational and training programs." Health and traffic in more direct references: the Moscow Declaration makes three references to health, understanding the nature of road traffic injuries problem as a major public health issue; recognizing the area as part of a crosscutting issue and timely access to emergency care.The subject of health's involvement with road traffic, however, is further explored in the Brasilia document.As an example, we highlight a sole paragraph (PP4), outlining the emphasis given to its contents (without attaching it to another article) by the importance of "public health role in reducing road traffic deaths and injuries and improved results in health, as well as the role of health systems, including through universal health coverage (...)".Worth noting in the last sentence is one more element reminding that emphasis on inclusive aspects of this Declaration.Reference to the promotion of universal access to health (and prehospital, hospital, post-hospital comprehensive care and reintegration of road traffic accidents victims) also reappears in PP25.In Brasilia, the sixth preambular paragraph already mentions the positive impacts on public health arising from the investment in road safety.On the other hand, operating items correlate protection and promotion of pedestrian safety and mobility of cyclists with broad improvement of health, in particular injuries and noncommunicable diseases.The OP22 item refers to health at work on road safety issues, with particular attention to professional drivers.As in the Moscow document, Brasilia refers to pre-and post-hospital care in response to accidents, however, it is more specific regarding outpatient and hospital guidelines, requiring appropriate legislation and qualification of timely access to comprehensive health care (OP25).Also on this issue, the next paragraph highlights "(...) to provide timely rehabilitation and social reintegration, including in the workplace, to injured persons and traffic-related disabilities, and to provide ample support to victims and their families" (OP26 ).
Particularly in the promotional aspect, health is highlighted in OP11 of the Brasilia document, where the following is alleged "(...) environmentally sound means of transport (...) especially public and non-motorized transport as safe intermodal connections, as a means to improve road safety, social equity, public health (...)".In addition, healthy lifestyle is literally referenced with emphasis on its interrelationship with road safety.Also in Brasilia, ultimately, health services are directly related to their function, along with other areas, of improving the quality of systematic and consolidated data collection (OP6) with specific reference to include "(...) information from different sources, as well as data on morbidity and mortality and disabilities, including disaggregated data; to reduce reliability problems and underreporting, data collection should be conducted by the appropriate authorities, including traffic police and health services, in line with international standards and definitions."In this respect, Moscow had made detailed call to standardization for the sake of comparability.Also in Brasilia, the following article (OP7) immediately invites the WHO to "strengthen the standardization of definitions, indicators and reporting and registration practices, including on road traffic deaths, injuries and risk factors, in order to produce comparable information, in line with best practices in this area."

Discussion
In contrast with declarations submitted, it follows that, while each reflect unique situations, to a certain extent, one includes and stems from the other.By the time Moscow mirrored an unprecedented congregation of sectors addressing road traffic under the leadership of a health specialist agency, the document approved there adhered to principles, as would befit an inaugural initiative, in a short text, allowing the Brasilia document to be more specific and detailed when it pleased to be.And so it was, from the identification of gaps, emerging issues and values seen as timely to highlight.In this regard, the second document was on the threshold between strengthening general recommendations and being more prescriptive.
In the interregnum between texts, there was no remarkable paradigmatic exchange as what occurred on the premises of the WHO's 2004 Report, compared to previous decades' approaches.Brasilia, in effect, reinforces Moscow, the basis that authorized its further action.However, it is certain that some aspects give personality to the second Declaration, as opposed to pioneering that characterized the first one.Of these, worth pointing out is the representativity of the 2015 text; the greater attention to developing countries; the issue of sustainability; and the aforementioned references to the issue of equity and health sector.
The Declaration of Brasilia resulted in nearly a year of negotiations between Member States, which, even due to their involvement in lengthy discussions, also felt more "proprietors" and committed to the document to which they adhered.On the other hand, while Brasilia's text is not a "charter of developing countries" per se, it is certain that the marked participation of these nations in the negotiations of each item of the document assigned their representatives a greater liberty to voice to their aspirations.The Brazilian policy guidelines, with a view to consecrating lines of dialogues with these countries, certainly corroborated to this aspect, given their host country status, as well as proposer of the basic text of the Declaration of 2015.In this same vein, Brasilia emphasized other elements associated with the issue of socioeconomic inequalities: the relevance of factors related to equity, inclusion, rights, and insistent highlights to the condition of the most vulnerable segments.
The influence of the 2030 Agenda in Brasilia was also capital to mark the relevance and recurrence of issues related to sustainability, where urban development and public transport receive privileged mention and attention.Perceived in the broader scope of urban mobility (circulation policies, transport and land use), road traffic inseparability in public transport is ratified.Finally, the role of the health sector in more traditional areas (attention to post-trauma, notifications, standardization of indicators and data collection and systematization) expanded, to the extent that the very importance given to sustainability signaled potential actions associating addressing noncommunicable chronic diseases to road traffic and transport policies.

Final Considerations
Greater involvement of health with the issue of road safety in recent decades contributed to a theme traditionally conducted by public security, engineering and legal sectors.Of these inputs, we highlight the most modern principles of epidemiology, health promotion vision, and to this, as opposed to legitimate concerns about the flow of road traffic or law and order, striving above all for integrity and quality of life.The powers conferred on the WHO the global coordination of efforts aimed at road safety imprinted, of course, much of the view of the health sector.This also helped to achieve, in many cases, their acceptance in other fields of knowledge and activity, confirming its mission to amass other sectors, facilitating a challenging multi-and sometimes intersectoral agenda.These efforts can be identified in the resulting output since 2004, and are reflected in the two Conferences and their respective Declarations.As it welcomed the Declaration of Moscow in 2010, the United Nations General Assembly formally endorsed the Declaration of Brasília 16 on April 4, 2016.As recalled, while not binding, Declarations inspire and signal the adoption of attitudes, initiatives and policies that translate, concretely and effectively, into transformations in the realities, the daily making of road safety and its implications on health.
While the Declaration of Moscow was drafted by the Russian government with the support of the United Nations Road Safety Collaboration, the Brasilia Declaration draft was proposed by the Brazilian government, discussed with "Friends of the Decade of Action" -an informal group, comprising governments and international agencies -from November 2014 to March 2015.This document was open to online civil society suggestions from April to May 2015.Once open consultations were closed, negotiations were restricted to Member States in the following months until September 2015.
the Resolution named The Global Safety Crisis 6 , the United Nations General Assembly (UNGA) saluted WHO's efforts to choose road safety as the 2004 World Health Day topic.Also in 2003, another UN Resolution 7 decides to hold a Plenary Session in April 2004, focusing on road safety in connection with this World Health Day and the launch of the World report on road traffic injury prevention 8 , developed by WHO.