EMERGENCY RESPONSE: CAN WE BETTER SERVE CHILDREN IN CAR CRASHES? 

When a car crash happens, time is everything. The faster help arrives and emergency treatment begins, the better the chances someone survives. Emergency services play a crucial role in saving lives. When a child is injured, we trust those first on the scene to do all they can.

Emergency responders have saved countless lives, both young and old. But there is an oversight when it comes to children. The way emergency systems are set up – from the equipment in ambulances to the protocols – is built with adults in mind. As a result, children helped by these services are not always getting the care for their child-specific needs.

This gap in design and readiness matters. Car crashes remain the leading cause of death for children globally. And while many efforts focus on prevention, we also need to take a hard look at how we respond when tragedy strikes. If emergency services were better adapted for children, we could save more young lives.

CHILDREN ARE NOT “SMALL ADULTS” 

Children are often thought of as miniature versions of adults. But in reality, their bodies and minds work differently and have different needs. Children have different physical proportions. They have smaller airways, more delicate bones, and different responses to trauma. They also experience fear and pain in ways that are not always obvious.

According to the National Highway Traffic Safety Administration (NHTSA) in the U.S., more than half of the children who die in crashes are still alive when help arrives. That means there is a critical window to save them. If emergency responders have pediatric-specific equipment and training, the chance of saving a child would increase. With the right approach, the mortality rate for injured children could drop by as much as 60%.

Almost everything about using roads – roads themselves, vehicle design, safety rules – is built around adult thinking and physiology. Think about something as simple as a seat belt. Seat belts are designed to save lives in a crash, but can actually harm a child if used incorrectly. That’s why we use car seats and boosters to make up for the differences in size, weight and body development between a child and an adult. But similar adjustments are not widely adopted in emergency care. Ambulances still rely on equipment designed around the needs of adults. And emergency systems, by and large, are still operating under a “one-size-fits-all” mindset that does not account for a child’s unique needs.

PEDIATRIC AMBULANCES

Inside most ambulances, you will find everything designed around the average adult patient – stretchers, restraints, oxygen masks, and IV setups. In most cases, nothing has been adjusted for younger, smaller bodies.

Stretchers and restraints in ambulances are not designed around child bodies. Much like seat belts being inadequate for children, incorrectly sized restraints can increase the risk of injury to children during transport. Child-appropriate emergency harnesses exist that would solve this problem. Unfortunately, they are not widely used.

In South Africa, Netcare, a major private healthcare provider, launched the country’s first pediatric intensive care ambulance in 2018. It is fully equipped to handle critically ill or injured children with the care and expertise they need. This is a fantastic step in the right direction, but an emergency vehicle specific to children is still a rarity.

If one specialised ambulance is seen as a groundbreaking innovation, we still have a long way to go. These features should be the standard, not the exception. Especially given the high rate of child fatalities related to our roads.

Specialised ambulances also come at a very steep cost. Often, only a feature of private healthcare providers, children from low-income families must rely on government emergency services. State ambulances are not equipped with the specialised equipment of a pediatric ambulance. Additionally, state paramedics receive little to no pediatric training. In the event of a car crash where child-specific equipment is required, paramedics must wait for an Advanced Life Support vehicle to arrive. Minutes spent waiting for these vehicles to arrive increases the chance of a child’s fatality.

Children from low-income families are more likely to be involved in a life-threatening crash. With no option but to rely on government services that are sub-optimal for their needs, the roads become that much more dangerous for them.

TRAINING & PROTOCOLS TO BEST SERVE CHILDREN 

Even the best equipment is only as good as the person using it. And here, too, there’s a shortfall. Most first responders receive only limited training in pediatric care, if any at all. They may not have specialised expertise in assessing a child’s vital signs, calculating medicine dosages based on weight, or calming a frightened toddler at the scene of a crash.

Guidelines on how to transport or treat children in emergencies differ from one place to another. Some EMTs may be unsure of the safest way to restrain a child in the back of an ambulance, and others might not have access to child-sized equipment at all.

More consistent, hands-on training in pediatric emergencies could change that. Emergency workers need to feel prepared. Not just for adult trauma, but for the unique challenges children present in emergencies. When we put children first in our emergency response systems, we are also positioning people to better advocate for the most appropriate care for children when they need it the most.

EMOTIONAL FIRST AID MATTERS TOO

A child involved in a car crash is not only physically injured. They are likely also scared, disoriented, and overwhelmed. Sirens, flashing lights, and unfamiliar faces can be terrifying, especially if a caregiver is not nearby.

Often, psychological care in emergencies is treated as an afterthought. But for children, the way they’re spoken to can make a big difference in how they cope, both in the moment and long after. Even just having someone explain to them what is happening to help them make sense of what is going on can ease some of the trauma.

Most emergency personnel are not trained in child psychology or trauma communication. Even a few basic techniques – like using calm tones, distraction tools, or child-friendly explanations – can reduce fear and make treatment easier. An ambulance that has a more child-friendly atmosphere, such as cartoon characters, warmer lighting, personnel with an affinity for working with children, and a seat for a parent to go with them to the hospital can provide some degree of comfort.

RETHINKING EMERGENCY CARE FOR CHILDREN

To reduce the number of children lost to road-related crises, we need to rethink how we handle emergency care for them. That means going beyond “good enough” and investing in emergency systems that are designed with children in mind.

Here’s what that could look like:

• Ambulances equipped with child-sized restraints and medical tools
• Specialised pediatric emergency vehicles or modular designs for mixed use
• Standardised protocols across all emergency service systems
• Mandatory pediatric training for all emergency responders
• Better emotional care during transport and treatment.

These changes do not need us to reinvent emergency care. They just need us to expand it thoughtfully. Children deserve systems that recognise their needs from the moment help arrives.

We count on emergency services to show up when things go wrong. They do heroic work every day. But it is time to ask more of the system itself. Children are not just small passengers in an adult-sized world. They are individuals with different risks, responses, and needs.

If we want to save more young lives, we have to build emergency systems that are ready for them.

Every day, millions of South African children walk long, dangerous journeys just to get to school. Some cross rivers, navigate unsafe roads, or face threats of violence—simply to access their right to education.
This draft policy is a starting point for change. It calls for a national, coordinated response to school transport—one that puts children’s safety, dignity, and rights first. We’re inviting parents, educators, policymakers, and civil society to help shape a transport system where every child can get to school safely. Every child. Every day.

REMOTELY AT RISK: ROAD SAFETY & RURAL CHILDREN

Children are vulnerable on our roads, but this is especially true for the rural child. In rural communities, there are fewer resources to create safer streets for children. As a result, low-income rural communities and their children are often forgotten when it comes to road safety.

In South Africa, 68% of schoolchildren walk to school. In rural areas, some children can walk as much as 3 hours per day. It is unjust that this is the length some of our children go through to get an education. In South Africa, education is often thought of as the solution to poverty, and there is credit to that. But for many children, especially those in rural areas, poverty itself is a barrier to education. Children cannot reliably and safely get to school.

To make roads safer for rural children, a combination of policy changes, infrastructure development, community participation, and education is essential.

UNDERSTANDING THE ROAD SAFETY RISKS FOR RURAL CHILDREN

Due to the remote and sparsely populated nature of rural areas, less resources are available to families. As a result, if there is only one school in an area, children must travel the distance to reach it, regardless of the distance.

In low-income communities, very few families have vehicles. Families need to rely on public transport or their children have to walk to school. Schools in low-income rural areas often face many financial restraints. A school bus is a necessity far beyond their means. Taxi services may provide transport for school children, but the lack of regulations around this means that it is not also without risk.
For child pedestrians, there are already many safety risks.
Children often walk to school without supervision. This means that they are responsible for their safety. As a result, they are vulnerable to bullying, abduction, sexual assault, injury or death. In rural areas, children may have to walk along poor roads, without pavements or pedestrian crossings. Many have to navigate crossing highways by themselves. Children are susceptible to being hit by a vehicle as they are less visible to drivers and lack good road awareness to always make correct judgements.

Rural areas may also lack enforcement of road safety laws which exacerbates the risks to children.

THE URGENT NEED FOR SAFER SCHOOL TRANSPORT

We have talked about the need for safe school transport in articles before. 36% of child fatalities up to the age of 19 years old are due to road-related incidents.
Many children have no other means of transport aside from taxis, or else walking. A school transport system would provide children who would otherwise be pedestrians a much safer way of getting to school. But, the current tragedies involving overcrowded taxis and unsafe drivers must be overcome first. Regulations around school transport vehicles must be improved to place the safety of our children at the forefront.
Schools do not only provide children with basic education. For those from low-income families who face socio-economic difficulties, a school can be a sanctuary. They can provide meals, basic healthcare, social resources and education, and offer extra-curricular activities to enrich children. Children who are unable to attend school are not only cut off from an education that can aid them in finding a sustainable future. They miss out on the other services and roles schools provide to kids. This makes safe and reliable school transport even more crucial.

ROAD SAFETY EDUCATION SAVES LIVES

Road-related incidents are the greatest cause of child fatalities. Thus, road safety education should be a mandatory part of school curriculums. This is especially true in rural communities where there may be a lower level of education. These families might not be equipped to teach road safety rules to their children.

When taught road safety in a way that is age-appropriate and engaging, children are enthusiastic to learn. Road safety for children should reflect their daily experiences. Arrive Alive stresses the importance of teaching children proper road-crossing techniques. This includes encouraging them to walk facing oncoming traffic, looking right and left before crossing and ensuring adult supervision in high-risk areas to prevent injuries or death.

EMPOWERING COMMUNITIES THROUGH AWARENESS

Children tend to reflect the general road safety behaviours, or lack thereof, of their community. This suggests that education on road safety cannot be the sole responsibility of schools. Rather, encouragement and awareness of road safety should include the greater community.

A paper on road safety education for children finds that although children may understand road safety rules in a classroom setting, they are far more likely to exhibit behaviours they see outside the classroom.
This could be an opportunity to involve your community to improve road safety for children and parents alike. Organising student walking patrols, having parents help children at road crossings and getting them involved in the discussion of school taxis will aid in improving safety.

We have previously spoken about our Halo Beanies project, which provides hi-visibility beanies for child pedestrians. We would love to get in touch with rural communities who wish to band together to knit beanies for their children.

Trying to change attitudes that seem ingrained in a community can be hard. Most of these problems may be larger than most people feel they have the power to fix. But change begins at home. If you do not feel like you have the power to change the country, then consider what you can do to change your town or even your neighbourhood. Please reach out to us to provide you with educational resources to help your community.

DEVELOPING INFRASTRUCTURE FOR SAFER ROADS

Rural areas see less road maintenance and are often left to decay. Roads that are not maintained become a danger to everyone, especially children.
In rural areas, it is common to see children playing together in the streets. Playing and walking around roads is very unsafe for children. They lack the same awareness of the roads as adults do. Playing distracts them from danger. They may not have learnt about road safety, and are not easily visible to drivers.
If children are expected to use the roads, we should ensure that roads are safer for them to use. This includes pavements, pedestrian crossings, and traffic-calming measures like speed bumps. Children are also least visible at dusk and dawn, therefore streetlights can enhance their visibility to drivers.

GOVERNMENT ACCOUNTABILITY

Our government needs to facilitate change by coordinating efforts between the Departments of Education and Transport, law enforcement and NPOs. Resources and policies must reflect a “child safety first” attitude.

A lot of road safety challenges are a systemic problem and require a comprehensive and multi-faceted effort to affect change. Greater investment should be directed towards road safety for rural children. The lack thereof has the greatest impact on a rural child’s daily experience.

To protect South Africa’s rural children, road safety must be prioritised. We need better infrastructure, stricter transport regulations, widespread education, and stronger policies. These interventions will reduce child pedestrian fatalities and make school commutes safer. Creating a secure travel environment for children is a fundamental responsibility that requires urgent and sustained action.

In South Africa, overloaded vehicles are a common sight on our roads.

It could almost be an emblem of road safety in developing countries. We have touched on overloaded vehicles in terms of school transport, but let’s dive deep into this weighty issue.

A few years ago, a video circulated of a minibus taxi. It was bursting with passengers, luggage stacked high on the roof and an entire living cow loaded in the boot. All while a man clung to the outside rear of the vehicle. Video proof here. While this does not specify where in Africa this took place, it does not seem to be South Africa. But we have all seen enough instances of overloading that it would not surprise us if it was.

This example takes it to the extreme, but it does not take a cow to push the loading weight of a vehicle over its limits. It may surprise you to know where the limits lie. Beyond being a gross violation of road safety, overloading also impacts vehicle maintenance, road infrastructure, and public safety.

WHAT IS OVERLOADING?

It’s time to get a little bit technical. Vehicles have a Gross Vehicle Weight Rating which is the maximum weight limit of the vehicle up to which it can be safely operated. This includes the vehicle, fuel, passengers and cargo. The load/payload capacity of a vehicle specifically refers to the weight of passengers and cargo. Load capacity is determined by the difference of the Gross Vehicle Mass minus the weight of the vehicle and all the parts, fluids, fuel and so on that are required for its operations..