Risk, Culture, and Transportation Safety

Brynna has the best hair, but Jonah isn't too far behind

Like many, I have spent a good portion of the past two years pondering risk, particularly human understanding of risk and how we weigh risks versus benefits. I have read newspaper articles and blogs, listened to podcasts, had long and intense conversations with friends and colleagues, and struggled with my own internal inconsistency of what constitutes acceptable risk. Risk assessment is not a novel concept for me; it is embedded in the practice of family medicine: discussing mammogram frequency, counseling on neonatal circumcision, reviewing and recommending childhood vaccinations, guiding decisions about antibiotics, cancer treatment, end of life choices, etc.

COVID-19, the great magnifier, revealed the power and influence of local norms and values on individuals' assessment of risk. That is, we assess our own risk based on how those around us assess the same risk. If people around us are worried, we are worried. If people around us are not concerned or are more concerned with the intervention than the threat, we feel similarly. This is a phenomenon I observed in caring for a vaccine-hesitant population in West Sonoma County, where suspicion of vaccines ran deep, even in families with standard science backgrounds. Local norms trump scientific evidence. They trump expert opinion. They trump public health guidelines. They trump the word of your trusted family doctor.

Which brings me to my Ecuador blog topic of today: transportation safety and the influence of local norms and values.

In the world I normally inhabit, it is utterly unthinkable to do anything but carefully strap a newborn infant into a bulky rear-facing car seat, which itself is strapped down into a well-designed vehicle so as to prevent any harm from a potential motor vehicle accident. Same goes for two-year-olds, though most people turn them frontward facing at some point earlier than they are advised. Most five-year-olds back home (mine included) are still strapped in five-point harnesses with some making a quiet shift to a lower profile booster seat, particularly if their five-year old is fussy or extraordinarily large.

The transportation safety norms I reference are, of course, all codified by state and federal laws. We have to belt our kids this way, or we could get in trouble, pay a fine, or face legal implications. Does the law shape our norms and values, or is it vice versa? Many of us in public health hoped that legal mandates during the pandemic would do a better job of changing behavior. They did change behaviors, but they were more apt to change behavior when local norms and values were already aligned with the mandates. The same mandates didn't work nearly as well where opposing local norms and values were readily dismissed.

Motor vehicle safety is not a value or norm that is highly regarded in rural Ecuador, at least not by my own assessment. Instead, people prioritize getting where they need to go with the resources that are available. As such, it is perfectly normal for a two-month-old to be held in one arm of his mother, while his mother's other arm clutches a toddler who is sandwiched between the father and the mother, while riding a motorcycle. The entire family unhelmeted. It is also acceptable for a five-year-old to ride shotgun unbelted on their mother's lap -- or for that matter, a complete stranger's. It is similarly fine for seven young children to be sitting atop a foam mattress, strapless under a comforter, in the back of a pick-up truck to travel, at times at high speed for forty miles.

And this all creates an interesting internal monologue, not unlike the discussions I have been having with myself about COVID. What is acceptable risk for me? What is acceptable risk for my children? When am I being reckless? When am I being reasonable? How concerned should I be? No, really, how concerned? When local norms and values clash with my own, which wins? And can one actually function in an alternate culture if one holds too tightly to one's previous norms?

Eleven years ago, when we were planning to bring Dillon to Ecuador for his first birthday, I had internal struggles and many conversations with Paul about transportation safety. Heck, I was an anxious first time mom AND a family doctor who counselled families on the topic all day long. Do we bring a car seat for him? If so, what kind? Is it totally irresponsible to not bring a car seat? Is it ridiculous to bring one? Why am I totally committed to one practice at home but willing to throw it out the window when I travel? And, the worst question of all for a mom, what if something happened? Could I ever forgive myself?

In the end, we did not bring a car seat. I had fleeting moments of terrible guilt, particularly in wild taxi rides through Quito and on a windy road in the Amazon, but the majority of the time it was fine. On more than one occasion, I found myself chuckling at the conjured image of me lugging a big bulky car seat around a country where kids generally don't get their own seat (save for a lap) and seat belts are buried deep. Where could I even have used the seat?! And what a burden it would have been!

Over the ensuing decade, Paul and I continued travelling with our growing family and were faced with similar risk conversations. We had already decided to take the trips; that was never the question. To bring or not to bring the car seat, that was the question. Sometimes we did, sometimes we didn't, depending on our children's ages, the country we were traveling to, the transportation we would be using. Meanwhile, back at home, I was a strict car seat person; both Brynna (now 5) and Jonah (now 7) still use a 5-point harness almost exclusively. When we visit friends or grandparents out of state, there is no car seat cheating. And Dillon, while technically allowed, basically never sits in the front seat.

And yet, here we live, a family of five, sans car seats and sans personal car in a country that does not, for all intents or purposes, promote or enforce seat belt or car seat rules. We made the choice not to rent or purchase a car for several reasons: there is excellent public transportation, the roads can be terrible, and we mostly don't want to have to deal with the hassle. But in choosing not to have a personal car, we are definitely at the mercy of local norms and values.

As I have mentioned before, the bus service that used to take people back and forth from La Maná was replaced by a convenient double-cabin pickup truck service, which runs more frequently. Said system also supports cramming as many people in as possible into not-large vehicles and makes seat belts even more laughable. Typically, when the five of us travel in a double cabin, we pay for and get three seats: one for me (Brynna on my lap), one for Paul (Jonah on his lap) and one for Dillon. Occasionally it's four, and Jonah gets a sliver of space. When we travel with my family's private car, I am always ushered into the shotgun position plus or minus Brynna on my lap; the boys reliably hop in back, happily.

Yes, there are technically some rules about transportation safety; for example, when we encounter a random police stop, the driver reliably grabs at his seat belt, mildly panicked, to make it appear he has been belted. Apparently seat belt rules can be enforced. Also, a friend was recently chastised by a transportation officer for his toddler daughter riding on his lap while driving. No citation given, though. And, while enforcement of such rules is more lax in rural areas than urban ones, even in big cities in Ecuador, kids are not routinely seat-belted or car-seated.

Ecuadorians, particularly rural people, pile into the pick-ups, jump into the backs of the pick-ups, hop on motorcycles, pull their kids into either, and hit the road; it's the only way to get where you need to get. They don't seem to worry about their 12-year-old sans helmet piloting a motorcycle or their two-year-old standing up in front of the motorcycle driver or grandma literally hanging off the back balancing a ten-gallon container of milk. They don't worry despite the fact that a local man, suffered a severe c-spine injury from a motorcycle accident (without helmet, drunk) that left him a quadriplegic. They don't worry about it, despite worrying plenty that my kids don't eat enough, or worrying that they have a runny nose, or worrying that they aren't wearing pants to go the finca, or worrying that they are climbing a moderately sized orange tree to pick oranges. It's not that Ecuadorians don't worry about their children. I assure you they do. It is just that local norms and values do not lift up transportation safety as a key safety issue.

I could drive myself mad fretting about my kids' safety. The risks are real; I don't mean to dismiss them or to be flippant. I know that motor vehicle accidents are the number one cause of death for children in the US and likely a leading cause of morbidity and mortality of Ecuadorian children. An alternate choice is to take a cue from those around me and try not to worry about it. It is, after all, not completely unlike our own childhoods: five-year-old me traveled across country in the back of my mom's VW Rabbit, seats removed, on my belly listening to books on tape for the entire journey. Paul has fond road trip memories of playing games with his unstrapped siblings on a piece of plywood in the back of his family's van.

And so, in a choice that is more emotional than rational, we go along with local norms. We hop into the pick-up truck where there is space, sometimes inside the cab, sometimes not. My kids, of course, absolutely love riding in the back, and I do get a thrill myself on short jaunts when it isn't raining. I remind my kids to hold on tight, I don't let them stand up mid-ride. When inside the cab, I try to buckle Brynna in with me as best I can. We have a strict no motorcycle rule. We take buses when possible. And mostly, I try not to worry.

Paul believes that, like cigarette smoking in the US, transportation safety culture in Ecuador will not change without very rigid and restrictive laws being enacted-- laws that would definitely be unpopular and would impose great hardships on large families with limited transportation. The public health person in me wants that for them, but I also don't see such changes coming any time soon.

The truth is that we have to modify our norms and values, or we couldn't be here, and an important part of our living here for this year is accepting the aspects of life and culture that are not ours to change. At the same time, we also cannot entirely turn off our own well-established norms and values, and I am certain we will all fall back into those next year quite readily. Let's hope that Brynna remembers how to buckle herself into a car seat.

Note the toddler in front

This is NOT how we ride, but it is just before we took off

Newborn baby in mom's arms in the city