Two-Wheeler Nation: The Preventable Epidemic of Traumatic Brain Injury

The duty mobile of a neurosurgical resident in a busy trauma center usually rings at midnight. The call is often for a young two-wheeler rider who has met with a road traffic accident. A quick evaluation reveals deteriorating consciousness, dilating pupils, and a fractured skull with maxillofacial injuries, while the history confirms the patient was riding a bike without a helmet. Post-intubation and stabilization, a computed tomography scan shows a severe head injury with mass effect. Counseling relatives that a decompressive craniectomy is required, and that despite surgery the patient may never regain complete functionality, is one of the toughest jobs for a neurosurgeon. All of us have gone through this ordeal, operating on many such young patients who could not be saved by our best surgical efforts, or who never returned to work and remained permanently disabled. This grim routine at high-volume apex trauma centers is witnessed across the country. This reality is highlighted in the latest report from the Ministry of Road Transport and Highways (MoRTH), which shows that in 2023, road accident fatalities reached 1,72,890, up from 1,68,491 in 2022.[ 1 ] This increasing trend is alarming, particularly because road infrastructure in India has steadily improved over the last decade. Roughly one life is lost in India every three minutes. Forty-five percent of these accidents involve two-wheeler riders, the majority being in the 18-to-45 age group. It does not come as a surprise to me that 54,568 of these victims were not wearing helmets. This report is not just data; it is a register of craniotomies that were never needed, of ventilators occupied, of young brains that did not have to be injured at all. A seminal 2008 study by Liu et al. in the Cochrane Database assessed the effects of wearing a helmet on reducing mortality and head and neck injuries in two-wheeler accidents. After analysing 61 observational studies, the authors concluded what the world already knows: “helmets were estimated to reduce the risk of death by 42% and risk of severe head injury by 69%”.[ 2 ] There is no intervention in our operation theatres, nor any drug in a pharmacy, that can deliver the risk reduction offered by merely strapping on a helmet. Helmet use was mandated by the Government of India under Section 129 of the Motor Vehicles Act in 1988. This Act clearly states that every person above four years of age riding a two-wheeler (both rider and pillion) must wear protective headgear.[ 3 ] A 2019 amendment to the Act raised the fine. Technically, Section 129 dictates the behaviour, while the actual penalty is executed under the new Section 194D, which recommends a fine of 1000 INR and a mandatory three-month driving licence disqualification.[ 3 ] Despite these changes in the law, hardly any change in public behaviour is visible in most Indian cities. Similar to India, Vietnam experienced an economic boom where the number of two-wheelers surged to 95 percent of all registered vehicles. Helmet compliance was as low as 6 percent before 2007, leading to a massive public health crisis related to traumatic brain injuries (TBI). On December 15, 2007, the Vietnamese government enacted Resolution 32, a strict rule mandating that all motorcyclists wear helmets on the roads. Compliance improved to 90 percent in a short span of time, resulting in 2,200 fewer deaths and 29,000 fewer TBIs. Hospitals reported an 18% drop in road traffic fatalities.[ 4 ] [ 5 ] The instrument of prevention in India has sat on the statute books for too long. It is time that more stringent measures are enforced, and people are sensitised that helmets dangling from handlebars, worn on forearms to satisfy a traffic constable, or left at home for “just a short ride” will attract penal actions. These actions are meant for the greater good; the money collected from such penal provisions could even be distributed to the families who have lost their loved ones in road traffic accidents. This approach might even improve the public's acceptance of these penalties. Neurosurgical societies and individual neurosurgeons must spearhead the movement advocating for mandatory helmet use by all two-wheeler riders. We are in a position to influence our local communities, state governments, and even voice our concerns at the national level. My suggestion is to include 'Helmet status' as a clinical vital sign in all emergency notes at the time of the patient's first visit to the hospital. Advocacy campaigns focusing on the morbidity of the 'long tail of survival', rather than just mortality, will also improve trauma audits. Furthermore, neurosurgeons can advocate for policy changes that not only penalise offenders but also mandate their education and a day of social service in trauma centers. Our profession must bridge the gap between acute intervention and preventative advocacy. A profession that defines itself by what it can salvage at three in the morning needs to be at least as loud about what could have been spared at dusk. Publication History Article published online: 16 July 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Private Limited A-13A, Graphix Tower 1, 6th floor, Sector 62, Noida 201309, Uttar Pradesh, India