INTRODUCTION

Background

The Republic of Korea has been under a ceasefire for nearly 70 years. The border area (BA) comprises cities and counties adjacent to the demilitarized zone (DMZ) [1]. The DMZ stretches approximately 250 km, with about 75% of its territory covered by mountainous forestland, which constitutes its natural environment. In winter, the mean temperature in most of the BA falls below –3 °C, a level under the standard freezing point [2]. These harsh, freezing temperatures combined with steep terrain pose significant risks to residents [3]. Additionally, the BA hosts numerous military camps, and frequent military training exercises—featuring explosions, shootings, and the movement of heavy equipment such as tanks, cannons, and trucks—are common in the region. Although soldiers and their families coexist with civilians in the BA, the area lacks large cities, tertiary hospitals, and specialized trauma centers needed for effective management of major trauma cases.

Consequently, the BA may be particularly vulnerable to trauma, necessitating targeted efforts to improve its conditions. However, evidence demonstrating poorer outcomes or a worse prognosis for trauma patients in this region remains limited.

Objectives

This study aimed to assess the vulnerability of the BA by comparing traffic accident (TA) outcomes in the BA with those in other areas.

METHODS

Ethics statement

This study was exempt from institutional review board approval because it analyzed aggregated statistical data from each region rather than individual personal data.

Study design and setting

Cities and counties (gun) in northern Gyeonggi and Gangwon provinces were categorized into the BA and the rear area (RA) (Fig. 1). The BA comprises Paju, Yeoncheon-gun, Cheorwon-gun, Hwacheon-gun, Yanggu-gun, Inje-gun, and Goseong-gun, which border the DMZ directly. Although Ganghwa-gun and Gimpo also border the DMZ, they were excluded due to their distinct geographic characteristics resulting from numerous islands. The RA is defined as the cities and counties immediately adjacent to the BA and includes Goyang, Yangju, Dongducheon, Pocheon, Gapyeong-gun, Chuncheon, Hongcheon-gun, Sokcho, and Yangyang-gun.

Data collection

We conducted a retrospective analysis using a nationwide Korean dataset. The Traffic Accident Analysis System (TAAS; taas.koroad.or.kr) compiles data from every traffic accident across the country and collects TA-related information from the Korean government to support traffic safety planning. Data on TAs between 2017 and 2021 were obtained from the TAAS, and information on road length, population, number of TAs, injuries, and fatalities for each city and county was extracted from the database.

Statistical analysis

We compiled the annual number of residents, road length, TA incidence, fatalities, and injuries for both areas. These values were averaged and compared to characterize each area. Additionally, we calculated the annual number of TAs and fatalities per 1 km of road and per 100,000 individuals. The differences between the two areas were then assessed.

We further evaluated vulnerability using two variables: severity (number of fatalities per 100 TA cases) and lethality (number of fatalities divided by the sum of fatalities and injured patients). These outcome variables were compared between the two areas using the Wilcoxon rank sum test. All statistical analyses were performed using IBM SPSS ver. 25.0 (IBM Corp), with statistical significance set at P<0.05.

RESULTS

A total of 55,463 TA cases from 2017 to 2021 were analyzed, with 11,967 cases (21.6%) occurring in the BA. Table 1 presents the annual mean road length, population, number of TAs, fatalities, and injuries. The RA had a longer road network, a larger population, and greater numbers of TAs, fatalities, and injuries compared to the BA.

Table 2 displays the annual number of TAs and fatalities per 1 km of road, indicating that the RA experienced more frequent TAs and fatalities per unit distance.

Table 3 presents the annual numbers of TAs and fatalities per 100,000 individuals. Although TAs per population were more common in the RA, the BA had a higher number of fatalities resulting from TAs.

Finally, Table 4 shows that the BA exhibited higher severity and lethality rates. Statistically, the BA had a higher ratio of deaths per 100 TA cases and among all trauma patients. These findings are summarized in Fig. 2.

DISCUSSION

This study compared TA outcomes between patients in the BA and the RA to determine the BA’s vulnerability. Using a nationwide database, we sought to establish whether the BA exhibits a higher proportion of fatalities following TAs. Our results indicate that the BA has higher severity, lethality, and fatalities per 100,000 people compared to the RA.

The RA appears to have safer road conditions than the BA. Although TAs and fatalities per 1 km of road were more frequent in the RA, these metrics have traditionally been used to assess road safety [4,5]. The presence of expressways, which Zhao and Deng [6] reported to have a 1.33-fold higher lethality than average roads, may partly explain these differences. Only two BA regions—Paju and Inje-gun—contain expressways, whereas several RA regions (Goyang, Yangju, Pocheon, Gapyeong-gun, Chuncheon, Hongcheon-gun, Sokcho, and Yangyang-gun) do. Furthermore, although the RA experiences a higher frequency of TAs per 100,000 individuals, TAs in the BA are markedly more lethal, as reflected by the higher fatality, severity, and lethality rates. These measures were critical in assessing regional safety.

Various methods have been proposed to analyze TAs. Wang et al. [7] used severity and fatality rates to assess TAs in China. Singh [8] applied severity and fatality rates per 100,000 people to examine changes in TA patterns during different periods in India. Qiu et al. [9] analyzed fatalities per 100,000 people and lethality rates to study the occurrence and severity of TAs in western regions. In a similar fashion, we employed these variables to compare the BA and RA, finding that the BA has a higher likelihood of fatal outcomes following TAs, while the RA experiences more frequent accidents.

Multiple factors may contribute to the BA’s vulnerability to TAs. Risk factors such as poor socioeconomic status, unsafe roads, and inadequate infrastructure, combined with insufficient post-crash care, can increase the likelihood of fatalities [10]. The BA is recognized as an underdeveloped, rural region with harsh geomorphic and climatic conditions. Security concerns related to threats from North Korea have further limited the development of large cities in the BA. In contrast, the RA includes urban centers such as Goyang, which houses over one million residents. Consequently, the BA has only one tertiary hospital, whereas the RA has nine training hospitals.

Moreover, the BA lacks a dedicated trauma center. In South Korea, regional trauma centers—comparable to level I trauma centers in the United States—offer the highest level of trauma care and have been shown to reduce preventable trauma death rates [11]. Two regional trauma centers are located in northern South Korea, one opened in 2015 and the other in 2018. Follow-up studies have demonstrated that establishing a trauma system with regional trauma centers reduces preventable trauma deaths [12]. Despite annual decreases in fatalities per 100,000 people, as well as in severity and lethality rates, research has not specifically focused on the BA or RA. In the BA, prolonged transport times to trauma centers remain a significant problem. Regions such as Montana and North Dakota in the United States, along with rural areas in northern Europe, face similar challenges. Additionally, mountainous terrain and severe climates contribute to delays in hospitalization. Several studies have linked increased prehospital time with higher mortality rates in rural settings [13,14]. Further investigation into transport logistics and efforts to reduce transport time, including air transport options, is warranted.

The data for this study were obtained from the TAAS of the Korea Road Traffic Authority, which collects TA-related information from the police, insurance companies, and mutual aid associations. Ashraf et al. reported an association between population density and accident frequency using TAAS data [15]. Similarly, Oh and Kim [16] used TAAS data to investigate risk factors for personal mobility accidents. This nationwide analysis, rather than a single-center study, provided unique insights into the characteristics of a large rural area.

Limitations

This study has several limitations. First, the TAAS database does not include detailed clinical information such as each patient’s diagnosis, vital signs, and mental status, which would better reflect injury severity. Second, the dataset lacks other clinical details—including prehospital and in-hospital procedures such as operations, medications, and transfusions—that are important for determining preventable deaths. Additionally, transport-related information, such as transport time, mode of transport (air or ground), and the level of transport, was not available. Future studies are needed to further elucidate the factors contributing to vulnerability in the BA.

Conclusions

In conclusion, the BA is associated with a higher risk of death following TAs and demonstrates greater vulnerability compared to the RA, even though the RA experiences a higher frequency of TAs and hazardous road conditions. Further analyses are necessary to assess these rural areas and to develop strategies for improving related conditions.

ARTICLE INFORMATION

Author contributions

Conceptualization: DK, SYJ, MK; Data curation: HC, MK; Formal analysis: MK; Funding acquisition: MK, SYJ; Investigation: DK, SYJ, MK; Methodology: HC; Writing–original draft: DK, MK; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Hangjoo Cho is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

This research was supported by a grant from Armed Forces Capital Hospital in 2023 (No. 2023MDD0076).

Acknowledgments

The authors thank Professor Sanghyuk Bae (Department of Preventive Medicine, The Catholic University of Korea, Seoul, Korea), for helping the statistical analysis of this study.

Data availability

Data analyzed in this study are available from the Traffic Accident Analysis System (TAAS) of the Korea Road Traffic Authority (taas.koroad.or.kr).

Fig. 1.

The border area and rear area of the Korean peninsula. The original image was purchased from @tunasalmon (crowdpic) and edited by the authors. A, northern Gyeonggi Province regional trauma center; B, military trauma center; C, Gangwon Province regional trauma center.

Fig. 2.

Comparison of traffic accidents (TAs) in the border area (BA) and rear area (RA). (A) Number of TAs per road length 1 km. (B) Number of fatalities per road length 1 km. (C) Number of TAs per 100,000 people. (D) Number of fatalities per 100,000 people. (E) Severity (number of fatalities per 100 TA cases). (F) Lethality (number of fatalities divided by the sum of fatalities and injured patients).

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Figure & Data

References

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