Tuesday, August 4, 2015

What the helmet debates are hiding

Cars, not helmets, should be the focus of safety concerns
Santiago, Chile: Mapping the blindspots around
a normal city bus: 16 bikes vanished before
participants' eyes at specific points beside, behind and
even in front of the bus, during a recent
workshop to improve on-road relations between
cyclists and buses. Source: Laboratorio de Cambio Social
As mentioned by other contributors to this blog, the scientific evidence for the effectiveness of helmets is highly questionable, and indeed, hotly debated by researchers themselves (for ongoing coverage of these issues, see The Helmet Foundation website, www.cyclehelmets.org). Rune and Vaa, authors of the bible-like Handbook of Road Safety Measures, for example, conclude that studies on the effectiveness of cycling helmets revealed bias and methodological weaknesses that make their results highly uncertain and overly supportive of helmet use. 
Other researchers point to a 36% increase in damage to the neck, resulting from helmet use, or an increase in risky behaviour. While requiring helmet use might reduce the total number of injured cyclists, Erke and Elvik (2007) considered it probable that accident and injury rates would rise.
Indeed, required helmet use seems to be the chosen strategy mainly for societies that are unwilling to address the main issues behind road deaths and injuries for all road users, particularly pedestrians, but also drivers and passengers themselves. More of the latter die or end up disabled due to unsafe driving. But for some reason the focus is seldom on them. 
In contrast, countries posting the world’s best road safety records, such as Sweden and the Netherlands, emphasize a whole raft of measures that separate drivers from those most vulnerable and make high speeds impossible and socially shunned, particularly in densely populated urban areas. To slow down drivers on rural roads, the Dutch provide a single lane for cars, with wide shoulders for cyclists and walkers on both sides. This design forces slower, more cautious driving, which improves safety for all.
Jacobsen’s now classic work (2003) clearly illustrates the importance of “safety in numbers”, based on studies of 68 Californian cities, Denmark, and even Pakistan, where Bhatia and Wier obtained similar results. The more pedestrians and cyclists on the road, the safer walking and cycling. A measure, such as compulsory helmet use, which reduced cycling by almost 50% in some Australian regions (Robinson 1996), clearly raises profound questions about helmet use as a “safety” measure. Other researchers have also raised the issue of “dangerization” of cycling through fear-mongering tactics (http://thinkingaboutcycling.com/article-fear-of-cycling/).
Avoiding the elephant in the room — drivers’ behaviour, speeds and road designs that favour speed at the cost of the lives and limbs of all — often leads to a “Blame-the-victim” attitude, similar to that experienced by rape victims, who are told their victimization is their own fault, because of the way they behave or dress, a terrible distortion of basic human values and rights. When someone is shot, the shooter, not the victim, is charged and sentenced. Like people with guns, drivers preside over their own and others’ lives. Blaming the victim only excuses, and ultimately perpetuates, often mortal violence.
Like the smelly red herring  
Focusing on cyclists’ rather than drivers’ behaviour pushes some really important issues, which could make a difference to us all, low on the policy agenda. Study after study confirms that in our obesity plagued world, over a life time, the health benefits of cycling are far greater than the risks of death or disability (see bibliography below). In other words, you’re more likely to die of diabetes II or a heart attack, than at the wrong end of a speeding car.
Equally important, many new cyclists put on their helmet and set out to conquer the city’s rough roads, convinced that this is enough to keep them safe. This attitude is reinforced by the perennial question, when a cyclist is run down or killed, “But was s/he wearing a helmet”? This is not scientific thinking. It is not based on experience or evidence. It is magical thinking, and it is a poor substitute for the known strategies for protecting people on roads, including cyclists.
As transitioning cities promote cycling for transport, a high proportion of people cycling are new to the experience. Dutch experts calculate it takes two years for a novice to become an expert cyclist. This is a minimum that could take longer elsewhere, since many cities do not provide the kind of well thought out, carefully designed protection afforded by the Netherlands’ “cycling-inclusive” transport planning. 
If no education is available, there is a high risk that people fall into dangerous habits and repeat them endlessly, without learning proper behaviour on the road. This risk is particularly high in developing cities, where many people do not have drivers’ licenses, so have not even cracked open the highway code or relevant traffic rules and laws. 
Two years or more. What are the implications in a city like Santiago, where cycling’s modal share doubled from 2006-2012, a remarkably short time, and the number of cyclists on major routes is soaring by 20-25% annually? Most cyclists do not have the skills to ride safely, but they nonetheless don their trendy helmets and off they go, ringing their bells at anyone who gets in their way, sliding past others into intersections, or whipping from sidewalk into intersections in the flash of an eye. 
This risky behaviour is further compounded by the fact that many safe manoeuvres are counter-intuitive, especially to people who have never driven a car. Cuddling up to the side of a bus or a lorry ignores the fact that 16 bicycles can fit in the blindspot of this size of vehicle. Squeezing into the curb leaves no margin to manoeuvre when something goes wrong on the road. At night, wearing a helmet is no substitute for using a plain white light on the front and a red light on the back — no flashing please. Riding to the right of a right-turning vehicle seems safer to novices and even some long-time but untrained cyclists. People blithely enter roads or switch lanes without so much as a glance over their shoulder, at anyone who might be coming at them. 
Under all these circumstances, a helmet is no substitute for mastering the requisite skills. 

Redefining costs and life-centred investments 
Santiago, Chile: A cyclist experiences bike-bus interactions
from the perspective of a bus driver, during a recent
workshop to improve on-road relations between
cyclists and buses. Source: Laboratorio de Cambio Social.
Speed kills millions of people on the world’s roads every year. Behind these deaths and disabilities, are mostly drivers of cars and other motorized vehicles who believe their rush to reach their destination is more important than anyone’s life or family or potential contributions. By and large, our societies have told them this, for generations, in publicity and public debates. They too become the victims of their own “accidents”: few are so heartless that they can easily write off their destruction of another’s life. For every person killed or disabled, many more suffer the loss, day after day for years and years. These costs are not counted or considered. 
Forcing individuals to invest in expensive helmets, many of which do not meet any standard and most of which are designed for falls in sporting activities, rather than collisions between cars and people, is a waste of their money and a misdirection of their attention.  
Similarly, investing often scarce public resources in police time to control the headwear of a small group of road users seems ridiculous alongside the need to control excessive speeds and other dangerous behaviour. Valuable police resources should focus on controlling potential killers. Road design should protect all vulnerable users. And more carefully considered education for all road users should be a major focus, if we really want to improve health and save lives.

SOME SOURCES ON THE HELMET DEBATE
Clarke, C. (2006). "The Case Against Bicycle Helmets and Legislation." World Transport Policy and Practice 12(3).
de Jong, P. (2012). "The health impact of compulsory helmet laws." Risk Analysis 32(5): 782-790.
Elvik, R. & Vaa, T. 2005. The handbook of road safety measures, Amsterdam ; San Diego, CA, Elsevier.

Elvik, R. (2011). "Publication bias and time-trend bias in meta-analysis of bicycle helmet efficacy: a re-analysis of Attewell, Glase and McFadden, 2001." Accid Anal Prev 43(3): 1245-1251.
Elvik, R. (2013). "Corrigendum to: “Publication bias and time-trend bias in meta-analysis of bicycle helmet efficacy: A re-analysis of Attewell, Glase and McFadden, 2001” [Accid. Anal. Prev. 43 (2011) 1245–1251]." Accident Analysis & Prevention 60: 245-253.
Gillham, C. and C. Rissel (2015). "Children’s cycling participation, inju- ries, fatalities and helmet legislation in the United States." World Transport Policy & Practice 21(1): 30-39.
McIntosh, A., B. Dowdell and N. Svensson (1998). "Pedal Cycle Helmet Effectiveness: A Field Study of Pedal Cycle Accidents." Accident Analysis and Prevention 30(2): 161-168.
Olivier, J., S. Walter and R. Grzebieta (2013). "Long term bicycle related head injury trends for New South Wales, Australia following mandatory helmet legislation." Accident Analysis and Prevention 2013(50).
Rissel, C. (2012). "The impact of compulsory cycle helmet legislation on cyclist head injuries in New South Wales, Australia: A rejoinder." Accident Analysis and Prevention 45: 107-109.
Rissel, C. and L. M. Wen (2011). " The possible effect on frequency of cycling if mandatory bicycle helmet legislation was repealed in Sydney, Australia: a cross sectional survey." Health Promotion Journal, Australia 22(3): 178-183.
Robinson, D. L. (1996). "Head injuries and bicycle helmets." Accident Analysis and Prevention 28(4): 463-475.
Robinson, D. L. (1996). Cycle Helmet Laws - Facts, Figures and Consequences. Velo Australis. Freemantle.
Robinson, D. L. (1996). "Head Injuries and Bicycle Helmet Laws." Accident Analysis and Prevention 28(4): 463-475.
Robinson, D. L. (2001). "Changes in head injury with the New Zealand bicycle helmet law." Accident Analysis and Prevention 33: 687-691.
Robinson, D. L. (2007). "Bicycle helmet legislation: Can we reach a consensus." Accident Analysis and Prevention 39: 86-93.
Rosenthal, E. (2012). To Encourage Biking, Cities Lose the Helmets. The New York Times. New York.
Reynolds, C. C., M. A. Harris, K. Teschke, P. Cripton and M. Winters (2009). "Review The impact of transportation infrastructure on bicycling injuries and crashes: a review of the literature." Environmental Health 8(47).
Scuffham, P. A. and J. Langley (1997). "Trends in Cycle Injury in New Zealand Under Voluntary Helmet Use." Accident Analysis and Prevention 29(1): 1-9.
Teschke, K., M. A. Harris, C. C. Reynolds, M. Winters and S. Babul (2012). "Route Infrastructure and the Risk of Injuries to Bicyclists: A Case-Crossover Study." American Journal of Public Health 102.12: 2336-2343.
Turner, L. (2012). "Australia's helmet law disaster." Institute of Public Affairs 64.1: 28-29.
Walker, I. (2007). "Drivers overtaking bicyclists: Objective data on the effects of riding position, helmet use, vehicle type and apparent gender." Accident Analysis and Prevention 39: 417-425.
Whitelegg, J. (2006). "The Case Against Bicycle Helmets and Legislation." World Transport Policy and Practice 12(3).
Winters, M. and K. Teschke (2010). "Route Preferences Among Adults in the Near Market for Bicycling: Findings of the Cycling in Cities Study." American Journal of Health Promotion 25(1): 40-47.

ADDITIONAL INFORMATION ON CYCLING AND HEALTH
Aldred, R. (2012). "Governing transport from welfare state to hollow state: The case of cycling in the UK." Transport Policy 23: 95-102.
Fee, E. and T. M. Brown (2003). "Bicycling for Pleasure and Power." American Journal of Public Health 93(9): 1409-1409.
Grabow, M. L., S. N. Spak, T. Holloway, B. Stone, A. C. Mednick and J. A. Patz (2012). "Air quality and exercise-related health benefits from reduced car travel in the midwestern United States." Environ Health Perspect 120(1): 68-76.
Pucher, J., C. Komanoff and P. Schimek (1999). "Bicycling renaissance in North America?: Recent trends and alternative policies to promote bicycling." Transportation Research Part A: Policy and Practice 33(7-8): 625-654.
Rojas-Rueda, D., A. de Nazelle, O. Teixidó and M. J. Nieuwenhuijsen "Health impact assessment of increasing public transport and cycling use in Barcelona: A morbidity and burden of disease approach." Preventive Medicine 57(5): 573-579.
Saelensminde, K. (2004). "Cost-benefit analyses of walking and cycling track networks taking into account insecurity, health effects and external costs of motorized traffic." Transportation Research Part A: Policy and Practice 38(8): 593-606.
Teschke, K., C. C. Reynolds, F. Ries, B. Gouge and M. Winters (2012). "Bicycling: Health Risk or Benefit?" UBC Medical Journal 3(2): 6-11.
Winters, M., M. Brauer, E. Setton and K. Teschke (2010). "Built Environment Influences on Healthy Transportation Choices: Bicycling versus Driving." Journal of Urban Health 87(6): 969-993.

Winters, M., G. Davidson, D. Kao and K. Teschke (2011). "Motivators and deterrents of bicycling: comparing influences on decisions to ride." Transportation 38: 153-168.


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