Mindell JS, Watkins SJ, Cohen JM (Eds). Stockport: Transport and Health Study Group, 2011.
Original paper: THSG, 2011
Public health needs ideas, it needs inspiration, it needs champions. Such are the scale and complexity of the challenges that must be addressed.
The causes of ill health, the solutions to some of our major health problems and the sustainability of our environment are intricately interwoven with the way that we move from place to place both locally and across the globe. The scope of any analysis in this area of public health also needs to encompass the way that goods and services are accessed and the ways that groups of people gather. For example, what a family chooses to eat, where they buy their food, where the food is sourced and how they acquire it may seem simple and routine. A few minutes reflection though and it is clear that the implications of millions of families’ choices and habits can have profound implications for the health of our country and the planet.
Health on the Move 2 is a clear and comprehensive account of what would constitute a healthy transport system.
The report is unusual in that it blends evidence, authoritative opinion from experts in their field as well as creativity. It is not only an educational tool and a series of recommendations for policy-makers, it is a powerful basis for advocacy. No-one should underestimate the scale of changes required to realise the vision for the future set out in this ground-breaking report.
If just a small number of towns and cities in the country would act on the ideas and evidence in it then we would begin to see the shape of a new future in which every move is a healthy move.
Sir Liam Donaldson, Chief Medical Officer for England (1998 – 2010)
Health on the Move 2 (HotM2) is a guide to unlocking the health-generating potential of daily travel.
In its 356 pages, HotM2 is clearly set out, from a vision of a healthy transport system, through the rapidly growing scientific understanding of the links between how we travel on the one hand, and obesity, chronic illness, injury, air quality and climate change on the other. It clearly aims to reach three, often separate audiences; public health professionals, local authority specialist transport and spatial planners and policy-makers who set the longer term framework within which the others work.
Sections cover community severance; the way transport choices by some can inhibit the movements of others, and other ways in which transport impacts on health inequality. There are chapters on public transport, walking, cycling, sustainability, congestion, rethinking streets and much more.
This Commentary relates primarily to HotM2's references to cycling safety and helmets. However, the whole work is recommended to give context to the helmet debate and as an important contribution to a wider understanding about health and transport.
After the first oil crisis in 1973, there was a revival of cycling in Britain. Unfortunately it was not greeted sympathetically by governments of the day and by the mid 1980's growth had ceased and decline returned.. The trend is long-established, although it is slower now than in the period 1985-2000.
Since the mid 1970s, cyclist fatality rates have fallen by slightly more than motorist fatality rates. As to serious injuries, it is often assumed that these are greatly under-recorded. The confusion arises because of the different ways that cycling and pedestrian injuries are recorded in hospital data; in brief, cycling falls are classified as transport injuries while pedestrian falls are not. Fair comparisons show that serious cycling injuries are not much under-recorded but pedestrian injuries are and that risks in cycling are of the same order as risks when motoring.
Children have a poor safety record in the UK, but risk per km travelled is about the same when cycling as when walking when the dominance of boys in cycling is accounted for.
Lifetime risk of fatality when cycling is about the same as for the average European motorist. Differences are that the cyclist would almost certainly not kill anyone else and the cyclist would expect to live a longer, healthier life.
On average for a UK cyclist a serious injury corresponds to about 2 million km of cycling, or less than one in 1,000 annually. Cycling does not incur risks that are unusual by the standards of daily life. Cycling in a city where the bicycle is popular is safer still, due to 'safety in numbers' (Jacobsen, 2003).
Overall, it is likely that the risks of cycling are within the range of risks faced by motorists.
HotM2 recommends strongly the promotion of cycling as a 'normal' everyday activity which has huge potential for improving public health. Images should acknowledge the diversity among cyclists and support factual evidence regarding the low risk in cycling. Riders should be depicted wearing normal everyday clothes and include a mixture of riders, with and without helmets, to reflect neutrality and individual choice.
HotM2 devotes several pages to a concise, but comprehensive, review of the outcomes of cycle helmet use. They are also discussed at some length in the later section on the promotion of cycling.
The authors note that research for the Department for Transport (Hynd, Cuerden, Reid and Adams, 2009) found that it is not possible to quantify the benefit from cycle helmets. The wider literature is considered, together with helmet standards and the mechanisms involved in head injury. Also considered is risk compensation (Wiki, 3) by cyclists and motorists and the effect of helmet promotion and laws on levels of cycle use.
With regard to the evidence, HotM2 considers that:
With regard to public policy, HotM2 concludes:
HotM2 says that discouraging healthy travel is much like cigarette advertising in the harm it inflicts. Public health professionals must recognise the hazard of unintended consequences from well meaning helmet campaigners, and be prepared to speak out against exaggerations of risk and distortions of data. “Myth shall prevail if the wise remain silent.” This should in no way be intended to undermine the principle that individuals may choose for themselves to use helmets, following realistic advice about the protective value, as is also the case with helmets for drivers and pedestrians.
It may seem strange for public health professionals to express reservations about safety campaigns, but public health is always concerned with priorities. A risk-averse society is different from a safe society. In a safe society, those who climb mountains take the right equipment, check the weather, ensure that people know their route and expected time of return, know their limitations, and contribute to the funding of mountain rescue teams. In a risk-averse society, people do not climb mountains. Ultimately, a risk-averse society is an unsafe society because people lose the capacity to handle risk sensibly.
HotM2 cites Hedlund, 2000:
"Don't over-predict benefits. Many injury prevention measures promise more benefits than they deliver, due to bad science, political pressures, or failure to consider risk compensation or system effects. While calm and realistic benefit estimates are difficult to produce, unduly optimistic predictions will hamper injury prevention efforts in the long run".
Hedlund J, 2000. Risky business: safety regulations, risks compensation, and individual behavior. Injury Prevention 2000 Jun;6(2):82-90.
Hynd D, Cuerden R, Reid S, Adams S, 2009. The potential for cycle helmets to prevent injury - a review of the evidence. Transport Research Laboratory PPR446.
Jacobsen PL, 2003. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Injury Prevention 2003;9:205-209.
Macpherson AK, Parkin PC, To TM, 2001. Mandatory helmet legislation and children's exposure to cycling. Injury Prevention Inj Prev 2001;7:228-230.
Mindell JS, Watkins SJ, Cohen JM, 2011. Health on the move 2. Policies for health promoting transport. Transport & Health Study Group .
Walker I, 2007. Drivers overtaking bicyclists: Objective data on the effects of riding position, helmet use, vehicle type and apparent gender. Accident Analysis & Prevention 2007 Mar;39(2):417-25.
Risk compensation. An explanation of the mechanism whereby safety equipment can sometimes lead to people acting less safely .