1 March 2015
In this inquiry, our concern is the safety of cyclists as road users, having regard to the costs of injury and death to them. We focus here on the design standard for bicycle helmets, made mandatory by federal trade practices legislation and administered by the ACCC, and its adequacy for supporting the nationwide regime of compulsion to wear a helmet. References to pages, tables and figures are to my chapter, “Bicycle helmets: a scientific evaluation”, which forms part of this submission.
Fear of fatal or chronically disabling head injury has led many cyclists in Australia to wear helmets, and to compulsion of it for the purpose of reducing hospital and other public costs of accidents. Such injury mainly occurs to the brain, especially diffuse axonal injury (DAI).
1. Adoption of compulsion to wear a helmet
Protection of one’s own person without harming others is by long tradition an individual choice. Law to compel it for the purpose of reducing fatal or disabling head injury therefore needs, first, evidence of increasing risk of serious casualty to cyclists, but from 1986 to 1989 it fell (see Figure 1). The second need is evidence that helmets protect the brain. Such evidence was not provided before adoption of compulsion, but was and is needed to underpin the mandatory standard that defines the helmets to be worn.
With emphasis on death and permanent intellectual incapacity from head injury, the Royal Australasian College of Surgeons (RACS) urged compulsion to wear a bicycle helmet upon a federal parliamentary inquiry in 1977. The inquiry recommended that the possibility of compulsion should be kept under review, precedents being motorcycle helmets and seat belts.
By 1984 and resumption of the federal inquiry, belief in the efficacy of helmets against brain injury was widespread and other medical bodies and some cyclists’ groups had added their support for compulsion. The inquiry’s final report in 1985 recommended it, but recognised that, to support it, a mandatory standard was needed to assure the public of the efficacy of helmets. The report also recommended research on whether helmets could be better ventilated and lighter, such as by dispensing with their hard shells.
But the research, by Corner et al (1987) did not simply endorse such revisions. It drew upon research findings that the main cause of brain injury is not a direct hit to the head, such as by a bullet or a falling stone, but rotation from an oblique impact. Corner reported that the standard tests were deficient in not testing for reducing rotation; worse, it found in experiments that adding a helmet to a dummy head can increase it – a finding corroborated in the USA in 2003 and in the UK in 2007. Corner suggested that helmets should have very stiff shells with a low impact sliding reaction, yet the standard was amended to allow soft shells. These are more acceptable to the public, making it easier to compel their use, but they tend to disintegrate on impact. And in Australia, the risk of fatal head injury to cyclists increased after the helmet laws, compared to other road users. But successive mandatory standards since 1990 take no account of these facts.
An influential factor in adoption of compulsion as federal policy in 1989 was a prominent surgeon’s advice direct to Prime Minister Hawke of savings in hospital and other costs if brain injury and permanent disability to young adults and children were prevented. The final factor was a national survey that found 84 per cent support for compulsion of all cyclists, rising to 93 per cent for children. By offering additional funds for roads tied to its “black spots” program, the Federal Government secured the agreement of the states and territories to pass legislation for compulsion.
2. Reviews of the mandatory standard
Official reviews were made in 1999 and 2009. In submissions to them, we argued that “the standard neglects the major cause of brain injury, rotation of the head following indirect impact … driven more by helmet suppliers’ technology than scientific knowledge”.
Indeed, the Treasury’s Regulation Impact Statement upon the 1999 review says that “bicycle helmets are designed to protect against impact injuries to the head and brain, and would appear to provide little if any protection against certain other types of brain injury… issues relating to helmets in head protection range to exacerbating the extent of rotational brain injury.” Then that critical issue is left up in the air; yet the official media release claims that helmets provide the necessary head protection.
3. Efficacy of present helmets and the mandatory standard
For evidence of the efficacy of bicycle helmets to underpin the mandatory standard, Australian authorities rely upon a ‘meta-analysis’ of 16 studies to the head, face or neck which the Australian Transport Safety Bureau (ATSB) published as Road Safety Report CR 195 in 2000, and in Accident Analysis and Prevention in 2001.. Of the four studies done in Australia, three were of data before compulsion and one after it. Eight of the studies were USA-based.
In articles published in AA&P in 2003 and 2005, I argued that the meta-analysis and a similar review by Thompson, Rivara and Thompson (TR&T) of the USA do not provide scientific evidence that bicycle helmets reduce brain injury and, indeed, have potential to aggravate it. In a response in 2006, Hagel and Pless from Canada criticised my 2005 article. I rebutted the criticism, and in a subsequent debate in AA&P, which included TR&T, I had the last word – see references 57 and 78-86 in my book chapter “Bicycle helmets: a scientific evaluation” (submitted in hard copy and available online).
ATSB explicitly declined to take part in the debate. Its letter of 5 April 2007, scanned copy subjoined, stated that “most of our research projects are carried out by external research professionals. We consider that prime responsibility for each project rests with the authors of the work … and we do not, as a rule, enter into public debate about the merit of individual studies”. This, despite one of the three authors of CR 95 being an officer of ATSB and it being published under the banner of the transport portfolio.
The present state of evidence on the efficacy of helmets against brain injury is therefore marked by uncertainty. Laboratory experiments indicate little efficacy and so do national data for deaths by head injury before and after the helmet laws. But the important resources of diagnoses of DAI in state and territory coroners’ reports and of persons treated in hospitals have not been tapped for the statistical analysis that might well provide the robust evidence needed to support compulsion.
Fear of fatal or chronically disabling head injury has led to many cyclists in Australia wearing helmets, and to compulsion of it for the purpose of reducing hospital and other public costs of accidents. As such injury occurs to the brain, especially DAI, the helmet laws need the support of sound knowledge that helmets reduce it.
The cause of DAI is rapid rotation of the head from oblique impact, but the mandatory standard does not test for it. Worse, experiments with dummy heads indicate that a helmet is likely to aggravate it and statistics suggest an increase in the risk of death by head injury after the helmet laws. Therefore, the mandatory standard is inadequate to support the helmet laws.
It is suggested that the inquiry should recommend to the Federal Government that it initiate an independent and open review of the adequacy of the mandatory standard. Such a review should be undertaken promptly and carried out in an open way to ensure full public scrutiny.
Australian Transport Safety Bureau
Our Reference: B1999/0163 Contact: John Goldsworthy
Mr Bill Curnow
President Cyclists’ Rights Action Group 27 Araba Street
ARANDA ACT 2614
Subject: Bicycle helmet research
Dear Mr Curnow
Thank you for your letter of 14 February 2007, to the Executive Director of the Australian Transport Safety Bureau (ATSB), concerning research on the efficacy of bicycle helmets.
Before addressing the specific matters raised in your letter, I would like to make some general comments about the ATSB’s role in Australian road safety. The ATSB endeavours to support the development of road safety policy by: facilitating national agreement on strategic road safety priorities; collecting, analysing and disseminating national road crash data; and undertaking or funding road safety research projects.
While the ATSB places a high value on good road safety research, our capacity to contribute directly to the research pool is limited by a modest annual budget and a small staff base. There are many competing demands on our resources and we are necessarily very selective about the work we undertake. Most of our research projects are carried out by external research professionals. The ATSB provides oversight and direction, and exercises a degree of quality assurance over the conduct of the research. However, we consider that prime responsibility for each project rests with the author(s) of the work.
As a matter of standard practice, the ATSB publishes and disseminates all its commissioned research reports. In doing so, we recognise that these reports will be exposed to professional scrutiny and, potentially, to public criticism. However, we regard this is as a healthy process and we do not, as a rule, enter into public debate about the merit of individual studies or the conclusions drawn by their authors.
You have raised some questions about the ATSB report, Bicycle helmets and injury prevention: A formal review (CR 195), published in 2000, and the ATSB’s subsequent advice to the Australian Transport Council on the efficacy of bicycle helmets. My response is as follows:
- The officers involved in the 2000 study no longer work for the ATSB, however I am advised that the review was undertaken by well-qualified analysts and that the report was widely received as a positive contribution to the research on bicycle helmet efficacy.
- The ATSB has not undertaken a systematic review of the literature since the completion of CR 195. We may do so in the future if circumstances permit, and I thank you for drawing attention to your own articles on the subject.
- The National Road Safety Action Plan 2007 and 2008 was developed jointly by federal, state and territory transport agencies, with input from the police and a number of international road safety experts. The ATSB coordinated this process, but the actual content of the Action Plan reflected the consensus views of all contributing parties. To my knowledge, the text highlighted in your letter was not based on any specific advice provided by the ATSB.
I trust this information is of assistance.
Joe Motha General Manager Road Safety
5 April 2007
A SUMMING UP
- A nation wide regime of compulsion for cyclists to wear helmets in all public places has been in force since 1992, as a result of the Hawke government offering to the states and territories additional funds for roads: the so-called black spots program.
- Because the helmet laws take away the long standing civil liberty of cyclists or their parents to decide how to protect their own persons and place that responsibility upon governments, it is up to governments to have very strong evidence that wearing a helmet will be beneficial in terms of reducing the risk of fatal or disabling head injury. Such injury occurs to the brain.
- The stated purpose of the Federal policy of compulsion is to minimise deaths and costs of hospitalisation resulting from cycling accidents.
- Government’s often say that helmets protect and that they save lives and to support this they cite statistical evidence from case controlled studies and statistics before and after compulsion, but the statistics relate to head injuries in general most of which are of low severity and not intellectually disabling.
- Focus of attention on severe brain injury shows a different story. There is good reason to expect that wearing a helmet is likely to increase the risk of it.