The 3rd International Conference on Injury Prevention and Control

The 3rd International Conference on Injury Prevention and Control

[NOTE: The official Web site for this conference, which was formerly located at www.nisu.flinders.edu.au, is no longer available. Links from this page have been removed accordingly. ]

The 3rd International Conference on Injury Prevention and Control was held in Melbourne, Australia from February 18-22 1996. For bicycle helmets, there was a poster session and an oral session.

Many of the world’s leading helmet activists were there: Michael Henderson (Australia); Diane Thompson, Robert Thompson and Frederick Rivara (HabourView/Puget Sound, Seattle); Philip Graitcer (head of the WHO Helmet Initiative); John Langley, Paul Scuffham (Otago, New Zealand); Stig Hakansson (Swedish Helmet Initiative); Peter Vulcan (Monash Accident Research Centre); and others. Representing “the other side” was Nigel Perry of New Zealand.

While a common theme which emerged was that “any helmet is better than no helmet”, this was rather contradictory to other issues raised, namely that bad fitting helmets can provide little or no protection; and that it is difficult for many people to find a helmet that fits properly. To add to that, from New Zealand we had an interesting new concept that people simply don’t know how to wear their helmets properly!

It was argued that real (i.e. anecdotal) cases should be used to promote helmets as this is very persuasive. Given that virtually all of the attendees were already completely sold on helmets as “the” solution, it was not considered an issue that this approach gives a misleading picture and over-emphasises helmet benefits while distorting the real scale of bicycle injuries. Someone was heard to state that “negative cases will always occur”. This is of course true, but it is no reason to dismiss them!

Moral, social, ethical and legal issues are not the concern of injury prevention professionals, or so they say. Never mind that the research studies they conduct are geared for one ultimate purpose: to provide the needed support for helmet legislation which they have already pre-determined as being “the way to go”. One researcher was heard to argue that it was their job to provide figures to politicians to make decisions on laws, and if they want these figures in context then they should ask. When asked shouldn’t these figures be provided in context it was simply argued that this wasn’t their job.

It was argued by one attendee that scientists have a responsibility to give a balanced view and that they were not doing so. By highlighting the benefits of helmets and ignoring the negative results, not putting cycle injuries into perspective, and ignoring the social impact of children being required to wear helmets virtually everywhere, it was argued that they had lost balance in injury control and that this was wrong.

The hypocrisy of it all. Head injury rates per time-exposure for car occupants and cyclists are about the same. Helmets can potentially benefit car occupants as much as cyclists. Injury prevention professionals know this but they see promoting such helmets as futile. Interestingly, this is largely due to the “dork factor” which they have systematically attacked and eroded for cyclists, but which poses a far greater obstacle with motorists. Add to that, most of the injury prevention professionals are probably not overly keen in having to wear helmets in their cars themselves. When it is put to them that they should wear a helmet in a car if they promote cycle helmets (and the corollary of bicycle helmet laws) they are at a loss. To them a cyclist is irresponsible if they don’t wear a helmet, and therefore must be forced to do so, but they are not irresponsible when they themselves ignore the dangers for motorists. The hypocrisy of this doesn’t seem to dawn on them.

In discussions on the Australian situation it was bemoaned by many that the Australian police now had little interest in enforcing the law. Action was called for to lobby the Government to start “re-emphasising helmet wearing” (Note: it is a fact that a fresh series of “wear your helmet” radio commercials emerged on Australian radio stations not long after the 3ICIPC conference). It was also commented that once the law had been passed the Government’s general attitude was that they had done all that was necessary for cyclists, so other measures were not needed. Representatives of cycling organisations have commented to similar effect, that it is difficult to “get anything done” these days.

Stig Hakansson gave a talk about helmet initiatives in Europe, but in particular the Swedish Helmet Initiative. They’ve been promoting various helmets for a long time, but everything was going fine until 1990 when the tragedies started – children dying from suffocation when their bike helmets got stuck in play equipment, trees and other objects – they’d hung themselves! A comment was made along the lines of “We knew we’d killed, but didn’t know we had saved anybody”. However their faith in the approach overcame all obstacles and they came up with the self-release buckle system so kids couldn’t get hanged. This system makes the helmets unsuitable for use in traffic. Nevertheless, someone was heard to suggest it was badly designed play equipment and a tree in the wrong place that caused the problems! It’s not as if the kids actually climb the trees on purpose, surely!

Thompson, Rivara and Thompson presented data from the latest of their emergency room case-control studies which this time found that helmets provide a 70% decrease in risk of head injury, but were reportedly at a loss to explain the negative results from New Zealand. Nothing was said of the similar failures shown by Australian data, possibly because Australian researchers have been slightly less than honest in ignoring the reduced cyclist numbers and generally safer roads after the law while readily quoting figures which showed less head injuries and high helmet wearing rates.

Rivara gave a five point plan or set of goals for increasing helmet use in their campaign in Washington State:

  • increase parent awareness
  • remove cost barriers
  • overcome the “nerd factor”
  • target 6-12 year olds
  • focus on helmets – not riding behaviourThe last point is interesting. Don’t address the cause just the symptoms. Just give them a helmet and point them towards heavy traffic. It was argued however that trying to improve behaviour doesn’t work. You have to wonder though if maybe they dismissed education too readily. Perhaps their idea of cyclist safety education is to tell people to wear a helmet; and if they still don’t wear a helmet then conclude that education has failed.

    Paul Scuffham of New Zealand presented the paper “Trends In Cycle Injury In New Zealand Under Voluntary Helmet Use”. This study concluded that “The percentage of serious head injury among cyclists has not shown the expected decline as cycle helmet wearing has increased”. This study also found that promotion of helmets (never mind legislation) had reduced cycling, something like a 27% drop in teenage cycling in the 5 years leading up to the law. The author was apparently given a hard time in his presentation, with some members of the audience attacking the results and saying they simply must be wrong, and yet it was reported that the New Zealand Land Transport Safety Authority (LTSA) had sent the research back “two or three times” to Otago for checking and further investigation – but the results stood. I have also heard that Peter Vulcan had stated that he had checked the New Zealand figures and couldn’t explain them, but insisted that helmets do work.

    The attacks on Mr Schuffham seemed a little unfair, as it seemed that he had obviously tried very hard to find a positive result which simply wasn’t there. While it is believed that Mr Schuffham is still in favour of helmets and helmet legislation, it was reported that he felt that, perhaps, the benefits of helmets were being oversold.

    “Regaining Balance In Injury Prevention”, presented by Nigel Perry of New Zealand. “This short presentation will highlight some of the ways in which New Zealand, a country held up as an example by the WHO Helmet Initiative, has erred and the absurdity of some of its actions. We will argue, that though the motives behind most pro-helmet campaigns might be commendable, that compulsory laws are a “step to far” and indicate a loss of balance in injury prevention. In introducing such laws we are building an undesirable environment for the next generation, and those that do exist should be abolished.”

    “Cycle Helmets: Fit To Buy Or Bought To Fit?”, presented by Judith McCool of New Zealand. In the wake of the other research from New Zealand which found that the risk of head injuries had not decreased with increased helmet wearing, Judith McCool visited all 53 shops in Christchurch which sell helmets and asked for help in purchasing one. In all 53 cases she argued that she had be given bad, poor, or wrong advice. Ironically, the paper was co-authored by John Langley, who was reported to have complained at a round-table discussion at the conference that he was unable to find a helmet that would fit him!

    So, wonderful lifesaving helmets aren’t protecting people from the big bad motor vehicles because people just aren’t strapping them on their heads the right way. Brilliant! It should also be pointed out that it takes “a good 10 to 15 minutes” to adjust your helmet properly. Many case-control emergency studies (such as the recent one from Seattle) have found very high protective benefits for helmets, but it seems that those studies must have been conducted in other parts of the world where people actually know how to wear a helmet properly.

    I should point out that most of the helmet legislation in Australia actually stipulates that the helmet must be “correctly fastened to the head” (or words to similar effect) so perhaps the solution is simply to get the police to start dishing out fines to offenders. After all, if your helmet isn’t properly fastened then you are breaking the law.

    “Efficacy Of Mandatory Bicycle Helmet Legislation In NSW”, by Merdyth-Ann Williams of NSW, Australia. This poster claimed that “Since legislation [in NSW] there has been a decrease in bicyclist fatalities of 60% and serious injury of 21%.” That is an impressive reduction in fatalities, until you look at the actual data:

        Number of Cyclists Killed in Road Traffic Accidents in NSW
                Year    Killed   Helmet  No Helmet  Unknown
                1989    19        3        13        3
                1990    20        1        18        1
                1991*   10        7         3        0
                1992     6        5         1        0
                1993     8        7         1        0
                1994    23       16         5        2
                1995     ?        ?         ?        ?
    
                * Helmets law introduced in NSW in 1991, on 1 January for 
                  cyclists 16 and over and on 1 July for children under 16.

    This table shows number of cyclists killed in NSW. Source: Roads and Traffic Authority of NSW, Road Traffic Accidents in NSW Annual Statistical Statements. CRAG does not at present have access to the statistical statements for 1995 and later.

    The 60% reduction was apparently derived by comparing 1990 (20 deaths) with the average for 1991-93 (8 deaths per year). There is no statistical significance in these figures, with such small numbers being subject to large variation due to random chance. However, two points are immediately obvious; one being the large increase in deaths in 1994 (the author may have been less than honest in ignoring the 1994 figures which she surely had no excuse for not being aware of), the other being the high representation of helmeted cyclists. In fact, helmeted cyclists accounted for 80% of the post-law deaths (excluding those where helmet wearing status was known), which matches the observed percentages of helmet wearing (85% for adults and 76% children, or 80% overall). This was noted by Robinson (Accident Analysis and Prevention, 1996): “excluding cases where wearing status was not known, 80% of cyclists in NSW from 1992-94 were wearing helmets when killed on the roads (RTA 1992-94)”.

    The “reduction in serious injury of 21%” is apparently a measure of the reduction in head injuries compared with non-head injuries. This type of analysis is misleading. Firstly because various anti-speeding and measures and RBT had made NSW roads safer at the same time as the helmets law was introduced. Reducing motor vehicle speed and involvement in bicycle accidents has been shown to lead to significantly greater reductions in head injuries compared with reductions in other injuries. Secondly, because they assume that all other factors are equal (eg that riders forced to wear helmets aren’t taking more risks and suffering more overall injuries than before, with the protective benefit of their helmets cancelled out by increased risk taking).

    Williams states that “since legislation bicyclist head trauma has been significantly reduced”, but this should not be so quickly attributed to helmets. After the law, NSW saw a 39% decline in total head injuries to children under 16, but child cycling also declined by 39%. At the same time, head injuries to child pedestrians declined by 19%, and head injuries to children from all road accidents declined by 26%. After allowing for the decreased cyclist numbers and safer roads (shown by the decrease in pedestrian injuries), the relative risk of head injuries to cyclists actually increased!

    For adults, head injuries also declined by 32% while non-head injuries declined by only 4%, but there is no reliable data for the measure of change in the numbers of adult cyclists (although it is likely to be similar to that of children since “adult” is defined here as over 16 and the older teenagers represent a large proportion of bicycle users and are the most averse to helmet wearing).

    For a more detailed look at the NSW data, click here.

    Finally, the poster “The Effectiveness of Wearing Pedestrian Helmet While Walking From Home to School in Elementary School Children” by Tatushiro Yamanaka and Arata Ogihara was also of interest. “The principal of the school can decide whether helmet wearing should be a rule for pupils”. Yes, in Japan some kids have to wear helmets while walking! The paper concludes that it hasn’t reduced injury rates significantly (injury rates were 0.18%/0.22% and head injuries 0.012%/0.018% for helmeted/unhelmeted kids). What is frightening is that they introduced the rule in the first place, and how few people amongst all those present seemed to think that it had gone too far.

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