Reducing injuries is important but not at expense of public health: Provincial Coroner's helmet recommendation misguided

The Provincial Coroner came out with his long-anticipated recommendations for reducing cycling deaths today. Alongside recommendations asking for a provincial cycling plan, complete streets, education and sideguards for trucks, he also recommended mandatory helmets for all age groups. His mandatory helmet recommendation is outdated, misguided and overshadows is otherwise (though somewhat broad) set of recommendations. The media has latched onto the helmet recommendation like it is the magical talisman that will solve all that harms cyclists. Drivers won't have to change anything, it's all up to the cyclists! Almost every headline is: "Ontario Coroner calls for mandatory helmets for cyclists..."

The limitation of this coroner's review is that it only looked at a relatively narrow perspective, that of deaths and injuries while cycling. The Coroner never considered were the broader public health implications. Nor did he consider, it seems, whether other jurisdictions saw a reduction in injuries and deaths. Nor how it is that some jurisdictions such as the Netherlands as pictured above can be very safe while most cyclists young and old don't wear helmets. When it comes to mandatory helmet legislation, it is widely considered by experts now to have either no impact or a negative impact on public health. I spelled out the broad issue yesterday. It is one thing to promote helmet use while still leaving the option open for people, but it has been shown that once you try to enforce helmet use many people just decide not to bother. The experts have shown that the health benefit of cycling is much greater than the risk of injury or death.

Even the Toronto Coroner's report on cycling fatalities in 1999 recognized that mandatory helmet use could backfire:

...helmet use is not a panacea for drastically reducing cycling related fatalities or serious head injuries. Stricter bicycle helmet legislation and mass helmet usage in other countries (U.S.A., Australia, and New Zealand) have failed to produce any statistically significant reduction in the rates of fatalities and head injuries, despite optimistic projections. In addition, compulsory helmet use may result in reduced bicycle usage.

Did you get that? Mandatory helmet legislation showed NO statistical evidence that it reduced fatalities and head injuries!

One could ask too why there is so much of an emphasis on helmets for cyclists when drivers and pedestrians also suffer head injuries that could be prevented with helmets? I personally have suffered a head injury sustained in a car crash. But I'm sure requiring helmets for drivers and passengers would create a loud outcry.

It's not clear if the Coroner took any consideration of the impact of this on the public bikesharing initiatives such as BIXI Toronto or Capital Bikes in Ottawa. Bikesharing in Melbourne, Australia is struggling because of mandatory helmets and Vancouver is having trouble launching its own service because of mandatory helmets there.

A bicycle helmet law came into effect in Ontario in 1995. It was originally meant to be applied to all ages but was amended by regulation to exempt adults. Helmet usage among children increased after the legislation but eventually dropped off because of a lack of enforcement.

I wish the Coroner had considered the public health aspect of his review before making any recommendation, but instead he had decided to forge ahead with a misguided recommendation. If the Liberal government takes up this recommendation I believe that it will put a big dent in cycling promotion in this province and put us even further behind. If Australia is any indication then we could see reductions in cycling by 20 to 40%! That is a hugely negative impact on public health, especially considering how Toronto celebrates when the number of cyclists increased by 6% in the decade from 1999 to 2009. Maybe the reductions won't be as large here, but even a small drop would likely overshadow any positive impact.


What about helmets for car drivers? Seems to work for race drivers.

What about helmets for pedestrians? Great protection when we're walking and texting.

What about helmets inside our homes? Need it in case the tape under the carpet gives way.

While I deplore the way the media have picked up on the helmet issue, I think we are shortchanging the coroner here. In fact his recommendation reads:

"Implementation of mandatory helmet legislation for cyclists of all ages, within the context of an evaluation of the impact of this legislation on cycling activity."

It's clear from reading the report that there were a few accidents where a helmet might have made a difference and he is a coroner. But the actual reading of the report suggests that he gets the fact that there will be an impact on cycling activity. Too bad the media don't get nuance.

This looks like a pretty lame report...there is nothing about bike lane many of these deaths occurred in locations with separated bike lanes, sharrows, 1 lane roads, 2 lane roads, highways? What was the speed limit on the roads? Seems like a pretty obvious thing to look at...but no stats or mention of it...

The report doesn't need to mention those things as the expert panel assembled by the coroner reviewed the specific circumstance of each and every death and came up with one or more remedies to prevent it.

The 14 recommendations are the culmination of the review, think of them as the most recurring remedies which would have prevented these deaths. The recommendations represent what the expert panel thought would be the most effective measures to take to have prevented these, as well as similar-- and future, deaths on our roads and streets.

Lloyd is indeed correct that the coroner was aware of the controversy surrounding mandatory helmet laws and had recommended that existing literature from existing helmet law jurisdictions be studied first and that the impact of a helmet law in Ontario be studied before and during. From page 23 of the report:

The OCCO envisions that such an evaluation would begin with a critical appraisal of the existing literature from jurisdictions in which mandatory helmet legislation has been implemented, and the collection of high-quality baseline data on cycling activity in Ontario. Following this, if the Ministry of Transportation proceeds with the implementation of mandatory helmet legislation, the impact of this legislation would be evaluated relative to the baseline data.

Albert Koehl, one of the representatives who called for the coroner's report noted in a letter to the Toronto Star:

The data studied by the coroner makes his recommendation for mandatory helmet use by cyclists perfectly logical. In over 50 per cent of cycling fatalities in Ontario a head injury caused or contributed to the cyclist’s death.

It’s important, however, to look carefully at the language behind the coroner’s recommendation. The coroner was aware and senstive to research showing that mandatory helmet use reduces cycling numbers. Less cycling means the community loses all of the significant health benefits from individuals following an active lifestyle.

For this reason, the coroner recommended that the Ministry of Transportation (and Public Health Ontario) first review the research from jurisdictions where helmets have been made mandatory. Then, if the minister still wants to pass a helmet law there ought to be a careful evaluation of the impact on cycling numbers.

The fact is that people won’t be more willing to get out of their cars to cycle just because they must wear a helmet. Cyclists don’t want to get hit by a car — and ending up with a coma instead of in a casket is not the type of advantage that will entice more people on to their bikes.

This is why the coroner’s 13 other recommendations — including “complete streets” (with bike lanes), driver education, and a provincial cycling plan — aimed at reducing collsions from happening in the first place make his report an excellent one.

As one of the lawyers representing a coalition of groups, including the United Senior Citizens, who called on the coroner to conduct the cycling death review, I say it’s now up to the province to take action on the full report.

I too have been frustrated that the mainstream media has focused almost solely on mandatory helmets as a panacea. Because of this in my blog I have almost exclusively focused my response to the report to show people the dangers of mandatory helmet laws. I feel that mandatory helmets could easily overshadow the good of all the other recommendations. This singular focus in my blog is unfortunate but necessary. I like all the other recommendations in the report, so I hope the province takes action on the full report, except for helmets.

I think this focus could have been avoided if the issue of cycling hadn't been brought up only in the context of cyclists death. As tragic as the deaths are, they only amount to 25 deaths per year (even one is too many but given all dangers we face it's not the highest). Over a hundred pedestrians die every year in Ontario. And over 2500 deaths per year from motor vehicles. Compared to the number of people using that mode of transportation, I believe that cyclists weren't at a much higher risk of dying than people walking or driving/riding (going by memory). Motorcyclists, on the other hand, are in a whole different category or risk.

So we may have been better served to not just focus on deaths, but injuries, and also the broader public health implications. Our own risk of dying while cycling is lower than our risk of dying from heart disease, diabetes, cancer and so on; all the diseases where our risk increases by leading a sedentary lifestyle.

Bunch of damn chicken littles around here.

Helmet laws aren't the end of days(That is 12/12/12... so get ready) for cycling and frankly helmets are pretty good at preventing injuries.

Maybe there is a reason you don't actually see theoretical head injuries that didn't happen not recorded in studies taking place where helmets are mandated and the subjects are not required to report a broken helmet or tumble to the authorities. Instead you've got a bunch of people guessing and telling you it's the truth.

Never-mind that the effects on the brain of a fall not really understood yet and getting a proper diagnosis is exceptionally difficult - even for a multi-million dollar NHL player.

You get the drift... Frankly I suspect you are making a tempest in a teacup here as most people I see regularly riding to work and events are, in fact, wear a helmet. Gasp.

@ dances

The recommendation that the helmet law be fundamentally changed is cause for concern in my opinion; its potential impact is even recognized by the Provincial Coroner in the report (hence the need to study existing helmet law).

Are you suggesting we ought to willingly accept this proposed change without equal or greater concern for the same?

I (and others I assume) feel quite strongly that a cheap, quick and unproven remedy to cycling fatalities would be attractive to some, without careful consideration for other options, and with little regard for the affect that it might have on cycling overall.

I would further argue that the potential negative effects of bicycle licensing are similar to those of a manditory helmet law.

The report explicitly states that the authors cannot conclude whether helmets have an effect on injuries, and that they are against mandatory helmets law for various reasons.

Then, in an adjacent paragraph, the Coroner's claims the opposite. That the data shows that helmets prevent fatalities, and that helmets should be mandatory (after an assessment of the legislation's impact).

I wonder why there should be an assessment. The claims of the Coroner are unsubstantiated, within his own report!

The logic in the Coroner's turn-around seems to be: 3/4 of fatalities didn't wear helmets, therefore helmets saves lives, therefore helmets should be mandatory. Following the same rationale, since 86% of the fatalities were male, being a women will prevent cycling deaths, thus males should be forbidden to cycle.

First of all there already is a mandatory helmet law. If you are a minor, you must wear a helmet. Only adults have the right to wear a helmet or not.

I will not wade into the debate on whether helmets should be mandatory or not. I do believe that wearing a helmet saved me from injury. I hit a pothole on my way home from work and went over the handlebars. When I examined the helmet after, it was cracked. I had a black eye, some nasty looking road rash, but that's it. I believe it would have been much worse without the helmet. I will never be sure, but I am glad I was wearing it that day.