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Economics References Committee
Personal choice and community impacts

BROWN , Dr Julie, Senior Research Fellow, NeuRA Injury Prevention Research Centre

GRZEBIETA, Professor Raphael, Past President, Australasian College of Road Safety

HEALY, Mr David John, Co Vice-President, Australasian College of Road Safet y

IVERS, Professor Rebecca Quentin, Member Executive Council, Australian Injury Prevention Network

KENFIELD, Dr Christian Benjamin, Chairman, Victorian Trauma Committee, Royal Australasian College of Surgeons

OLIVIER, Associate Professor Jake, Member, Aust ralasian College of Road Safety

ROSENFELD, Professor Jeffrey Victor AM, OBE, Member, Neurosurgical Society of Australasia

CHAIR: Welcome. Do you have any additional comments to make about the capacity in which you appear?

Prof. Olivier : I am also representing the Australian Injury Prevention Network.

CHAIR: Thank you for appearing before the committee today. I will now invite each of you, if you wish, to make a brief opening statement before we proceed to questions. We will begin with Dr Brown.

Dr Brown : I am representing our injury prevention teams at NeuRA. NeuRA is an independent medical research organisation, and our overall strategic aim is to reduce the burden of disorders of the nervous system, including the brain. The best approach for reducing the burden of traumatic brain injury is prevention or mitigation of the risk of brain injury.

So we see bicycle helmet laws as having a positive impact on health and welfare, because helmets work to mitigate this risk of head injury. Helmet laws also work to encourage the use of helmets, particularly amongst children, since we know that helmet-wearing behaviour of children depends a lot on what they see other people doing, particularly their parents.

The consequences of traumatic brain injury are great, particularly amongst children, since a traumatic brain injury can really change the course of someone's life. It also disrupts families and reduces opportunities for education and participation in the workforce. Over a lifetime, it can really reduce earning potential not just for the person with the brain injury but also their family and carers.

It also carries an enormous cost to the healthcare system over the lifetime of the individual. From an economic perspective, I think the debate we should be having is not really about whether helmet laws should be mandatory; it should be about how we get more people to use helmets, particularly how we get more children to use helmets. Mandating helmet-use laws is one strategy, and a very important one, in increasing the use of helmets but what we should be talking about is how we might enhance the impact of legislation on helmet use. Thanks.

Prof. Rosenfeld : Thank you, Senators, for the opportunity. I treat brain injuries every day from minor to the most severe. My aim is to reduce injuries and their severity, and the outcomes that we have just heard about; the costs to the community—monetary and societal; family disruption; and individual health issues as a result of brain injury. Anything that we can do to reduce brain injury we should do as a society. This is not a matter of human rights; this is a matter of human safety and protecting people, and helmets protect people.

The evidence is stark, and it is very clear that wearing bicycle helmets prevents severe injuries—sorry, reduces the number of severe injuries that we see, reduces the severity of the injuries and particularly reduces injuries to the superficial aspects of the scalp, skull and brain. There is no doubt about that one. For instance, if you get a depressed fracture of the skull cutting into the brain, the person can be disabled for life with epilepsy and other neurological problems. The helmet no doubt protects against and prevents that type of injury. As far as the more diffuse, severe injuries go, there is very good, strong epidemiological evidence that wearing the helmets reduces the risk of injury quite dramatically. There is just no doubt about that from all the Australian studies and the overseas studies.

I wish to table this afternoon two documents. One is on the cost of brain injury to Australia, from the Access Economics report of 2009, just to give you an idea of what the cost is to the community, to the taxpayer and to the government in terms of money costs. The second document I wish to table is an editorial that I did with Professor Frank McDermott and Professor Peter Cameron—we are all experts in trauma—in TheMedical Journal of Australia back in 2013, also pointing out that helmets make a stark difference to the number and severity of head injury. There is just no question in our mind that we should retain helmets in the legislation. It should not be changed.

CHAIR: You have some documents to table?

Prof. Rosenfeld : Yes.

Mr Healy : Thanks for the opportunity to present very briefly. The Australasian College of Road Safety submission is a joint submission with our partners, and I commend the submission to you for more detailed consideration. The Australasian College of Road Safety is a peak regional body which involves and entails a network of road safety professionals and stakeholders, and it is very much concerned with making a difference. We understand collectively that to make a difference you have to work with strong, scientifically based evidence to ensure that we are going to get the result that we would like in terms of reduced death and injury.

It is instructive to look very briefly at the history of road safety in Australia. Back in 1970, some 3,800 persons were killed on our roads. Last year it was of the order of 1,200, so it is less than one-third of what it was, which represents a magnificent save in terms of burden of injury and cost to our community more generally. But one of the reasons that we have moved in that direction is that there have been a number of interventions introduced which we call population based interventions. Essentially that means that for a particular population, for a minor inconvenience to many, you really save lives and reduce serious injuries for a significant minority. It is for these reasons that we have shown such progress. Random breath testing and compulsory seatbelt wearing are examples, and, of course, mandatory wearing of bicycle helmets by cyclists is an excellent example.

I was involved in the public education and support system surrounding its introduction in Victoria, and at that time a parliamentary road safety committee inquiry strongly recommended that mandatory bike helmet wearing be introduced, off the back of the research that was available at that time. Since that time, between then and now, the research has only grown stronger and more substantial to support the fact that bicycle helmet wearing really does work.

I will refer you before closing to three aspects of a report to draw your attention to, and I am sure my colleagues will provide greater detail. First of all, helmets reduce risk of serious injury or death by about 60 per cent—in the case of death by about 74 per cent. For cyclist admissions to hospitals, where a cyclist was wearing a helmet, it is one-third the cost of a cyclist who was not wearing a helmet being admitted. In other words, not wearing a helmet represents a burden three times the amount to the system, to the health resources available to us nationally, than for a cyclist being admitted to a hospital who was wearing a helmet. These are very compelling figures.

Finally, there is a reference in our submission to a survey, which indicates that in a democratic society, such as ours, there is very strong community support for mandatory wearing of helmets. Continuation of that law is an expression of the will of the Australian society. I refer you to our submission and, in particular, page 21, which has seven recommendations. Central to that is the maintenance of compulsory bicycle-helmet wearing by all cyclists in Australia. Thank you.

Prof. Ivers : I am Professor of Public Health at the University of Sydney. I am also Director of the Injury Division at The George Institute. As I said, I am here representing the Australian Injury Prevention Network, which is the peak body for researchers, practitioners and policymakers around injury prevention in Australia, representing 22 organisations. We contributed to the submission. We also have a position paper on our website from which part of that submission was based.

The Australian Injury Prevention Network is very supportive of helmet legislation. There is no question that increasing cycling participation and other forms of active transportation is going to be critical to the future, as our cities urbanise, for both environmental and health reasons. I am on the record as having written an opinion piece, very recently, in TheSydney Morning Herald, encouraging better infrastructure in New South Wales on that point. However, helmet legislation is not the barrier to increasing cycling participation that others have promoted it to be. There is very clear evidence that bicycle helmets are effective in reducing head injury in the event of a crash. That is undeniable. There is very clear, strong and consistent evidence. There is also evidence that cycling participation does not decline with the introduction of helmet legislation. Over time, cycling participation has been increasing. Increasing cycling participation with helmet legislation and with helmet-wearing rates is what we should be looking for.

In jurisdictions without helmet legislation, helmet-wearing rates are low. There is also evidence that it is very difficult to increase helmet-wearing rates without legislation. As you have heard, we have a very proud tradition of legislation and enforcement in improving road safety and in other forms of health and safety across Australia. It is very well known that it is very hard to change people's behaviour without legislation and enforcement in the area of road safety. That is why we have such high seatbelt-wearing rates and why we have low drink-driving rates. It comes back to that combination of legislation not on its own but with enforcement and effective public campaigns. Helmet legislation is not the enemy. We should be increasing cycling participation with helmet wearing and helmet legislation and finding ways that we can better increase that.

On a second note, I note the other discussions about the impact on young Aboriginal people. I run Aboriginal support programs for driver licensing across New South Wales. I run a large-scale trial and we deal, significantly, with the issue of bicycle-helmet fines and unpaid fines for Aboriginal youth, and I have seen the impact that has. I am prepared to talk about that as well. That is an issue of institutional racism and a lack of support for young Aboriginal people in rural areas. It is a much bigger more complex issue than just helmet laws and helmet fines. Thank you.

Dr Kenfield : Thank you for the opportunity to be a part of this submission. I am a trauma surgeon at the Royal Melbourne Hospital and I see bicycle accidents on a near-daily basis. The Royal Australasian College of Surgeons is the leading advocate for surgical standards, professionalism and surgical education in Australia and New Zealand, representing 7,000 surgeons and approximately 1,300 surgical trainees and international medical graduates. We also have a public health contribution to the community and feel that regarding anything that can deter injury and improve health we agree with all of the policies that have been forwarded, to date.

On a personal level, something that is not borne out in all of the papers that have been presented is the degree of brain injury that we see being reduced in those patients who have had bicycle helmets correctly fitted. Many of the papers talk about brain injuries as a binary—either they have a brain injury or they do not have a brain injury—and the spectrum is quite large when it comes to brain injuries. Quite often in the emergency department we will see patients who have damaged their helmet who might have a very mild concussion and they are deemed fit to return home and fit to return to work, and they return to work quite quickly, as opposed to those patients we have in hospital for weeks or even months at a time who go to a neurological rehabilitation centre and many of them never return to work and require full-time care.

Senator CANAVAN: Thank you all for your evidence and your work in this area. I want to start with Professor Rosenfeld. Professor, you said words to the effect that we should do everything we can to reduce brain injury. If that is true, though, why wouldn't we just ban cycling altogether, because that would get rid of all brain injury, at least for cycling?

Prof. Rosenfeld : You cannot ban something that is part of normal life. People are not going to stop cycling. I do not think it is a practical proposition. What you have to try do for people who are cycling is to make it as safe as possible for them when they do ride their bikes.

Senator CANAVAN: I approach this from the position that there should be some level of cost-benefit analysis about whether this particular intervention is best for the community rather than targeting just one particular metric, which is brain injury. The evidence we have heard this morning is that, yes, it might reduce brain injuries but it might also reduce exercise and have consequent effects of people's health and potentially cardiovascular illnesses. Are you saying we should not weigh that up, that we should just target brain injury? Or do we need to look at the holistic impacts?

Prof. Rosenfeld : We need to look at the holistic impact but the head injury aspect is the most expensive for society and, as I said, for the individuals and the families who are affected in terms of their health and wellbeing. But the monetary cost is enormous. If we can reduce all of that, it is well worth doing, and it is our mission as neurosurgeons to do that. I did not say that I represent a large society of all the neurosurgeons in Australia, and we are all of one mind: we need to have helmets to protect people's brains. That is our mission.

I think the argument you are getting onto about obesity and more people would ride their bikes if they did not have to wear a helmet, and they might lose some weight, we all do not accept that argument. There is no evidence for that at the moment. Mind you, there have not been any large studies of that, but actually we feel that the people who are obese do not necessarily look at cycling to reduce their obesity. They might look at other things, like diet, but cycling is not necessarily high on their list. So we do not see that as a major argument to say, 'Let's get rid of helmets and more people are going to ride bikes', because the evidence is not there for that.

Senator CANAVAN: With all due respect, I think it is perhaps a little bit strong to say there is no evidence. I do not know if you have seen the other submissions, and I am not picking on you, Professor Rosenfeld; I am happy for anybody to answer this question. There was some quite compelling evidence presented by Dr Robinson on census data. It is just an indicator, and like all data it could have other reasons—and I am happy for that to be brought to bear. But it quite clearly showed that at the time these laws were introduced in Australia there was a substantial reduction in the percentage of people cycling to work. Do you have other data to say that is wrong, or incorrect, or there is another way to interpret that?

Prof. Olivier : The negative health impacts are around people not cycling because of legislation, because there is not really much evidence that there is any other potentially negative impact.

The census is taken on a day, five years apart. There are over 1,300 days between those. It is not a very accurate representation as to what is happening in day-to-day changes in cycling. Between Monday, Tuesday, Wednesday, Thursday and Friday there are going to be fluctuations in the amounts of cycling. We do not know, because it is only taken every five years, if that difference is just caught up in the random variation.

In addition to that, if you look at the proportion cycling to work in Australian cities, where most of the cycling is occurring, from 1986 to 1991 the proportions for cycling went from 1.14 per cent to 1.13 per cent and—

Senator CANAVAN: What were those years? I just missed that—

Prof. Olivier : From 1986 to 1991.

Senator CANAVAN: Right. That is census data then?

Prof. Olivier : That is census data.

Senator CANAVAN: You said 1.1—

Prof. Olivier : It was 1.14 per cent to 1.13 per cent. And in 1991 when the census data—

Senator CANAVAN: So we are still looking at about a fifth—a 20 per cent reduction—something like that?

Prof. Olivier : No, 1.14 per cent to 1.13 per cent. The difference is in the hundredths of a per cent.

Senator CANAVAN: Yes, but in terms of a percentage of people cycling it would be about a 20 per cent reduction.

Prof. Olivier : But the number went up. This is the proportion of people who were taken on the census day for those days. The actual count of cyclists went up in that one.

Senator CANAVAN: Sorry—went up or down? I have 1986 at 1.4 per cent—

Prof. Olivier : It was 1.14 per cent—

Senator CANAVAN: Right—sorry—okay. And in 1991?

Prof. Olivier : It was 1.13 per cent.

Senator CANAVAN: Okay—sorry—I had 1.4. I misheard you. That does not seem the same as the data here. Oh, I see—okay. But then in regional areas there was a massive reduction. I am not sure what that was. So there was a slight increase in some capital cities, but they were not the states which introduced the mandatory helmet laws. I suppose one of the issues here is that the introduction of some of these helmet laws was after 1991, weren't they?

Prof. Olivier : Sure.

Senator CANAVAN: A couple of states did them before they—

Prof. Olivier : They were coming in from 1990 to 1992. The last states to have legislation in Australia came in in 1992.

Senator CANAVAN: Yes, and there was a reduction between 1991 and—

Prof. Olivier : And so there is a lot of time between 1991 and 1996. It is hard to make a causal argument that helmet legislation caused that.

Senator CANAVAN: Obviously, there is going to be a lot of uncertainty in this field. I suppose—

Prof. Olivier : Sure.

Senator CANAVAN: The previous witnesses—again, Professor de Jong—presented a detailed study of the net benefit costs. Again, there were a lot of assumptions made in all of these assessments. I have been involved in them before. You have tabled some evidence on the total costs of brain injury, but do you know of any cost-benefit study about the marginal impact of the laws—not the overall impact of brain injury?

Prof. Olivier : To be honest, there is not enough Australian data to make that assessment.

Senator CANAVAN: Okay.

Prof. Olivier : Professor de Jong is using numbers based on UK data for the benefits of cycling, and using assumptions from all sorts of other sources. He is also assuming that everyone will cycle less with legislation, and there is actually evidence against that as well.

Senator CANAVAN: They are laws that came in in Australia that would have predated the regulatory impact assessment processes which are now in place as a result of National Competition Policy. Do you know of any state that has done a regulatory impact statement since the introduction? A sort of post-evaluation assessment?

Prof. Olivier : No.

Senator CANAVAN: Okay. I suppose that we do have some degree of competitive federalism in Australia, where the Northern Territory have relaxed their laws. I am not sure if you are familiar with this but the evidence to us is that apparently they have allowed bicycle use without a helmet on footpaths, and I think on low-speed roads as well. Do you have evidence that that has led to an increase? They did that in 1994 or some such—in the mid-1990s, so it was some time ago. Has that led to a marked difference in the quantum or severity of brain injuries in the Northern Territory as a result of cycling, relative to the rest of the country? Is there any evidence there?

Prof. Ivers : I am not aware of the specific details about head injury, but I think it is worth noting that the fatality rate for the Northern Territory is three times that of the rest of the country. The fatal—

CHAIR: On bicycles?

Prof. Ivers : No, overall.

CHAIR: Overall?

Prof. Ivers : Yes, that is right.

CHAIR: Not specific to bicycles?

Prof. Ivers : No, that is right. It is not specific to bicycles. As I said—

CHAIR: There might be a few other reasons for that.

Prof. Ivers : There are, but I think Northern Territory laws are not necessarily best-practice across the country, either.

Senator CANAVAN: The whole thing I am coming at here is that whether or not it is best-practice is an evidence-based question. I am not asking you to do that evidence, because it is not your job. I was just wondering if there is any.

Prof. Rosenfeld : The thing is that what you are talking about in Darwin—and I am not familiar with the situation there—is riding at low speed on footpaths. That is not the same as riding on urban streets in Melbourne. You just cannot compare them.

Senator CANAVAN: Absolutely. But that is a very relevant question for us. I am not sure if you were here before when we were told that the Queensland parliament last year recommended implementing the Northern Territory situation in Queensland. Are you saying, then, that in relation to relaxation of laws on footpaths and possibly low-speed roads you would support that it is a relevant thing to look at—the relative risk on different roads of wearing a helmet or not wearing one?

Prof. Rosenfeld : It can be looked at, but the problem with introducing a law like that is that it allows creep and people stretch it and it ends up with people not wearing their helmets when they should. I would not support that type of partial legislation.

Prof. Ivers : Helmets are most effective in low-speed crashes, of course. So in fact people who are out cycling on cycle pathways are at risk of head injury, as well. Helmets are going to be very effective, so actually having helmet legislation that applies to cycle paths is critical, especially as we have increasingly separated infrastructure. There is as high risk of head injury on cycle paths as there is elsewhere.

Prof. Olivier : In the Northern Territory the number of fatalities per year, prior to legislation, would have been around zero, one or two, or maybe even three in some years. After that, it would have been just a bit less than that. You are not talking about big numbers to begin with, so if you want to make the argument that things are just as safe before and after the legislation in the Northern Territory you are really not talking about big numbers to begin with. Any sort of big variation is just one extra case. There is really not enough data to make that assumption one way or the other.

Senator CANAVAN: That is what I continue to hear—that there is not enough data. In your opening statements and submissions you have made some fairly strong conclusions and assertions, but if there is not the data there to judge these matters how do you make those strong assertions and judgments? Apart from just anecdotes, if the data is not there how do we—

Prof. Rosenfeld : I am basing what I said—the strong words I used—on the epidemiological data on injury severity and rates before and after helmet introduction, and also comparing us with, say, Holland—the paper that came out, which I have here. There are multiple papers showing that the injury severity and rates are reduced by helmet wearing.

Senator CANAVAN: I am not contesting that. But I thought we established that we had to look at everything in a holistic way and not at individual areas. If there is a lack of data on exercise and its influence on how people react to the laws—the information we have is incomplete—potentially the conclusions we can draw should perhaps be suitably qualified. Is your opinion here so strident that you would not even want to entertain the potential for some relaxation, even if it is just in a randomised trial where we see what happens if we slightly relax the laws and judge the evidence of it. A randomised trial would seem to be something the medical profession, particularly, would potentially support.

Dr Brown : I would like to point out that it is great to look at epidemical studies and look for good data, but the effectiveness of helmets basically comes down to laws of physics. Helmets work by slowing down the head or giving a greater distance over which the head comes to a stop, and distributing the load over a greater area. It manages the forces that are applied to the head through the laws of physics. So, trying to get ethical approval to have a randomised, controlled trial where you expose somebody to risk is impossible. There is no way that you would put a participant at risk by putting them in a situation where they are going to be exposed to a head injury risk, when you know that your other group is going to be protected.

Senator CANAVAN: People are exposed to risk all the time. Bikes in general and driving a car—all of these things potentially cause injury. It has to be a question about the overall impact of the law and not just on head injuries themselves. I understand that you have experiences that I do not have and I understand how that would affect what you want to see done, but as legislators we have to look at the whole impact of the laws that we put in place, rather than on one metric or outcome. Is the evidence you are providing heavily weighted towards the way these laws impact on head injuries—and that is fine if that is where your evidence is coming from—or are you saying that even if you look at it from a benefit cost, economy-wide process that it would still be a net benefit? Do you have any studies or evidence to back that up?

Dr Brown : My submission is based on the fact that we need to encourage activity and encourage cycling. From a holistic public health perspective cycling is a really good thing, but we do not want to exchange one public health problem for another public health problem. We want to increase activity and we want to do that in the safest way we can. The most expensive diagnosis in the healthcare system is for traumatic brain injury, and we know we have an effective way to prevent that.

CHAIR: The national cycling strategy has an aspiration to increase cycling as well, and that has been in effect for some years now. Why do you think it is a dismal failure? The numbers are simply not being achieved—why do you think that is?

Dr Brown : Some of my colleagues here are probably better placed to speak to that than I. My understanding is that what we really need is a lot more attention to better infrastructure.

CHAIR: Just on infrastructure, the Australian government review in 2013 found that the net health benefit, adjusted for injury, for each kilometre cycled was 75 cents—about half of the total economic benefits of a typical bikeway project. If it is true that helmet laws discourage people from cycling—and I will refer to some evidence in that respect in due course and we have a lot of submissions to that effect—isn't it counterproductive to discourage people from participating in an activity that generates 75 cents of health benefit for every kilometre cycled?

Dr Brown : I have not made up my mind that cycling does go down with helmet wearing. I think there are some studies, but I am not on top of—

CHAIR: We have had a lot of evidence to suggest that that is the case. It is survey evidence that has not been contradicted by anybody else's submission. Some of the submissions have contradicted the evidence in submissions made by organisations represented at the table here. One says: 'The effect of helmet laws was most noticeable in areas with high and increasing levels of cycling, for example, cycling to work in small cities in regional which have lower traffic volumes and shorter travel distances. In 1991, just before WA's helmet law, an estimated 5.7 per cent of trips in Perth were by bike. Despite valiant efforts to increase cycling post-law, cycling plummeted to 1.6 per cent of trips by 2003-2006.'

Dr Brown : I am not on top of the cycling surveys. We did have some data.

Prof. Rosenfeld : One comment that I would make in answer to that, and I am not familiar with the surveys you are talking about, but my own observation is that people are not riding bikes because they do not want to wear a helmet. They are frightened to ride because of the safety issues on the road today—there is not enough safe infrastructure for them to ride on. The number of accidents that are reported or they see or their friends are having is the reason I am not riding a bike. I would love to ride a bike and I would ride it with a helmet but I am not going to ride it when I feel it is unsafe to do so. That is why most people are not riding. They are worried about the roads and the cars on the roads are not bike friendly—they will run over the bikes.

CHAIR: I acknowledge that is a concern. I am not really disagreeing with you on that. The point is, though: the roads were not any safer 25 years ago when helmets were not obligatory—

Prof. Rosenfeld : There were a lot less cars on the road.

CHAIR: Rates of cycling as a proportion of the population, based on the submissions we have received, have, in fact, declined over those 25 years. If that is a factor, if perceptions of danger are a reality—and, as I said, I am not disagreeing with that—you would think it would pretty much apply then and now. Yet the evidence would suggest that we have seen a fairly substantial reduction in cycling, especially, for example, transport cycling—kids going to school, people going to the shops or workers commuting to work. That does not include sport cycling—mountain bikes, road racing and that sort of stuff. That seems to be doing quite well.

Prof. Rosenfeld : If I had a kid at cycling age—they have all grown up now—there is no way that I would let them ride on the roads. There are a lot more cars on the road. It is much more dangerous environment than maybe it was 25 years ago. That is the way I would look at it.

CHAIR: One of the submissions earlier today suggested that, if that is true, one of the reasons might be due to the fact that drivers are less conscious of cyclists than they used to be because there are fewer of them. 'Safety in numbers' was the statement used. If there were more cyclists, drivers would be more used the seeing them and would drive more appropriately.

Prof. Ivers : That is a really good point. Having more cyclists on the road is certainly going to increase safety as cars become more used to them. It is long though to think that actually reducing cycling helmet legislation and allowing people to ride without helmets is significantly going to increase cycling participation. In almost all of those surveys that you are referring to—where people are asked about whether cycle helmets stop them from cycling—if people cite cycle helmets it is a long way down the list. Even if they cite cycle helmets as being important, it is still a stretch to actually say, 'If we reduce helmet legislation, all of those people would cycle and would become regular transport cyclists.' You need to be very careful about assumptions that you are making as well. That is not something based on evidence. It is actually conjecture based on a thought that if people say they are going to ride more without a helmet they will, in fact, do so. So we need to be very careful about what the evidence actually says.

CHAIR: I agree. Prospective indications of intention are risky under any circumstances. But this committee has received evidence showing a correlation—not necessarily causation; that is what we are trying to establish—between introduction of mandatory helmets and a substantive decline in cycling as an activity, particularly transport cycling. On the one hand, we have evidence, data; on the other hand, we are speculating about what might happen if we undo that situation. There are also other indicators that would suggest that if people feel that it is dangerous—and this has been suggested to us—then the obligation to wear a helmet reinforces that perception of danger.

Prof. Ivers : Again, that is something that is not well based in science. It is a theory, and it is not well supported by evidence.

CHAIR: Is there contrary evidence though?

Prof. Ivers : I will let Jake comment on that.

Prof. Olivier : There was a report that came out a couple of years ago that estimated the proportions of Australians going to work by different travel modes, starting in 1900. Cycling to work peaked around World War II at about eight to nine per cent. Afterwards, cycling and other active transport modes, like walking and public transportation, declined. It declined all the while motor vehicle travel increased. It dropped around one per cent—which is what we are seeing in census data—long before helmet legislation ever came around.

Senator CANAVAN: My question goes back to the data we were talking about before. I might ask you to have a look at this on notice, given that evidence. And I presume that that would absolutely be the case. However, the evidence on the first page of Dr Robinson's submission is that from 1976 to 1991 there had been an increase in the number of people cycling to work, particularly in the states with no helmet laws until 1991—in regional areas, in particular, outside the capital cities—and then these laws were introduced, of course, and there was a decline. Could you perhaps look at that on notice for us. The data here only starts at 1976. So I reckon you are probably right. But you said there was basically a decline from World War II through to the introduction of the laws. I might just ask you to have a look at that and see if that is actually the case or whether there was a bit of a bump up in the seventies or eighties or it bottomed out perhaps sometime in between.

Prof. Olivier : It was from a BITRE—Bureau of Infrastructure, Transport and Regional Economics—report.

Senator CANAVAN: That would perhaps be useful for us.

Prof. Olivier : Just to be clear about that: the census started in 1976. This is using other historical data. It goes beyond that.

Senator CANAVAN: That would be useful then.

Prof. Olivier : The other thing I would say about Dr Robinson's report is that it looks like there is a lot of variability because she has narrowed the focus of the percentages down. When you have actually boosted them up to around eight to nine per cent, which they were historically, you do not see much variability—

Senator CANAVAN: You are saying this question started in 1976 census?

Prof. Olivier : The census did, yes.

Senator CANAVAN: The census did not start in 1976, but this particular question—

Prof. Olivier : The data they used to estimate that actually goes back to 1900.

Senator CANAVAN: I am not accusing Dr Robinson of anything, just to be clear; it is a fairly comprehensive set of data, in my view. She has 15 years of data before the introduction of the laws, so that seems reasonable enough. But I take your point and, if there is other data that we should look at, that would be very useful.

Prof. Olivier : To be clear, that is three days pre-law not 15 years pre-law. That is three days pre-law.

Senator CANAVAN: I do not want to get into an argument about the accuracy. I take your point that data is not perfect—although I sort of think that census data is probably as close to perfection as we can get. I just want to ask about the regional areas. In this data, again, the drop-off in regional areas was much, much greater. There has been some talk about the relative risks of different roads. In your experience—obviously I do not know where you all practice or work—are the risks lower in regional areas, where there are roads with fewer cars and lower numbers of people, as we were saying, than in the cities? And therefore should we perhaps have more flexible laws in those areas, relative to our urban areas?

Mr Healy : In relation to the safety of cyclists: quite apart from the wearing of helmets, the issues are really about mixing traffic—so mixing motorised vehicles with cyclists. Ideally, you have separation, or, if they are together, you make sure that the speeds are sufficiently low such that any collision does not lead to death or serious injury—including the fact that they are wearing a protective helmet. So, in the regional areas where, clearly, you have higher speeds on the open road, it is a very poor mix between any cyclist who chooses to ride on the sides of those roads versus the very high speeds of cars. The perspective in road safety now is, and will be into the future, very much about: we are human beings and we make mistakes. Potentially a driver could be distracted by a child in the back; if they are travelling at 100 kays and there is a cyclist on their left and they veer slightly and collect that cyclist, then clearly the outcome is going to be horrific.

So speed is a key determinant of the outcome. Most of the evidence suggests that, at speeds in excess of 30 kays or so, in terms of the impact speeds, for a cyclist wearing a protective helmet, the chances of death or injury may begin to escalate quite rapidly. So you can imagine that, in rural environments, particularly outside the towns, where you may well have lower speeds in some of those streets, similar to cities such as Melbourne, in fact it represents a very risky environment. That is what I think you would have to say.

CHAIR: I want to look at this more broadly. We have now had 25 years of mandatory helmets in Australia, and yet Australia, New Zealand and the United Arab Emirates are the only countries in the world which have mandatory helmet laws for cyclists. Why do you think that is? Are we smarter than the rest of the world and know something that the rest of the world does not know or vice versa?

Mr Healy : I think Australia has been—rightly so—historically recognised as being a leader in relation to road safety. That is in relation to a number of measures, some of which are still struggling to be introduced in many other jurisdictions. It goes right back to December 1970 in Victoria with mandatory seatbelt wearing. Random breath testing was introduced in Victoria in 1976 as a trial. That has certainly been used elsewhere, but still some countries are struggling with that notion. And certainly mandatory bicycle helmet wearing on 1 July 1990 was the first of its kind. All those were introduced because the evidence was sufficiently strong to embark on those. Subsequent to that, as I tried to indicate earlier, the outcome evidence in terms of reduced levels of head injury—and we have perspectives from a whole range of different players, including surgeons here today—is that it is a lay-down misere. They work. They reduce head injury significantly. Not only that; head injuries are the most expensive and costly.

CHAIR: That is in dispute. Just saying it does not help. The point is, of course, that with seatbelts and random breath testing there was no dispute amongst drivers or anybody else. There was a direct cause-and-effect relationship in terms of their implementation and the reduction in road accidents.

Prof. Grzebieta : That is not true.

CHAIR: What is not true?

Prof. Grzebieta : There was dispute over mandatory seatbelts. There was dispute over the random breath testing. There was significant resistance.

CHAIR: What you are suggesting, if I understand, Mr Healy, is that the rest of the world is just slow to catch up and we are leading the world.

Mr Healy : I cannot comment on every jurisdiction in terms of their decision making. I can say that those three measures that I referenced have all been very effective in terms of reducing serious trauma. Each jurisdiction must make up its own mind. I believe that, in other areas and in particular in relation to protecting cyclists by way of infrastructure and speed management, we have a lot to learn from other jurisdictions such as the Netherlands, Denmark and the like.

CHAIR: Does Australia have a significantly lower rate of serious head injuries and deaths amongst cyclists than other countries in the OECD?

Mr Healy : We would have to take that question on notice.

CHAIR: If you would. The information we have is that it does not, but, if you have evidence to the contrary, I would like to hear it.

Prof. Olivier : You can look at deaths per population, but in Australia we do not have exposure data. We do not have any idea how often people cycle—how much they cycle. In countries like the Netherlands they collect that data routinely. Australia does not.

CHAIR: We do have some evidence. We have evidence relating to participation in cycling. We have evidence in relation to cycling accidents. One of you—I cannot recall which—said that cycling participation has not declined following introduction of mandatory helmet laws, and yet even here in Victoria 679 fewer teenage cyclists were counted in identical pre- and post-law surveys, but the number of teenage cyclists wearing helmets increased by only 30. Doesn't this suggest that the main effect of the law was to discourage cycling rather than encourage helmet wearing?

Prof. Olivier : No.

CHAIR: Fewer cyclists, only 30 more helmets over pre and post? What does that suggest to you?

Prof. Olivier : If you are trying to estimate the prevalence of people cycling, you do not do it by standing on the street corner and counting. That is not a proper statistical method for estimating prevalence. We would not do that with infectious diseases. We would not do it with other diseases or any other health related thing. We would not just stand on a street corner and ask people: 'Do you have HIV? Yes or no?' and then do that over several years and count the number of times someone says yes. That is not how it is done. It is very weak data and, from other stuff that we have done and I have done with colleagues here, we know that, as the data has got stronger—there is not any ideal data around the time of the helmet legislations across the Australian states—and better in terms of quality, we do not find big drops in cycling. We do not find any significant changes in cycling.

CHAIR: But others do, so I am struggling to understand how you can be so positive.

Prof. Olivier : Because, as the data is better—

CHAIR: What data? Which data set are you relying on?

Prof. Olivier : The census data of hospitalisations in New South Wales.

CHAIR: Okay. We have data based on that as well. One of their submissions this morning incorporated injuries. I will pass to Senator Canavan while I find the graphs.

Senator CANAVAN: Have you seen the evidence that was in the Queensland parliamentary committee report two years ago? I think it was in a submission as well. It is data about comparing the use of bikes and ride share schemes in different cities in the world. Brisbane and Melbourne have both consistently recorded use of bikes at less than a trip a day per bike, whereas other cities of the world have two, three and sometimes higher usages of bikes. My understanding is that those other cities do not have mandatory helmet laws. I remember being in DC, grabbing a bike and riding over to Arlington National Cemetery. It was great. Isn't that at least pretty good evidence that the mandatory laws are deterring bike use in that environment? It does not necessarily say it stops commuters using bikes. It certainly stops tourists and maybe people commuting or getting from one place to another in town. What is your response to that data?

Dr Kenfield : Having just returned from Geneva—this is anecdotal—I say the bicycle culture over there is completely different. Many of the European cities have an infrastructure that really supports the bicycle riders. They are separated from car drivers. The Senator mentioned before that the danger of being on the road over the last 10 years has not increased. I think that is false. I think we are all-time fourth—

Senator CANAVAN: You can come back to that, but this is slightly different from this point. This is a point in time, not over time.

Dr Kenfield : Indeed. I think that all that statement says is that, yes, our bicycles are not being used as frequently as they are in schemes in Europe, but that does not mean that it is because of bicycle helmets.

Senator CANAVAN: There are also Boston, DC and Miami Beach on this as well.

Dr Kenfield : Okay, sure.

Senator CANAVAN: It is anecdotal, but I do not necessarily think the bike lane infrastructure in DC is any better or worse—probably worse, actually, from memory—than our cities. But that data is very stark. It seemingly had a fairly strong influence on the Queensland parliament to make a recommendation—

Dr Kenfield : Is that because of the compulsory bicycle helmets or is it because of the perceived danger of looking at the roads? If we look downstairs here at Spring Street, it does not look very dangerous, because the traffic there is not bad, but certainly the other roads throughout the CBD and also in the other suburbs are very dangerous places to ride. There are more people. There is more traffic on the road. Visitors from overseas note how aggressive drivers are in Australian cities and that there is no look-out for bike riders. Potentially that is due to the small number of bike riders on our roads compared to elsewhere, but I do not think that it is because of compulsory bicycle helmets but rather because of the perceived danger. I certainly do not ride because of that. I have a very nice bike at home and it has not been ridden.

Prof. Olivier : The Australian bike-sharing schemes have been set up very poorly. A lot of us were at the Gold Coast a month ago for a conference. My hotel was a bit away from the conference centre and my hotel had some bike share bikes. It would have cost me $99 to use them over three days, or I could have spent $5 a day and ridden the tram. The hotel had bike helmets they could give me to borrow and also a lock to lock the bike up. None of that had anything to do with helmets. It had everything to do with cost and how it was set up.

Prof. Grzebieta : If you go to Gothenburg, they will give you the bike for free to ride around.

CHAIR: I found the numbers. They were in one of the submissions. It is an interesting plot. It plots the number of non-head injuries with the number of head injuries based on admissions in Victoria. They pretty much parallel each other—in fact, they are really very close. If you were to assert that helmets had reduced head injuries, you would have thought that they would have fallen below non-head injuries and yet they have followed the same pattern almost exactly for three years prior to the helmet laws and for four years after the helmet laws came into place in Victoria. We just have not seen the evidence that helmets had a substantial effect.

Prof. Rosenfeld : On what, Senator? Are you talking about head injury or general injury?

CHAIR: Head injuries.

Dr Kenfield : As I mentioned before, 'head injuries' is a huge spectrum. It would be counted as a head injury if someone has a laceration to their forehead or if they are in the intensive care unit for a couple of weeks and in hospital for months.

CHAIR: I accept that.

Prof. Rosenfeld : I would just refer to McDermott's paper from 1993, Journal of trauma, a study of 1,710 helmeted and unhelmeted cyclists, which found that head injury was reduced by at least 39 per cent by wearing a helmet.

CHAIR: So, obviously, we have competing data and competing interpretations of data. I can understand that, as doctors who deal with head injury, you would regard it as the most important injury, and there is no question that people suffering traumatic bone injury suffer badly and it is expensive to taxpayers. If we had a group of cardiac specialists sitting here, we might get a different answer about the significant effects that lack of exercise has on cardiovascular disease and how cycling should be encouraged for the purpose of reducing the prevalence of cardiac disease. So I guess we have a particular point of view represented here. But, allowing for that, to what extent do we say, 'Okay; traumatic brain injury is the most serious injury. It is really very bad. It can incapacitate people and they do not die'? And if they die, it costs society less money. As Dr Brown said, the question should be how we get more people to use helmets. It is not just cycling in which traumatic brain injury can occur. Would you advocate mandatory helmets for skateboarding, driving a car or anywhere where you could fall and bash your head? Where do we draw the line?

Dr Brown : We have done a lot to reduce the risk of head injury for car drivers. We do regulate our cars. We have laws that regulate the occupant protection level that our cars need to provide. But when you want to introduce some legislation that requires somebody to pick up the helmet and put it on their head, you have to be able to enforce it—there is no use in just having legislation. So there are some activities where legislation would not work. With Kids on Wheels, for example, a lot of effort goes into public education and public awareness campaigns to try to encourage the use of helmets. If there was a way to ensure that all children did wear helmets, I think that would be a good idea.

CHAIR: At all times—well, not in bed!

Dr Brown : When they are out having fun, taking part in physical activity and enjoying life. That is what we want to encourage. But when we know there are ways to mitigate risk then we should take those actions.

CHAIR: One of the witnesses this morning suggested that bicycle helmets are actually not all that effective at preventing head injury because of the way they are designed—very lightweight and various aspects—and that they can in fact contribute to more serious injuries of the neck, I think it was. I raised the question of whether or not a motorcycle helmet might be a better option for children, and I think the comment was that they are a bit heavy. Leaving that aside—presumably they can be made lighter—do you think that is a reasonable option? What I am looking for here is whether it is worth doing these sorts of things to prevent head injury.

Dr Brown : With the performance of bicycle helmets we have mandatory standards that set a minimum level of performance that all helmets that are on the market must meet. It sets performance requirements in terms of the energy the helmet needs to attenuate as well as how the energy is distributed. But they are minimum requirements, and there is always room to encourage manufacturers and encourage people to design beyond those minimum requirements. So yes, it would be a good idea to work towards improved performance, in particular improved coverage provided by helmets—coverage of the head. But, as I said at the start, really what we want to do is try to find ways to encourage increased use of helmets. So, other aspects of design are important as well—fit, comfort and weight. It would make good sense to put attention on ways to improve designs to do that without necessarily saying, 'Move straight to a motorcycle helmet.' But yes: improving performance is a good thing.

Prof. Rosenfeld : Also, Senator, to pick you up on that point you made about neck injuries being increased by helmets, I do not accept that evidence. I do not know where it came from, but if you look at Yilmaz's 2013 paper on injury, where he compared Melbourne patients with Holland's patients, neck injuries were less common in the Melbourne group, among helmet wearers. So, there is evidence that neck injury are actually reduced by the helmets, and the severity of the head injuries is reduced by the helmets as well. That was found in that study.

Prof. Ivers : There is a vast body of evidence about the effectiveness of bicycle helmets. If you look across the evidence, it is very compelling, and there are many people who are opposed to helmet legislation who will accept the effectiveness of bicycle helmets. I think actually starting to comment about the effectiveness of helmets is like talking about people who smoked until they were 100 and did not get lung cancer. It is sort of verging into anecdote and very small, one-off studies. There is very clear evidence. And I think it is worth commenting also on what Julie was saying about starting to look at motorcycle helmets. Bicycle helmets are designed for purpose as well as for safety, so of course the effectiveness of bicycle helmets in reducing injury is important, but so is that they are fit for purpose and that they are light enough for people to wear when they are sweating and engaging in physical activity. Obviously once you start looking at motorcycle helmets, they are heavy. There is also an issue with heat and exchange of air within the helmet which deems them inappropriate for use for cyclists. That is the reason we do not have them, and clearly you need to be practical about what people can wear and what is going to be effective and what is actually practical in terms of what people are doing when they are wearing them. That is why helmets are designed the way they are, with airflow.

CHAIR: I guess that is what the dispute is about: what is appropriate and what is practical. Some people have presented evidence to this committee that says it is neither practical nor appropriate to wear a helmet, because the risk is so small, and that the deterrent effect on cycling is real. Some witnesses have said they accept that they may incur an increased risk of head injury by not cycling but they incur an increased risk of cardiovascular disease—and of obesity, presumably, and associated diseases arising from obesity. I guess the question is, who decides what is appropriate? That is really what we are looking into here.

Prof. Ivers : Absolutely.

Prof. Grzebieta : We are questioning the evidence that was presented to you this morning, and we suggest to you that it is not appropriately peer reviewed and rigorous scientific evidence.

CHAIR: That raises an interesting question. At least two of you are surgeons and physicians. Does that make you epidemiologists?

Prof. Grzebieta : I am a road safety person. Actually, my qualifications are in crashworthiness. And I work in a similar field to Dr Brown, in crashworthiness. Senator, imagine if you were about to be hit in the head with a hammer. What would you rather: not have a helmet on, or have a helmet on?

CHAIR: Well, the evidence we heard was that that is not likely to be the most typical injury incurred when you fall off your bike—that you are more likely to have a twisting injury. That was the suggestion.

Prof. Grzebieta : Yes, that is the Curnow hypothesis. Curnow put together evidence on the basis of other people's work that was not substantiated through appropriate testing. McIntosh and a number of others at the University of New South Wales did some tests using a Hybrid III crash test dummy head and neck with and without a helmet. They dropped the headform from 0.5 metres, from one metre and from 1.5 metres at a speed of zero, 15 and 25 kilometres per hour—effectively 66 tests, 29 helmeted and 37 unhelmeted—testing the hypothesis of Curnow. At 15 kilometres per hour at a half-metre drop height the rate of rotation in the helmeted group was 2.14 kiloradians per second squared. In the unhelmeted group it was 12.8—that is 10 times more. The head injury criterion, which we use for all of our safety for vehicles and crashworthiness et cetera, was 110 for the helmeted. For the unhelmeted it was 367. At 25 kilometres per hour, you are comparing 1.19 kiloradians per second for the helmeted with 10.53—that is 10 times—for the unhelmeted. The head injury criterion was 88 for the helmeted and for the unhelmeted was 836. At 15 kilometres per hour from a one-metre drop height it was 2.2 kiloradians per second squared for the helmeted and 16 for the unhelmeted. The head injury criterion was 288 for the helmeted and 1,427 for the unhelmeted. There is no dispute.

CHAIR: No dispute about what?

Prof. Grzebieta : About the evidence that wearing a helmet not only reduces the acceleration that is imparted to your brain but also reduces the rotation. I heard what Mr Curnow said this morning, and we dispute his results.

Prof. Rosenfeld : Senator, if I could pick you up on another point you made, you talked about the two physicians or surgeons who were on the panel this morning and you said we were not epidemiologists. I think by that you mean that we probably are not qualified to interpret the scientific data—

CHAIR: Well, you see the end result of head injury, but you are not there when it is caused. That is the point I am making.

Prof. Rosenfeld : We are not there when it is caused?

Dr Kenfield : Do you mean at the roadside?

CHAIR: Well, no. I guess what I am questioning is whether seeing the end result of head injury makes you qualified to say what caused that head injury.

Prof. Ivers : There are a couple of epidemiologists here on the panel—both me and Jake Olivier.

CHAIR: Yes, I acknowledge that.

Dr Kenfield : And I agree that I am not an epidemiologist, but I do see these patients on a daily basis. I also treat obesity on daily basis. I am an obesity surgeon as well as a trauma surgeon, and there are two problems with the Australian obesity epidemic, which is probably one of our biggest health issues at the moment. There are those patients who are already overweight and obese and then there are the rest of the population who are at high risk of becoming overweight and obese. Those patients who are already overweight and obese tend not to want to ride a bike. They do not feel safe on a bike, and I speak to them about this on a regular basis. When they have lost weight after the operations that I perform, many of them do take up cycling and it is one of their great joys. I dispute though that the people in society who are at risk of becoming obese are not riding bicycles because of compulsory bicycle helmet laws. When I was polling the neurosurgeons, the emergency physicians and also some other colleagues of mine prior to this meeting today, with all due respect, there was a lot of eye rolling. People could not believe we were having this discussion in regard to the potential for the compulsory bicycle helmet laws to be implicated with obesity. There was only one surgeon who actually said, 'I think it's a good idea and I don't think we should be using bicycle helmets.' And that was one of the liver transplant surgeons from the Austin, who feels that our transplant numbers are too low and that this would be a good form of natural selection, which—

Senator CANAVAN: With all due respect, Dr Kenfield, we have had reams of evidence about how mandatory helmet laws have reduced bicycle use. I will admit I do not know a lot about this topic, but I have spent the day googling and I have just found a National Bureau of Economic Research paper, which looks at 20 US states that have mandatory helmet laws and other states in the US who do not. The US is a great little laboratory in that regard for these types of things. It is fairly monocultural across the country and has a proper federation, where states do different things. These economists show very clearly that there is a statistically significant reduction in bicycle use, particularly among youth, in those states that have introduced these laws. We can completely have different values about weighing those up—whether it is more important to protect brain injuries and have mandatory helmet laws, not withstanding the potential downsides of lower bicycle use. But I have just not seen any evidence to contradict the weight of evidence on the other side that there is this impact. To deny that impact seems to me obstinate, but I completely understand that you have a different value base, and that is fine. We all—

Prof. Rosenfeld : Why don't you come and visit us in the hospitals? You will see what impact head injuries have.

Senator CANAVAN: These economists in particular are not saying that the laws should be gotten rid of, they are just assessing the evidence, and the evidence seems pretty clear. Whether that necessitates a change to the law is a completely different question, which we can all have disputes about, because we have to value the threat of a brain injury and someone ending their life in that regard—which is terrible and we all recognise that—relative to a lower amount of exercise on bikes. The study does not look at how people might take up other forms of exercise et cetera, but to actually deny that there has been this impact—I don't know. The data from across the world and in many different forms seems clear, notwithstanding the limits of data.

Dr Kenfield : I am certainly not saying that what we are saying is more important than the rising obesity epidemic, because I do not believe that either. But I also do not believe that people are not riding bicycles because of compulsory bicycle helmet laws. I think is because of the perceived danger on the roads.

Prof. Grzebieta : And you have to go back to the source of the data that is being used for those papers which you are quoting and citing. Every time we have looked at the source of the data we have found that there is an issue with that source in its accuracy and its relevance.

CHAIR: That is what other submitters have said about your submissions as well.

Prof. Grzebieta : Yes they would say that.

Prof. Ivers : I think one of the things you have to be very clear about is that there are issues with the data. There are different sources of data and there are going to be different interpretations of the data. You cannot actually say that it is very clear. It is actually not very clear. As an epidemiologist, I can tell you that it is not clear and that the sources of data are imperfect. So it is very difficult to make very definitive statements when you look at it objectively. One of the things you have to say is that it is difficult to understand the impact of legislation on cycling participation rates in Australia because we have very poor data. There are studies that have shown that it has had an impact, and there are equal numbers of studies that have shown that it has not had an impact and that cycling participation is increasing.

The other issue that you need to be very clear about is that there is not strong—

CHAIR interjecting—

Prof. Ivers : Well, cycling participation is increasing in Australian cities where we have improvements in infrastructure. It is also not clear that if you remove the helmet legislation many more people will get on their bikes and ride. That is conjecture and that is actually coming from the assumption that when you have a number of people saying that cycling helmets stop them from riding, that if you remove helmet legislation they will jump on their bikes and ride off into the sunset. That is also conjecture. As policymakers, we understand that often you are actually making decisions in the absence of evidence. You need to be very clear that that is actually the situation we are looking at. We do know, though, when you have no helmet legislation, helmet-wearing rates are low. We also know that cycling helmets are very effective.

Those two things are not in dispute. We know cycling helmets are effective. We know brain injuries are terrible things to happen, and I know you are not disputing that. We do not know that if you remove cycling helmet legislation, many more people will jump on their bikes and ride. So you need to be very clear about that.

Mr Healy : My observation of the introduction of laws over the years has been that you get a newness effect: there is reaction. I do not know the evidence in relation to each jurisdiction, but it is possible that in the very short time, and oftentimes the evaluations are in the very short term, that there could be a reduction in cycling. It is a reaction. It happens when you introduce any law. It might be a speed limit change. What happens is you might get a change but is not what you are after. What happens over time is there is normalisation of what the new law represents. In the case of speed limit changes, what happens is there is a gradual change of speed, moving towards that as being normality. I would imagine similar trends would happen in relation to bicycle helmet wearing, that in fact what was new, what was different and, for some, a reaction against, it becomes normalised behaviour.

I agree absolutely with what Professor Ivers said. Just because in some instances you can point to the data, and people are right to question the veracity of that data, that in the very short term there was a small drop, potentially, in exposure of cyclists does not mean that that will be the case if you withdraw. After normalisation, it is pure conjecture that you will get the same outcome. Certainly, the survey results as presented in our joint submission—and I refer you to figure 5 the table 2—would suggest that for those who cycle occasionally and from the point of view of females, as stated before, the reasons they do not choose to cycle or to cycle more relate much more to road conditions, speed, volumes of traffic, lack of bicycle lanes and the like, which are all very valid but I suspect the most influential in terms of the decision making around whether to cycle or not. The issues surrounding the fact that you have to wear a bike helmet fall well down the scale and they are presented quite clearly in our submission.

CHAIR: We are over time. We have some more witnesses to hear from.

Senator CANAVAN: The submission of the Australian Injury Prevention Network says, 'A multicentre study found the cost of medical treatment was triple for cyclists not wearing a helmet when they crashed' and it has the data. However, Dr Robinson's submission says that the source you have quoted actually compares costs for cyclists and motorcyclists together with the data you have used, that when you use just the cyclist data there is a different result. The link you have provided does not seem to be working, and it is probably not your fault, but I cannot independently assess that. Could you have a look at that?

Prof. Ivers : I will have a look at that.

CHAIR: I would be interested in that too. I am also aware of that difference. Thank you, ladies and gentlemen. For everybody who has been asked to get back to us with answers, could you please do that by 30 November. If there is any problem with that, could you let the secretariat know. Thank you very much.