There is an old joke about a man who goes through a customs post with a wheelbarrow of sand every day. The increasingly frustrated customs officers make intensive searches of the contents, but never find any contraband.
After many years, all are retired and by chance they meet in a pub. When prevailed upon to reveal what he had been smuggling, he volunteers that it was . . . wheelbarrows.
This story evokes parallels in many aspects of healthcare, whereby a focus on the tangible and the traditional can distract attention from the often less well-defined but bigger issue.
In traffic medicine, an area in which I am working in addition to geriatric medicine, the focus is on the very real problems of injury, pollution and lack of exercise arising from overreliance on the private car. But this focus can divert attention away from the less dramatic but equally important consideration of adequate access to transport as a mediator of health and wellbeing.
Until recently there were few opportunities for academics and professionals in public health and transportation to tease out the complex interrelationships between health and transport. So I was fortunate to attend the recent inaugural International Conference on Transport and Health in London, which was a big step forward in filling this gap.
If a theme unified the broad range of disciplines involved, it was that of “livability”: from good urban design that embraced and enhanced multi-modality of transport (particularly walking, cycling and public transport), to consultation with end-users, to the use of emerging technologies such as electric bikes and transport apps on mobile phones.
Manipulated photographs
The range of projects and techniques were innovative, from using manipulated photographs to tease out the most desirable cycling streetscapes, to a prospective study of physical activity from those moving into the new housing created out of the Olympic village in London.
A global perspective was notable, with a great talk by an Indian traffic expert about how the experiences of low-income countries stress-test the perceived wisdom on promoting traffic safety. He noted in particular the need for a local body of academic expertise in traffic medicine and road safety to implement change, something that is developing in Ireland.
The importance of transport access to health was highlighted in a number of papers. For example, the only determinant associated with mental health problems in an Italian study of the built environment was transport accessibility. A UK study showed that use of health services depends largely on mobility levels.
However, much work needs to be done to promote this aspect of transport and health. The standard health impact assessment model for transport in the UK misses out on inequalities, which was notable in other presentations about health impacts during the conference.
Negative view
A part of this relates to an ambivalent if not negative view of the car by many in the field. One transport planner, talking about consultation with end-users, stated that a desk in an office is not the best place to plan transport for others. So, too, a privileged academic position in a large city with good public transport and increasing cyclist access may not be the best place to visualise the broader picture, particularly for those in rural and suburban areas, and people with disabilities.
Not only is the car recognised as a valuable means of extending independent living for older people in the community, but the condition that stops them using the car usually also hinders them from using most forms of public transport. Effective alternative transportation is generally by way of someone else’s car.
I personally regard any minute spent behind the wheel of a car as one stolen from my life, and I use public transport and cycle whenever I can. But I am aware that this pattern exists in addition to access to a car when and where I need it.
Indeed, it is notable that the Netherlands, whose €31 billion fiscal advantage from cycling was vaunted at the conference, has one of the highest rates of car ownership in the world.
So, while all societies will benefit from better urban and infrastructure planning, improved walking and cycling access and more efficient public transport, it seems clear that these should be seen as complementary to the car in its various and evolving guises (including short-term rental such as GoCar, Uber and driverless).
The trick is to encourage multi-modality of transport as a lifelong strategy.
Prof Des O’Neill is a consultant geriatrician and director of the National Programme Office for Traffic Medicine, RSA/RCPI. This article is based on a BMJ Blog.