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City cycling: Road to fitness, or accident waiting to happen?

By Lesley Evans Ogden
March 4, 2014 -- Updated 1042 GMT (1842 HKT)
A cyclist rides a public hire
A cyclist rides a public hire "Boris Bike" in central London, November 2013.
STORY HIGHLIGHTS
  • Some argue that cycling can lower risk of certain diseases - but at what cost?
  • Copenhagen, Amsterdam are bike-friendly cities, with extensive cycle routes
  • Studies show that safety improves in a city as the total number of cyclists increases
  • Northern Europe leading the way for city cycling infrastructure

Editor's note: CNN.com is showcasing the work of Mosaic, a new digital publication that explores the science of life. It's produced by the Wellcome Trust, a global charitable foundation that supports research in biology, medicine and the medical humanities, with the goal of improving human and animal health. The content is produced solely by Mosaic, and we will be posting some of its most thought-provoking work.

(CNN) -- It was just another morning commute. That is, until a bus driver ran a red light, turned right, and drove straight into Ann-Doerthe Hass Jensen. The bus knocked the social worker off her bike, trapping her underneath, a wheel pinning down and crushing her left foot. It was a school bus heading to a Copenhagen kindergarten, and the children aboard were screaming. Ann was rushed to hospital in excruciating pain, every bone in her foot shattered.

In the six weeks of hospitalization that followed, part of Ann's foot was amputated. Salvageable bones were wired back into place and skin grafts were taken from her thigh to replace the torn and missing flesh. "I'm pretty lucky," says Ann. "People normally die when this happens."

Here, the taxi drivers are a menace, and I was really scared of accidents.
Ann-Doerthe Hass Jensen, cyclist, Copenhagen

It was a year before she could walk again. During that year, she had to take a taxi to work every day. "I hated it," she says. "Here, the taxi drivers are a menace, and I was really scared of accidents." She also hated having to wait. Traveling by bike in Copenhagen is often the fastest way to get around, which is the top reason why Copenhageners cycle.

Ann's physiotherapy was tricky. The missing portion of her foot is a crucial stepping point, and its absence affects her balance. But walking wasn't the only part of her rehabilitation. In Copenhagen -- where people own 5.2 bicycles for every car, over a third of residents pedal to work, school or college. So rehabilitation often literally means getting you back in the saddle. The City of Copenhagen helped Ann get a specially adapted Nihola cycle: a sturdy, stable three-wheeler that has allowed her to regain independent mobility.

In cities across the world, researchers, planners and policy makers are examining the many potential plus points of cycling. Increasing the proportion of people who cycle or walk, rather than drive, could not only reduce air pollution and greenhouse gas emissions, but also lower people's risk of developing a number of diseases. But at what cost? To what extent does cycling in cities expose you to the risk of injury or death? What makes some cities so much safer and attractive for cyclists than others?

The drastically different design and policy approaches taken by large cities in Europe and North America provide some stark comparisons on cycling safety, equity and its impact on public health. To weigh up the risks and benefits of city cycling, and explore what can be learned where public health, urban design and transport engineering meet, I did what I had to do: I hopped on a bike.

Paris

Cycling smart, in Paris, France.
Jean-Philippe Ksiazek/AFP/GettyImages


In Paris, new bike lanes are pervasive. Though many of the streets are centuries old, sometimes cobbled, and claustrophobically narrow, bike lanes have been prominently marked. There are also some segregated cycle paths, often crazily disconnected -- disappearing and appearing again in a seemingly random fashion. Skinny one-way streets might have bike lanes on the right, so you cycle with the direction of the traffic, or on the left, so you're in the contraflow.

Oddly though, I didn't feel unsafe cycling these narrow lanes. Many are marked 30 kph for cars. Having parked cars on the right of the bike lane, so they're facing you, can be advantageous: it's the passenger-side door that opens into bike traffic, so it's less likely you'll be struck than if it were the driver's side exposed. And if you were to cycle into an open passenger door, you're more likely to close it than open it further.

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On some major streets, like Boulevard Saint-Michel, there are special lanes shared by bikes and buses. Though I felt less squeezed cycling in these wide lanes, where traffic was much lighter than the adjacent lanes for cars, I did feel a little intimidated about sharing the lane with buses. That said, the Parisian bus drivers gave me plenty of space, and didn't behave aggressively. I did get a sense that traffic here has become accustomed to bicycles. There are some off-street cycle paths too. Zooming alongside the Seine on the elevated bike path, totally segregated from motorized traffic, was pure delight.

Velib' bikes, from Paris's bicycle-sharing system, were in use everywhere. I saw men in suits, teenagers, women in chic business attire, pensioners, and female university students riding side by side on the bikes. Posting celebrity Velib' sightings on social media has apparently become something of a local pastime. The bikes are such a fixture that I saw one young man taking a break on a parked Velib', feet on the handlebars, chatting on his mobile phone.

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In the midst of Paris's cycling revolution, it seemed fitting to meet Ari Rabl at Le Procope, a city restaurant where some of the leaders of the French Revolution gathered. With Audrey de Nazelle, a Lecturer at the Center for Environmental Policy at Imperial College London, Rabl, a consultant and retired senior scientist at the Centre Energetique et Procédes of the Ecole des Mines in Paris, has looked at the health benefits when people move from cars to walking or cycling.

Rabl explains that they found that the population-level costs due to fatal accidents are outweighed at least 10-fold by the health benefits of walking or cycling. Monetizing the costs and benefits, Rabl and de Nazelle estimated that for a driver who switches from driving to cycling for their 5 km commute, the overall health benefit from physical activity is worth about €1,300 ($1,795) per year. Of course, it's important to point out that while fatal accidents might be reported as small "population-level costs" in public health studies, they have tragic, catastrophic costs for individuals and their loved ones.

Copenhagen

City of cyclists. Copenhagen, Denmark
Attila Kisbenedek/AFP/Getty Images


Four days earlier, and some 1,000 or so kilometers north-east, I'm sitting in a conference room at the University of Copenhagen's Department of Public Health, overlooking the picturesque Lakes area. Around the table are health researchers Astrid Ledgaard Holm, Henning Langberg and Henrik Bronnum-Hansen.

People here can easily be riding back and forth 5 km per day, and if you ask them ... if they are physically active, they will say 'No, I don't do any exercise.'
Ledgaard Holm, doctoral student, Copenhagen

Ledgaard Holm, a doctoral student, has modeled the health impacts of increased cycling. Accounting for physical activity, exposure to accidents and air pollution, she and colleagues found that the overall burden of disease -- including heart disease, stroke, type II diabetes, breast cancer, colon cancer, cardiopulmonary disease and lung cancer -- was reduced in people who cycled. The positive health effects of increased cycling were more than a third larger than the potential loss of health from bicycle accidents and air pollution.

Other studies investigating the health impacts of cycling have found similar positive benefits, although the magnitude varies. In a different study based in Copenhagen, researchers analyzed data from over 13,000 women and 17,000 men to explore the impact of physical activity on mortality. Even after adjusting for other factors, such as physical activity in leisure time, they found that people who did not cycle to work experienced a 39% higher mortality rate than those who did. In other words, cycling improved longevity.

One of the most interesting insights the Danish researchers share is how they've discovered that many Danes don't consider cycling exercise. "People here can easily be riding back and forth 5 km per day, and if you ask them on a questionnaire if they are physically active, they will say 'No, I don't do any exercise'," says Holm. For many here, she says, it's not a choice of activity, but your mode of transport.

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What's immediately striking about cycling in Copenhagen is the incredible diversity of individuals on bicycles. Embedding myself in the morning rush-hour traffic on Norrebrogade, one of Copenhagen's busiest cycle routes, I see a woman in a long flowing black jilbab pedaling a cargo bike with two small children in the basket. I see men of all ages in suits; women in dresses, high-heeled boots and smart coats, flowing garments protected from the spokes by metal skirt guards on the wheel hub. I see university students and children cycling to school; toddlers strapped into child seats on the front or back of mum or dad's bike; and baskets of children pedaled along in sturdy Christiana or streamlined Bullit bikes. Some children ride the cycle paths independently. Others are shepherded by parents cycling alongside, who guide their charges with the occasional gentle hand on the back.

It's a very strong story about finding the right measures, and designing a road space in a way that protects the users, especially those cycling.
Niels Torslov, traffic director, City of Copenhagen

While cycling to interviews at the University of Copenhagen one morning, I happen upon a makeshift memorial on the side of the street. At the intersection of Store Kongensgade and Dronningens Tværgade in the city center, a stretch of tarmac the length of a body is adorned with fresh flowers and candle jars inscribed with handwritten notes. I discover later that it's where a 20-year-old woman on her bike was struck and killed several weeks earlier by a tourist bus making a right-hand turn.

Decades after streets were first painted with white crosses to mark fallen cyclists, cycling accidents, although rare, are still not taken lightly here. Only one Copenhagen cyclist was killed in 2012, and no year from 1998 to 2012 has seen more than seven cyclists killed in the city, according to Statistics Denmark. These figures are quite something in a city where the population cycles an estimated 1.27 million km every day. The risk associated with being a cyclist in Copenhagen "has dropped by more than 70% over the last 15 years" according to Niels Torslov, the City of Copenhagen's traffic director. "And it's a very strong story about finding the right measures, and designing a road space in a way that protects the users, especially those cycling."

The use of cycling helmets is growing among Copenhageners, noticeably more than in Amsterdam, where helmet wearing is still very much an exception. At the time of her accident, in 2006, Ann-Doerthe Hass Jensen was wearing a helmet, though clearly, as she says herself, a helmet protects your head but not your feet. She says that working at Copenhagen's Center for Rehabilitation of Brain Injury, as she does, makes you fanatical about helmets. "There is no way I would not have a helmet on," she says.

After several days of exploring Copenhagen by bike, I meet Ann at the Center, where she leads me outside to see her specially adapted tricycle. Her sense of pride is palpable. It takes her between 30 and 40 minutes to make the trip from home to work. "The first few times I got back on a bike again, it was hard. Really, really hard," she says. "There was a lot of crying." Now, though, there is no stopping her.

"The first few times I got back on a bike again, it was hard ...There was a lot of crying
Ann-Doerthe Hass Jensen, cyclist, Copenhagen

In her first year of recovery, Ann's rehabilitation team felt she needed to re-establish both the freedom of mobility and the quality of life that her bicycle had previously allowed. It wasn't easy. Beyond the physical challenges of getting Ann back in the saddle, there was another hurdle: her enormous fear. "I had to work with a psychologist... because I was scared like hell," she says. Using cognitive therapy, she and her psychologist worked through the entire experience, going over the incident report in excruciating detail. Pushing through that fear was tough. "It wasn't my perception that was off that day. It was somebody who actually did something wrong. And it took me a while to get my confidence again," she says. Ann's fear was not unreasonable. Her experience wasn't just "an accident." It was the action of a negligent driver, whose license was revoked when the case came to court two years later.

London

Cycling in the shadow of a London bus.
Peter Macdiarmid/Getty Images


Research shows that perceived safety -- how safe you feel -- is at least as critical as measured safety to the willingness of citizens to hop on a bike. For me, of all the cities I cycled in, London was the most terrifying.

I hate the Tube, it's really unhealthy and sweaty and overcrowded
London cyclist

Cyclists were prevalent in the center of the city, and what immediately struck me, beyond the dense, fast-moving traffic they were attempting to navigate, was the rapid speed they were cycling at. In impromptu interviews with cyclists stopped at traffic lights, I asked one woman why she cycled. Her answer: "I hate the Tube [London's underground train system], it's really unhealthy and sweaty and overcrowded." Asked if she felt safe cycling, she said, "No. That's the honest answer." But her sentiments weren't shared by everyone I asked. A student who had just moved to London said, "It's about five to 10 years ahead of New York," adding that she felt quite safe cycling on London's cycle superhighways.

I, on the other hand, did not. I spent some time watching cyclists crossing the Southwark Bridge section of one of the cycle superhighways. Riding along CS7's blue painted bike lane on a Boris Bike (the nickname for bikes in London's cycle hire scheme, introduced in 2010 under Mayor Boris Johnson) largely unseparated from mixed, fast-moving traffic, made me anxious and uneasy. What's more, I suffer from asthma, making me a bit of a human canary for air pollution. After the noticeably clean air of Copenhagen, the polluted air of London made for labored breathing.

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London is beginning to make progress on provisions for cyclists, and there are good sections of the growing infrastructure, but I saw plenty of room for improvement. On both sides of Southwark Bridge, which crosses the river Thames, the short, separated span of blue bike lane, protected by a concrete barrier, fed straight into a bus stop. This forced cyclists to choose between two unappealing options: wait like a sitting duck behind the bus while it stops, or pull out into traffic to overtake, and risk being in one of the bus's many blind spots when it pulls out from the curb. Peter Wright is the delivery planner for cycling at Transport for London (TfL), the local government body chaired by Johnson. Wright explains that bus-stop bypasses are planned, "to try and avoid conflict so that cyclists don't have to come out into general traffic." A similar hazard was delivery vehicles parked in bike lanes, a common sight in London and Paris.

In 2015, we will be spending £145 million ($240 million) a year on cycling.
Ben Plowden, TfL Surface Transport

In November 2013, when asked about the spate of cycling deaths, Johnson told the Guardian that if cyclists did not follow the rules, "there's no amount of traffic engineering that we invest in that is going to save people's lives." Growing evidence suggests that statement is untenable, not to mention that it blames the victim. I requested an interview with Johnson. His press office did not reply.

To be fair, though, London's Mayor -- a cyclist himself -- is making gradual progress. In 2013, TfL announced its Safe Streets for London plan, which aims to reduce the number of people killed or seriously injured by 40% by 2020. Ben Plowden from TfL Surface Transport said: "In 2015, we will be spending £145 million ($240 million) a year on cycling, or roughly £18 ($30) a head, up with the best in Germany and almost on a par with the Netherlands. This represents around 2% of TfL's overall expenditure and is roughly proportionate to the current 2% mode share of cycling." He added that cycle spending would total £913m ($1.5 billion) during the next 10 years, more than treble previously planned levels.

Safety in numbers

Annual fatalities per 10,000 bike commuters

Copenhagen 0.3

Amsterdam 0.4

Vancouver 0.9

Toronto 1.3

Portland 1.9

Montréal 2.0

Annual fatalities per 100,000 daily cyclists

Paris 8.2

London 11.0

New York 37.6.

(All 2010 except Paris, London and New York, 2009)

(Source: "City Cycling," John Pucher, Ralph Buehler, 2012)

It is not completely clear how and why accident rates change as the number of cyclists varies, but a "safety in numbers" effect seems to occur: safety improves in a city as the total number of cyclists increases. This effect has been seen in studies in Denmark, the Netherlands, 14 other European countries, Australia and 68 cities in California.

"It is likely that causation runs in both directions: safer cycling encourages more cycling, and more cycling encourages greater safety," writes John Pucher, Professor of Urban Planning at Rutgers University, in his recent book "City Cycling." Motorist behavior probably contributes to this phenomenon. In places like Copenhagen -- where four out of five individuals have access to a bicycle -- most drivers are also cyclists, and so are accustomed to sharing public space with bicycles.

It can be difficult to compare safety between cities because of the lack of consistency in data collection and because of the need to frame injuries and deaths within the context of "exposure" -- the overall numbers of trips, total distance or time spent cycling. Under-reporting of cycling crashes is also a well-documented problem. Nevertheless, Pucher's 2012 book written with Ralph Buehler, "City Cycling," listed figures for annual fatalities per 10,000 daily cyclists (see sidebar).

Unless you are traveling at breakneck speed, though, there is nothing inherently dangerous about cycling -- it's the environment you're in that creates danger. Ian Roberts, professor in the Nutrition and Public Health Intervention Research Unit at the London School of Hygiene and Tropical Medicine, began his career as a pediatric trauma doctor. "I saw lots of children hit by cars," he says, "and it really is awful." He describes these deaths as "kinetic energy disease" -- a reference to the idea of mismatched masses in motion. When one of those masses is protected by metal casing, but the other isn't, it's clear who is more likely to be hurt.

Over the years it became obvious that people were walking and cycling less than ever before in the history of humans on the planet.
Professor Ian Roberts, London School of Hygiene and Tropical Medicine

One of the trends Roberts has puzzled over is the long-term decline in the death rates of British pedestrians, despite an increase in motorization. "Road safety people would point to it as an example of how roads are getting safer. But I was a little bit skeptical... because [the] volume of kinetic energy on the road was going up."

An alternative hypothesis was that in industrialized countries, there were fewer people walking, something investigated in research he conducted while working in New Zealand. "Over the years it became obvious that people were walking and cycling less than ever before in the history of humans on the planet," says Roberts. "The world was not getting safer, it was getting more hostile, and people were voting with their feet by getting out of the way."

"Vehicular cycling"

Vehicular cycling in Buenos Aires, Argentina.
Daniel Garcia/AFP/Getty Images


In North America in the 1970s, cyclists -- or at least the most vocal advocacy groups purporting to represent them -- did not want to get out of the way. So-called vehicular cycling was emerging, a philosophy that has influenced transport policy in both North America and Britain. Fathered by Californian industrial engineer and cycling activist John Forester, vehicular cycling encourages cyclists to travel on the road in mixed traffic. On his website, Forester writes: "Vehicular cycling, so named because you are acting as the driver of a vehicle, just as the traffic laws require, is faster and more enjoyable, so that the plain joy of cycling overrides the annoyance of even heavy traffic."

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In 1970s California, lots of athletic cyclists were forming touring groups for riding fast on roads, explains Anne Lusk, a research scientist at the Harvard School of Public Health. Back then, she says, such groups may have legitimately feared that U.S. adoption of Dutch-style cycle paths would restrict bike access to roads. "At the time, paths were becoming crowded by joggers, walkers, in-line skaters and baby-carriage pushers," says Lusk, so cycling advocates fought forcefully against proposals for cycle paths.

The vehicular cycling philosophy became incorporated into U.S. guidelines for transport design, and its influence was felt for decades, limiting the building of physically separated cycle tracks and putting cyclists on the road with cars. "It's something that really stuck in North America," says Meghan Winters, assistant professor in the Faculty of Health Sciences at Simon Fraser University, Canada. Asked if the philosophy of vehicular cycling is evidence-based, she says no. "But it's something that was sticky and was adopted very broadly for very, very many years," she adds.

Forester's teachings included how to operate as a motor vehicle, with skills like not riding in the door zone (the area next to a parked car where an opened door could hit a moving cyclist). They were useful, says Lusk, in that they did teach people how to bike with cars if they had to. But she does not endorse Forester's view that there should be no cycle lanes painted on the road, no separate cycle tracks and no cycle symbols.

Cycling is too important as a mode of transport to leave it only to the daring helmeted cycle warriors in conspicuous jackets.
Tom Godefrooij, Dutch Cycling Embassy

Lusk, and other researchers who have studied the particular needs of certain groups of cyclists -- such as women, children, elderly people and parents transporting children -- point out that many of these riders cannot operate as a vehicle as confidently as, say, a fit young man on a racing or touring bike. Utilitarian cycling, with bike-specific transport infrastructure, is about being inclusive, addressing the needs of cyclists young and old, male and female. The need for speed is not universal among cyclists, nor is feeling comfortable cycling in heavy, motorized traffic.

It's precisely the recognition that cyclists come in all shapes and sizes, and with all kinds of needs, that has driven the last several decades of cycling infrastructure and policy in Denmark and the Netherlands. Tom Godefrooij of the Dutch Cycling Embassy writes: "Cycling is too important as a mode of transport to leave it only to the daring helmeted cycle warriors in conspicuous jackets. Cycling should not be elitist, but for all.

Amsterdam

Cycle friendly: Amsterdam, Netherlands
Timothy Clary/AFP/Getty Images

Outside Amsterdam's Schiphol airport, I see a worker giving his colleague a lift to the airplane on the back of his bike, an example of just how deeply embedded cycling is in Dutch culture.

A bicycle is by far the best and quickest way to get around Amsterdam, local journalist Bennie Mols tells me. One new hazard he laments is tourists on bikes, who lack the understanding of how and where to ride. His description stirs a guilty pang. I learn quickly (but too late) that the hand signal for "stop" is essential in busy bike traffic. Failing to use it as I slow down to navigate, I cause a near-collision as a herd of bicycles behind me screeches to a halt, one woman yelling "Seriously?" at me multiple times as she skids to a stop on the grassy verge. Wishing I could dissolve into the bike path, I sheepishly review the hand signals in my guidebook. It's a mistake I don't make again.

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Amsterdam and Copenhagen weren't always the cycle-friendly cities they are today. In the Netherlands, as car-buying wealth grew in the postwar era, cycling rates dropped precipitously from about 85% of all trips in the 1950s to about 20% in the early 1970s. As the numbers of cyclists fell, discontent grew over the increasing numbers of cyclists and pedestrians killed in traffic accidents. A journalist whose daughter had been killed in traffic launched the "Stop Kindermoord" (stop the child murder) movement. There were widespread street protests.

Danish transport policy reached a tipping point in the 1970s and 1980s, when the nation veered away from urban planning dominated by provisions for motorized vehicles, towards the establishment of cycling-specific infrastructure and traffic calming. As Stop Kindermoord emerged in the Netherlands, a coincident movement grew in Denmark. The public rose up against a proposal to build a major motorway alongside a picturesque area of Copenhagen known as the Lakes. Massive demonstrations ensued. It was during this era that protesters began painting white crosses on the streets where cyclists had been killed in traffic.

So while most other developed nations continued through the 1980s and beyond with road transport design that prioritized the needs of motorized vehicles, a dramatic change was taking place in northern Europe. The shift in thinking catalyzed by public protest was that, rather than requiring children and cyclists to adapt to motorized traffic, traffic should adapt to children and cyclists.

I think North America may be coming around now.
Meghan Winters, Simon Fraser University, Canada.

Northern Europe's shift towards a safer, more convenient infrastructure for cyclists and pedestrians created an unplanned natural experiment -- albeit one fraught with uncontrolled variables including car taxes, climate, topography, political differences and dependence on the car industry for employment. Nevertheless, in cities oriented towards motor vehicles, the limited provision of transport routes that safely accommodate bikes and a default assumption that riders will adopt vehicular cycling have resulted in stagnantly low numbers of (mostly male) cyclists, for the best part of three decades.

"There are dramatic differences in terms of cycling rates and cycling safety between those two places [northern Europe and North America]," says Winters. "So I think the evidence clearly illustrates which one of these strategies is effective if your goal is to get large segments of the population cycling, and cycling safely... In a sense, this is a global experiment on that, and I think North America may be coming around now," she says. Perhaps. But there's a long road ahead.

Toronto

Toronto, Canada
Chip Somodevilla/Getty Images

In the summer of 2013, Toronto traffic was a mess. In the midst of major street reconstruction and resurfacing, traffic queued bumper-to-bumper heading south on Bay Street, near City Hall. There were a few demarcated bike lanes, and only one separated bike path (not including the completely off-street routes like the largely recreational path along the lakeshore). Taxis wove in and out of lanes, sometimes coming very close to the curb -- the space shared with bicycles. It felt like a hostile environment for cyclists, and I did not sense much tolerance of bikes from motorists.

One of the cyclists I speak to in an impromptu interview says that it's pedestrians rather than vehicles that he worries about most. Other hazards for Toronto cyclists include streetcars. Their tracks, which can trap a bicycle wheel if crossed in parallel, are particularly nerve-wracking. Toronto is not an unfamiliar city to me -- I lived there for more than a decade -- but returning to cycle downtown was not a pleasant experience.

Vancouver

Recumbent cycling in Vancouver, Canada
Mark Ralston/AFP/Getty Image

In Vancouver, however, there's a shift in transportation thinking. I noted a growing number of bike lanes, segregated bike paths, and painted bike boxes at junctions, which give cyclists a safe place to await a green light and turn safely, ahead of motorists.

Though recreational cycling in places like Stanley Park has been possible for decades, it's cycling as transportation that is the focus of the Vancouver City Council and Mayor Gregor Robertson, who cycles to work. Some of the new separated bike paths feel very safe and easy to use. But there are still places where lanes end in a fairly hazardous way, such as one junction where the bike lane ends abruptly only to reappear a few meters later in the middle of two lanes of car traffic. Cycling along Dunsmuir and over the bridge viaduct on the fully segregated bike lane feels incredibly liberating. Perhaps I'm pushing my luck riding a bike around downtown Vancouver on Friday the 13th, but where the bike routes are marked, or traffic is calmed, I feel relatively safe.

The science of urban cycling is messy, but the case for separated bike lanes combined with traffic-calming measures (to reduce vehicle speed) is mounting. A 2009 paper that examined findings from 23 studies from across the world suggested that "purpose-built bicycle-specific facilities reduce crashes and injuries among cyclists."

Recent research in Vancouver and Toronto by a collaboration of 14 researchers, including Winters, found that "at local street intersections, traditional stops are safer than traffic circles [roundabouts], and at non-intersections, cycle tracks alongside major streets and traffic diversion from local streets are safer than no bicycle infrastructure."

Montreal

Braving the snow in Montreal, Canada
Rogerio Barbosa/AFP/Getty Images

Montreal was the most cycle-friendly Canadian city I visited. Even where bike lanes were not explicitly marked, motorists were generally patient and considerate in terms of sharing space with cyclists. Though definitely more hilly than Amsterdam and Copenhagen, the undulating topography doesn't seem to be an impediment to Montrealers.

Montreal means "Mount Royal," referring to the steep -- if not entirely mountainous -- hill and park near the center of town. The Plateau area, an uphill climb from the city center, is one of the most heavily cycled parts of the city. It hosts the city's oldest major bike path, along Rue de Brébeuf, a route that spans the entire island of Montreal. During morning rush hour, I saw a steady stream of bikes along Boulevard de Maisonneuve, one of several bi-directional, fully segregated bike paths with bike-specific traffic lights. Bikes are also allowed in Montreal's parks, many of which have trails for recreational or commuting use.

It was in Montreal, the only large North American city to have cycling infrastructure dating back to the 1980s, that Anne Lusk and colleagues tested the safety of separated cycling infrastructure versus road cycling. They found that separated cycle tracks have lower crash and injury rates (or at least no higher) than the street, and have seen a similar trend in the USA. And research by Winters and colleagues adds to the evidence, finding that bicycle-specific infrastructure that reduces interactions between cyclists and motor vehicles can reduce the occurrence of injuries, potentially by more than 50%.

Safe cycling

So, how do we make our cities better for cyclists? Safe-cycling cities, policies and legislation already exist, and can inspire others. In Oregon, Portland's "vulnerable user law," for example, is modeled on a European safety concept, says Portland attorney Ray Thomas, a partner at Swanson, Thomas, Coon and Newton, who specializes in cycling law. In Copenhagen, in one of many chance interviews with cyclists on city streets, I happen upon a young American student -- Mike Milan, from Greenville, South Carolina -- who is studying architecture there. "As I've learned in my urban design class here, Copenhagen has tried to slow down the city to a human pace, and a human scale," he says. His thoughts conceptually crystallize the city's transport philosophy, and are equally applicable to Amsterdam.

We need infrastructure that allows a broader cross-section of society to get onto a bike.
Jack Harris, Tally Ho! Cycle Tours, London

"Making people feel safer on bikes should not mean equipping them with high-vis and reflective helmets," says Jack Harris, owner of London's Tally Ho! Cycle Tours. "We need infrastructure that allows a broader cross-section of society to get onto a bike." The places that are serious about encouraging cycling as a safe, accessible and pleasant mode of transport have some tough decisions to make about vulnerable users, including cyclists, in the allocation of urban space.

At the Copenhagen rehabilitation center where Ann-Doerthe Hass Jensen works, her physiotherapist colleague Daniel Thue Bech-Pedersen says: "Our main goal of rehabilitation is to allow any individual to be more active again." This can mean being active for work, for leisure, for getting yourself around. "When you can transport yourself and make sure you lower your risk of having another stroke or whatever," he says, "then one plus one equals three."

Ann suffers chronic pain from her foot, wears special orthopedic shoes and walks with a cane, so getting back to cycling made a massive difference to her mobility. It also gave her back her independence. On her cargo trike, she can take her two-year-old niece out on excursions, something that would be impossible on foot or by bus. Asked how she feels at this point along her recovery and about riding to work each day, she replies confidently and without hesitation: "I love it." Her tricycle has given her much more than just a means of getting about. Being mobile means being independent, but even more, it means being free.

Research for this article was supported in part by a journalism award to Lesley Evans Ogden from the Canadian Institutes of Health Research. #citycycling

Copyright 2014 The Wellcome Trust. Some rights reserved.

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Lika Rose Caticon, 7, who is suffering from Typhoid fever, holds a doll as she lies in a makeshift cot at the overcrowded JP Rizal Memorial District Hospital in Calamba City south of the Philippine capital Manila on March 5, 2008.
As we travel ever further afield, which infectious diseases do you need to know about?
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Vital Signs is a monthly program bringing viewers health stories from around the world.
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