The paradox of prevention

BMJ 1996; 313 doi: (Published 02 November 1996) Cite this as: BMJ 1996;313:1104

“Sentimentality is the worst of all motives in the making of social policy.” So began one of dozens of vicious attacks recently launched against the New South Wales government when it amended the law to make it illegal for taxis to carry babies unless they are secured in a car seat.

The restraints have been mandatory in private cars for over a decade. In 1993, 19 unrestrained children were involved in car crashes; five died. Among 228 restrained children only one died.

All week, radio programmes and newspapers threw their lines and letters pages over to angry parents who regaled “government stupidity” with real and predicted stories of taxis refusing to carry babies, consequent long walks with crying, sick children, and the government being out of touch with the needs of people who use taxis because they cannot afford a car. Cab drivers complained that storing the bulky car seats in their boots would not allow them to carry luggage. The plan required taxi companies to provide a cab fitted with a car seat when a parent phoned a booking. No extra charge could be made, and the main problem was expected to be longer waiting times.

Part of the difficulty in selling the new rule lay in the infrequency of injuries and deaths to babies in taxis. Since 1983 only 11 children aged under 1 year have been killed or injured in taxis in New South Wales, compared with 1327 in private cars. Few would therefore have experienced such injuries to their infants or heard of them happening to others. The reason for this difference is that for every taxi there are 451 cars, and babies do not travel far in taxis.

But the parallel observation can, of course, be made about inconvenience. Because transporting babies in taxis is comparatively uncommon, being inconvenienced when waiting for a taxi fitted with a car seat will be correspondingly uncommon. In other words, defenders of the car seats argued: What does it really matter if several times a year parents might have to wait 30 minutes extra for the right taxi when the trade off is immense protection from horrendous injury?

The history of public health is strewn with protests from people complaining that they are inconvenienced by laws imposed for the health, safety, and wellbeing of disadvantaged groups. Seat belts, crash helmets, random breath testing, speed limits, and traffic calming have all met with similar protests. This latest protest comes at a time when Australia's toll of road deaths reflects the benefits of these safety measures in reaching a record low.

Ten years ago kerbs, public buildings, and taxis made no provision for the minority of citizens who use wheelchairs. There were howls of protest about the expense the able bodied community would have to bear when businesses and councils passed on the costs of installing ramps and access facilities.

After all the heart wrenching scenarios of parents stranded in the rain with shivering babies have been paraded, the bottom line of attacks on the new law is the view that people are justified in gambling with a baby's life when they might be merely inconvenienced.

The state transport and health ministers have suffered immense criticism over their decision. Their resolve to act in the interests of babies, who cannot speak up for their own rights, is a rare but welcome example of “unpopular prevention.” They deserve the thanks of every parent whose child will be protected. But the chances are that they won't ever get it.

That's the paradox with prevention—it works when nothing happens. People thank doctors for performing a lifesaving operation, but if they grow up without being badly injured or without taking up smoking and developing emphysema they are seldom thankful for the preventive actions of people who bore the brunt of public anger about inconvenience years ago.—SIMON CHAPMAN, associate professor of public health and community medicine, Sydney

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