Introduction to Health Impact Assessment
PHS 740 HIA of Global Environmental Change
UW Madison
Spring 2010
Aaron Wernham, M.D., M.S.
Director | The Health Impact Project
901 E Street, NW, Washington, D.C. 2004
p: 202.540.6346
e: awernham@pewtrusts.org
www.healthimpactproject.org
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Public health
•
•
•
•
•
10 % “health” care
30 % genetics
5 -25% “environmental factors”
15 % social circumstances
40 % “modifiable” behavior:
• Diet, but… -food pricing, school nutrition programs,
food deserts, advertising, etc…
• Exercise … -mechanization, lack of walkable
urban environments, danger, time
constraints…
Environmental health and chronic
disease: an evolving relationship
Environmental health
-sanitation
-pollution control
-vector control
Chronic disease
HP/DP: focus on behavior
modification: Diet & exercise
guidelines, smoking cessation..
“Health in all policies”
“Health and the built environment”
Exercise: safe routes to school, access to
parks, complete streets
Diet:
agricultural policy and food pricing,
access to grocery stores
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World Health Organization
Ottawa Charter for Health Promotion
Ottawa, 1986
The Prerequisites and prospects for health cannot be ensured
by the health sector alone. More importantly, health promotion
demands coordinated action by all concerned: by governments, by
health and other social and economic sectors, by nongovernmental
and voluntary organization, by local authorities, by industry, and by
the media.
Public Health: Where are we going?
"(The) toxic combination of bad policies, economics, and
politics is, in large measure, responsible for the fact that a
majority of people in the world do not enjoy the good health that
is biologically possible.” WHO Commission on Social Determinants of
Health, 2009
Health in all policies.” APHA supports
requiring all new federal policies and
programs to take into consideration all
Impacts, both positive and negative, on
the
public’s health.
“Health is the responsibility of all
sectors,” but…
How
No common
language:
do we
put this


into practice?
transportation engineers don’t understand health data.
public health professionals don’t understand the
constraints and limitations of the planning process
 Few routine/formalized requirements
 No routine/formalized interaction between health and
other sectors
 No funding for new public health activities
 “Going out on a limb:”
Public health is science-driven, and policy and planning
are governed by many other considerations: economics,
politics, technology, deadines, etc …
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Health Impact Assessment
A combination of procedures, methods and tools that
systematically judges the potential effects of a policy,
programme or project on the health of a population and the
distribution of those effects within the population. HIA identifies
appropriate actions to manage those effects.
(IAIA 2006, adapted from world health organization, 1999)
A practical approach for collaborating with other sectors,
translating public health research into predictions and
reasonable recommendations that policy makers can use to
ensure that new public decisions contribute to healthier
communities.
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The HIA Process
1. Screening –is HIA feasible and likely to add value?
2. Scoping – determine the important health effects,
affected populations, available evidence, etc
3. Assessment – analyze baseline conditions and
likely health effects
4. Recommendations, Implementation and Advocacy
5. Reporting – disseminate the report to the public,
stakeholders, solicit input
6. Monitoring and Evaluation
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Analytical Framework
Proposed policy,
project, program
Determinants of
health
Health outcomes
• Broad framework: considers multiple determinants and
dimensions of health
• Considers direct and indirect pathways
• Qualitative and quantitative methods common
• Focus: predicting outcomes, in order to manage effects
• There may be conflicting influences on a health outcome:
predicting the outcome may be less important than
identifying the various influences on it, and managing them
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Types of HIA
Rapid
Voluntary
Retrospective
Participatory
Comprehensive
Regulatory
Prospective
Procedural
Initiated/conducted by:
Community/
Industry
Ad hoc
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Agency
Behind the standard definitions: what is it
that really differentiates HIA?
Is there anything besides the analysis and the report that defines
the field?
One possible answer: emphasis on engagement: brings public
health professionals,
community stakeholders,
planners, developers, and
decision-makers to the table, with a
focus on practical, realistic
solutions.
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Public participation in HIA
Not typically included in the basic definition of HIA, but it
probably should be. Several variables:
• Transparency: is the HIA public?
• Public/stakeholder participation: does the HIA allow
opportunities for key stakeholders to participate in the
analysis?
• Public input: does the HIA process afford the opportunity for
the public to comment?
• Accountability: how does the HIA respond to public
comment?
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Health Impact Assessment
Current Applications:
Canada and Australia: considerable work, both within
EIA and for other policies and projects.
EU: common use of HIA
• broad applications in policy-making, land-use, etc
• variety of governance structures
U.S.: Roughly 60 HIAs to date:
• Sporadic, often funded by foundations
• Other than some EIA laws, no formal requirements
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Health Impact Assessment
International business is starting to use it.
World Bank and IFC: part of evaluation standards
for large development loans
(IFC Guidance Note 4:
http://www.ifc.org/ifcext/enviro.nsf/Content/GuidanceNotes)
Equator Principles: ratified by the majority of large
lending banks worldwide, the Equator Principles
delineate ethical requirements for large
development loans: they refer to IFC standards
(http://www.equator-principles.com/principles.shtml )
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Completed HIAs in the United States
1999–2009 (N = 54)
WA 4
MT 1
MN 5
OR 2
MI 1
MA 2
PA 1
OH 1
NJ 1
CO 2
CA
25
MD 1
GA 4
AK 3
FL
1
Courtesy A. Dannenberg, A. Wendel, CDC
NCEH
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HIA Compared to other analytic approaches
•
•
•
•
Risk Assessment
Environmental impact assessment
Social impact assessment
Evaluation
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HIA Compared to other analytic approaches
Evaluation
“The systematic investigation of the merit, worth, or
significance of an object:”
• Can be retrospective or prospective
• Asks “what happened, or what is happening,” not “what
might happen?”
• Generally focused on existing programs, policies, or
projects (past or present events)
Present
Past
Future
Evaluation
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Impact Assessment
HIA
Risk Assessment
Focus of the
Assessment
Identify all of the pathways
through which anticipated
physical, social, and
economic changes
associated with a decision
may affect health
Calculate the risk associated
with a specific exposure
pathway
Objective
Identify all of the important
links between an proposal
and health, and manage the
effects to benefit health
Evaluate the risk of exposure
to a certain potentially harmful
substance or environmental
factor.
Methods
-A mixture of quantitative and Generally quantitative
qualitative/descriptive;
modeling, based on a set of
flexible, and dependant on
baseline assumptions.
the project being analyzed;
-Participatory
Conceptual
Framework
Broad/inclusive: social
epidemiology, environmental
justice
Narrow, and often focused on
specific dose-response
information, toxicology.
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HIA examples: San Francisco
New housing development near congested roads
• Decision: new zoning for a large
housing development. --HIA done
by SFDPH, in collaboration with
Planning Dept
• Example impact analysis and
outcome:
Impact: Air modeling showed air
pollution “hot spots” closes to
major roadway.
Outcome: new buildings required
to include particulate air filtration.
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HIA examples: Humboldt County General Plan
Alternative growth scenarios
Three alternative growth scenarios:
a. Focused infill: infill development – limited to current
municipal boundary, locations where there is existing
infrastructure
b. Moderate growth: infill development, and limited
expansion
c. Expanded development: minimally restricted expansion
outside current municipal border
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Humboldt County General Plan HIA
Examples of health determinants
Alternative A
Impact
Alternative B
Impact
Alternative C
Impact
ST.4
Proportion of households
with 1/4-mile access to local
bus
+
~
-
ST.5
Proportion of average
income spent on
transportation expense
+
~
-
ST.6
Ratio of miles of bike
lanes/pedestrian facilities to
road miles
+
-
-
ST.7
Proportion of commute trips
and trips to school made by
walking or biking
+
~
-
Indicator
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Description
Humboldt County General Plan HIA
Examples of health determinants
Indicator
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Description
Alternative A
Impact
Alternative B
Impact
Alternative C
Impact
To be
determined
To be
determined
-
ST.8
Number and rate of
bicycle/pedestrian injury
collisions
ST.9
Proportion of population
living on residential
streets with <35 mph
speed limits
+
~
-
ST.10
Percent of population
who have access to
pedestrian facilities
+
~
-
Oil leasing on Alaska’s North Slope
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Nuiqsut, Alaska
A small Inupiat community 7 miles from large oil development.
Over 10 years,
communities raised a
wide range of health
concerns as proposed
development drew
nearer to the
community
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Community health concerns
“The benefits of oil
development are clear -I don’t deny that for a moment.
The negative impacts are more
subtle. They’re also more
widespread and more costly
than most people realize. We know
the human impacts of development are significant and longterm. So far, we’ve been left to deal with them on our own.
They show up in our health statistics, alcohol treatment
programs, emergency service needs, police responses –
you name it." George Ahmaogak, Former Mayor of North Slope Borough
Keynote Address, Alaska Forum on the Environment 2004.
The First Federal HIA/EIS:
Oil and gas leasing in the National Petroleum Reserve
• Local government became a
“cooperating agency” – a role
defined by the National
Environmental Policy Act
through which local
governments can formally
participate in an EIS
• The community
health agency
drafted an HIA
through this role
• The lead federal
agency (BLM)
incorporated the
HIA into the EIS
Result of the NPR-A HIA?
Mitigation measures in the Northeast NPR-A EIS
General Outcome:
This was a very contentious leasing proposal.
Community engagement via the cooperating agency
relationship and HIA process resulted in:
• Improved relationships between the community and
the agency
• A compromise leasing plan that was widely accepted
on both sides
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Result of the NPR-A HIA?
Mitigation measures in the Northeast NPR-A EIS
Health Concern
Mitigation Measure
Need to address
health in planning
future projects
“Social ills”: alcohol,
STIs,
Air pollution
BLM will consult with relevant health
agencies in the development of future
proposals in Northeast NPR-A
Expand cultural orientation for workers
Additional baseline, modeling, and
monitoring above CAA requirements.
Contamination of local Baseline levels and ongoing monitoring
food sources
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Other examples of HIA
• Alaska: HIA of two large mines, done by two tribal health
organizations and integrated into the EISs for those projects
• Oregon: Upstream Public Health ( a non-profit group) health
benefits of a range of strategies to reduce Vehicle Miles
Travelled, for a new bill to reduce GHG emissions
• California: an HIA of Humboldt County’s Growth Plan,
commissioned by the County Health Department and
supported by the Planning Department
• Baltimore, MD: HIA by the Planning Department for a
proposed new light rail project, the Baltimore Redline
Visit www.healthimpactproject.org/hia or
www.humanimpact.org for links
The Health Impact Project CFP
Examples of applications received to date
1.State Budget Process: Two applications to address state
budget decisions, weigh the relative consequences of various
likely budget cuts, safety net spending, etc
2.State Cap-and-Trade regulations: an HIA to inform the
rulemaking process for California’s carbon cap and trade rule
3.Prison Reform: A university-based policy institute would
address a state legislative package of 6 bills on prisoner reentry
4.Agriculture Policy: A non-profit would engage in a county
agricultural plan that will shape the local economy, land use
patterns, and diet.
5.State immigration legislation: a university would examine
proposed state legislation to restrict access to public services
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HIA Basics:
Screening
Dual challenges in screening:
1. How does a public health official identify the
important legislative, administrative, regulatory,
or private decisions that might benefit from HIA?
2. From the list of possible HIAs, choosing the
projects most likely to add value.
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HIA Basics:
Screening
1. How does a public health official identify the
important legislative, administrative, regulatory,
or private decisions that might benefit from HIA?
• Legislative tracking
• Looking at federal and state EIAs
• Collaboration with planning dept, education
dept: set up routine meetings, working groups
-- build a culture of collaboration
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HIA Basics:
Screening
2. From the list of possible HIAs, choosing the projects most
likely to add value.
• Are there likely health effects?
• Is health already being considered? HIA may add the
most value to decisions where health is not the focus.
• Does the public have health concerns?
• Is the HIA likely to be successful?
• Are there legal or regulatory levers that would allow
implementation of health recommendations.
• Do you have the resources to do the HIA?
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HIA Basics:
Scoping
1. What aspects of the proposed project, policy, or program
might affect health?
2. What are the potential health effects?
3. Who will be affected?
• Geographic boundaries
• Demographics
• Vulnerable populations
4. Who are the stakeholders?
5. What are the data sources? Data gaps?
6. Public comments: what are the public’s concerns?
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Scoping:
Determining important health pathways
• Logic Frameworks
• Scoping tables
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Logic Frameworks
Policy/
Project
Education:
safety training
Engineering:
improve
pedestrian
facilities, traffic
calming
Enforcement:
increase police
presence,
crossing guards
Dedicated
resources:
walking school
busses
Proximal/Intermediate
Impacts
Health
Outcomes
walkability
safety
Motor vehicle
use
Injury
Air and noise
pollution
Asthma
Obesity
Physical
activity
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EXAMPLE: using a table for systematic scoping
Air
Quality
Injury
Infectious
Disease
Chronic
Illness
Hazardous
Mat. Exp.
Psychosocial
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Water
Quality
Subsistence
Economy Demographics
Big Picture: Cap & Trade HIA Components
Revenue
CA
Cap &
Trade
# of
Allowances
& Allocation
Strategy
Buy/Sell Allowances
Carbon
Price
Covered
entity
Buy/Sell Offsets
On-site Reductions
Potential
Health
Impacts1
Alternatives
1Potential
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health impacts can be positive, negative or neutral
Assessment:
Basic steps
1. Describe the baseline health status, and factors
that influence health.
2. Analyze the impacts
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Indicators for HIA analysis
In order to describe the baseline, you need to select
appropriate indicators. A good indicator should:
•
•
•
•
Measure something likely to be affected by the proposed
action
Measure something important to health
Occur frequently enough that you can reliably measure
changes.
The information should be available, or readily obtained
within the resources available for the HIA!
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www.thehdmt.org
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Assessment step 2:
Analyze the impacts
Impact assessment in HIA can be:
• Quantitative – modeling, risk
assessment
• Qualitative or descriptive:
- Nature of impacts
- Direction of impacts
- Literature review
Severity
Beneficial Mild problem
supporting the
analysis
- Expert opinion
Probability Unlikely/
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/
Frequency
rare
Uncertain
Likely/
common
Moderate
problem
Severe/lifethreatening
Assessment: what is the goal?
A case example
Basic concern: oil and gas development could displace caribou,
and have a significant adverse impact on food security.
Pathway analysis (based on available studies of similar projects):
• Seismic exploration and pipelines can push caribou farther from
communities and potentially reduce harvest
• Revenue from oil and gas to local Alaska Native corporations
has actually increased harvest by facilitating purchase of better
hunting equipment, fuel, etc.
Take home point? While it is going to be very hard to accurately
predict the impact on food security, identifying the conflicting
pathways allows management to improve health outcomes.
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Assessment Step 2:
Analyze the Impacts
Prominent public
concerns
Prevalent Health
Problems and
Health Disparities
Environmental
Consequences in
other areas (air
quality, economy, etc)
Public Health
Consequences
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Public Health
Data (literature
review) and
expert opinion
Assessment
Your data are incomplete, your predictions are uncertain…
What to do?? …
Adaptive Management
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HIA Recommendations
What are you hoping to accomplish?
• Stop a proposed project?
• Promote legislation?
• Maximize benefits and minimize harms
associated with alternatives under
consideration?
• Establish a strong platform for good
management ?
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Recommendations, implementation, and
advocacy: A few key points
1. A clear plan of how you will promote implementation of the
recommendations is essential
2. The line between scientific neutrality and advocacy is
challenging!
3. HIA recommendations are most effective when they account
for the “real time” political, regulatory, economic, and
technological context .
4. The strategy varies based on who is doing the HIA:
- Health agency doing HIA at the request of another agency
- EJ group advocating for or against a proposal
- University center trying to provide unbiased information
- Agency leading a formal process such as EIA
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Reporting
Key Issues
• Transparency: is the report public?
• Response to public input:
- Will there be opportunity for the public to comment on
a draft?
- How will comments be responded to?
• Dissemination:
- How to ensure stakeholders are aware of it and can
view the HIA?
- Accessibility: is there a non-technical summary?
What about the languages of stakeholders?
Monitoring and Evaluation
A few key points
1. Unfortunately, it’s often not done!
2. Huge opportunity for public health: in some cases, it may be
possible to build monitoring for health indicators into a
project or policy implementation plan – a largely unexplored
opportunity to fund public health surveillance efforts.
3. If possible, each recommendation should include monitoring
parameters
4. What are you evaluating?
• The impact/outcomes of the HIA
• The impact/outcomes of the decision addressed by the HIA
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HIA Evaluation
A few key points
1. Start by asking, “What were we hoping to achieve?”
• Improvements in health outcomes?
• Improvements in health determinants?
• Influencing the design of a project or the implementation of a
new policy or regulation?
• Increasing awareness of/dialogue about public health in nonhealth sectors?
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Was the HIA was “successful”?
Health issues
adequately
acknowledged?
Decisions modified due to HIA?
YES
YES Direct effectiveness:
Changes made
because of HIA
NO Opportunistic
Wismar M, et al.
Effectiveness of HIA. WHO,
2007
effectiveness:
Health-promoting
choice made anyway
NO
General effectiveness:
HIA acknowledged but
changes not made;
health awareness
raised
No effectiveness:
HIA ignored
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HIA: the stages from the standpoint of
effective cross-sectoral engagement
HIA Stage
Eg. of cross-sectoral strategy
Screening
Early discussion of HIA, HIA training for all
stakeholders
Scoping
What are policymaker’s constraints, concerns,
practical limitations?
Assessment
What information do other sectors bring? AQ?
Traffic models? Do they understand our data?
Reporting
Peer review by other stakeholders, policymaker:
honest efforts to address all concerns
Recommendations
What can policymaker do, practically? Why are
some options more or less viable
Monitoring and
Evaluation
Can policy maker require monitoring? Are there
funding streams from outside public health?
The Health Impact Project:
A collaboration of the Robert Wood Johnson
Foundation and The Pew Charitable Trusts
www.healthimpactproject.org
Overall Objective: To promote and support the use
of HIA as a tool to ensure that decisions in nonhealth sectors, whether at the local, state, tribal, or
federal level, are made with health in mind.
Geography
AK
WA
WI WY
AR AZ
VA
TN
TX
OR PA
CA
OH
CO CT
NM NY
NH NJ
DC
NE
FL
NC
MT
MA
MS
We have reviewed
GA
MO ME
LA IL HI
LOIs from 35 states!
MN
KY
MD
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Subject AreaHousing Policy,
2%
Education, 3%
Natural
Resources and
Energy, 6%
Air Quality/
Contaminant
Cleanup, 6%
Agriculture, 6%
Topic of HIA
Climate Change,
2%
Health
Promotion, 2%
Labor/
Employment
Policy, 2%
Land Use/
Development/
Transportation/
Urban Planning
28%
Other, 6%
Economic
Policy, 6%
Maternal/Child
Health, 8%
Healthcare,
12%
Obesity
Prevention/Fitnes
s/
Nutrition, 13%
Discussion?
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