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Introduction to Health Impact Assessment

PHS 740 HIA of Global Environmental ChangeUW MadisonSpring 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

Public health

• 10 % “health” care• 30 % genetics• 5 -25% “environmental factors” • 15 % social circumstances• 40 % “modifiable” behavior:

•Diet, but…

• Exercise …

-food pricing, school nutrition programs, food deserts, advertising, etc…

-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 diseaseHP/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 OrganizationOttawa Charter for Health PromotionOttawa, 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 thepublic’s health.

“Health is the responsibility of all sectors,” but…How do we put this into practice? No common language:

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 Comprehensive

Voluntary Regulatory

Retrospective Prospective

Participatory Procedural

Initiated/conducted by:

Community/ Industry Agency

Ad hoc

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 HIANot 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 AssessmentCurrent 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 AssessmentInternational 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 )

AK 3

CA 25

CO 2

FL 1

MA 2

NJ 1

Completed HIAs in the United States1999–2009 (N = 54)

MN 5

GA 4

WA 4

OR 2

OH 1PA 1

MD 1

MT 1

MI 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 approachesEvaluation“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)

•

Evaluation Impact Assessment

PresentPast Future

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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 qualitative/descriptive; flexible, and dependant on the project being analyzed;-Participatory

Generally quantitative modeling, based on a set of baseline assumptions.

Conceptual Framework

Broad/inclusive: social epidemiology, environmental justice

Narrow, and often focused on specific dose-response information, toxicology.

HIA examples: San FranciscoNew 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 PlanAlternative 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 HIAExamples of health determinants

Indicator Description

Alter-native A Impact

Alter-native B Impact

Alter-native C Impact

ST.4Proportion of households with 1/4-mile access to local bus

+ ~ -

ST.5Proportion of average income spent on transportation expense

+ ~ -

ST.6Ratio of miles of bike lanes/pedestrian facilities to road miles

+ - -

ST.7Proportion of commute trips and trips to school made by walking or biking

+ ~ -28

Humboldt County General Plan HIAExamples of health determinants

Indicator Description

Alter-native A Impact

Alter-native B Impact

Alter-native C Impact

ST.8

Number and rate of bicycle/pedestrian injury collisions

To be determined

To be determined -

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

+ ~ -

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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 moresubtle. They’re also morewidespread and more costly than most people realize. We knowthe human impacts of development are significant and long-term. 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 BoroughKeynote 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

BLM will consult with relevant health agencies in the development of future proposals in Northeast NPR-A

“Social ills”: alcohol, STIs,

Expand cultural orientation for workers

Air pollution Additional baseline, modeling, and monitoring above CAA requirements.

Contamination of local food sources

Baseline levels and ongoing monitoring

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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

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The Health Impact Project CFPExamples 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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Education: safety training

Obesity

Asthma

Motor vehicle use

Air and noise pollutionEnforcement:

increase police presence, crossing guards

Engineering: improve pedestrian facilities, traffic calming

Injury

Physical activity

Dedicated resources: walking school busses

walkability

safety

Policy/ Proximal/Intermediate Health

Project Impacts Outcomes

Logic Frameworks

Air Quality

Water Quality

Subsis-tence

Economy Demo-graphics

Injury

Infectious Disease

Chronic Illness

HazardousMat. Exp.

Psycho-social

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EXAMPLE: using a table for systematic scoping

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Big Picture: Cap & Trade HIA Components

1Potential health impacts can be positive, negative or neutral

Alternatives

# of Allowances & Allocation

Strategy Potential Health

Impacts1

CA Cap & Trade

Buy/Sell Allowances

Buy/Sell Offsets

On-site Reductions

Covered entity

CarbonPrice

Revenue

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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

supporting the

analysis- Expert opinion

SeverityBeneficial

Mild problem

Moderate problem

Severe/life-threatening

Probability/

Frequency

Unlikely/ rare

Uncertain

Likely/ common

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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 Data (literature

review) and expert opinion

Public Health Consequences

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AssessmentYour data are incomplete, your predictions are uncertain…

What to do?? … Adaptive Management

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HIA RecommendationsWhat 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

ReportingKey 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?

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Monitoring and EvaluationA 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 EvaluationA 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 non-

health sectors?

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Health issues adequately acknowledged?

Decisions modified due to HIA?

YES NO

YES Direct effectiveness: Changes made because of HIA

General effectiveness: HIA acknowledged but changes not made; health awareness raised

NO Opportunistic effectiveness: Health-promoting choice made anyway

No effectiveness: HIA ignored

Was the HIA was “successful”?

Wismar M, et al. Effectiveness of HIA. WHO, 2007

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 non-health sectors, whether at the local, state, tribal, or federal level, are made with health in mind.

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AKARAZ

CA

COCTDC

FL

GAHI ILKYLAMAMDMEMN

MO

MS

MTNC

NE

NH

NJ

NM

NYOH

OR

PA

TN

TX

VAWA WI WY

Geography

We have reviewed LOIs from 35

states!

Subject Area

Land Use/Development/

Transporta-tion/ Urban

Planning 28%

Obesity Preven-tion/Fitness/

Nutrition, 13%

Healthcare; 12%Maternal/Child

Health; 8%

Economic Policy; 6%

Other; 6%

Agriculture; 6%

Air Quality/ Con-taminant Cleanup,

6%

Natural Resources and Energy, 6%

Education; 3%

Housing Policy; 2%Climate Change; 2%

Health Promotion, 2%

Labor/ Employment Policy, 2%

Topic of HIA

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Discussion?