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Introduction to Health Impact Assessment 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.orgawernham@pewtrusts.org www.healthimpactproject.org 1

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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

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Environmental health and chronic disease: 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 4

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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.

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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 publics health.

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Health is the responsibility of all sectors, but Health is the responsibility of all sectors, but How do we put this into practice? No common language: transportation engineers dont understand health data. public health professionals dont 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 7

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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. 8

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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 9

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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 10

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11 HealthImpact Assessment Health Impact Assessment Key Values underlying HIA 1.Democracy -- allowing people to participate in the development and implementation of policies, programmes or projects that may impact on their lives 2.Equity -- HIA assesses the distribution of impacts from a proposal on the whole population, with a particular reference to how the proposal will affect vulnerable people 3.Sustainable Development -- that both short and long term impacts are considered, along with the obvious, and less obvious impacts 4.Ethical Use of Evidence -- the best available quantitative and qualitative evidence must be identified and used in the assessment. A wide variety of evidence should be collected using the best possible methods

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12 Types of HIA Rapid Comprehensive Voluntary Regulatory Retrospective Prospective Participatory Procedural Initiated/conducted by: Community/ Industry Agency Ad hoc Ad hoc

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13 Rapid HIA Often called a desktop HIA Generally doesnt involve a lot of outreach/public input Can be used where limited time/resources are available, or where the discussion is anticipated to be fairly simple Utilizes existing data sources literature review, existing baseline data, etc Is usually carried out in days to weeks with minimal resources. Report may be simple: comment letter, public testimony, etc

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14 An Intermediate HIA Provides more detailed information of possible health impacts Most frequent HIA approach Generally involves some form of public input/comment Analytic complexity may be higher than rapid HIA Time requirements: months to a year

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15 A Comprehensive HIA Provides a thorough assessment of potential health impacts Often involves collecting and assessing new data using multiple methods and sources Generally involves multi-stakeholder input May take a year or more

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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. 17

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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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18 Health Impact Assessment 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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19 Health Impact Assessment 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) 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 ) http://www.equator-principles.com/principles.shtml

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AK 3 CA 25 CO 2 FL 1 MA 2 NJ 1 Completed HIAs in the United States 19992009 (N = 54) MN 5 GA 4 WA 4 OR 2 OH 1 PA 1 MD 1 MT 1 MI 1 Courtesy A. Dannenberg, A. Wendel, CDC NCEH 20

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HIA Compared to other analytic approaches Risk Assessment Environmental impact assessment Social impact assessment Evaluation 21

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HIA Compared to other analytic approaches Social Impact Assessment Like HIA, SIA has its roots in EIA Focus on predicting and managing potential impacts of proposed projects, policies, or programs on social indicators: -General well-being -Social interactions -Community dynamics -Employment, income, demographics -Culture -Spirituality A lot of overlap with HIA: HIA uses health indicators to describe many social changes 22

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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) EvaluationImpact Assessment Present PastFuture 23

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24 HIARisk 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.

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25 EIAHIA Screening The trigger for but NOT the focus of an EIA is impacts on the physical environment: if an EIA is required, it considers not just phys env., but socioeconomics, health, etc. Trigger is a proposed action likely to impact health Scoping Broad consideration of direct, indirect, and cumulative effects Public input, literature review, expert opinion Similar approach: Proposed action DTOH outcomes Public input Assessment Assess baseline Predict impacts of alternatives Recommend mitigation/alternatives Employs both qualitative methods, and quantitative analysis Health baseline: DTOH and health indicators Predict impacts qual and quant common Recommend mitigation Reporting Draft EIS public comment Final EIS MUST address substantive comments Variable approach to public input. Often final report only Monitoring / Evaluation Often neglected Ideal: adaptive management Often neglected Chance to build PH monitoring into other sectors

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New housing development near congested roads 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. 26

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Alternative growth scenarios 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 26

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Humboldt County General Plan HIA Humboldt County General Plan HIA Examples of health determinants IndicatorDescription Alter- native A Impact Alter- native B Impact Alter- native 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 +~- 28

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Humboldt County General Plan HIA Humboldt County General Plan HIA Examples of health determinants IndicatorDescription 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 - ST.9 Proportion of population living on residential streets with