Research Informing Policy: the Potential of Health Impact Assessments Academy Health June, 2010 Aaron Wernham, M.D., M.S. Director | The Health Impact Project 901 E Street, NW, Washington, D.C p: e: 1

By RWJF and University of Wisconsin Madison, County Health Rankings program: g/about-project/background g/about-project/background

Health in all Policies… "(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.

Health in all policies, but… 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 standard forums where health works with 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

Definitions Definitions IAIA 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)

Analytical Framework Proposed policy, project, program Determinants of health Health outcomes Broad framework: considers multiple determinants and dimensions of health Considers direct, indirect, and cumulative pathways Both qualitative and quantitative methods used, as is expert opinion Focus: predicting outcomes or pathways/linkages, in order to manage effects

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 – develop health-based recs and a feasible plan for implementing them 5.Reporting – disseminate the report to the public, stakeholders, solicit input 6.Monitoring and Evaluation 9

Examples of Housing HIAs Jack London Gateway (JLG) Senior Housing Project Authors: Human Impact Partners and SFDPH Decision: Plan for 61 new senior housing units close to 2 freeways & Port of Oakland. Impacts: indoor & outdoor air quality, noise, safety, retail planning Recommendations: AQ monitoring; installation of ventilation systems; noise- insulating windows; pedestrian protection medians; traffic calming measures; and many others. 8 Outcomes: Many recommendations adopted. Additional HIA projects were funded. Healthy Development checklist adopted by the Development Committee.

Integrating HIA into the environmental impact statement process: Decision: Bush energy plan proposed expanded oil leasing in Alaskas North Slope, necessitating an EIS Local government became a cooperating agency – a role through which local governments can formally participate in an EIS The community health agency drafted an HIA through this role The lead federal agency incorporated the HIA into the EIS

Oil and gas leasing on Alaskas Arctic Slope A small Inupiat community 7 miles from large oil development Community testimony: Benefits: revenues pay for services, infrastructure Risks: social change, drugs and alcohol, STIs, contaminants, cancer, and breathing problems, interference with hunting and fishing

Result of the NPR-A HIA? Health Concern Mitigation Dietary change from interference with hunting and fishing (exacerbating risk of diabetes, obesity, etc) BLM withheld critical hunting areas from leasing in part because of health and broader cultural impacts Social ills: alcohol, STIs, Expand cultural orientation for workers Air pollutionAdditional baseline, modeling, and monitoring above CAA requirements. Contamination of local food sources Baseline levels and ongoing monitoring

Examples of HIAs Examples of HIAs Paid Sick Days Workers rights issue vs. Public health issue Disparities: income, race/ethnicity, occupation Methods: Lit and health data review, statistical analyses, focus groups Key Findings: ER visits, flu spread restaurant workers, nursing homes Outcomes: Changed discourse, revitalized campaigns across US

What are the elements that define HIA? 1.Forward-looking: addresses a proposed action 2.Seeks to inform decision-making 3.Follows 6 steps (5 in some texts) 4.Broad framework: broad defn of health; considers social, economic and environmental influences on health 5.Participatory process: engages the public and other stakeholders 6.Cross-disciplinary: effective collaboration with decision- makers, other agencies 7.Focus on vulnerable populations/equity

A collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts The Health Impact Project: A collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts 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. Visit

Funded Projects The Health Impact Project Funded Projects 1.State Budget Process: New Hampshire Center for Public Policy will address the NH budget 2.State Cap-and-Trade regulations: CA DPH an HIA to inform the rulemaking process for Californias carbon cap and trade rule 3. Agriculture Policy: Kohala Center, a nonprofit in HI, will do an HIA to inform HI Countys A non-profit would engage in a county agricultural plan that will shape the local economy, land use patterns, and diet. 4.Wilshire Transportation Corridor, LA: LA DPH and UCLA will do an HIA of planned transportation corridor in LA 5.Farm to School Legislation: a non-profit in OR will do an HIA to inform deliberations on a farm to school bill.

16 Funded Projects The Health Impact Project CFP Funded Projects 7.Transit Oriented Development: a.ISAIAH (a faith-based coalition) will use HIA to address planning decisions on a light-rail project in the Twin Cities. b.TSU will use HIA to look at a proposal for TOD 8.Coal Gasification Plants: Green River Health Department will do an HIA of 3 proposed clean coal plants in KY 9.Construction waste power plant: Mass. Dept of Public Health will do an HIA of a proposed biomass power plant in an economically depressed area of Springfield, MA 10.Farm to School legislation: an OR non-profit public health group will undertake and HIA of proposed legislation to fund farm to school programs

HIA and Science HIA practitioners may be experienced and well-versed in public health, but it is a misguided conceit to predict the nature and extent of a health impact without substantiating this by reference to empirical data (…most of which is uncertain and wont substantiate impacts) Thompson … it is not reasonable to suggest that uncertainty should prevent HIA from making any predictions. Certainty or even high probability are luxuries which HIA practitioners do not enjoy…it is little help to the decision-maker to be told that they should wait 5 years for more research Kemm

Questions for discussion 1.Are there minimum standards of evidence that could be applied without restricting the range of potential applications of HIA? What are they? 2.How should HIA handle predictions in which there are potentially important health effects and a high degree of uncertainty regarding the predictions? 3.How can HIA avoid becoming a biased tool for advocacy when it relies on subjective judgments

Discussion? 19

20 Northeast NPR-A Example: hunting and diabetes Baseline: Type 2 diabetes prevalence low: ~2.5% Diet: ~50% wild foods – caribou, salmon, marine mammals Impact Assessment: Pipelines Revenue Seismic Displace caribou farther from village Fuel & equipment for hunting Dietary Change Diabetes Risk

21 Assessment Assessment Your data are incomplete, your predictions are uncertain… What to do?? … Adaptive Management