Health Impact Assessment: A tool for health-focused public policy Aaron Wernham, M.D., M.S. Director | The Health Impact Project 901 E Street, NW, Washington, D.C p: e:

“Health:” (as measured by premature mortality) What makes us healthy? “Health:” (as measured by premature mortality) 10 %health care 30 % genetics 5-20 % environmental exposure (depends on how you define “environment”) 15 % social circumstances 40 % “modifiable” behavior: Diet … Exercise … but what if you can’t afford fresh produce and your school lunch program gives your kids low-quality food? but in some neighborhoods there’s no safe place to walk

Health and the Environment Why is HIA important? Health and the Environment Health promotion directs “policy makers in all sectors and at all levels … to be aware of the health consequences of their actions …” WHO, Ottawa Charter for Health Promotion, 1986

What is 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 translating public health research into predictions and practical recommendations that decision- makers can use to ensure that their policies contribute to healthier communities.

“Health is a responsibility of all sectors” Why is HIA important? “Health is a responsibility of all sectors” Health promotion directs “policy makers in all sectors and at all levels … to be aware of the health consequences of their actions” Ottawa Charter for Health Promotion, 1986 “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. "(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

What are the practical barriers? “Health across sectors” What are the practical barriers? No common language: transportation engineers don’t understand health data. public health professionals don’t understand the constraints and limitations of the planning process No routine/formalized requirements No funding for new public health activities “Going out on a limb:” Public health is science-driven, and policy and planning are steeped in other considerations: economics, politics, timelines, etc …

Health Impact Assessment Health Across Sectors: 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 multidisciplinary process within which a range of evidence about the health effects of a proposal is considered in a structured framework, …based on a broad model of health which proposes that economic, political, social, psychological, and environmental factors determine population health."

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 Current Applications: Health Impact Assessment Current Applications: U.S.: Roughly 60 HIAs to date: Sporadic, often funded by foundations Other than some EIA laws, no formal requirements Canada and Australia: considerable effort, 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

10 Applications Worldwide: Health Impact Assessment Applications Worldwide: World Bank and IFC: part of evaluation standards for large development loans (IFC Guidance Note 4: 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 (

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.

Oil and gas leasing in the National Petroleum Reserve HIA Examples: Alaska’s North Slope Oil and gas leasing in the National Petroleum Reserve Decision: whether & where BLM would sell oil leases Health Impacts: dietary, air and water quality, social HIA: local government worked with BLM to do HIA as part of EIS Outcome: restricted leasing in key hunting areas; air and food contaminant monitoring; resolved longstanding conflict between BLM and tribes

Paid Sick Days HIA Examples: Paid Sick Days Decision: Legislation is pending in the U.S., CA, MA, and NH, and has been considered in many other states. Historically viewed mainly as a labor rights issue. Health Issues: reduced disease transmission, faster recovery Outcomes: Lots of media attention: effectively shifted the dialogue re. costs and benefits to include health

Atlanta Beltline HIA Examples: Atlanta Beltline Decision: Planning for an extensive new transit, paths, open-space, and redevelopment project HIA identified vulnerable communities, health risks, and many opportunities for health benefits (safety, exercise, air qual.) Outcomes to date: Public health now formal part of planning: new open space, transit, etc $1 million EPA grant to speed development (health benefits cited)

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 orwww.healthimpactproject.org/hia for links

Why is HIA a promising tool for “health in all policies”? A flexible approach that translates health data into practical, balanced information to inform an active decision-making process Well-defined series of stages, with considerable variation in: Analytical methods, complexity of analysis Time demands Improved interagency/cross-sectoral collaboration, and increased awareness of health in other sectors Public engagement and participation

Why is HIA a promising tool for “health in all policies”? Emphasis on engagement: brings public health professionals, community stakeholders, planners, developers, and decision- makers to the table, with a focus on practical, realistic solutions

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 A national initiative to promote the use of HIAs in decision-making at the local, state, tribal, and federal level. Creating a national Center to support the field see the CFP at a series of demonstration projects that address real-time decisions on proposed policies, programs, and projects at the local, state, and tribal level: see the CFP at Building a technical assistance network to support new HIA practitioners Completing two federal HIAs Reviewing existing laws, regulations, and policies that might support the use of HIA

Questions

Alaska’s North Slope: Villages in relation to active leasing and exploration

21 Nuiqsut, Alaska Nuiqsut, Alaska: small Inupiat community 7 miles from large oil development. Over 10 years, communities raised a wide range of health concerns as proposed development expanded

22 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 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 Borough Keynote Address, Alaska Forum on the Environment 2004.

NEPA: The National Environmental Policy Act National Environmental Policy Act of USC § Created the Environmental Impact Statement, or EIS process: Simply stated, and EIS is a comprehensive review of the potential impacts of a proposed decision, undertaken in a publicly transparent and accountable manner.

24 The Problem No systematic analysis of public health in EIS process: 1.Survey of 45 EIS: -No discussion of health in 83% -In the remainder, discussion of health limited to single-substance cancer risk assessment Steinemann, A Rethinking Human Health Impact Assessment. Environmental Impact Assessment Review 20: Survey of NEPA professionals: -Found little understanding, discussion, or analysis of health among EIS professionals Cole et al Prospects for Health Impact Assessment in the United States: New and Improved Environmental Impact Assessment of Something Different? Journal of Health Politics, Policy, and Law 29 (6)

25 NEPA and Human Health: Purpose The purposes of this Act are: … to promote efforts which will prevent or eliminate damage to the environment and biosphere and stimulate the health and welfare of man; to enrich the understanding of the ecological systems and natural resources important to the Nation; and to establish a Council on Environmental Quality NEPA Sec. 2 [42 USC § 4321]

26 CEQ Regulations and Guidance 40 C.F.R Effects: “Effects” includes ecological, aesthetic, historic, cultural, economic, social, or health, whether direct, indirect, or cumulative.” 40 C.F.R Significantly: (b) Intensity: includes “ The degree to which the proposed action affects public health or safety.” “Agencies should recognize the interrelated cultural, social, occupational, historical, or economic factors that may amplify the natural and physical environmental effects of a proposed agency action.”

Health Impact Assessment, and integrated HIA/EIA 27 HIAEIA -Scaling (baseline) -Assessment -Recommendations -Reporting -Decisionmaking -“Description of the Affected Environment” -“Consequences of the Alternatives” -Potential Mitigation Measures -Draft EIS, Final EIS -Record of Decision For more information on HIA, see

The First Federal HIA/EIS: Oil and gas leasing in the National Petroleum Reserve Local government became a “cooperating agency” – a role defined by NEPA 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

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 pollutionAdditional baseline, modeling, and monitoring above CAA requirements. Contamination of local food sources Baseline levels and ongoing monitoring

Integrated HIA/EIS in Alaska: Building on the NPR-A Precedent General Observations: Despite 40 years of precedent for minimal health analysis, NEPA and many state versions clearly support incorporating HIA Engagement by local health agencies lead to a new precedent: integrating HIA into NEPA

Integrated HIA/EIS in Alaska: Building on the NPR-A Precedent Since the NPR-A HIA/EIS: 3 HIA/EISs for other oil and gas leasing plans 1 HIA/EIS for expansion of a large lead/zinc mine EPA is contracting with the state tribal health agency to do an HIA for a proposed open-pit coal mine. EPA in California is calling for HIAs on a large highway project and port expansion Several federal agencies are considering developing guidance for HIA