Health Impact Assessment: U.S. Experience Andrew L. Dannenberg, MD, MPH National Center for Environmental Health Centers for Disease Control and Prevention Health Impact Assessment Workshop Design for Health, University of Minnesota Minneapolis, January 30, 2007

Community Design and Health Obesity, physical activity, CVD Water quantity and quality Air pollution and asthma Climate change contribution  Car crashes  Pedestrian injuries Mental health impact  Social capital Related to land use Related to automobile dependency Related to social processes

Walkable Community Designs: Connectivity and Physical Activity Suburban Development Traditional Neighborhood Drawing by Duany Plater Zyberk, in ITE Journal 1989;59:17-18

Durham, NC

A Vision of Health Impact Assessment Community planners and zoning boards will request information on potential health consequences of projects and policies as part of their decision-making process Local health officers will have a tool to facilitate their involvement in community planning and land use decisions that impact health

Definition of Health Impact Assessment Collection of procedures and tools by which projects, policies, and programs can be evaluated based on their potential effects on the health of a population and the distribution of those effects within the population

Value of Health Impact Assessment Focuses attention of decision-makers, who typically do not have a health background, on the health consequences of projects and policies that they are considering Ideally an HIA will lead to a better informed decision

Source: Atlanta Journal-Constitution, March 10, 2006 Transportation Planning and Land Use Choices

Unwalkable park entrance

Steps in Conducting an HIA Screening –Identify projects or policies for which HIA would be useful Scoping –Identify which health impacts should be included Risk assessment –Identify how many and which people may be affected –Assess how they may be affected Reporting of results to decision-makers –Create report suitable in length and depth for audience Evaluation of impact of HIA on decision process

Health Impact Assessment Workshop RWJF and CDC, Princeton, October 2004 Purpose: To move HIA forward in the United States Participants: HIA experts from UK, Canada, and WHO, and US participants from local health departments, academia, transportation, environmental health, urban planning, CDC, and the Robert Wood Johnson Foundation (RWJF) Findings: Priority needs are to conduct pilot tests, develop staff capacity, develop database of HIA resources, build political support for HIA use, and conduct evaluations Summary: Dannenberg AL, et al. American Journal of Public Health. 96: , February 2006

Examples of Health Impact Assessments Conducted in the United States

HIA on Housing Rental Voucher Program Child Health Impact Working Group, Boston Examined impact of changes to Massachusetts housing rental assistance program for families who otherwise would be homeless or live in substandard dwellings Qualitative and quantitative assessment Findings: Program alterations may lead to reduced program eligibility, increased housing instability, and adverse effects on children’s health Funded by multiple public agencies, two anonymous donors, and in-kind donations by working group members

HIA of Housing Redevelopment Projects Rajiv Bhatia, San Francisco Health Department Rapid assessment of health impacts in two housing redevelopment projects and one area plan Qualitative review of Environmental Impact Report, community engagement, secondary data analysis Findings: Effects on housing affordability, vehicle commutes, displacement of residents, segregation, and public infrastructure HIA analyses led to improvements in project plans Funded & conducted by city public health department

HIA of Los Angeles City Living Wage Ordinance Brian Cole, UCLA Quantitative estimate of potential mortality reduction from proposed ordinance to raise minimum wage for city contract workers or provide them with health insurance Findings: Employers are more likely to increase wages than to offer health insurance, thereby losing much of health benefit intended by ordinance Funded by Robert Wood Johnson Foundation

HIA of Coal-Fired Power Plant McLeod and Simmons, Healthy Development, Inc. Examined health impacts of proposed 800 megawatt coal-fired power plant in Florida Rapid, quantitative assessment Findings: Fine particulate matter pollution containing SO 2 will decrease life expectancy by 2 days after 16 years of plant operation Full HIA now funded to recommend social and economic interventions to improve local health Conducted by private HIA consultants with county health department funding

The Atlanta BeltLine Proposed 22-mile urban light rail loop Accompanied by a continuous multi-use trail Connects existing parks and 40+ neighborhoods Opens acres for mixed-use redevelopment To be built on existing abandoned or little used rail rights of way

HIA of Atlanta Beltline Examining health impacts of transit component and of trails and parks component Conducted during ongoing project planning Quantitative and qualitative estimates of physical activity, respiratory disease, injury, mental health, social capital, social equity, and other health outcomes Conducted by Georgia Tech with technical assistance from CDC Funded by Robert Wood Johnson Foundation

Public Health Benefits of BeltLine Obesity Reduction Physical activity helps prevent obesity Obesity and physical inactivity are associated with increased risk of overall mortality, heart disease, diabetes, hypertension, and some cancers Opportunity for Recreational Physical Activity BeltLine trails and parks offer an attractive setting for walking, bicycling, and other recreational physical activity Increased availability of trails is recommended by CDC to promote health Existing Silver Comet, Stone Mountain, Chastain Park trails are very popular Exercise Easily Incorporated into Daily Commute Walking to and from BeltLine stations could readily fulfill the U.S. Surgeon General’s recommendation of 30 minutes of physical activity each day

Public Health Benefits (continued) Cleaner Air BeltLine could reduce use of automobiles whose emissions are major contributors to ground level ozone in Atlanta Ozone is linked with increased asthma attacks and heart disease mortality Atlanta exceeded EPA’s air quality standard for ozone 51 times in Fewer Traffic Injuries Driving less reduces each individual’s risk of injury on the highways Nationally, motor vehicle crashes are the leading cause of death among persons years old Brownfield Redevelopment Urban redevelopment of underutilized land can reduce sprawl and preserve greenspace Redevelopment promotes health by offering economically and socially thriving communities that are walkable

Review of 16 Health Impact Assessments Conducted in the United States,

CALIF 9 TEXAS 1 GA 2 FL 2 MA 2 Location of 16 Completed HIAs in United States, Other HIAs in progress

HIAs of Projects (N=6) 1. Housing redevelopment: Trinity Plaza CA 2. Housing redevelopment: Rincon Hill CA 3. Urban redevelopment: Oak to Ninth CA 4. Corridor redevelopment: Buford Hwy GA 5. Transit, parks and trails: Beltline GA 6. Power plant: Taylor County FL

HIAs of Policies (N=10) 1. Local planning: Eastern neighborhoods CA 2. School siting: Austin TX 3. After-school programs: Statewide CA 4. Walk-to-school programs: Sacramento CA 5. Living wage ordinance: San Francisco CA 6. Living wage ordinance: Los Angeles CA 7. Low income rent subsidies: Statewide MA 8. Low income home energy subsidies: Statewide MA 9. County land use planning: Polk County FL 10. Federal farm bill: National

Decision-Making Organization for Project or Policy City council; planning commissionN=7 State legislatureN=3 Local partnershipsN=2 Nonprofit organizationN=1 US CongressN=1 School districtN=1 Electric utility companyN=1

Organization that Conducts HIA Academic group; CDCN=10 Local health departmentN= 5 Private consultantN= 1

Funder of HIA Robert Wood Johnson Foundation N= 6 Health department - internal staff N= 5 Health department - external contract N= 1 Volunteer; multiple sources N= 4

Scoping: Health Determinants Considered in 16 HIAs in the United States, Physical activity and obesity Housing adequacy and affordability Pedestrian injuries Air quality, asthma, other respiratory diseases Parks and greenspace Income adequacy; social equity Diet, nutrition, food safety, food insecurity Adolescent risk behaviors – alcohol, drugs, sex Noise Mental health Social capital, community severance Access to jobs, stores, schools, recreation

Population Affected by Project or Policy in 16 U.S. HIAs Small area within cityN = 5 City or county-wideN = 5 Statewide N = 5 NationalN = Primary impact on: Persons with low incomeN = 9 Children/adolescents N = 3 Whole populationN = 4

Community Involvement in Conduct of 16 U.S. HIAs  Community input involved in conduct of 10 of 16 HIAs  Barriers to community involvement in HIAs include lack of time or resources, IRB or OMB restrictions

Conduct of 16 HIAs in U.S. Screening –Some targeted to goal, others more academic Scoping –Generally clearly described Risk assessment –Various quantitative and qualitative methods Reporting –Most on web, a few published; public testimony Evaluation –Relatively little conducted

Quantitative and Qualitative Health Indicators in 16 U.S. HIAs Quantitative –Physical activity –Pedestrian injuries –Mortality –Impact of particulate matter in air –Crime –Parks and greenspace Qualitative –Academic performance –Income adequacy; social equity –Diet, nutrition, food safety, food insecurity –Adolescent risk behaviors – alcohol, drugs, sex –Noise –Mental health –Social capital, community severance –Access to jobs, stores, schools, recreation –Housing adequacy and affordability

Key Results in 16 HIAs in U.S.  Most identified improvements needed to mitigate adverse health impacts  Redevelopment projects that lacked affordable housing; rental voucher program  A few encouraged projects or policies that would be health-promoting as designed  Walk-to-school program; Beltline transit project  One concluded that proposed program would fail to reach its intended target population  After-school programs

Impact of HIA on Subsequent Decisions: 16 HIAs in U.S.  Documentable impacts, such as change in redevelopment plans to add affordable housing, was evident in only a few HIAs  Most HIAs raised awareness of health issues for some audiences

Challenges in Conducting Health Impact Assessments Conducted in the United States

HIA Level of Complexity Qualitative – describe direction but not magnitude of predicted results –Easy to predict; hard to use in cost/benefit models –Example: Build a sidewalk and people will walk more Quantitative – describe direction and magnitude of predicted results –Difficult to obtain data; useful for cost/benefit models –Hypothetical example: Build a sidewalk and 300 people who live within 200 yards of location will walk an average of 15 extra minutes per day

Minutes of Walking To and From Public Transit Per Day Besser LM, Dannenberg AL Amer J Prev Med 29:273, 2005 Data from National Household Travel Survey, 2001, USDOT N= 3312 transit users

Voluntary vs. Regulatory Approach to Using an HIA Voluntary (a tool used by a health officer to inform a planning commission) –Simpler, less expensive, less litigious –Less likely to be used if not required –More politically acceptable Regulatory (modeled on a required environmental impact statement) –More complex, more expensive, more litigious –More likely to be used if required –Less politically acceptable

Relationship of HIA to Environmental Impact Assessment HIA components could logically fit within an EIA process HIA incorporated into EIA is necessarily regulatory and insures it is conducted Extending an EIA to include an HIA likely to encounter resistance from developers who see it as an additional barrier

Community Involvement in Conducting an HIA Increases community buy-in to project Helps identify social issues as well as health issues Commonly used in HIAs in Europe Need balance of community input with scientific evidence May add substantially to time and resources needed to conduct HIA

Other Challenges in Conducting HIAs in the U.S. Resources - who pays? Resistance - some decision-makers may not want health input Evaluation of impacts of HIA requires time and resources Quality of science - cause and effect may be difficult to prove

Friedman et al. JAMA 2001;285:897 Asthma and Air Pollution Asthma-related emergency room visits by children decreased 42% Children’s emergency visits for non-asthma causes did not change during same period Natural experiment during 1996 Summer Olympic games in Atlanta Peak morning traffic decreased 23% and peak ozone levels decreased 28%

HIA Capacity Building Activities NACCHO/APA training workshop on HIA held in 2006; repeat workshop planned in 2007 Course on HIA now being taught by Rajiv Bhatia at University of California, Berkeley HIA training manual being prepared Seattle group has begun an HIA listserve for the United States Several states and one U.S. Senator are beginning to mention HIA in proposed legislation

HIA in the United States: Next Steps Conduct pilot tests of existing tools for HIA of projects and policies Develop staff capacity to conduct HIAs including training materials and train-the-trainer workshops Develop incentives and political support for use of HIAs Develop a database for measuring health impacts of common projects and policies Conduct process, impact and outcome evaluations of HIAs

Health Impact Assessments can help guide community design and land use choices to promote human health