secure the resources that will be needed for the development of HIA practice. Second, few U.S. academic institutions offer formal education in HIA. Consequently, there are few professionally trained HIA practitioners in the country, and there is little agreement among them as to what constitutes good practice. High-quality education and training will be vital for the advancement of HIA in the United States. Third, continuing education of HIA professionals, policy-makers, and the public will be important for improving the quality of HIA practice in this country. The committee notes that a professional association or society could facilitate continuing education and develop, monitor, and facilitate standards of professional education and practice in HIA.

Structures and policies to support HIA. First, substantial interagency collaboration at the local, state, and federal levels is necessary to conduct HIA of policies, programs, plans, and projects, especially those emanating from nonhealth sectors, such as transportation, finance, urban planning, education, and agriculture. Such collaboration is essential, given the resource-constrained environments in which makers of public policy and other officials often work. The committee offers several suggestions for promoting interagency collaboration in the present report. Second, systematic use of HIA ultimately will depend on the adoption of policies and legal mandates to integrate health considerations into decision-making. As noted above, NEPA requires the analysis of health effects when EIA is conducted, but the spirit of the requirement needs to be reinvigorated and strengthened. Explicit guidance demonstrating how health considerations could be incorporated into NEPA would be beneficial. The committee emphasizes that policies and legislation outside the context of NEPA will most likely be needed to facilitate the use of HIA.

Research on and scholarship in HIA. First, few evaluations of HIA effectiveness have been conducted in the United States, especially because it has emerged so recently. Because conducting HIA will probably require the investment of substantial public and private resources, research is needed to document HIA practices and their effectiveness in influencing decision-making processes and promoting public health. Second, the quality of HIA could be substantially improved if there were better evidence on the relationship of “distal” factors to health outcomes. For example, research on how health is affected by federal, state, and local policies and actions traditionally considered to be unrelated to health—such as transportation, agriculture, education, housing, financial, and immigration policies—would be extremely beneficial.

The recognition that health is affected by much more than medical care, personal choice and behavior, and genetic predisposition is fundamental for the development and implementation of strategies to improve public health. However, the mere promulgation of a legal requirement to consider health would most likely not result in the health improvements that the United States needs. A tool, method, or approach is needed to facilitate the integration of health into decision-making. HIA is particularly promising in light of its broad applicability, its focus on adverse and beneficial health effects, its ability to incorporate various types of evidence, and its emphasis on stakeholder participation.

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