1

Introduction

There is growing evidence that our social, economic, and physical environments affect public health. Thus, our health is affected by how buildings and communities are designed, where roadways are located, and what economic, agricultural, and educational policies and programs are implemented. Health can no longer be seen solely as the result of personal choice and behavior. The task of integrating health considerations into such a breadth of activities is potentially daunting. However, a new field—health impact assessment (HIA)—can assist decision-makers in examining the potential health effects of proposed projects, programs, plans, and policies. It has gained momentum internationally, although it is not yet widely used in the United States. Some attribute the difference to the absence of a uniform framework and guidance for conducting such assessments. Given the potential of HIA to improve public health, the Robert Wood Johnson Foundation (RWJF), the National Institute of Environmental Health Sciences (NIEHS), the California Endowment, and the Centers for Disease Control and Prevention (CDC) asked the National Research Council (NRC) to develop a framework, terminology, and guidance for conducting HIA. As a result of that request, NRC convened the Committee on Health Impact Assessment, which prepared this report.

HEALTH IMPACT ASSESSMENT

The idea that many factors outside the traditional health field affect public health is not new. In fact, the decrease in mortality from infectious disease in the 19th and 20th centuries and the increase in life expectancy are attributed more to such factors as better nutrition, housing, and sanitation than to advances in medicine (McKeown 1979). Studies have demonstrated the relatively small influence of the medical practice on public health as opposed to the substantial effect of living conditions (Kemm and Parry 2004). Accordingly, many have recognized that improvements in public health will occur only if health consid-



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1 Introduction There is growing evidence that our social, economic, and physical envi- ronments affect public health. Thus, our health is affected by how buildings and communities are designed, where roadways are located, and what economic, agricultural, and educational policies and programs are implemented. Health can no longer be seen solely as the result of personal choice and behavior. The task of integrating health considerations into such a breadth of activities is potentially daunting. However, a new field—health impact assessment (HIA)—can assist decision-makers in examining the potential health effects of proposed projects, programs, plans, and policies. It has gained momentum internationally, although it is not yet widely used in the United States. Some attribute the difference to the absence of a uniform framework and guidance for conducting such assessments. Given the potential of HIA to improve public health, the Robert Wood Johnson Foundation (RWJF), the National Institute of Environmental Health Sciences (NIEHS), the California Endowment, and the Centers for Disease Control and Prevention (CDC) asked the National Research Council (NRC) to develop a framework, terminology, and guidance for conducting HIA. As a result of that request, NRC convened the Committee on Health Impact Assessment, which prepared this report. HEALTH IMPACT ASSESSMENT The idea that many factors outside the traditional health field affect public health is not new. In fact, the decrease in mortality from infectious disease in the 19th and 20th centuries and the increase in life expectancy are attributed more to such factors as better nutrition, housing, and sanitation than to advances in medicine (McKeown 1979). Studies have demonstrated the relatively small in- fluence of the medical practice on public health as opposed to the substantial effect of living conditions (Kemm and Parry 2004). Accordingly, many have recognized that improvements in public health will occur only if health consid- 14

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15 Introduction erations are factored into projects, programs, plans, and policies in non-health- related sectors, such as transportation, housing, agriculture, and education (Kemm and Parry 2004; Cole and Fielding 2007). Given the studies of the determinants of public health, a new field, HIA, arose in the 1980s and 1990s. The most commonly cited definition of HIA was provided in what is known as the Gothenburg consensus paper: A combination of procedures, methods and tools by which a policy, pro- gramme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population (WHO 1999, p. 4). Other definitions have arisen over the decades, and several examples are pro- vided in Table 1-1. As shown, HIA has been defined in various ways and de- scribed by such terms as method, process, approach, tool, and framework. Di- verse practices have been associated with HIA, and that diversity has been attributed somewhat to how health has been defined (or not defined) by the vari- ous governments and organizations that use HIA. Parry and Kemm (2004), however, asserted that the essential features of HIA are predicting the conse- quences of various options and educating and assisting decision-makers. The International Experience HIA has been used throughout the world to evaluate the potential health consequences of various projects, programs, plans, and policies (see Appendix A for discussion of the international experience in implementing HIA). Europe and such countries as Canada, Australia, and Thailand—and states, provinces, and territories in these countries—have used various approaches to introducing and promoting HIA. Some have integrated it into existing environmental- assessment frameworks or practices, and others have established it as a stand- alone or distinct process. Some have tried to legislate its use, and others have relied on voluntary processes in which various degrees of government support and resources are provided. Each country’s experience offers different perspec- tives and lessons to be learned. For example, although the experience in a few countries has suggested that legislation is needed to provide an impetus for con- ducting HIA, the experience in many other countries has emphasized that legis- lative requirements alone are not sufficient to ensure its consistent implementa- tion. Education, training, and resources appear to be critical to the success of its use, and engaging traditionally non-health-related sectors and agencies and heightening awareness of HIA also appear to be key. International organizations have contributed to the development and evo- lution of HIA. Over the last few decades, the World Health Organization has supported the development and use of HIA through declarations, initiatives,

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16 Improving Health in the U.S.: The Role of Health Impact Assessment TABLE 1-1 Selected Definitions of Health Impact Assessmenta Definition Reference “Any combination of procedures or methods by which a proposed Frankish et al. 1996 policy or program may be judged as to the effects it may have on the health of a population.” “A methodology which enables the identification, prediction and British Medical evaluation of the likely changes in health risk, both positive and Association 1998, p. 39 negative, (single or collective), of a policy, programme, plan or development action on a defined population. These changes may be direct and immediate, or indirect and delayed.” “The estimation of the effects of a specified action on the health of Scott-Samuel 1998, a defined population.” p. 704 “A method of evaluating the likely effects of policies, initiatives Scottish Office and activities on health at a population level and helping to develop Department of Health recommendations to maximise health gain and minimise health 1999, Section 98 risks. It offers a framework within which to consider, and influence, the broad determinants of health.” “A means of evidence based policy making for improvement Scott Samuel 1997 in in health. It is a combination of methods whose aim is to assess Lock 2000, p. 1395 the health consequences to a population of a policy, project, or programme that does not necessarily have health as its primary objective.” “A multidisciplinary process within which a range of evidence Grant et al. 2001, p. 1 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.” “A developing approach that can help to identify and consider the Taylor and Quigley potential—or actual—health impacts of a proposal on a population. 2002, p. 2-3 Its primary output is a set of evidence-based recommendations geared to informing the decision making process.” “A structured framework to map the full range of health WHO 2002, p. 2 consequences of any proposal, whether these are negative or positive. It helps clarify the expected health implications of a given action, and of any alternatives being considered, for the population groups affected by the proposals. It allows health to be considered early in the process of policy development and so helps ensure that health impacts are not overlooked.” (Continued)

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17 Introduction TABLE 1-1 Continued Definition Reference “A combination of procedures, methods and tools that Quigley et al. 2006, systematically judges the potential, and sometimes p. 1 unintended, effects of a policy, plan, 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.” “A combination of procedures, methods, and tools to assess the IFC 2009, p. 4 potential health impacts of a project on nearby populations, and to recommend mitigation measures. HIA addresses both negative and positive aspects of health. HIA will also try to identify benefits to health that may be enhanced.” a Key phrases have been highlighted in the definitions to indicate the various ways that HIA has been defined. Sources: Krieger et al. 2003; Kemm and Parry 2004. conferences, workshops, and networks (Cole and Fielding 2007; Forsyth et al. 2010). Its work was driven initially by the need to incorporate HIA into envi- ronmental assessments of water-management projects but soon broadened to encourage the use of HIA to define healthy public policies. Multilateral devel- opment banks and the International Finance Corporation have also contributed to the development of HIA; many have now adopted standards that include re- quirements to conduct HIA for projects submitted for funding (IFC 2009; Krieger et al. 2010; Harris-Roxas and Harris 2011). Many countries and organizations have developed their own guidance on conducting HIA (for example, B.C. Ministry of Health 1994; Fehr 1999; NHS 2000; enHealth 2001; Abrahams et al. 2004; PHAC 2005; Quigley et al. 2006; Harris et al. 2007; IFC 2009; Metcalfe et al. 2009). Regardless of the similarity of the guidance, some have observed that no consistent approach or methods have been used (Kemm 2007; Bhatia 2010). Others have concluded that the cri- teria for initiating, conducting, and completing HIA need to be clarified (Krieger et al. 2003) and that terminology needs to be standardized (Kemm and Parry 2004). After reviewing numerous examples of HIA, Parry and Kemm (2004, p. 417) concluded that improvements are needed “in terms of methodological tech- niques and practical application if [HIA] is to truly fulfill its promise and be- come a useful adjunct to decision making.” Health Impact Assessment in the United States In the United States, HIA as a practice independent of environmental or other regulatory impact assessment was first used in San Francisco in 1999 to evaluate a policy to increase the minimum wage (Bhatia and Katz 2001). Al- though not widely or commonly practiced, HIA has been used in all levels of

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18 Improving Health in the U.S.: The Role of Health Impact Assessment government and across the country to evaluate health impacts of proposed pro- jects, policies, plans, and programs. Much of the activity, however, has been centered on local communities, has focused on policies and programs associated with land-use, housing, and transportation planning, and has been sponsored by local public-health and planning agencies, nonprofit organizations, and aca- demic institutions. Several academic institutions—notably the University of California, Berkeley and the University of California, Los Angeles—have helped to advance HIA at the local level by providing training and technical assistance and by developing methods and approaches for conducting HIA. At the state level, Washington and Massachusetts have passed legislation to support HIA, and several other states—including California, Maryland, Min- nesota, and West Virginia—have proposed legislation. Even without legislation, several states—such as Hawaii, Alaska, California, Wisconsin, and Oregon— have been conducting and using HIA to evaluate proposed projects, programs, plans, and policies. At the federal level, the use of HIA has been largely in the context of im- plementing the National Environmental Policy Act (NEPA), which requires fed- eral agencies to evaluate the health effects of proposed federal actions [42 U.S.C §§ 4321-4347]. However, the analysis of human health effects has historically been minimized in assessments conducted under NEPA. Several factors— including the lack of focus of early legal claims on human health, misinterpreta- tion of case law, and the lack of involvement of traditionally health-related mu- nicipal, state, tribal, or federal agencies in the NEPA process—contributed to the de-emphasis of human health effects. That situation has changed recently with work conducted by native Alaskans to incorporate health, social, and cultural effects into NEPA documents for oil- and gas-leasing programs and leasing sales (BLM 2007; MMS 2007a,b; EPA 2009). That activity has focused atten- tion on and promoted interest in HIA in various federal agencies (see Appendix A for further details on the HIA experience in the United States). THE COMMITTEE’S TASK AND APPROACH The committee that was convened in response to the request by RWJF, NIEHS, the California Endowment, and CDC includes experts in HIA, envi- ronmental impact assessment, public health, epidemiology, urban planning, so- cial sciences, economics, and decision and risk analysis (see Appendix B for biographies of the committee members). The committee was asked specifically to develop a framework, terminology, and guidance for conducting HIA of pro- posed policies, programs, and projects at federal, state, tribal, and local levels, including the private sector. The committee was to assess the value and potential value of such assessments; the impediments and countervailing factors that have limited the practice of HIA to date; the circumstances and criteria for conducting HIA; the concepts, tools, and information required; and the types, structure, and content of HIA. On the basis of those considerations, the committee was to de-

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19 Introduction velop a systematic conceptual framework and approach for improving the as- sessment of health impacts in the United States (see Appendix C for the commit- tee’s statement of task). To accomplish its task, the committee held five meetings. During the first three, public sessions were held in which the committee heard presentations by the sponsors and invited speakers in federal, state, and tribal government; aca- deme; professional associations; nonprofit organizations; and consulting firms. The committee reviewed numerous publications on HIA and considered the ex- perience of various countries and organizations in implementing HIA. A sum- mary of the committee’s review of HIA experience is provided in Appendix A. The committee’s consideration of the literature and the HIA experience shaped its conclusions and recommendations for the framework and guidance that it offers here. The committee notes that it was given a broad task, that is, to develop a framework and guidance for HIA applicable in all contexts. Therefore, the committee had to develop a flexible framework that is amenable to all types of HIA and could not simply provide a cookbook or technical manual on HIA. The committee, however, has provided extensive reference lists that should help to guide the reader with regard to specific assessments. Furthermore, the commit- tee recognizes that HIA exists on a spectrum of impact assessment and planning tools that have been used for decades. However, the committee’s focus was on developing a framework and guidance for HIA, not on comparing and contrast- ing all possible approaches and tools that are available. Similarly, although the committee reviewed the international and U.S. experience with HIA, it did not thoroughly examine and compare all types of HIAs that have been conducted or determine their impact and how the information has been used on release of the HIA. Finally, the committee uses various terms throughout the report, many of which are defined in the glossary (see Appendix D). The committee notes that it uses the term public health in this report in the broadest sense possible, that is, generally the health of the public. Implicit in the concept of public health used by the committee is the idea that health is affected by a wide array of factors that range from the societal to the biologic. ORGANIZATION OF REPORT The committee’s report is organized into five chapters and six appendixes. Chapter 2 discusses the rationale for conducting HIA and the key role that it can play in improving public health and reducing health disparities. Chapter 3 out- lines the elements of the HIA process (that is, the framework), describes the current variability, and highlights features that the committee finds are critical for any HIA. Chapter 4 provides the committee’s suggestions for best practices for conducting HIA, and Chapter 5 discusses what is needed for advancing HIA. The review of HIA experience, the committee biographies, the statement of task,

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20 Improving Health in the U.S.: The Role of Health Impact Assessment a glossary of commonly used terms, and a discussion of the analysis of health effects under NEPA are provided in appendixes. REFERENCES Abrahams, D., A. Pennington, A. Scott-Samuel, C. Doyle, O. Metcalfe, L. den Broeder, F. Haigh, O. Mekel, and R. Fehr. 2004. European Policy Health Impact Assessment: A Guide, University of Liverpool, England; RIVM, Netherlands; Institute of Public Health, Ireland; loegd, Institute of Public Health, NRW Bielefeld, Germany. Pre- pared for the Health and Consumer Protection Directorate General, European Com- mission. May 2004 [online]. Available: http://ec.europa.eu/health/ph_projects/2001/ monitoring/fp_monitoring_2001_a6_frep_11_en.pdf [accessed May 16, 2011]. B.C. Ministry of Health. 1994. Health Impact Assessment Toolkit: A Resource for Gov- ernment Analysis. Population Health Resource Branch, Ministry of Health, Van- couver, British Columbia. Bhatia, R. 2010. A Guide for Health Impact Assessment. California Department of Public Health. October 2010 [online]. Available: http://www.cdph.ca.gov/pubsforms/Gu idelines/Documents/HIA%20Guide%20FINAL%2010-19-10.pdf [accessed Apr. 22, 2011]. Bhatia, R., and M. Katz. 2001. Estimation of health benefits accruing from a living wage ordinance. Am. J. Public Health 91(9):1398-1402. BLM (Bureau of Land Management). 2007. Northeast National Petroleum Reserve- Alaska (NPR-A) Draft Supplemental Integrated Activity Plan/Environmental Im- pact Statement (IAP/EIS). U.S. Department of the Interior, the Bureau of Land Management [online]. Available: http://www.blm.gov/ak/st/en/prog/planning/npra _general/ne_npra/northeast_npr-a_draft.html [accessed Nov. 30, 2010]. British Medical Association. 1998. Health and Environmental Impact Assessment. Lon- don: Earthscan. Cole, B.L., and J.E. Fielding. 2007. Health impact assessment: A tool to help policy mak- ers understand health beyond health care. Annu. Rev. Public Health 28:393-412. enHealth (enHealth Council). 2001. Health Impact Assessment Guidelines. Canberra: Commonwealth of Australia. September 2001 [online]. Available: http://www. health.gov.au/internet/main/publishing.nsf/content/35F0DC2C1791C3A2CA256F1 900042D1F/$File/env_impact.pdf [accessed May 5, 2011]. EPA (U.S. Environmental Protection Agency). 2009. Red Dog Mine Extension Aqqaluk Project. Final Supplemental Environmental Impact Statement. Prepared for U.S. Environmental Protection Agency, Seattle, WA, by Tetra Tech, Inc., Anchorage, AK. October 2009 [online]. Available: http://www.reddogseis.com/Docs/Final/F ront_Matter.pdf [accessed Nov. 30, 2010]. Fehr, R. 1999. Environmental health impact assessment: Evaluation of a 10 step model. Epidemiology 10(5):618-625. Frankish, C.J., L.W. Green, P.A. Ratner, T. Chomik, and C. Larsen. 1996. Health Impact Assessment as a Tool for Population Health Promotion and Public Policy. Pre- pared for Public Health Agency of Canada, by Institute of Health Promotion Re- search, University of British Columbia [online]. Available: http://www.phac- aspc.gc.ca/ph-sp/impact-repercussions/index-eng.php [accessed Apr. 22, 2011]. Forsyth, A., C.S. Slotterback, and K. Krizek. 2010. Health impact assessment (HIA) for planners: What tools are useful? J. Plan. Lit. 24(3):231-245.

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21 Introduction Grant, S., J.R. Wilkinson, and A. Learmonth. 2001. An Overview of Health Impact As- sessment. Occasional Paper No. 1. Technical report. Northern and Yorkshire Pub- lic Health Observatory, Stockton on Tees, UK. May 2001 [online]. Available: http://dro.dur.ac.uk/5613/ [accessed May 9, 2011]. Harris, P., B. Harris-Roxas, E. Harris, and L. Kemp. 2007. Health Impact Assessment: A Practical Guide. Sidney, Australia: Centre for Health Equity Training, Research and Evaluation, the University of New South Wales. August 2007 [online]. Avail- able: http://www.hiaconnect.edu.au/files/Health_Impact_Assessment_A_Practical _Guide.pdf [accessed May 9, 2011]. Harris-Roxas, B., and E. Harris. 2011. Differing forms, differing purposes: A typology of health impact assessment. Environ. Impact Assess. Rev. 31(4):396-403. IFC (International Finance Corporation). 2009. Introduction to Health Impact Assess- ment. Washington, DC: World Bank [online]. Available: http://www.ifc.org/ifcext/ sustainability.nsf/AttachmentsByTitle/p_HealtheImpactAssessment/$FILE/HealthIm pact.pdf [accessed May 5, 2011]. Kemm, J. 2007. What is HIA and why might it be useful? Pp. 3-13 in The Effectiveness of Health Impact Assessment: Scope and Limitations of Supporting Decision- Making in Europe, M. Wismar, J. Blau, K. Ernst, and J. Figueras, eds. Trowbridge, Wilts, UK: The Cromwell Press. Kemm, J., and J. Parry. 2004. What is HIA? Introduction and overview. Pp. 1-13 in Health Impact Assessment: Concepts, Theory, Techniques, and Applications, J. Kemm, J. Parry, and S. Palmer, eds. Oxford: Oxford University Press. Krieger, G.R., J. Utzinger, M.S. Winkler, M.J. Divall, S.D. Phillips, M.Z. Balge, and B.H. Singer. 2010. Barbarians at the gate: Storming the Gothenburg consensus. Lancet 375(9732):2129-2131. Krieger, N., M. Northridge, S. Gruskin, M. Quinn, D. Kriebel, G. Davey Smith, M. Bassett, D.H. Rehkopf, and C. Miller. 2003. Assessing health impact assessment: Multidisci- plinary and international perspectives. J. Epidemiol. Community Health 57(9): 659-662. Lock, K. 2000. Health impact assessment. BMJ 320(7246):1395-1398. McKeown, T. 1979. The Role of Medicine: Dream, Mirage, or Nemesis. Oxford, UK: Blackwell. Metcalfe, O., C. Higgins, and T. Lavin. 2009. Health Impact Assessment Guidance. Insti- tute of Public Health in Ireland [online]. Available: http://www.publichealth.ie/ files/file/IPH%20HIA_0.pdf [accessed May 9, 2011]. MMS (Minerals Management Service). 2007a. Outer Continental Shelf Oil and Gas Leasing Program: 2007-2010. Final Environmental Impact Statement, Vol. 1. OCS EIS/EA MMS2007-003. U.S. Department of the Interior, Minerals Management Service, Herndon, VA. April 2007 [online]. Available: http://www.boemre.gov/ 5-year/2007-2012FEIS/Intro.pdf [accessed Nov. 30, 2010]. MMS (Minerals Management Service). 2007b. Chukchi Sea Planning Area Oil and Gas Sale 193 and Seismic Surveying Activities in the Chukchi Sea. Final Environ- mental Impact Statement. OCS EIS/EA MMS2007-026. U.S. Department of the Interior, Minerals Management Service, Alaska OCS Region [online]. Available: http://alaska.boemre.gov/ref/EIS%20EA/Chukchi_FEIS_193/feis_193.htm [accessed Nov. 30, 2010]. NHS (National Health Service). 2000. A Short Guide to Health Impact Assessment: In- forming Healthy Decisions. NHS Executive, London [online]. Available: http:// www.who.int/hia/examples/en/HIA_londonHealth.pdf [accessed May 9, 2011].

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22 Improving Health in the U.S.: The Role of Health Impact Assessment Parry, J., and J. Kemm. 2004. Future directions in HIA. Pp. 411-417 in Health Impact Assessment: Concepts, Theory, Techniques, and Applications, J. Kemm, J. Parry, and S. Palmer, eds. Oxford: Oxford University Press. PHAC (Public Health Advisory Committee). 2005. A Guide to Health Impact Assess- ment: A Policy Tool for New Zealand, 2nd Ed. Wellington, New Zealand: PHAC [online]. Available: http://www.phac.health.govt.nz/moh.nsf/pagescm/764/$File/gui detohia.pdf [accessed May 9, 2011]. Quigley, R., L. den Broeder, P. Furu, A. Bond, B. Cave, and R. Bos. 2006. Health Impact Assessment: International Best Practice Principles. Special Publication Series No. 5. Fargo: International Association for Impact Assessment. September 2006 [on- line]. Available: http://www.iaia.org/publicdocuments/special-publications/SP5.pdf [accessed May 6, 2011]. Scott-Samuel, A. 1997. Assessing how public policy impacts on health. Healthlines 47 (Nov.):15-17. Scott-Samuel, A. 1998. Health impact assessment—theory into practice. J. Epidemiol. Community Health 52(11):704-705. Scottish Office Department of Health. 1999. Towards a Healthier Scotland: A White Paper on Health. Edinburgh: The Stationery Office. Taylor, L., and R. Quigley. 2002. Health Impact Assessment: A Review of Reviews. National Health Service, Health Development Agency, London [online]. Avail- able: http://www.nice.org.uk/niceMedia/documents/hia_review.pdf [accessed May 10, 2011]. WHO (World Health Organization). 1999. Health Impact Assessment: Main Concepts and Suggested Approaches-the Gothenburg Consensus Paper. Brussels: European Centre for Health Policy, WHO Regional Office for Europe. WHO (World Health Organization). 2002. Health Impact Assessment: A Tool to Include Health on the Agenda of Other Sectors: Current Experience and Emerging Issues in the European Region. Technical Briefing, Regional Committee for Europe, 52nd Session, September, 16-19, 2002, Copenhagen [online]. Available: http://www.euro. who.int/__data/assets/pdf_file/0004/117049/ebd3.pdf [accessed Apr. 22, 2011].