4

Current Issues and Challenges in the Development and Practice of Health Impact Assessment

Chapter 2 discussed the need for health-informed decisions and the advantages of using health impact assessment (HIA) to evaluate the potential health consequences of an array of projects, plans, programs, and policies. Chapter 3 provided a framework for HIA and highlighted critical elements of each step in the HIA process. This chapter identifies and explores several topics considered by the committee to be the most salient issues or challenges for the successful emergence, development, and practice of HIA. First, the committee addresses how health should be defined for HIA and how its definition influences the application and scope of HIA practice. Types of decisions that are potential candidates for HIA are then considered. The committee next reviews several methodologic issues for HIA, including the need to balance timely information with variable data quality, expectations for quantitative estimates, synthesizing conclusions on dissimilar health effects, assigning monetary values to health outcomes, enabling stakeholder participation, and the benefits of a peer-review process for HIA. The committee then examines the potential for conflicts of interest among HIA practitioners, sponsors, and funders and considers whether it is realistic to expect the practice of HIA to result in a change in the decision being made. The committee concludes with a discussion of how HIA is related to the consideration of human health effects in environmental impact assessment (EIA) as required by the National Environmental Policy Act (NEPA) and similar state laws.

DEFINING HEALTH FOR HEALTH IMPACT ASSESSMENT

How health is defined and considered by society and government institutions—that is, what is or is not considered by practitioners, decision-makers, and



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4 Current Issues and Challenges in the Development and Practice of Health Impact Assessment Chapter 2 discussed the need for health-informed decisions and the advan- tages of using health impact assessment (HIA) to evaluate the potential health consequences of an array of projects, plans, programs, and policies. Chapter 3 provided a framework for HIA and highlighted critical elements of each step in the HIA process. This chapter identifies and explores several topics considered by the committee to be the most salient issues or challenges for the successful emergence, development, and practice of HIA. First, the committee addresses how health should be defined for HIA and how its definition influences the ap- plication and scope of HIA practice. Types of decisions that are potential candi- dates for HIA are then considered. The committee next reviews several method- ologic issues for HIA, including the need to balance timely information with variable data quality, expectations for quantitative estimates, synthesizing con- clusions on dissimilar health effects, assigning monetary values to health out- comes, enabling stakeholder participation, and the benefits of a peer-review process for HIA. The committee then examines the potential for conflicts of interest among HIA practitioners, sponsors, and funders and considers whether it is realistic to expect the practice of HIA to result in a change in the decision being made. The committee concludes with a discussion of how HIA is related to the consideration of human health effects in environmental impact assessment (EIA) as required by the National Environmental Policy Act (NEPA) and similar state laws. DEFINING HEALTH FOR HEALTH IMPACT ASSESSMENT How health is defined and considered by society and government institu- tions—that is, what is or is not considered by practitioners, decision-makers, and 90

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91 Current Issues and Challenges in Development and Practice of HIA stakeholders to have relevance to and a bearing on health—ultimately estab- lishes the boundaries for HIA practice. That determination will clearly influence which decisions are considered appropriate subjects for HIA and which health effects are considered to be within its scope. Many have recognized that a nar- row definition of health or factors that influence health probably limits the scope, application, and value of the practice. The constitution of the World Health Organization (WHO) considers health broadly and states that “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO 1946, p. 100). Although there are many definitions of health—many less expan- sive than the WHO definition—there is a growing consensus that health at the individual and population levels is shaped by a combination of genetic, behav- ioral, social, economic, political, and environmental factors. As discussed in Chapter 2, the root causes or determinants of health include the quality and ac- cessibility of infrastructure, such as housing, schools, parks, and transportation systems; the safety of the environment and economic security; the number and quality of social interactions; cultural characteristics, such as diet; and the level of equity and social inclusion. It is therefore essential that those many determi- nants be considered in defining the boundaries of HIAs. In the present commit- tee’s view, HIA must be concerned broadly with individual and public health and all its social, cultural, political, economic, and environmental determinants. Using such a broad definition of health has clear implications for which decisions may be subject to HIA, the scope of issues and measures used to char- acterize health in HIA, and how health effects are weighed in relation to compet- ing outcomes. In general, the public-health practice has traditionally defined health more narrowly and focused on disease, morbidity, and longevity. Thus, many decisions that affect health determinants have been considered outside the scope and mandate of public-health institutions. As discussed in Chapter 2, the failure to attend to the broader health determinants—for example, economic conditions—have contributed to avoidable disease and health disparities (CSDH 2008). However, broadening the definition of health has implications for the work of other sectors and their relationships with each other and with public health. Expecting institutions outside the health-care and public-health sectors to advance public-health interests will be challenging because actions needed to protect and promote health are often in conflict with the interests and objectives of other sectors. Critics may question whether addressing public-health objec- tives should be weighed more heavily than meeting the objectives of the sector in whose domain a decision is being debated. Ultimately, broadening the defini- tion of health creates the setting where tradeoffs among health and other social objectives can be made transparently. Recent calls for public agencies to con- sider and take actions to improve health indicate changing attitudes and the need to create a more multidisciplinary approach to public health (CSDH 2008). The committee supports the recent government actions and emphasizes the need to

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92 Improving Health in the U.S.: The Role of Health Impact Assessment define health broadly in the practice of HIA but recognizes that implementation will require some care to balance health with the many other considerations that are important to any given decision. ARE ALL DECISIONS POTENTIAL CANDIDATES FOR HEALTH IMPACT ASSESSMENT? A frequent question—given the breadth of potential applications of HIA— is whether there is a limit on the types of decisions to which the practice might be applied. For example, is HIA better suited to decisions in particular policy sectors (such as education, urban planning, and finance), to a particular scale (such as policy vs project) or jurisdictional level, or to particular health out- comes? The question is important because there are few formal requirements for analyzing the health effects of decisions except for the requirements for health analysis under NEPA and state environmental policy acts (SEPAs), and as de- mand for HIA grows, there will be a greater need to target its applications effi- ciently. The broad definition of health discussed above suggests that a wide array of decisions—including some of those made in almost all government sectors on local, state, national, and international scales—may be appropriate candidates for HIA (Harris-Roxas and Harris 2011). A review of the sectors in which HIAs have been completed in the European Union (EU) (Wismar et al. 2007) and in the United States (Dannenberg et al. 2008; HIA-CLIC 2010; RWJF/PEW 2011) underscores this breadth of potential applications (see Table 4-1). Although most U.S. examples reflect applications in the transportation, housing, or urban- planning sectors, there is growing diversity in the United States and a wider di- versity in the existing spectrum of EU applications. The growth may be because of greater experience with and public support for HIA and increased public rec- ognition of the many determinants of health. In the committee’s view, restricting the spectrum of HIA practice to par- ticular decisions, sectors, decision scales, jurisdictional levels, or health issues is unwarranted. At this early stage, there is no evidence to suggest that HIA is more important, appropriate, or effective in any particular decision context. On the contrary, HIA may be useful across a broad array of decision contexts, in- cluding many decision types to which it has not yet been applied. Furthermore, new global health challenges are likely to emerge from issues related to atmos- pheric and climate change, population growth, food and land scarcity, revolu- tionary industrial technologies (such as nanotechnology and gene modification), globalization, and economic inequities (WWF/ZSL/Global Footprint Network 2010). For example, a changing climate and an increase in extreme weather events will have many effects, including widespread effects on health (Costello et al. 2009; Luber and Prudent 2009). Public policy in general and public health and HIA in particular must recognize the emerging challenges and support the

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93 Current Issues and Challenges in Development and Practice of HIA identification of adaptive and preventive strategies. HIA may play a substantive role in emphasizing the importance of the emerging issues to public health and to policy-makers and stakeholders. TABLE 4-1 Health Impact Assessment by Sector Sectora European Unionb United Statesc Transport 27 (17%) 21 (28%) Housing or urban planning 23 (15%) 28 (38%) Environment 18 (11%) 3 (4%) Health 14 (9%) 0 (0%) Employment 10 (6%) 4 (5%) Social care 8 (5%) 0 (0%) Finance 8 (5%) 0 (0%) Energy 7 (4%) 8 (11%) Agriculture 7 (4%) 2 (3%) Industry 4 (3%) 5 (7%) Education 3 (2%) 3 (4%) Tourism 2 (1%) 0 (0%) Multiple sectors 17 (11%) 0 (0%) Other 10 (6%) 0 (0%) Total 158 74 a The list of sectors was taken from Wismar et al. (2007). The authors did not provide the criteria used to determine whether a report was considered an HIA, and they did not ex- plicitly define how HIAs were categorized into sectors. There is clearly potential for poli- cies, plans, programs, and projects to fall into two or more categories. b Wismar et al. (2007) was used as the source for the EU data. c HIAs conducted in the United States were identified from lists maintained by the Health Impact Project (RWJF/PEW 2011), the University of California, Los Angeles (HIA- CLIC 2010), and Dannenberg et al. (2008) and from committee experience. To be in- cluded in the table, an HIA must have been identified as such by the authors and must have documented at least some steps of the HIA process. The committee recognizes that the list may not be up to date or exhaustive, but the table shows examples of the sectors that do HIAs. As seen here, many more HIAs have been carried out in the EU than in the United States. In both the United States and the EU, HIAs are carried out most often in the transportation, housing, and urban-planning sectors.

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94 Improving Health in the U.S.: The Role of Health Impact Assessment Although most decisions have the potential to affect health, conducting HIAs of all decisions is clearly not practical or expected. Accordingly, HIA pro- ponents should try to select decisions that have the greatest opportunities for advancing public-health goals and promoting the awareness of the health impli- cations of decision-making. As described in Chapter 3, one purpose of the screening step in HIA is to focus HIA on high-priority topics by explicitly con- sidering the value of conducting HIA in a particular situation. For example, find- ings of an HIA of a proposed decision may be appropriately applied to a similar decision in another context or on another scale (for example, regulations for labor standards on city, state, and federal scales), so the value of conducting another HIA may be diminished. The committee emphasizes that as long as HIA is conducted as a voluntary process, it will be difficult to ensure that it is directed at the most important health priorities and decision opportunities. Aside from the limited analysis of health effects that is currently conducted within the regulatory structure of EIA, practitioners of or those funding or sponsoring HIA are in most cases selecting decisions by using ad hoc mechanisms based on their own interests and goals and are considering a limited set of candidate decisions (for example, land-use projects in a particular locality). Without clear mandates, screening criteria, and procedural rules for HIA, the selective approach to conducting an HIA may miss decisions for which HIA would have value and produce some HIAs that have little utility for decision-makers or stakeholders.1 Furthermore, HIA could con- ceivably contribute to health inequities if more socioeconomically or politically advantaged communities develop greater capacity to demand HIA or if health issues that are highlighted in HIA are focused on the health needs of the advan- taged. In contrast, institutional rules for HIA—for example, rules articulated in laws at the local, state, or federal level—could establish consistent procedures for the field and ensure that a sufficiently broad set of candidate decisions are screened. For example, decisions subject to HIA might be selected and ranked on the basis of the likelihood of addressing the Healthy People 2020 objectives of the U.S. Department of Health and Human Services or on the basis of the most realistic opportunities to address environmental injustice or to reduce health inequities. Institutional rules could effectively narrow a large number of candidate decisions to a manageable ordered set, enhance the use of HIA, and advance its rationale and equitable use. Such rules could also help to organize and direct the creation of a coherent and systematic body of knowledge about decision-related health effects and analytic methods that could be used for HIA. 1 The committee notes that although screening is considered an essential step in the HIA process, there is little published documentation or evaluation on the implementation of the screening step and thus little information on cases in which HIA might have been considered and not conducted. Some but not all HIA reports explain the rationale for conducting the assessment, but still there is little understanding of why HIAs have or have not been pursued.

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95 Current Issues and Challenges in Development and Practice of HIA Thus, the committee finds that any future policies, standards, or regulations for HIA should include explicit criteria for identifying and screening candidate de- cisions and rules for providing oversight for the HIA process; such criteria and rules would promote the utility, validity, and sustainability of HIA practice. BALANCING THE NEED TO PROVIDE TIMELY, VALID INFORMATION WITH THE REALITIES OF VARIED DATA QUALITY A substantial challenge facing HIA practitioners is the quality and avail- ability of evidence on which to base predictions about health effects (Mindell et al. 2004; Petticrew 2007; Veerman et al. 2007; Bhatia and Seto 2011; Mindell et al. 2010). More broadly, scholars acknowledge that the studies and empirical evidence linking improvements in health directly to changes in specific public policies are sparse (Curtis et al. 2002; Dow et al. 2010; Graham 2010). Further- more, many decisions occurring outside the health sector have not previously been seen as important for health, so they have typically not been the subject of rigorous empirical health research. Thus, making prospective judgments about the effects of policy decisions on health is challenging, and concerns about va- lidity arise in the face of variable and often sparse evidence. The committee emphasizes that concerns about validity must be balanced against the reality that decisions that are not informed by health analysis have the potential to harm health (see Chapter 2); this implies that the degree to which the evidence limits judgments must always be weighed against the potential se- verity and scope of harm that could occur if available information were not con- sidered. But practitioners should also consider the risk, both to optimal decision- making and to the legitimacy of the field, that is inherent in overstating the pre- cision or certainty of health-effect estimates provided by HIA. There are challenges to addressing concerns about the validity of HIA predictions. Regardless of evidence-related constraints, HIA must operate in the context of practical realities and timelines of the decision-making process, and HIA reports need to express clearly the quality of evidence and the degree of confidence in inferences drawn from the evidence. The committee notes that society regularly accepts such practical limitations in making policy decisions and that predictive certainty or causal certainty would be an impractical standard for HIA. Practical and agreed-on methods for addressing concerns about validity are needed, and the committee offers three strategies, discussed below, that should help to improve the validity of health-effects judgments made in the con- text of variable evidence:  Consider diverse evidence sources by using expertise in multiple disci- plines.  Assess the quality of available evidence.

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96 Improving Health in the U.S.: The Role of Health Impact Assessment  Include a strategy for assessing and managing uncertainty. HIA practitioners can also learn from the health-risk-assessment field where some analysts have demonstrated the ability to adapt their analyses to varied evidence, ranging from data extrapolated from the literature when local informa- tion is lacking to primary reliance on local data that leverage knowledge and statistical power from the broader literature (Hubbell et al. 2009). Consider Diverse Evidence Sources by Using Expertise in Multiple Disciplines As discussed in Chapter 3, many types of evidence can be used in HIA, including peer-reviewed academic studies; unpublished, publicly available stud- ies and databases, that is, gray literature; survey, monitoring, or interview data specific to the affected population or to the policy, plan, program, or project in question; the experience of people who will be affected by the proposed changes; and expert opinion. The committee recommends that practitioners re- view all the available evidence systematically (Mindell et al. 2010). Practitioners should use published, peer-reviewed systematic reviews—such as those con- ducted by the Cochrane Collaboration, WHO, the U.S. Environmental Protec- tion Agency, and other authoritative bodies—if they are available. Although studies conducted within the population that might be affected are ideal, they may not exist or be feasible to conduct, so analysis will turn to literature and data on other populations. HIA is necessarily a multidisciplinary practice. It is often, although not exclusively, carried out by public-health professionals, but it almost always re- quires access to experts in the core domains that are affected by the proposal under consideration. Multiple disciplines will help to reveal differences of opin- ion, will provide the team with access to a variety of evidence and analytic methods, and may provide a more robust critique of methods, findings, and con- clusions. The participation of multiple public agencies—such as health, plan- ning, and transportation agencies—not only will contribute expertise but may ensure that the process addresses questions pertinent to the decision at hand and thus increase the likelihood that the recommendations are actionable and will be adopted. Furthermore, conducting HIA as a multidisciplinary practice can assist in developing ownership and commitment for health goals among multiple insti- tutional and disciplinary sectors. The committee nevertheless recognizes that it can be challenging to conduct multidisciplinary analysis or to manage the par- ticipation of multiple agencies or participants. In selecting evidence and evaluating quality, practitioners should recog- nize their own biases and the biases of decision-makers, project proponents, or HIA sponsors. Biases may affect the value attached to particular types of evi- dence. For example, evidence from consultation, which can be more readily dismissed as hearsay or anecdotal, may not be accorded as much weight as the

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97 Current Issues and Challenges in Development and Practice of HIA quantitative modeling of environmental exposure or economic effects (Ozonoff 1994). Other biases related to conflicts of interest are discussed later in this chapter. Evaluate Evidence Quality HIA practitioners should select the strongest evidence and analytic meth- ods that are available for a particular decision context. For transparency, it is equally important to state the rationale for choosing particular evidence or methods when alternatives are available. Key factors that should be considered in determining whether to use a given study or dataset include the relationship between study end points and the issues evaluated in the HIA, the quality of the data and their statistical power, the adequate assessment of factors that could impede causal inference (that is, the internal validity of an empirical study) (Susser 1986; Rothman and Greenland 1998; Weed 2005), and the applicability of the evidence to the target population (that is, external validity). The quality of evidence used in HIA may also be assessed according to the core standards of the discipline in which the data originate; for example, epidemiologic studies should generally be evaluated according to quality standards for epidemiologic studies with attention to such issues as the potential for bias and confounding. There are no uniform standards for evaluating all potential evidence that might be used in HIA given the diversity of applications and of the evidence base. However, many of Bradford Hill’s (Hill 1965) causal criteria—such as strength of association, consistency of evidence among studies and data sources, coherence with known facts of the exposure and disease, and analogy to similar situations—could be applied to HIA when evaluating the likelihood of health effects. Other criteria could be developed to extrapolate findings on study popu- lations to the target populations for specific decisions. And criteria could be de- veloped in ways that are specific to the needs of different policy contexts. Setting any uniform evidence standards carries some risk of limiting the scope of health effects and pathways assessed in HIA. In health risk assessment, even with assumptions and acceptance of uncertainty, evidence requirements in practice have constrained analysis to a limited set of exposures and outcomes (NRC 2009). Even if HIA practice evolves standardized approaches for the analysis of particular decisions, determinants, or health effects, there will be a need for flexibility to address new and emerging issues. Characterize and Manage Uncertainty Uncertainty will always be present, and impact assessments—including HIAs—should characterize and manage the uncertainty to the extent possible and practicable that is inherent in the analyses and decisions. Although uncer- tainty should not be ignored in HIA, it should also not paralyze the decision process. Furthermore, there may be situations in which the magnitude of uncer-

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98 Improving Health in the U.S.: The Role of Health Impact Assessment tainty is large enough to make selection among competing alternatives challeng- ing, but the potential impact may be important enough to justify intervention in the face of that uncertainty. Managing uncertainty in HIA can include planning how the analysis will address uncertainties and establishing procedures to characterize or reduce key uncertainties. Uncertainty in the analysis of health effects can be characterized in a variety of ways, ranging from qualitative descriptions to quantitative analy- sis. Quantitative analyses of uncertainty are common in related fields, such as health risk assessment, and are relevant if the key health effects are quantified in the HIA. Distributions of estimates based on various assumptions have been presented in HIA (Schram-Bijkerk et al. 2009), but it typically includes only a subset of assumptions for which distributions can be readily quantified and omits some major sources of uncertainty for which quantification is impractical. More generally, although formal propagation and quantification of uncertainty can be helpful in elucidating the influence of key assumptions, they contribute to a lack of methodologic transparency for many stakeholders and raise potential issues with timeliness. At a minimum, uncertainties in assumptions used to sup- port health-effect characterization should be described qualitatively. In other words, HIA practitioners should evaluate and document the uncertainty of their conclusions by describing the evidence on which their conclusions are based and by identifying any limitations, gaps, or weaknesses in the assumptions. That exercise should go beyond parametric uncertainty described in individual studies to consider broader questions, such as whether a measure of exposure used in HIA was a reliable proxy for personal exposure or whether an exposure- response function extracted from the literature can be generalized to the popula- tion of interest. Similar issues have been confronted in the domain of health risk assess- ment. The National Research Council report Science and Decisions: Advancing Risk Assessment (NRC 2009) concluded that the plans for uncertainty analysis should be discussed during the scoping process to ensure that the information generated meets the needs of decision-makers and to avoid unnecessarily com- plex (and untimely) uncertainty analyses. For example, if a mitigation or alterna- tive is readily available and affordable for managing a health impact of concern and has greater benefits than other alternatives, a formal treatment of uncertainty may be unnecessary. Planning of how uncertainty will be evaluated and man- aged—including quantitative and qualitative elements—should be a component of the scoping process of HIA (see Chapter 3). The plan should consider how stakeholders may wish to see uncertainty information presented, including the method of presentation and the emphasis on distributions vs expected values vs upper or lower bound values for aspects that can be quantified. Various ap- proaches for characterizing the sophistication of uncertainty analysis (Pate- Cornell 1996; IPCS 2006) could be adapted for HIA, as could previously rec- ommended strategies for addressing and communicating uncertainty in complex multifactorial models (NRC 2007) and in cost-effectiveness analysis (Briggs 2000; Claxton 2008).

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99 Current Issues and Challenges in Development and Practice of HIA As suggested, characterization of uncertainty will often need to go beyond quantitative methods to include other forms of information. Using a deliberative group process to arrive at judgments is a nonquantitative way to manage uncer- tainty and to moderate the effects of individual and organizational values and biases. HIA conducted as a deliberative group process that involves open discus- sion and debate among the stakeholders may also be useful in generating judg- ments that will be widely accepted. The National Institutes of Health uses a de- liberative process to achieve consensus on many clinical issues in medicine (NIH 2011); this approach may have value in managing uncertainties in HIA. As the practice of HIA evolves, there may be uncertainties and data limita- tions that call for a set of practical assumptions to avoid subjective or ad hoc variations in analyses. In the practice of health risk assessment, default science- policy assumptions are used to allow the analysis to proceed with incomplete information (NRC 1983). For example, carcinogens whose mode of action is unknown are generally assumed to have linear dose-response functions at low doses, whereas nonlinear dose-response functions are assumed for noncancer health effects in the absence of specific evidence about mode of action or chemical pharmacodynamics. Similarly, when exposure or dose information is lacking, numerous default assumptions are used to capture breathing rates, drinking-water consumption, and various other behaviors or activities. In each case, there is inadequate information on the specific pollutants and settings of interest, but the analysis proceeds with assumptions derived from a combination of evidence from analogous situations and science-policy judgments. Although the variety of applications of HIA makes specific default science-policy assump- tions difficult to formalize, the concept can be used to provide more transpar- ency and interpretability. Over time, for policy contexts in which numerous HIAs are conducted, default science-policy assumptions could be generated and could facilitate comparability among HIAs. Regardless, HIA practitioners should explicitly describe where key judgments or assumptions were made, whether or not uncertainty can be formally characterized, and what implications the assumptions have on the HIA recommendations. In that way, the ultimate choice among competing options can be made by decision-makers given their preferences regarding action in the face of uncertainty. BENEFITS AND CHALLENGES OF QUANTITATIVE ESTIMATION Some decision-makers and HIA users expect HIA to provide quantitative estimates of health effects. Quantitative estimates of health effects have a num- ber of desirable properties: they provide an indication of the magnitude of health effects, they can be easily compared with existing numerical criteria or thresh- olds that define the significance of particular effects, they allow one to make more direct comparisons among alternatives, and they provide inputs for eco- nomic valuation (see section “Assigning Monetary Values to Health Conse- quences” below). They can be produced when there has been sufficient empiri-

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100 Improving Health in the U.S.: The Role of Health Impact Assessment cal research on relationships between particular determinants and health out- comes. Accordingly, quantification is most feasible if a causal relationship can be inferred and if there is an externally valid effect measure or a defined expo- sure-response relationship (Hertz-Picciotto 1995; Fehr 1999; Mindell et al. 2001; O’Connell and Hurley 2009; Bhatia and Seto 2011). If information is lacking or uncertain, quantification may still be possible with the use of assump- tions and inferences based on information drawn from analogous situations. In other situations, such as when assumptions are not defensible, quantitative esti- mates should not be advanced. HIAs have applied quantitative techniques to decisions to estimate health effects related to expected changes in infectious-disease risks, traffic hazards, environmental pollutants, housing conditions, and tobacco and alcohol con- sumption (see Box 3-4; Veerman et al. 2005; O’Connell and Hurley 2009; Bhatia and Seto 2011). For example, quantitative impact-assessment methods have been used to estimate human health externalities associated with different fuels in Europe; the analysis was used to inform member states about the im- pacts of various fuels for electricity (such as nuclear fuel, coal, and natural gas) and was considered in numerous policy analyses, including strategies for inter- nalizing external costs and development of sustainable-transport policies (O’Connell and Hurley 2009). Noise exposures and particulate-matter concen- trations were modeled and associated with sleep disturbance and premature mor- tality, respectively, in local-scale assessments of residential development in San Francisco and waterfront development in Oakland; the assessments used quanti- tative exposure-response functions from the epidemiologic literature (Bhatia and Seto 2011). The effects of rezoning in San Francisco on pedestrian injuries were modeled on the basis of multivariate regression models derived from geocoded accident data and site characteristics, and changes in body-mass index and acci- dent risks associated with increased walking of children to school in Sacramento were estimated by using data derived from epidemiologic investigations (Bhatia and Seto 2011). Regardless of the advantages, relying exclusively on quantitative estima- tion in HIA presents some drawbacks. First, quantification has high information requirements. Given the breadth of health effects potentially considered in HIA, the sparse data available to support quantitative approaches, and the variability in practitioner capacity, it would be challenging if not impossible to expect all HIAs to predict all potentially important health effects quantitatively. Thus, an HIA that presents only quantifiable results would present only a partial account- ing of health effects if not all important effects are amenable to quantification (Veerman et al. 2005; O’Connell and Hurley 2009). Second, because quantifica- tion can be resource-intensive, it may require more time than allowed for the evaluation of a policy, plan, program, or project. Third, a quantitative approach has implications for communicating the process and results to a wider audience because the methods are typically highly technical and include assumptions that may be difficult to communicate outside the technical team. Quantitative esti- mates may create an unwarranted impression of objectivity, precision, and im-

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108 Improving Health in the U.S.: The Role of Health Impact Assessment could potentially bias the scope of the assessment and the associated results. Mission-driven grant-makers may have strong expectations that HIA will pro- duce substantive change in the issues and interests that they champion, or they may wish to see clear evidence that the HIA influenced a decision. Government agencies sponsoring HIAs may also have interests that exert influence on HIA practices or conclusions. For example, government agencies may be less welcoming of results that potentially raise criticisms of their actions, identify their oversights, or challenge their positions. Like development-project proponents, public agencies may have a preferred decision outcome and may be interested in ensuring that HIA reflects favorably on that alternative. Such con- flicts may be heightened if the agency conducting the HIA is also the responsi- ble decision-maker. In some cases, stakeholders or practitioners may decide to champion, sponsor, or conduct an HIA because of a strong interest in a specific decision outcome. They may seek to use HIA as a means to support or advocate for a particular policy outcome (Harris-Roxas and Harris 2011). In such cases, there may be a substantial risk of introducing bias into the HIA process. The committee emphasizes that a lack of trust by any stakeholders in the HIA practitioner can undermine the legitimacy and influence of HIA. Therefore, it is important to guard against and mitigate the conflicts of interest described above. It may be useful for future practice guidance to establish a clear line be- tween a practitioner’s role in conducting HIA and later efforts toward advocacy of particular decision outcomes.3 Although public entities may be somewhat less vulnerable to influence because of public funding sources, oversight mecha- nisms, and requirements for transparency, they are not immune to influence. Public-health agencies that have the necessary experience and expertise and the confidence of stakeholders may be in good positions to conduct or coordinate HIA given their mandate to protect public health. Other mechanisms to manage or mitigate influence may include the eventual creation of a dedicated public funding source to conduct HIA and a process of independent peer review of HIA as discussed above. MANAGING EXPECTATIONS: INFORMATION MAY NOT CHANGE DECISIONS HIA clearly is intended to inform decisions, but information alone does not necessarily change decisions. The committee recognizes that the underlying motivation of HIA is to make policy and decisions that are more cognizant of and aligned with the interests of public health. Informing decision-makers can certainly influence attitudes and preferences and lead to more responsive health- 3 The committee distinguishes between advocacy (that is, trying to influence the deci- sion outcome) and explaining or educating decision-makers on the findings and recom- mendations made in an HIA.

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109 Current Issues and Challenges in Development and Practice of HIA supporting actions, but it is not reasonable to base the effectiveness of HIA on whether it changes decisions in which health is only one of many considerations and over which the HIA team lacks decision-making authority. Furthermore, support and legitimacy of the practice may be compromised if an HIA is con- ducted explicitly as a mechanism for decision advocacy. It is reasonable to hope that identifying valid information about the health- related harms or benefits of a decision will motivate decision-makers to take protective actions.4 However, generating high-quality health information and effectively communicating it does not ensure that the information is given high priority in the decision-making process or triggers action. HIA is not designed or practiced as a mechanism to regulate decision-making directly (that is, to require responsive actions if impacts exceed criteria). Although effective communica- tion can raise awareness of and attention to health concerns, improved knowl- edge alone cannot necessarily change the ideology, interests, and attitudes of decision-makers. Health is typically one of many objectives under consideration in a given policy question, and decision-makers and other stakeholders are rea- sonably influenced by factors and tradeoffs beyond the quality or findings of an HIA. Although HIA does not guarantee particular decision outcomes, providing publicly available information on health effects clearly is a mechanism of influ- ence. Thomas Jefferson famously stated that “information is the currency of democracy.” In the case of EIA under NEPA, the purpose of the process was to give environmental consequences due consideration (Yost 2003). Although the courts observed that NEPA provides protection only from the harm of unin- formed decision-making, not from adverse environmental consequences them- selves, informing decisions has substantial power. Institutional rules for EIA have opened decision-making to public scrutiny, raised the profile of environ- mental considerations, and altered the norms and practices of public and private organizations in a way that is more protective of the environment (Canter and Clark 1997; Cashmore et al. 2007). Given that HIA practitioners are not typically in decision-making posi- tions, effective and broad communication of findings is essential to the informa- tional objectives and to later influence on decision-making. Communication of findings may be optimal when there is an opportunity for assessors to have dis- cussion with decision-makers and stakeholders. Effective dissemination may require educating decision-makers about the public-health evidence underlying conclusions and may require consideration of and response to criticisms about the findings or about the efficacy or feasibility of recommendations. Many oth- ers, apart from practitioners, may be in strong positions to communicate findings of HIA and their importance in the decision-making process. The accounting of health effects by HIA should allow the public and stakeholders to use informa- 4 The committee notes that revisions might be made in a proposal or its alternatives in anticipation of an HIA being conducted; such changes might not ultimately be considered to be a result of the HIA but might not have occurred if the HIA were not planned.

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110 Improving Health in the U.S.: The Role of Health Impact Assessment tion in the political process to advance health interests. The political use of HIA evidence—like other types of information disclosed to the public—should be viewed as a normal mechanism of its influence on decisions. ADVANCING REQUIREMENTS FOR HEALTH ANALYSIS IN ENVIRONMENTAL IMPACT ASSESSMENT This chapter has thus far discussed HIA as it is practiced outside the con- text of EIA. NEPA and some SEPAs explicitly require the identification and analysis of health effects when EIA is conducted, and there are various views on how HIA might be related to or support health-effects analysis in the EIA proc- ess (see Appendixes A and F for further discussion). Although the scope of health-effects analysis has been limited in U.S. EIA practice, some argue that greater use should be made of NEPA and related state laws as a mechanism for health-informed policy-making given that it has the same substantive ends as HIA (Bhatia and Wernham 2008; Wernham 2009; Morgan 2011). Others, how- ever, contend that EIA has become too rigid a practice to accommodate the at- tention and resources needed for conducting a comprehensive analysis of health effects (Cole et al. 2004) and that attention should be focused on the independ- ent practice of HIA. The committee is keenly aware of the time and resources that NEPA com- pliance can entail. However, assessment of direct, indirect, and cumulative health effects in EIA under NEPA and many SEPAs is a matter of law, not dis- cretion, when it is likely to add important information that is relevant to deci- sion-making (see Appendix A for further discussion). Therefore, when legal requirements call for an integrated analysis of health effects in the EIA process, this analysis should be conducted in observance of the same procedures and standards as for any other environmental or social effects being considered. In the case of health, those procedures would arguably mirror the general steps of HIA as described in Chapter 3 and would include a description of the baseline health status of the population; an analysis of the direct, indirect, and cumulative health consequences of the proposed action and alternatives; and a consideration of potential mitigation measures to address the health concerns identified by the analysis. If adequately conducted, the steps would be consistent with and might be considered equivalent to conducting an HIA. To date, however, despite the requirements for the analysis of health ef- fects in EIA, the consideration of health effects in EIA practice has been limited, and public-health experts have rarely been involved in the EIA process (Davies and Sadler 1997; Steinemann 2000; Hilding-Rydevik et al. 2006). The limited practice may partly reflect that historically, NEPA practice has been shaped primarily by pressure and litigation brought by environmental groups, and pub- lic-health advocates have only rarely demanded health-effects analysis. The lim- ited practice also may reflect the resource constraints facing many public-health departments and more generally the lack of familiarity with EIA practice. Chal-

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111 Current Issues and Challenges in Development and Practice of HIA lenges to changing EIA practice to include more substantive health analysis in- clude resistance on the part of agencies leading EIA to invest time and resources in routine health analysis, lack of familiarity with or expertise in public health on the part of agencies that commonly lead EIAs, and limited relationships with local, state, and tribal health authorities or others that have the capacity to con- duct public-health analyses (Cole et al. 2004; Hilding-Rydevik et al. 2006; Cor- burn and Bhatia 2007; Bhatia and Wernham 2008). Because of those challenges, some HIA practitioners have voiced concern that, in contrast with independent HIA, integrating health into EIA might produce a narrow consideration of health effects (Cole et al. 2004). Furthermore, it is possible that agencies responsible for EIA may give less importance to health effects than to other environmental concerns; consider only health effects that are quantifiable with traditional methods, such as human health risk assessment; or allocate insufficient funding for health-effects analysis. Those concerns are valid, but the committee notes that the problem is not unique to the setting of integrated EIA. Currently, HIA conducted independently of EIA has no mechanism to monitor or ensure the adequacy of resources and breadth of analysis, and like EIA, the scope of HIA has been limited by practitioner decisions and available resources (Dannenberg et al. 2008). Considering those important challenges, the committee concludes that im- proving the integration of health into EIA under NEPA and related state laws is needed and would serve the mission of public health and the goals of HIA. Fed- eral agencies file thousands of EIA documents each year. Decision-making that is subject to EIA requirements at the federal and state levels includes a wide array of projects, programs, and policies that have broad importance for health. Furthermore, health issues are among the most common concerns raised by af- fected communities. Agencies formally responsible for conducting EIAs and practitioners in the field of public health have an interest in improving the consideration of health in EIA. When health effects are relevant to a proposed action, agencies responsible for conducting EIA should seek out appropriate public-health exper- tise and should invite tribal, federal, state, or local health agencies to participate as cooperating agencies (40 C.F.R Sections 1501.6, 15018.5). Adequate re- sources should be accorded to health-effects analysis in EIA. Similarly, public- health officials need to take a more active role in EIA by offering appropriate information and expertise to aid the analysis. Recent experience in the field has demonstrated that a greater considera- tion of direct, indirect, and cumulative health effects can be accomplished in EIA if the associations described are well supported by public-health theory and evidence (Wernham 2009; Bhatia and Wernham 2008; Morgan 2011). The offi- cial submission of findings by public-health agencies into the public record (for example, via public comment on draft environmental documents) has triggered comment and analysis by responsible agencies (Bhatia 2007). Interagency part- nerships that have involved public health during an EIA have reduced skepti- cism on the part of agencies unfamiliar with public health and HIA, have fos-

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112 Improving Health in the U.S.: The Role of Health Impact Assessment tered a broader shared understanding of potential health effects, and have led to health-protective mitigations and alternatives to the proposals that were assessed (Wernham 2007; Bhatia and Wernham 2008; Morgan 2011). In several cases under both NEPA and the California Environmental Quality Act, the scope of health effects and alternatives considered has been substantially augmented with the financial resources and expertise needed to conduct related analyses. In other cases, health-effects analyses have trigged substantive mitigations. There re- main, however, substantial opportunities to improve the consideration and analysis of health effects under NEPA and SEPAs. Conflicts and negotiation of interests among environmental assessors and health professionals concerning values, objectives, scope, and use of information should be expected in the course of developing a stronger integrated practice (Morgan 2011). Anecdotally, some concerns have been raised that broadening the scope of health analysis in NEPA may increase the potential for litigation. The committee finds little factual support for that view; indeed, only rarely has EIA litigation been based on inadequacy of health analysis. Indeed, the failure to address po- tentially important effects and substantive concerns is a leading reason for litiga- tion under NEPA and may result in an order to the agency to address the omis- sions; this could cause delays in projects. Given that there is increasing attention to the relationship between public policies and health in the United States, the failure to address potentially important health effects may leave agencies more vulnerable to litigation; ensuring a comprehensive analysis of health in EIA may be a good way for agencies to avoid such risks. CONCLUSIONS  Although there are many definitions of health, there is a growing con- sensus that health at the individual and population levels is shaped by a combi- nation of genetic, behavioral, social, economic, and environmental factors. It is essential that those determinants be considered in defining the boundaries of HIA.  It is not necessary or appropriate to conduct HIA for all decisions at the local, state, or federal levels; however, restricting the spectrum of HIA practice to particular decision types, institutional sectors, decision scales (for example, policy, program, or plan), or jurisdictional levels or to specific health issues is not warranted. The use of HIA should be focused on applications in which there is the greatest opportunity to protect or promote health and to raise awareness of the health consequences of proposed decisions.  The committee finds that three strategies should help to improve the va- lidity of health-effects predictions made in the context of varied evidence: con- sider diverse evidence sources by using expertise in multiple disciplines, assess the quality of available evidence, and implement a strategy for assessing and managing uncertainty.

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113 Current Issues and Challenges in Development and Practice of HIA  Quantitative estimates of health effects in HIA have a number of desir- able properties, but it is impractical to expect quantitative estimates in all appli- cations of HIA given the sparseness of quantitative data on associations between many policy decisions and health.  An HIA that analyzes multiple dissimilar health effects should describe and characterize each effect separately and consider ways to provide aggregate or summary measures of dissimilar effects.  Although HIA is not a cost-benefit analysis, economic valuation of health effects may be requested by decision-makers and should be considered when relevant data are available. As with any HIA component, economic valua- tion should be provided with a discussion of key assumptions and methodologic limitations.  The committee emphasizes the importance of stakeholder engagement and participation in HIA. Information gained through stakeholder involvement can help to focus the scope of the HIA and improve its quality and specificity by highlighting local living conditions, prevalent health issues, and potential effects that might not be visible to practitioners outside the community.  A formal peer-review process for HIA could increase the acceptability or utility of conclusions on health effects or related mitigations and should be considered when the benefits of added scrutiny and rigor would outweigh the disadvantages of added delay and process.  To the extent feasible, practitioners conducting HIA should strive to avoid real and perceived conflicts of interest. It may be useful for future practice guidance to establish a clear line between the practitioner’s role in conducting HIA and later advocacy of particular decision outcomes. A dedicated public funding source and a process of independent peer review of HIA may help in managing or mitigating conflicts of interest.  HIA aims to influence attitudes and preferences and leads to actions that support health, but HIA may not change decisions when health is only one of many considerations. Conducting HIA as a mechanism for advocacy may compromise support for and legitimacy of the practice.  Improving the integration of health into EIA practice under NEPA and related state laws would serve the mission of public health and the purpose of HIA and EIA. Despite known challenges, agencies responsible for EIA and pub- lic-health practitioners share responsibility for improving the consideration of health effects in EIA practice. However, to ensure reasonable priority of health issues under NEPA, public-health agencies should be afforded a substantive role in the scoping and oversight of health-effects analysis in EIA, and health-effects analysis must be afforded resources commensurate with the task.  The committee concludes that any future policies, standards, or regula- tions for HIA should include explicit criteria for identifying and screening can- didate decisions and rules for providing oversight for the HIA process; such criteria and rules would promote the utility, validity, and sustainability of HIA practice.

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