stakeholders to have relevance to and a bearing on health—ultimately establishes 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 narrow 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 expansive than the WHO definition—there is a growing consensus that health at the individual and population levels is shaped by a combination of genetic, behavioral, social, economic, political, and environmental factors. As discussed in Chapter 2, the root causes or determinants of health include the quality and accessibility 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 determinants be considered in defining the boundaries of HIAs. In the present committee’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 characterize health in HIA, and how health effects are weighed in relation to competing 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 objectives should be weighed more heavily than meeting the objectives of the sector in whose domain a decision is being debated. Ultimately, broadening the definition of health creates the setting where tradeoffs among health and other social objectives can be made transparently. Recent calls for public agencies to consider 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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