“Health In Everything” is an important slogan, pointing out that personal and social well-being is impacted by every public policy and every aspect of our built and cultural environments. Partly based on this insight, there is increasing interest in creating Health Impact Assessments (HIA) as part of the preparation for all kinds of policies and projects that don’t traditionally fall within the purview of public health – from transportation to commercial development, from agriculture to public safety.
For example, the 2009 enabling law creating the new Massachusetts Department of Transportation states that MassDOT “shall…institute and establish methods to implement the use of health impact assessments to determine the effect of transportation projects on public health and vulnerable populations for use by planners, transportation administrators, public health administrators and developers…”
The public health world has (for obvious reasons) happily embraced this trend, as have advocates in other fields looking to marshal the moral and police-power authority of public health to support their issues. This enthusiasm is based on two assumptions: that doing the “right thing” (meaning what the advocates are supporting) is also the “healthy thing.” And that creating an HIA is a useful way for identifying, gain political traction for doing, and then making sure that the “healthy thing” is actually implemented.
The first assumption is usually true. But the second needs a lot more discussion: the impact of an HIA depends on how a variety of questions get played out.
- What kind of HIA is being done?
- Why is the HIA being done?
- How formal and open is the evaluative process?
- What is being measured?
- How are things being measured?
- How will the HIA be used?
Depending on the answers, a Health Impact Assessment can be a powerful tool for collecting meaningful data that helps build support for positive decisions and actions, as well as provides a benchmark against which to measure how well the end result meets its stated goals. Or it can be a waste of time and energy, a bureaucratic way to defend decisions that were probably going to be made anyway, and that ends up diverting advocates limited resources from more useful strategies while providing cover for bad decisions and projects.
Health In Everything
It can be very useful to think ahead about the possible health impact of a policy or project. The public health community has increasingly come to appreciate the power of this evidence-based approach to planning. For the first time, the U.S. Department of Health and Human Services recommends HIA as a planning resource for implementing Healthy People 2020.
But the importance of evaluating health impacts is increasingly recognized in areas once considered far outside the scope of public health. For example, in Massachusetts the “Modernizing the Transportation Systems of the Commonwealth” law passed in 2009 creates a remarkable, nationally-unique Healthy Transportation Compact (HTC) led by the Cabinet-level leaders of Transportation, Health & Human Services, and Energy & Environment as well as their immediate reports in charge of Highways, Mass Transit, and Public Health. Its purpose is to “further cooperation, adoption of best practices, and increased efficiency for the purposes of achieving positive health outcomes through the coordination of land use, transportation, and public health policy.”
This component of Massachusetts’ transportation decision-making process could have a radically transformative impact. It embodies the growing understanding of the convergence of many different issues in many different fields – at the least indirectly impacting the accomplishment of each of their goals but often so synergistically intertwined that doing one intimately involves the other (think of the relationship between sustainable resource and environmental protection). But, while some of the issues the HTC addresses (sustainable energy, environmental protection, smart growth, expanded walking and bicycling facilities) have been addressed through other MassDOT initiatives, little has been done with the Compact itself beyond a couple of public meetings and statements. Only now, several years later, has the McGrath Highway redesign project been selected to pilot the use of an HIA – a real step forward and an important precedent-setting effort if done well. The delay can’t be ascribed only to bureaucratic resistance; going from HIA theory to practice is extremely complicated and requires an investment of time, people, and resources (increasingly and scarily scarce in the public sector) as well as patience and creativity.
Which is the point. There are a lot of different interpretations of what a Health Impact Analysis is – what its function should be, how it is done, and by whom. At root, a HIA is supposed to describe how a particular project or policy will affect the health of the population and the distribution of those effects within the population. It can also suggest ways to manage the risks, to reduce the negative impacts and/or increase the positive ones. Or not.
Data and analysis are important ingredients for decision. And despite philosophical/religious controversies over the objective versus subjective nature of reality and our perceptions thereof, despite the enormous range of conclusions that can be drawn from the same set of facts depending on the examiners’ pre-existing assumptions or interests, valid data can help cut through the babel and move reasonable conversations forward. HIAs can – but may not always – help.
Maddie Ribble, Director of Policy and Communications at the Massachusetts Public Health Association, also notes that public health requires a broad, multi-constituency perspective that requires advocates to walk a fine line between competing interests: “The goal of an HIA should not necessarily be to determine ‘yes’ or ‘no’ on a project, but rather how to make a project healthier. Public health should not let ourselves be pigeonholed as anti-development or let HIAs be seen in that light. Recently, for instance, a presenter used an example of an elderly housing development that was being sited near an expressway and how an HIA raised concerns about negative health impacts from pollutants, which led to design changes to mitigate this hazard. Would it have been better to site the building elsewhere? Perhaps. Were there people in that neighborhood who fought the development of the building? Almost certainly. But additional housing for frail seniors provides an important health benefit in and of itself, so an HIA should be about identifying the possible positive and negative outcomes. We shouldn’t let HIAs be co-opted by folks who want to stop development at all costs, and who have proven they will use any rationale against projects they don’t like.”
What is a Health Impact Assessment?
A Health Impact Assessment is a prospective analysis. It is done either during the initial go/no-go decision-making stage or as part of the early planning. A HIA is different from, but most valuable if followed by, health focused in-process monitoring and final evaluation.
A Health Impact Assessment draws on what is already known about the types of health impacts that a particular type of policy or project might have and the usefulness of various mitigating strategies, combined with an analysis of the relevancy of that evidence to the specific policy or project under consideration.
A HIA can happen as a one-off response to public anxiety about a particular issue or be built into the planning process. It can be as informal as a few summary paragraphs based on personal knowledge of, or ad hoc discussions about, similar situations. Or it can involve an in-depth review of a broad range of research and project-evaluation literature, field measurements, expert testimony or commissions, formal hearings using legal evidentiary rules, public input, and a lengthy report subject to court review. A HIA can take one person a couple of days or few weeks, or a team of people several months to more than a year to complete. There are many legal definitions including the World Health Organization’s: “a combination of procedures, methods, and tools by which a policy, program, 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.”
The CDC describes the major steps in conducting an HIA as:
- Screening (confirming that a particular an HIA would be appropriate for a particular project or policy),
- Scoping (identify which health effects to consider),
- Assessing risks and benefits (identify which people may be affected and how they may be affected),
- Developing recommendations (suggest changes to proposals to promote positive or mitigate adverse health effects),
- Reporting (present the results to decision-makers), and
- Evaluating (determine the effect of the HIA on the decision).
Why is the HIA being done?
An HIA can be done voluntarily or it can be required by law, Executive Order, regulatory requirements, administrative policy, or court order. If voluntary, what was promised to be done? If required, what are the mandated parameters in terms of scope, process, transparency, time frame, and results?
While having good data can help advocates make a strong case, it is seldom enough to win a fight. Similarly, just because an agency is required to do a health impact analysis, and even if they are presented with compelling data, there is no reason to assume that they will come to the desired conclusions. The agency might give countervailing data heavier weight. Or the formulas the agency uses to estimate impact might have distorting assumptions. Or a highly placed elected official might have a political (or contributor) reason to require that a certain conclusion be reached.
Ultimately, both the conclusions the HIA comes to and what is done with its recommendations are based on political, not scientific, processes. Advocates need to know the legal and political forces at play shaping the HIA context and use that knowledge, as well as all the openings provided by agency statements or regulations, to build public pressure for the desired outcome.
How Formal Is The HIA Process?
When it comes to HIAs, the “elephant in the room” is the fear of most private developers and public project managers that they’ll end up having to deal with another Environmental Impact Statement-like process. EIS became legally required when the National Environmental Protection Act passed Congress in 1970 as a result of enormous public pressure created by the 1969 Santa Barbara oil spill, increasing anger at the urban destruction created by the expanding Interstate Highway system, and the nation-wide outpouring for the first Earth Day on April 22. NEPA requires federal agencies to prepare an Environmental Impact Statement (EIS) for any project that uses federal funds, or that is regulated or could be prohibited by a federal agency, and even in some cases, if it must be reviewed by a federal agency. The EIS mandate has helped give environmental impacts greater visibility and weight within the planning process. But the formally legal and extremely complex EIS process is expensive and time-consuming – and still doesn’t always result in improved environmental outcomes.
Advocates need to decide if the advantages of a proscribed process with official opening for public input outweighs the burdens it imposes (on both project budgets and advocates own resources) – as well as the greater difficulty in getting such a process adopted (and honestly implemented). On the other hand, allowing project proposers to keep things too informal increases the odds that issues will be ignored and that advocates will have few hooks to use to pull open the process for public view.
A middle ground is needed balancing quantitative, qualitative, and participatory elements. Perhaps different size projects or different types of policies could have different levels of analysis, from relatively easy and informal to EIS-style legalities. Perhaps mediation rather than court suits could be the first step of appeal. Perhaps agencies can use the European model of “citizen policy evaluation committees” – groups of ordinary citizens who are given access to a broad range of data and analyses and then allowed to make recommendations – whose track record of sensible suggestions is at least as good as most of our more bureaucratic/political approaches.
And it wouldn’t hurt if advocates from different perspectives were brought in for discussions during the conceptual or preplanning stages of policy/project development (as lobbyists so frequently already are) so that key issues could be identified and, perhaps, dealt with before things turn into a public shouting match.
What is Being Measured?
A HIA has little or no information about individual wellbeing, what will happen to any particular person. Rather, it is designed to estimate risk levels: how much more likely is it that some percentage of the overall population (and various subsets based on age, gender, ethnicity, income, location, or some other factor) will have a particular health-related impact should the policy or project occur – or not occur.
Within this population focus, there are (at least) three layers of health-related impacts that a HIA can measure: outcomes, behaviors, and contextual factors. Outcomes are the actual health status issues such as the presence of asthma, physical injury, heart disease, cancer, etc. Outcomes might also include precursors of disease such as increased Body-Mass-Index (BMI), high blood pressure or cholesterol, etc. These are the numbers that are most frequently touted as “public health” statistics.
Behaviors are the things people do that directly or indirectly impact health outcomes such as smoking, amount of physical activity, diet, marital status, a tendency to get into fights, even a short-temper.
As much as we like to hold people responsible for their own lives, behaviors are actually the result of a combination of individual choices and the shape of the surrounding context which makes some things easy or desirable and others difficult or unpleasant. When large numbers of people behave in similar ways it is likely that something in the surrounding environment is tilting the playing field – some combination of factors, obvious and hidden, that is influencing people’s decision-making process.
In some ways, estimating the impact of a policy or project on contextual factors is the most important job of a HIA. But it is also the most difficult and the most controversial. Current research seldom provides a definitive description of what factors have how much of what kinds of impact on which health outcomes. Second, contextual factors are extremely diverse, deviously indirect in their impact, and often hard-to-estimate. Third, because the science is so often open to interpretation, the importance of various factors is subject to political, religious, and self-interested debate.
Still, the World Health Organization describes three major categories within people’s “determinants of health” including the social and economic environment, the physical and built environment, and a person’s individual characteristics and behaviors. The WHO then points out that “individuals are unlikely to be able to directly control many of the determinants of health.”
From an advocacy perspective, the most important of these determinants are those that are “actionable” – capable of being affected by public action of some kind. The level of air and water pollution. The availability of parks, playgrounds, sidewalks, bike lanes, recreational activities, and other activity-facilitating infrastructure and programs. The location of affordable healthy food compared with unhealthy options. The amount and nature of the commercial messages that people are exposed to from childhood on. The NECON “Strategic Plan for the Prevention and Control of Overweight and Obesity in New England” created by a consortium of over 100 health researchers and officials in the six states, identified six “Areas of Concern” needing attention – the health care system, the education system, worksites, the social environment, the built environment, the mass media, and our economic system.
The possible breath of contextual factors is simple too big for any one HIA to take on. So, from an advocacy perspective, the key issue is to decide what are the most important ones to push to include.
How Are Things Being Measured?
The bad news is that much of what is really important in shaping our lives is simply not being monitored on a regular basis among the populations that will be impacted by a policy or program. For example, what percentage of people in a multi-town region lives in areas where the condition of the sidewalk and the location of stores make it easy to walk to shop? Or it might be difficult to measure. For example, how much will eating habits of low-income people in a town change if a new supermarket is built on the outskirts of town?
For some issues it is possible to find a couple of studies about a roughly similar population, and then project to the current situation. But in most cases, it is necessary to use surrogate measures – things that are roughly comparable. Which ones? Are they appropriate? And how will the numbers be transferred to the new situation?
Even more complicated are the analyses and formula’s used to calculate the future trends of a situation or the population-level health impact of the current and future numbers. For example, traffic engineers predict future congestion levels using formulas that assume a regular increased in the number of cars on the road. It is often difficult to find out the assumed growth percentages, much less to decide if those predicted trends will actually occur. The world is much different today than it was when those Interstate-focused formulas were developed, and the future world is likely to be different from today. Who knows exactly how!
These technical issues are where the hidden politics of an HIA occur. It is not enough to get a HIA; advocates need to have enough technical expertise to monitor the details.
How will the HIA be used?
Ultimately, this is the issue for advocates, with everything else feeding into the answer. Will it be used as an “advisory” document, able to be ignored? Will it be responded to, but without really dealing with the problems it forecasts or the solutions it proposes? And what process will be in place to see that the solutions actually incorporated into the policy or project is actually being implemented? Is a follow-up evaluation going to happen – and if so, done by whom using what criteria? Who will have the power to decide any of this?
At best, there are some mandated requirements. But even if the entire HIA process is a sham, even if a good HIA is won but then ignored, it provides an opportunity for good public education and political organizing.
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