Transcript Slide 1

Health Impact Assessment:
U.S. Experience
Andrew L. Dannenberg, MD, MPH
National Center for Environmental Health
Centers for Disease Control and Prevention
[email protected]
Health Impact Assessment Workshop
Design for Health, University of Minnesota
Minneapolis, January 30, 2007
Community Design and Health
Related to land
use
Related to
automobile
dependency
Related to social
processes
• Obesity, physical activity, CVD
• Water quantity and quality
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•
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Air pollution and asthma
Climate change contribution
 Car crashes
 Pedestrian injuries
• Mental health impact
•  Social capital
Walkable Community Designs:
Connectivity and Physical Activity
Suburban
Development
Traditional
Neighborhood
Drawing by Duany Plater Zyberk,
in ITE Journal 1989;59:17-18
Durham, NC
A Vision of
Health Impact Assessment
• Community planners and zoning boards will
request information on potential health
consequences of projects and policies as part
of their decision-making process
• Local health officers will have a tool to facilitate
their involvement in community planning and
land use decisions that impact health
Definition of
Health Impact Assessment
• Collection of procedures and tools
by which projects, policies, and
programs can be evaluated based
on their potential effects on the
health of a population and the
distribution of those effects within
the population
Value of
Health Impact Assessment
• Focuses attention of decision-makers,
who typically do not have a health
background, on the health
consequences of projects and policies
that they are considering
• Ideally an HIA will lead to a better
informed decision
Transportation Planning
and Land Use Choices
Source: Atlanta Journal-Constitution, March 10, 2006
Unwalkable
park entrance
Steps in Conducting an HIA
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Screening
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Scoping
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Identify how many and which people may be affected
Assess how they may be affected
Reporting of results to decision-makers
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Identify which health impacts should be included
Risk assessment
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Identify projects or policies for which HIA would be
useful
Create report suitable in length and depth for audience
Evaluation of impact of HIA on decision process
Health Impact Assessment Workshop
RWJF and CDC, Princeton, October 2004
• Purpose: To move HIA forward in the United States
• Participants: HIA experts from UK, Canada, and WHO, and
US participants from local health departments, academia,
transportation, environmental health, urban planning, CDC,
and the Robert Wood Johnson Foundation (RWJF)
• Findings: Priority needs are to conduct pilot tests, develop
staff capacity, develop database of HIA resources, build
political support for HIA use, and conduct evaluations
• Summary: Dannenberg AL, et al. American Journal of
Public Health. 96:262-270, February 2006
Examples of
Health Impact Assessments
Conducted in the
United States
HIA on Housing Rental Voucher Program
Child Health Impact Working Group, Boston
• Examined impact of changes to Massachusetts housing
rental assistance program for families who otherwise would
be homeless or live in substandard dwellings
• Qualitative and quantitative assessment
• Findings: Program alterations may lead to reduced
program eligibility, increased housing instability, and
adverse effects on children’s health
• Funded by multiple public agencies, two anonymous
donors, and in-kind donations by working group members
HIA of Housing Redevelopment Projects
Rajiv Bhatia, San Francisco Health Department
• Rapid assessment of health impacts in two housing
redevelopment projects and one area plan
• Qualitative review of Environmental Impact Report,
community engagement, secondary data analysis
• Findings: Effects on housing affordability, vehicle
commutes, displacement of residents, segregation,
and public infrastructure
• HIA analyses led to improvements in project plans
• Funded & conducted by city public health department
HIA of Los Angeles City
Living Wage Ordinance
Brian Cole, UCLA
• Quantitative estimate of potential mortality
reduction from proposed ordinance to raise
minimum wage for city contract workers or
provide them with health insurance
• Findings: Employers are more likely to
increase wages than to offer health insurance,
thereby losing much of health benefit intended
by ordinance
• Funded by Robert Wood Johnson Foundation
HIA of Coal-Fired Power Plant
McLeod and Simmons, Healthy Development, Inc.
• Examined health impacts of proposed 800
megawatt coal-fired power plant in Florida
• Rapid, quantitative assessment
• Findings: Fine particulate matter pollution
containing SO2 will decrease life expectancy by
2 days after 16 years of plant operation
• Full HIA now funded to recommend social and
economic interventions to improve local health
• Conducted by private HIA consultants with
county health department funding
The Atlanta BeltLine
• Proposed 22-mile urban
light rail loop
• Accompanied by a
continuous multi-use trail
• Connects existing parks
and 40+ neighborhoods
• Opens 2500+ acres for
mixed-use redevelopment
• To be built on existing
abandoned or little used
rail rights of way
HIA of Atlanta Beltline
• Examining health impacts of transit component
and of trails and parks component
• Conducted during ongoing project planning
• Quantitative and qualitative estimates of
physical activity, respiratory disease, injury,
mental health, social capital, social equity, and
other health outcomes
• Conducted by Georgia Tech with technical
assistance from CDC
• Funded by Robert Wood Johnson Foundation
Public Health Benefits of BeltLine
Opportunity for Recreational Physical Activity
• BeltLine trails and parks offer an attractive setting for walking, bicycling, and
other recreational physical activity
• Increased availability of trails is recommended by CDC to promote health
• Existing Silver Comet, Stone Mountain, Chastain Park trails are very popular
Exercise Easily Incorporated into Daily Commute
• Walking to and from BeltLine stations could readily fulfill the U.S. Surgeon
General’s recommendation of 30 minutes of physical activity each day
Obesity Reduction
• Physical activity helps prevent obesity
• Obesity and physical inactivity are
associated with increased risk of
overall mortality, heart disease,
diabetes, hypertension, and some
cancers
Public Health Benefits (continued)
Cleaner Air
• BeltLine could reduce use of automobiles whose emissions are
major contributors to ground level ozone in Atlanta
• Ozone is linked with increased asthma attacks and heart disease
mortality
• Atlanta exceeded EPA’s air quality standard for ozone 51 times in
2002-2003
Fewer Traffic Injuries
• Driving less reduces each individual’s risk of injury on the highways
• Nationally, motor vehicle crashes are the leading cause of death
among persons 1 - 34 years old
Brownfield Redevelopment
• Urban redevelopment of underutilized land can reduce sprawl and
preserve greenspace
• Redevelopment promotes health by offering economically and
socially thriving communities that are walkable
Review of 16
Health Impact Assessments
Conducted in the
United States,
1999-2006
Location of 16 Completed HIAs
in United States, 1999-2006
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CALIF 9
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MA 2
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GA 2
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TEXAS 1
FL 2
• Other HIAs in progress
HIAs of Projects (N=6)
1. Housing redevelopment: Trinity Plaza CA
2. Housing redevelopment: Rincon Hill CA
3. Urban redevelopment: Oak to Ninth CA
4. Corridor redevelopment: Buford Hwy GA
5. Transit, parks and trails: Beltline GA
6. Power plant: Taylor County FL
HIAs of Policies (N=10)
1. Local planning: Eastern neighborhoods CA
2. School siting: Austin TX
3. After-school programs: Statewide CA
4. Walk-to-school programs: Sacramento CA
5. Living wage ordinance: San Francisco CA
6. Living wage ordinance: Los Angeles CA
7. Low income rent subsidies: Statewide MA
8. Low income home energy subsidies: Statewide MA
9. County land use planning: Polk County FL
10. Federal farm bill: National
Decision-Making Organization
for Project or Policy
City council; planning commission
State legislature
Local partnerships
Nonprofit organization
US Congress
School district
Electric utility company
N=7
N=3
N=2
N=1
N=1
N=1
N=1
Organization that Conducts HIA
Academic group; CDC
Local health department
Private consultant
N=10
N= 5
N= 1
Funder of HIA
Robert Wood Johnson Foundation
Health department - internal staff
Health department - external contract
Volunteer; multiple sources
N= 6
N= 5
N= 1
N= 4
Scoping: Health Determinants
Considered in 16 HIAs in the
United States, 1999-2006
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Physical activity and obesity
Housing adequacy and affordability
Pedestrian injuries
Air quality, asthma, other respiratory diseases
Parks and greenspace
Income adequacy; social equity
Diet, nutrition, food safety, food insecurity
Adolescent risk behaviors – alcohol, drugs, sex
Noise
Mental health
Social capital, community severance
Access to jobs, stores, schools, recreation
Population Affected by Project
or Policy in 16 U.S. HIAs
Small area within city
City or county-wide
Statewide
National
-------------------------Primary impact on:
Persons with low income
Children/adolescents
Whole population
N=5
N=5
N=5
N=1
N=9
N=3
N=4
Community Involvement in
Conduct of 16 U.S. HIAs
 Community input involved in
conduct of 10 of 16 HIAs
 Barriers to community involvement
in HIAs include lack of time or
resources, IRB or OMB restrictions
Conduct of 16 HIAs in U.S.
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Screening
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Scoping
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Various quantitative and qualitative methods
Reporting
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Generally clearly described
Risk assessment
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Some targeted to goal, others more academic
Most on web, a few published; public testimony
Evaluation
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Relatively little conducted
Quantitative and Qualitative
Health Indicators in 16 U.S. HIAs
• Quantitative
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Physical activity
Pedestrian injuries
Mortality
Impact of particulate matter in air
Crime
Parks and greenspace
• Qualitative
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Academic performance
Income adequacy; social equity
Diet, nutrition, food safety, food insecurity
Adolescent risk behaviors – alcohol, drugs, sex
Noise
Mental health
Social capital, community severance
Access to jobs, stores, schools, recreation
Housing adequacy and affordability
Key Results in 16 HIAs in U.S.
 Most identified improvements needed to mitigate
adverse health impacts
 Redevelopment projects that lacked affordable
housing; rental voucher program
 A few encouraged projects or policies that would be
health-promoting as designed
 Walk-to-school program; Beltline transit project
 One concluded that proposed program would fail to
reach its intended target population
 After-school programs
Impact of HIA on Subsequent
Decisions: 16 HIAs in U.S.
 Documentable impacts, such as change
in redevelopment plans to add affordable
housing, was evident in only a few HIAs
 Most HIAs raised awareness of health
issues for some audiences
Challenges in Conducting
Health Impact Assessments
Conducted in the
United States
HIA Level of Complexity
• Qualitative – describe direction but not
magnitude of predicted results
– Easy to predict; hard to use in cost/benefit models
– Example: Build a sidewalk and people will walk more
• Quantitative – describe direction and
magnitude of predicted results
– Difficult to obtain data; useful for cost/benefit models
– Hypothetical example: Build a sidewalk and 300
people who live within 200 yards of location will walk
an average of 15 extra minutes per day
Minutes of Walking To and From
Public Transit Per Day
31
30
19
20
10
ile
%
75
ED
IA
N
M
ile
0
%
Data from National Household
Travel Survey, 2001, USDOT
N= 3312 transit users
Besser LM, Dannenberg AL
Amer J Prev Med 29:273, 2005
10
25
Minutes per day
40
Voluntary vs. Regulatory
Approach to Using an HIA
• Voluntary (a tool used by a health officer to inform a
planning commission)
– Simpler, less expensive, less litigious
– Less likely to be used if not required
– More politically acceptable
• Regulatory (modeled on a required environmental
impact statement)
– More complex, more expensive, more litigious
– More likely to be used if required
– Less politically acceptable
Relationship of HIA to
Environmental Impact
Assessment
• HIA components could logically fit within
an EIA process
• HIA incorporated into EIA is necessarily
regulatory and insures it is conducted
• Extending an EIA to include an HIA likely
to encounter resistance from developers
who see it as an additional barrier
Community Involvement in
Conducting an HIA
• Increases community buy-in to project
• Helps identify social issues as well as
health issues
• Commonly used in HIAs in Europe
• Need balance of community input with
scientific evidence
• May add substantially to time and
resources needed to conduct HIA
Other Challenges in
Conducting HIAs in the U.S.
• Resources - who pays?
• Resistance - some decision-makers may
not want health input
• Evaluation of impacts of HIA requires
time and resources
• Quality of science - cause and effect
may be difficult to prove
Asthma and Air Pollution
• Natural experiment during
1996 Summer Olympic
games in Atlanta
• Peak morning traffic
decreased 23% and peak
ozone levels decreased 28%
• Asthma-related emergency room visits by
children decreased 42%
• Children’s emergency visits for non-asthma
causes did not change during same period
Friedman et al. JAMA 2001;285:897
HIA Capacity Building Activities
• NACCHO/APA training workshop on HIA held in
2006; repeat workshop planned in 2007
• Course on HIA now being taught by Rajiv Bhatia
at University of California, Berkeley
• HIA training manual being prepared
• Seattle group has begun an HIA listserve for the
United States
• Several states and one U.S. Senator are
beginning to mention HIA in proposed legislation
HIA in the United States: Next Steps
• Conduct pilot tests of existing tools for HIA of
projects and policies
• Develop staff capacity to conduct HIAs including
training materials and train-the-trainer workshops
• Develop incentives and political support for use
of HIAs
• Develop a database for measuring health impacts
of common projects and policies
• Conduct process, impact and outcome
evaluations of HIAs
Health Impact Assessments
can help guide community
design and land use choices
to promote human health
www.hiagateway.org.uk
www.cdc.gov/healthyplaces