This document provides an overview of health impact assessment (HIA). It discusses: - The background and experience of the author in conducting HIAs - Why health matters and the environmental and social determinants of health - What HIA is and when it is conducted - The typical steps involved in an HIA including screening, scoping, assessment and recommendations - Examples of different types of projects and policies that HIAs have been conducted for - How HIA relates to and incorporates environmental health issues - Resources available for learning more about HIA

1. Health Impact Assessment
Ben Harris-Roxas
www.harrisroxashealth.com
@ben_hr on Twitter

2. Section 1
Who am I?

3. I’ve been working on HA since 2003
Mainly through
supporting and conducting HIAs
I consult and am a Conjoint Lecturer at UNSW

4. Trained more than 700 people in HIA
Active in international HIA community
IAIA Health Section Co-Chair

5. Section 2
Why does health matter?

6. • Many of the early gains in public health
were linked to improving the
environmental factors that cause disease
• The environmental determinants of health
• You’ll learn more about these during the
course

7. Source: WHO Global Burden of Disease 2002Source: WHO Global Burden of Disease 2002

8. Much of this disease still
has environmental causes
Many of the new causes of
disease seemed to be
different in nature to
traditional environmental
health concerns
Under-considered factors that
powerfully influence health
and health related behaviours

9. NSW Health (2006) Report of the NSW Chief Health Office, NSW Health: Sydney.
http://www.health.nsw.gov.au/public-health/chorep/dia/dia_typehos.htm

10. The causes of
the causes?
Image: Supermietzi

11. Schroder S. (2007) We Can Do Better: Improving the health of the American people. New
England Journal of Medicine, 357, 1221-1228.

12. What determines health?
(A fuzzy pie chart)
Genetics
10-25%
Risk Factors
20-40%
Opportunities/
Socioeconomic
Status
20-30%
Environment
& Place
5-15%
Health
Services
15-30%

13. Dahlgren G, Whitehead M. (1991) Policies and Strategies to Promote Social Equity in Health.
Stockholm: Institute of Futures Studies.

14. The Social Determinants of Health
• Stress
• Early life
• Social exclusion
• Work
• Unemployment
• Social support
• Addiction
• Food
• Transport
• The social gradient in health

16. Health Statistics NSW
healthstats.nsw.gov.au/Indicator/ses_lomidhiavodth

17. Murphy M et al. (2006) The
Widening Gap in Mortality by
Educational Level in the
Russian Federation, 1980-
2001. American Journal of
Public Health, 96:1293–99.
cited in
Marmot M. (2007) Achieving
Health Equity: From root
causes to fair outcomes.
Lancet, 370:1153-1163.

18. Section 3
What is HIA?

19. A combination of procedures, methods
and tools by which a policy, program or
project may be assessed for its potential
and often unanticipated effects on the
health of the population and the
distribution of these impacts within the
population.
Gothenburg Consensus Paper
European Centre for Health Policy (1999) Gothenburg Consensus Paper on Health Impact
Assessment: main concepts and suggested approach, WHO Europe: Brussels (adapted by
Mahoney & Morgan).

20. HIA is a developing approach that can
help to identify and consider the potential
- or actual - health impacts of a proposal
on a population. Its primary output is a set
of evidence-based recommendations
geared to informing the decision making
process.
Taylor & Quigley
Taylor L, Quigley R. (2002) Health Impact Assessment: A review of reviews. London: National
Health Service, Health Development Agency.

21. Key Aspects of HIA
• A prospective activity
• Uses a combination of
methods
• Looks at intended and
unintended impacts
• Looks at the distribution of
impacts
• Results in evidence-
informed recommendations

23. When is an HIA done?

24. http://hiaconnect.edu.au/wp-content/uploads/2012/05/Health_Impact_Assessment_A_Practical_Guide.pdf

25. Explicit Focus on the
Distribution of Impacts
1. Age
2.Gender
3.Socioeconomic status
4.Location
5.Ethnicity and culture
6.Existing levels of health and
disability

26. Thinking about the distribution of impacts:
Avoidability and fairness
Lead exercise

27. Determinant of Health Difference Avoidable? Fair?
1. Natural biological variation
Children absorb lead more quickly than adults
2. Health damaging behaviour if freely
chosen
Exposure to lead through lead lighting as a
hobby
3. Transient health advantage
The lead in the land around the houses in an
affected area is being removed. Some people
will have their houses done before others.
4. Health-damaging behaviour where choice
of lifestyle is restricted by socioeconomic
factors
If a low income family rents close to a lead
smelter because of cost despite knowing it
may be damaging the health of their children

28. Determinant of Health Difference Avoidable? Fair?
5. Exposure to excessive health hazards in
the physical and social environment
People in mining communities chose to work
in the mine despite knowing of the harm to
their health
6. Restricted access to essential health
related care
Children whose development has been
affected by exposure to lead have limited
access to special education classes
7. Health -related social mobility
Workers who have been exposed to lead over
many years, often prior to understanding of
the risks, may be forced to retire early

29. Section 4
Steps of HIA

30. The Steps of HIA
• Screening
• Scoping
• Identification
• Assessment
• Decision-making and
recommendations
• Evaluation and follow-up

31. If you
implement the
proposal
These will be
the impacts
If you make
these changes
These will be
the gains
Assessment Recommendations

32. Where does health risk assessment
(HRA) fit in?

33. HRA is a structured framework for assessing
risks associated with environmental
hazards (prospectively and retrospectively)

34. “The process of estimating the potential
impact of a chemical, biological, physical or
social agent on a specified human population
under a specific set of conditions and for a
certain time frame’
enHealth HRA Guidelines

36. Scoping Activity
Master Plan for Cheonggyecheon,
Seoul

37. First, get in your time machine –
back to 2003

38. • Project timeline 2003 - 2005
• US$900 million project

39. After Construction Now (2003)

40. • Proponent receptive to HIA, but must be
completed in 5 months (mustn’t hold up
construction!)
• Proponent is Seoul City Government, who
are reasonably convinced the proposal is a
good idea
• Proponent has asked that the HIA’s focus
should be on improving proposal and
tweaking, not suggesting new major
initiatives or “vetoing” the initiative

41. Now (2003)

42. Now (2003)

43. Now (2003)

44. Now (2003)

45. After Construction

46. Group work – scoping exercise
1. What impacts should be considered in the HIA?
2.What methods could you use to collect
information about potential impacts?

47. So what happened?

59. Braess’ Paradox
Resettlement and dislocation

60. Section 5
Where did HIA come from?

61. Environmental health
Social view of health
Equity
Each bring with them their own
disciplinary beliefs, values,
support base and baggage

62. 1950s 1960s 1970s 1980s 1990s 2000s
Environmental Disasters
Regulatory Environmental Impact Assessment
Environmental Health
Health Equity
HIA
1956 Clean Air Act (UK)
1969 Santa Barbara
Channel (USA)
1969 US National
Environmental
Policy Act (USA)
1978 Love Canal (USA)
1984 Bhopal (India)
1986 Ottawa Charter
1990 Concepts &
Principles of Equity
in Health
1997 Jakarta Declaration
1998 Independent
Inquiry into
Inequalities in
Health (UK)
1999 Gothenburg
Consensus Paper
on HIA
2008 WHO Commission
on the Social
Determinants of
Health: Closing the
Gap in a
Generation
Social View of Health
1972 Lake Pedder Dam
controversy
(Australia)
1974 Environmental
Protection (Impact
of Proposals) Act
(Australia)
2005 Health included in
IFC Performance
Standards
1994 Framework for
Environmental and
Health IA
(Australia)
2007 1st Asia-Pacific HIA
Conference
(Australia)
1978 Seveso (Italy)
1990 Environmental
Protection Act (UK)
1980 The Black Report
(UK)
1972 The Indian Wildlife
(Protection) Act
1974 Lalonde Report
(Canada)
1998 Merseyside
Guidelines for HIA
1978 WHO Seminar on
Environmental
Health Impact
Assessment
(Greece)
2004 Equity Focused HIA
Framework
(Australia)
1978 Declaration of
Alma Ata
1992 Asian Development
Bank HIA
Guidelines
1959 Minamata Bay
(Japan)
1980 International
Association for
Impact Assessment
formed
1969 Cuyahoga River
Fire (USA)
1962 Silent Spring
2007 HIA’s use included
in Thailand’s
Constitution
1998 The Solid Facts
1979 Three Mile Island
(USA)
2005 Guide to HIA in the
Oil and Gas Sector
1986 Chernobyl
(Ukraine)
1989 Exxon Valdez Oil
Spill (USA)
2009 Montara West
Atlas Oil Spill
(Australia)
2010Marmot Review

63. Section 6
What forms does it take?

64. There are currently four models of
HIA being used internationally
(to varying extents)

66. Mandated HIA generally occurs in the
context of an EIA, IIA, or ESHIA
and is done to meet a regulatory or
statutory requirement

67. Example: Basslink Integrated IA

68. HIA for decision support is generally
done voluntarily with the goal of
improving decision-making and
implementation

69. Example: Lower Hunter
Regional Strategy HIA

70. HIA for advocacy is usually undertaken
by organisations who are neither the
proponent or the decision-maker

71. Example: HIA of the National
Emergency Response in the
Northern Territory

72. Community empowerment HIAs are
usually undertaken by communities
whose health is likely to be affected by
a proposal

73. Example: Maules Creek HIA

74. This diversity is widespread and the challenges
efforts to make HIA embedded in the policy
development and decision making process
Example: Lack of consensus about HIA from the
National Public Health Partnership
But also enables responsiveness
to emerging issues

75. Section 7
What type of things are HIAs done on?

76. Source: Harris E, Baum F, Harris-Roxas B, Kemp L, Spickett J, Keleher H, HarrisM, Morgan R, Dannenberg
A, Sukkumnoed D, Wendel A. The effectiveness of health impact assessments conducted in Australia and
New Zealand; Australian Research Council Discovery Project Grants; 2010-2011. [DP1096211]

77. Source: Winkler M et
al. (2013) Untapped
potential of health
impact assessment,
Bull World Health
Organ 2013;91:298–
305.
doi:10.2471/BLT.12.11
2318

78. Source: Harris-Roxas B, Harris P. Learning by Doing: The value of case studies of health impact assessment. NSW Public Health Bulletin,
2007:161-163.
Types of Health Impacts

79. Source: The Rise of HIAs in the United States
http://www.pewhealth.org/reports-analysis/data-visualizations/the-rise-of-hias-in-the-united-states-85899464695

80. Increasingly also on:
• Climate change (adaptation)
• Transition-to-town issues (food miles,
sustainability, etc)
• Energy
• Social programs and education

81. Section 8
How does HIA fit in with
environmental health?

82. Environmental health issues are
considered in every HIA, such as:
1. Vector-related diseases
2. Respiratory and housing issues
3. Veterinary medicine/zoonotic issues
4. Sexually transmitted infections
5. Soil- and water-borne diseases
6. Food- and nutrition-related issue
7. Accidents/injuries
8. Exposure to potentially hazardous materials
9. Psychosocial
10. Cultural health practices
11. Health services infrastructure and capacity
12.Noncommunicable Diseases (NCDs)

83. HIA moves beyond describing the effects of
the environment on health to doing
something about it
HIA brings together
population health activity -
health protection (environmental health),
health promotion, and health service
enhancement
It’s a practical tool to improve the
consideration of health and environmental
health in planning and decision-making

84. Section 9
HIA Resources

85. HIA Blog
http://healthimpactassessment.blogspo

86. HIA Gateway
http://www.hiagateway.org.uk

87. HIA ebook
http://benhr.net/HIAebook

88. These slides are available at
http://www.slideshare.net/benharrisroxas
Email: ben@harrisroxashealth.com
Twitter: @ben_hr or @hiablog

89. Section 10
HIA Exercise
(If there’s time)

90. ASEAN Highway
What are the potential health
impacts?
What information could we use
to assess these potential
impacts?