Health Impact Assessments: A NewPublicHealth Q&A with Pamela Russo
The National Research Council (NRC) released a report today offering concrete guidance for decision-makers on ways to identify and address the potential impact on health of proposed projects or policies in sectors outside of health and health care at the federal, state, tribal and local levels, including the private sector. The report provides a framework, terminology, and guidance for conducting a health impact assessment (HIA) on a pending policy decision or project, like building a new transit system, agricultural policy or changing zoning in a city.
It is the third national body to encourage the use of HIA this year, following the National Prevention, Health Promotion and Public Health Council and the Institute of Medicine committee on Public Health Strategies to Improve Health. Several other national reports have recommended the use of HIA, including the U.S. Department of Health and Human Services Action Plan on Disparities and the White House Childhood Obesity Task Force Action Plan.
The NRC committee on HIA was funded by the Robert Wood Johnson Foundation (RWJF), the National Institute of Environmental Health Sciences, the California Endowment, and the Centers for Disease Control and Prevention. NewPublicHealth spoke with Pamela Russo, M.D., M.P.H. a senior program officer at RWJF, about the foundation’s investments to increase the use of health impact assessments and the contents of the new report, which sets standards for terminology and HIA practice with a thorough explanation of the steps in an HIA. Among its recommendations it calls for collaboration at all levels of government to support the incorporation of health considerations into decision-making.
NewPublicHealth: Health impact assessments have been conducted in the U.S. for a while. Why is the Foundation a proponent of HIAs, and why was there a need for this report now?
Pamela Russo: Over the past ten years, the Robert Wood Johnson Foundation has invested in a variety of different types of projects and programs meant to demonstrate, document, and increase awareness that health – an individual’s health or a population’s health-- is influenced not simply by the medical care that they get, but probably much more strongly by where they live, what kind of job opportunities they have, what their economic status is, what the physical environment around them is like—including environmental exposures and access to healthy opportunities. HIA is a very practical way to bring that concept into decisions that are being made, and we thought it is an incredibly promising tool, but there wasn’t a standard approach to practice. We believed that having a respected institute like the National Research Council study the issue, and come up with guidance on how HIAs should be done was a key way to advance the field. One of the important reasons for having the National Research Council conduct the report is their long history of risk assessment in a variety of areas. This is really taking their history of environmental risk assessment to a new, broader platform.
It’s clear that as more and more HIAs are done, more people become aware of them. And you’re going to have a whole variety of parties wanting to perform HIAs from health departments to interest groups to industry. So, we and three other funders asked the National Research Council to develop a framework, define terminology so that everybody was talking about the same thing, and give guidance for conducting HIAs in America.
NPH: What are the report’s key findings?
Pamela Russo: I think the report is extremely, emphatically positive about the potential role of HIAs as a tool to bring considerations of health effects forward in a scientific way and simultaneously incorporating the views of stakeholders on decisions that are being made in a whole variety of sectors - sectors where previously people in those fields wouldn’t have considered health as part of the decision because they didn’t recognize that a decision, for example, in transportation or education would have ramifications for health.
NPH: What is the current investment by the Robert Wood Johnson Foundation in the HIA field?
Pamela Russo: The biggest investment right now is with the Health Impact Project, which is a collaboration between the Pew Charitable Trusts and the Robert Wood Johnson Foundation. The project is really about promoting and supporting the use of HIA and increasing awareness of HIA among federal, state, and local policymakers. That is done by supporting demonstration projects and other activities. For example, the Health Impact Project commissioned a recently completed a comprehensive review of the laws and regulations which could offer support for integrating health into decision making. This was one of the themes of the new NAS report as well. There are relatively few places right now in the nation where an HIA is required, but there are many laws that could facilitate conducting an HIA, and that’s a strong message of both the Health Impact Project and the new report.
NPH: Do you think any of the recommendations in the report will result in changes at the Health Impact Project or changes in criteria for grantees?
Pamela Russo: No, I don’t. The messages about framework and guidance and terminology in the report are the same as the ones that the Health Impact Project uses, particularly the emphasis that the time to do an HIA is when there is a pending decision. That’s a very strong requirement for the Health Impact Project, and the committee report makes the same point - that there should be a decision that’s going to be made that the HIA has the potential of influencing by showing what the potential effects on health would be and the ways that risks could be modified and decreased, and health be promoted.
NPH: Who are you certain will be reading and studying the report, and who else do you hope will be paying attention to it?
Pamela Russo: The report is a wonderful guide for health departments. This is something that they can now turn to as one concise well-distilled synthesis of all the work on health impact assessment in America. Public Health Institutes are also going to be very interested in the guidance. Universities are likely to begin to look at this, particularly public health schools, in terms of developing curriculum. Industries and developers are certainly going to be reading this report. And the greatest hope would be that staff and leadership of agencies at both the state level and the federal level will look at the report and begin to understand why it might make sense to bring into their work. We hope that other funders will realize that this is a solid approach with a lot of history and knowledge behind it that can actually make an impact on people’s health and quality of life –and that would not be only health funders but also funders of infrastructure in general, in education, housing and transportation among other areas.
In the case of legislators, it’s crucially important for them to read and understand the key messages in the report. There are now some examples in different states where laws have been passed for specific sectors. For example, in Massachusetts, there’s now a law on the books that requires an HIA in major transportation projects. So having briefings based on the report and drawing on the examples described in the report will show that this is a codified process considerable experience behind it.
NPH: How prominent a tool is HIA right now?
Pamela Russo: HIA has been growing exponentially over the last two years, but just three years ago there were only about 30 projects known and documented in the US. We are now in a period where the awareness, the interest and the attention is skyrocketing. The Health Impact Project, together with CDC and Johns Hopkins University researchers, are tracking the use of HIAs. They’re trying to get information on every HIA that’s done in terms of how it was done, what the aims were, the impact. I think we’re probably moving up toward 150 that are known and on which there is documentation.
NPH: Are there local and state governments making HIA a more routine part of decision making?
Pamela Russo: Oh, absolutely. Alaska, for example, now has standing interagency meetings on HIAs. The health department in Alaska has hired an epidemiologist dedicated to the performance of HIAs. As I mentioned, Massachusetts has a law requiring HIAs on transportation projects. Baltimore and San Francisco have become hotbeds for HIA. California is considering legislation requiring HIA for different types of projects. HIA is increasingly being used within environmental impact assessments to assess potential impacts to people’s health – and the report has an entire appendix devoted to how the National Environmental Policy Act – the law that mandates environmental impact assessments--was intended to also assess potential effects on human health, although the law was not implemented in that way.
NPH: What is an example of a complete or ongoing HIA that does a good job of illustrating how HIAs can improve people’s health?
Pamela Russo:I think one of the strongest examples is a project that Aaron Wernham [director of the Health Impact Project] did that brought him to the attention of the Foundation. We had funded a project that he was doing looking at oil and gas leasing on the north slope of Alaska and its effects on the local residents--largely indigenous tribes. The potential benefit for the residents is that there would be jobs and taxes coming into that area, a very remote area, but it also meant that the energy development would harm the hunting and fishing areas that had traditionally been the community’s food supply. It also brought in, for the workers, and residents, the risk of increased alcohol and drugs, violence, trauma and, sexually transmitted diseases. Additionally the change from the sources of food to convenience foods available for workers had been shown to rapidly raise obesity rates in tribes where other energy development projects had taken place.
By combining the potential of all of these effects, Wernham and team were able to bring the indigenous residents and the oil and gas leasing developers and the state agencies together so that they could overcome a major political divide, work specific protections for health into the plan, and prevent lawsuits that would have delayed the project.
NPH: Does the report highlight any challenges to doing HIAs well and implementing HIA findings?
Pamela Russo: There’s a chapter in the report that deals with the nature of science, the uncertainty, the assumptions underlying predictions. Their basic emphasis is that because we’re living in the real world, there’s always going to be insufficient data to make precise quantitative assessments and interactions that cannot be predicted.
As more and more HIAs are done, we’ll have more and more of a body of knowledge that can help to predict the effects, but there will still be methodological issues about how good the data is, whether or not we can expect to have tight quantitative estimates and how we’re going to make a final decision when there are potentially positive health effects in certain areas, but negative health effects in others. We need to be very clear and transparent up front and during the process about how confident we are about the data and the analysis. The more we can be transparent and clear about the decisions that have been made, the stronger the HIA will be. We also have to bring in the stakeholder’s opinions about what outcomes are valuable to them. We have to be prepared that the HIA could be attacked and so we have to do everything that we can to show that it’s as valid as it could possibly be – and we have to do that from the beginning of the process when we make decisions about what outcomes we’re going to look at and what the data sources are and what’s really important to the community. An HIA as a process really engages stakeholders from all sides of an argument and in particular the public, the residents who are going to be affected by decisions in the process from the start. HIA is not an ivory tower kind of analysis.