Health Impact Assessment: Towards Institutional Accountability to the Public’s Health

1. Health Impact Assessment: Towards Institutional Accountability to the Public’s Health Prepared for the Grantmakers In Health February 25th, 2009 Audio Conference Rajiv Bhatia, MD, MPH San Francisco Department of Public Health

2. Our Nations Health: Intolerable Facts • Annual health care spending $6405 per person (1st place) • Average life expectancy is a full year less than peer-countries (30th place) • The most affluent live 4.5 years longer than the least affluent • Neighborhood to neighborhood differences in life-expectancy within cities can exceed ten years of life. Rajiv Bhatia, MD, MPH Health Impact Assessment

3. Diverse social and environmental conditions impact human health! • Employment wages and job quality predict disease and mortality from most causes • Asthma aggravated and lung development and life expectancy compromised for residents near freeways • Physical activity & mental functioning improved by access to parks and green space • Heart disease, hypertension, and sleep disturbance triggered by traffic noise exposure • Pedestrian injuries and deaths increased for people near busy roads • Crowding, displacement, infectious diseases, hunger, and exposure aggravated by unaffordable housing. Rajiv Bhatia, MD, MPH Health Impact Assessment

4. An Institutional Vision For A Healthy Public Policy • A public health community engaged in informing policy making • The public and decision makers aware of the health impacts of public decisions • Health objectives achieved through institutional policies in all sectors • Institutions accountable to health protective rules and mandates Rajiv Bhatia, MD, MPH Health Impact Assessment

5. Case Study: Sprawl • Public policies resulted in sprawl • Sprawl promised healthy communities! • What did we miss? • Environmental consequences • Urban Disinvestment and Blight • Inequities • Health Impacts Rajiv Bhatia, MD, MPH Health Impact Assessment

6. The Case for Considering Health Impacts in Public Policy • Prevent harm • Leverages public investments to promote health • Supports community engagement in policy • Stimulates cross-sector ownership of health objectives • Mobilizes political support for social change Rajiv Bhatia, MD, MPH Health Impact Assessment

7. Health Impact Assessment Definition Health Impact Assessment is a systematic process to make evidence-based judgments on the health impacts of public decisions Rajiv Bhatia, MD, MPH Health Impact Assessment

8. HIA responds to the question: How do decisions affect our health? • Mobilizes and synthesizes evidence to forecast the health impacts of public decisions, considering health holistically • Communicates findings to inform and influence the policy process • Involves stakeholders in both assessment and communication Rajiv Bhatia, MD, MPH Health Impact Assessment

9. The HIA Process Rajiv Bhatia, MD, MPH Health Impact Assessment

10. HIA is Different from… • Community Assessment • Health Risk Assessment • Systematic Reviews • Health Element of the General Plan • Healthy Development criteria • Design and Planning Exercises Rajiv Bhatia, MD, MPH Health Impact Assessment

11. Several Existing Institutional Rules Promise Healthy Public Policy • The National Environmental Health Policy Act (NEPA) requires analysis health and safety problems caused physical changes • National and State Environmental Justice Policy mandates agencies to identify and address adverse health effects on low income and minority populations • Federal rules require cost-benefit analysis of environmental quality regulations Rajiv Bhatia, MD, MPH Health Impact Assessment

12. Three Common Contexts for HIA • Required by HIA policy, regulation or law • Conducted to comply with requirements of EIA regulations • Initiated by project proponent, stakeholder, responsible public agency, or policy-maker Rajiv Bhatia, MD, MPH Health Impact Assessment

13. Policy settings appropriate to the application of HIA • Transportation - Speed policy; highways; transit • Housing - Public housing; Housing Subsidies • Labor - Minimum wage; employment benefits • Agriculture - Crop and water subsidies • Natural - Dams; oil drilling; water Rajiv Bhatia, MD, MPH Health Impact Assessment

14. Health Impacts of a Living Wage (1999) • Quantified the following Health and Social Benefits of a Living Wage • Life-expectancy • Graduation rates • Teenage childbearing • Depression’ • Sick days • HIA Outcomes • Support for local living wage laws • Public health could contribute analysis to social and economic policy Rajiv Bhatia, MD, MPH Health Impact Assessment

15. HIA of the Healthy Families, Healthy Workplaces Law (2008) • Paid Sick Day mandate proposed in California Legislature • Legislative sponsors requested HIA • HIA found health benefits from • Taking leave from work to care for ill children and dependents. • Reduced community and workplace transmission of communicable disease • Protection of household budget • Sponsors used HIA to develop a public health communication frame for the legislation • Requests for replication nationwide Rajiv Bhatia, MD, MPH Health Impact Assessment

16. Environmental Impact Assessment:Key Requirements When EIA is required, Public Agency’s must: • Analyze the decision’s environmental effects • including direct and indirect health effects • Identify mitigations for adverse effects; • Consider alternatives; • Document analysis; • Respond to public comment. Rajiv Bhatia, MD, MPH Health Impact Assessment

17. Infill Development & Residential Displacement Trinity Plaza Case Study, San Francisco (2003) • Organized tenants challenged the demolition and redevelopment of 360 rent-controlled apartments citing human impacts • SFDPH provided an HIA as a comment on the scope of an EIA documented adverse health effects of on stress, social cohesion, and housing • Outcomes: • City required study through EIA or mitigations • Project redesigned to provide replacement housing at current rents • City level planning policy changes for replacement housing Rajiv Bhatia, MD, MPH Health Impact Assessment

18. Integrating HIA / EIA for the Eastern Neighborhoods Rezoning, San Francisco (2007) • City proposed rezoning of historically industrial lands; • Potential environmental impacts on residents from noise, air pollutants, traffic hazards, and limited infrastructure • SFDPH contributed analysis and mitigations to EIR as “cooperating agency” • EIA required new mitigations to protect respiratory health, reduce noise exposure and added “improvement measures” to reduce pedestrian injuries Rajiv Bhatia, MD, MPH Health Impact Assessment

19. Vehicle-Pedestrian Collision Analysis for the Eastern Neighborhoods EIR Predicted % change in pedestrian injury collisions based on estimated changes in resident population and traffic volume. 20% 21% 15% 24% Rajiv Bhatia, MD, MPH Health Impact Assessment

20. Modeling Vehicle PM2.5 for a Residential Development using CAL3QHCR—Harrison and Beale Streets, San Francisco Rajiv Bhatia, MD, MPH Health Impact Assessment

21. West Oakland Port Expansion HIA (2009) • Growth of goods movements • Expansion plans subject to EIA • Health impacts on neighborhoods • Air Pollution • Noise • Vehicle collisions • Retail Environment • Employment Opportunities • Available analytic methods • Port of Oakland HIA case study Rajiv Bhatia, MD, MPH Health Impact Assessment

22. Freight Routes and Truck-related collisions in West Oakland Rajiv Bhatia, MD, MPH Health Impact Assessment San Francisco Department of Public Heath Health Impact Assessment Mini-Course – July 2008 Port of Oakland Case Study Page 21

23. Health Impacts of Congestion Pricing (2009) • San Francisco is considering a fee to drive • A transportation study will addresses impacts on traffic, transit, and business • Strong and vocal public pushback already emerging • In progress HIA evaluating impacts on • Air Pollution exposure • Environmental noise • Pedestrian and Vehicle Injuries • Walking environments • Household budgets • Expected Outcomes of HIA • More fair and balanced discussion of costs and benefits • Potential public support for proposal Rajiv Bhatia, MD, MPH Health Impact Assessment

24. HIA in the Bay Area: Key Lessons • HIA resonates with community needs and concerns • Not every Public Decision Requires a HIA - need to pick issues, plans, policies strategically • A scientific approach along with practical solutions in HIA can successfully change decisions outcomes • Stakeholder involvement is critical to HIA outcomes • EIA is underutilized to protect public health • Need to conduct objective analysis Rajiv Bhatia, MD, MPH Health Impact Assessment

25. Value of integrating Health Into EIA • EIA is an established regulatory tool • A broad scope of policies, plans, programs, and projects trigger EIA • EIA requires health effects analysis • Costs of EIA analysis internalized • Integrated analysis builds on existing data, creates a setting for inter-disciplinary research, and fosters cross-sector ownership of public health objectives • EIA analysis catalyzes both new regulations and subsequent policy design Rajiv Bhatia, MD, MPH Health Impact Assessment

26. HIA is One of Several Tools for Healthy Public Policy • Assess and monitor of health-relevant environmental conditions • Contribute to policy design • Develop and enforce needed health-protective laws & regulations • Conduct health impact assessments of policies, plans, and projects • Monitor institutional accountability to existing health protective laws and institutions • Use authoritative power to advocate for healthy policy Rajiv Bhatia, MD, MPH Health Impact Assessment

27. HIA: Practice and Research Needs • Public and policy-maker awareness of the value of HIA • Guidelines and standards to ensure HIA practice quality • Resources for HIA practice • HIA practice evaluation Research and technical tools development to fill gaps in evidence to assess policies • Engagement in the EIA process Rajiv Bhatia, MD, MPH Health Impact Assessment

28. San Francisco Bay Area HIA Collaborative • Includes: San Francisco Department of Public Health, UC Berkeley, & Human Impact Partners • Conducts: • HIA practice • Academic instruction & professional training • Facilitation and mentorship • Technical tools, guidelines, and standards • HIA policy development Rajiv Bhatia, MD, MPH Health Impact Assessment

29. SF HIA Collaborative Resources SF Department of Public Health • www.sfdph.org/phes/ UC Berkeley HIA Group • http://sites.google.com/site/ucbhia/ Human Impact Partners • www.humanimpact.org Healthy Development Measurement Tool • www.TheHDMT.org Rajiv Bhatia, MD, MPH Health Impact Assessment