Health impact assessment: a step toward health in all policies.

FOR THE PAST 4 DECADES, THE ENVIRONMENTAL IMpact statement (EIS) process has been used to assess the environmental effects of major projects and policies that involve federal funds, such as designing highways, altering waterways, extracting resources on federal lands, and setting Corporate Average Fuel Economy standards. Created under the National Environmental Policy Act of 1969, EISs do not determine policy but rather ensure that stakeholders have full information about unintended environmental impacts before reaching a decision. By evaluating alternative proposals and their relative risks and benefits, an EIS helps decision makers choose options that promote favorable outcomes and mitigate adverse environmental consequences. A natural extension of this work is the use of health impact assessment (HIA) to examine the effects that a policy, program, or project may have on the health of a population. An HIA is defined as “a combination of procedures, methods and tools that systematically judges the potential, and sometimes unintended, effects of a policy, plan, programme or project on the health of a population and the distribution of those effects within the population. HIA identifies appropriate actions to manage those effects.” Most health professionals are probably more familiar with EISs and their intent and usage than with HIAs. Yet there has been a movement to adopt HIAs in public policy settings and legislation and in a recently emerging health policy literature that describes and advocates for this process. HIAs offer great potential for promoting health by encouraging decisions that protect and enhance health and health equity. There is increasing recognition that many contemporary health issues are profoundly influenced by factors outside the traditional realm of health and health care. Factors such as literacy, poverty, employment, and racism contribute to disparities in life expectancy as well as to health-related quality of life. Concerns about how to address these factors have led to a focus on “health in all policies,” in which policies in social sectors such as transportation, housing, employment, and agriculture ideally would contribute to health and health equity. An HIA offers a vehicle to make these health effects explicit. Unfortunately, the evaluation of health effects in policy making has been slow to take hold. The United States lags behind many European nations, Canada, and other countries in the use of HIAs. This situation is somewhat surprising, given that US environmental policy explicitly requires the examination of health effects as part of the National Environmental Policy Act. Although most EISs in the United States incorporate little about health effects, experience in California and Alaska has demonstrated that a wide range of health effects can be successfully integrated into the EIS process. Beyond increasing attention to health outcomes within EISs, the potential applications of HIAs are clearly evident. For example, although air pollution and injury prevention are often considered in major transportation projects, the influence of road design on physical activity and obesity is not. An HIA that recommends the addition of pedestrian and bicycle facilities (“complete streets”) to a transportation plan would contribute to a built environment that promotes the public’s health. The agriculture sector seeks to maximize productivity, meet consumer demand, and sustain livelihoods. From a health perspective, agricultural policy determines food quantity, quality, and prices that directly affect consumption patterns and therefore affect health. HIAs could be used to examine the health effects of proposed agricultural policies, such as ones that enhance production of energy-dense, nutrient-poor foods that contribute to the increasing obesity epidemic. HIAs of proposed zoning plans, which would contribute to decreased density of fast-food and liquor stores or increased density of restaurants and full-service grocery stores, especially in low-income areas, could result in changes that better promote health. In education, a timely HIA might have reduced the inadvertent effects of the No Child Left Behind legislation on physical education programs and health curricula by pro-