Readings, Week Nine

This week’s reading focused on building HIA capacity. The first reading was a lovely report from the Victoria Transport Institute analyzing the health impacts of density, land-use, and transportation on health. The report reviews the literature on the impact of density and land-use on transportation behavior, and the then the impacts of density, land-use, and transportation on physical and emotional health and social capital.

A friend of mine from Hong Kong who is now in Toronto told me recently that’s she’s jealous that I’m involved in public policy. There are fewer opportunities in Canada to be involved public health policy since the social welfare supports in Canada are much stronger and because of universal healthcare—her currently job is as a health services researcher. I had a similar impression of Canada, and also thought that it had a very robust planning process that took into account health impacts and public engagement. So I was surprised that there was a need for this kind of report.

It was also interesting to read about urban planning policy from the perspective of our northern neighbor. In my urban planning class this semester, we’ve had regular discussions about urban sprawl and the impact that it has on public services. The discussion has gone something like this: when developers build on open land beyond the boundaries of existing suburbs, local governments have to scramble to provide water and sewage lines and other public services like libraries and schools. The Canadian report discussed this phenomenon too—but also mentioned that public entities need to provide social welfare services. In the last semester, with the exception of public housing complexes, the placement of social welfare services in the city or new suburbs has never been mentioned. I thought this omission was very revealing of the U.S. concept of public services, even in a liberal academic setting. The need for social welfare infrastructure– like EBT or unemployment offices– never crossed my mind, especially because it’s not something I usually associate with a new suburb.

The Victoria Transport Institute report had a conversational style without being too casual and lots of interesting research results, charts, and graphs. The report was also sprinkled here and there with anecdotes of innovative programs. For instance, the University of Washington and the University of British Columbia both found that giving faculty, students, and staff with parking passes a bus pass reduced the number of people driving alone. At UW, solo car trips decreased by 10% over five years. There were also interesting differences between cross-sectional and longitudinal studies of the impact of attitudes and the build environment on transportation use. The longitudinal studies foudn that both attitudes and the physical environment affected transport behavior. I’ve been keeping all the readings in my HIA folder, but this will definitely be a report to return to. I had to chuckle though, when they included a series of maps showing how obesity rates in Canada have increased over time.

The second reading for today was from Brian Cole and Jonathan Fielding outlining their ideas for growing the HIA field. Their suggestions include establishing a quasi-governmental body, a congressional task force, and clarifying the consideration of health impacts within NEPA legislation. The paper was written in 2008, I would be interested to hear what they think about future directions for the field today. Could the Pew/RWJF center fulfill the role they envisioned for the quasi-governmental body? Do they still think it’s important to establish a congressional task force? Or is it more important to build the body of examples first? I think Rajiv Bhatia might argue for the later, though I’m guessing he would also support stronger health considerations within NEPA.

The case study from today was a HIA on the transportation plan from a county in Georgia—reading it reminded me that I’ve forgotten to include demographic information in my HIA. They had several maps in the HIA that used census tract data to map the county’s population of seniors, young children, people without cars, and people living in poverty, I wonder if I can find some Met Council maps that would be relevant to the SRTS legislation…

That’s the last reading, week 10 in the syllabus is the presentation. (I was relieved to see that there was a week ten, since I’m fond of the subtitle for the blog…)

Conversation with Kristin Raab

Community Engagement

“I have strong views on it, I think community engagement is really a hallmark of good HIA, but it really depends on who you talk to.  Sometimes decisions need to be made quickly and there’s no time to do a full community engagement process”

“Things that the health department is interested in may not be what the community is interested in. For the Healthy Corridor for All project, the health department wanted to measure asbestos, radon, and lead. These ideas were very much driven by the resources that were immediately available.”

One drawback to community-led HIAs – community groups may not have the authority of the health department. The health department is seen as neutral. Kristin was on the technical team for the Healthy Corridor for All Project, but MDH was brought on in an advisory role.

“In the Healthy Corridor for All project, St. Paul was not happy that the HIA was taking place—they had done public meetings (that were not well attended). So there was friction. The community organizers with ISIAH were happy that there was friction. So everyone has a different perspective.” Helathy Corridor for All was really driven by ISIAH , they facilitated the process, PolicyLink brought on by ISIAH.


“This also depends on who you talk to, I have conflicting feelings about it. In theory, I support the idea. But in practice there are drawbacks based on how HIAs are conducted and who would conduct them.

The same argument was made when NEPA was being considered. But pollutants are easier to measure and quantify, social determinants of health are more fuzzy and more political.”

In some places if you do an EIS, you have to do an HIA, that seems like a good match”

Tools & Trainings

When ASTHO / CDC had money to sponsor trainings, we had a conversation about competencies. But each HIA is very different.


  • Planner
  • Engineer—especially with transportation
  • *Someone to crunch health data
  • *Facilitator/ Project Planner
  • Writing Skills – otherwise all for naught (HK: always great to hear! :-) )
  • Someone to figure out how to get the recommendations into the hands of decisionmakers

* Always needed

Do you think the SFDPH training would be worth the investment?

Probably not—you’d gain a little bit from the last day. I was interested in the modeling, but can’t take off a week, you have to attend all 5 days.

HIA is really one of those things that you have to experience. I did the readings, but participating on an HIA was a completely different experience.


“6 months ago, I would have said that nationally we should be promoting comprehensive HIAs because that’s how tools will be developed, that’s how we will learn”

“Now I’m with Rajiv—HIAs bring health to the table when it’s not at at the table. A desktop HIA works for that.” They can cost $200,000, so it’s difficult to find funding.

In MN: two HIAs in progress, also possible HIAs on using sand fracking, child custody law

Kristin also requested that I send her a copy of my desktop HIA.

Readings, Week Eight

The focus of this week’s readings was the integration of HIA into EIA.

The first piece was by Rajiv Bhatia and Andrew Wernham. This was a very valuable article, and I wish I had encountered it before heading to D.C., there was one session in particular that would have been easier to understand with some background in EIA terminology and concepts. The authors explain EIA and CEQA, California’s version of the federal law. At the time the article was written in 2008, 19 states and territories had adopted environmental impact review laws. There is something called an “environmental assessment” which is a less formal EIA. The second article in the reading list had a similar focus, and was by the UCLA group.

Some things I learned from these two readings:

Under NEPA, the entities involved must produce a “Record of Decision” that documents the permitted activities, mitigation measures, and how the EIA informed the decision.

NEPA requires collaboration of local jurisdictions affected by the project

It also requires community input.

The number of EIAs per year has dropped recently while the EIA-lite “environmental assessment” has become more common. EAs are much shorter– average at 12 pages, and do not require community input. All the quotes below are from the Cole article.

Procs/Cons to EAs:

“Proponents of EAs say their increased use is evidence of a trend toward earlier, more proactive consideration of environmental impacts in project planning and incorporation of mitigation measures in the planning process. Critics contend they circumvent the intent of NEPA, particularly provisions for public involvement in decision making”

Cole’s article also included the results of interviews with EIA practitioners. Cole found that practitioners mentioned improved planning, increased transparency and public involvement, and the integration of environmental goals as the top benefits to EIAs. Noticeably missing from the list of benefits was mention of inter-agency collaboration. On the topic of improved planning, Cole writes that,

Even the critics of NEPA among the interviewees expressed the view that
NEPA and SEPAs have had a positive impact on planning generally by
requiring an earlier, clearer, and more complete conceptualization of project
plans and objectives. Projects were said to be designed from the outset
to minimize environmental impacts—if possible to bring the potential
impacts below the threshold requiring a full EIA or at least minimize
impacts in order to reduce the likelihood of criticism and calls for costly
and time-consuming project modifications in the EIA review process

While public participation was seen as a benefit, practitioners said that there was a lot of room for improvement. The practitioners that Cole talked to felt that HIA should be integrated into EIA.

The drawbacks mentioned on EIAs integration are similar to previous readings (length of EIAs, mandates a process not an outcome). The Cole piece seemed more ambivalent about whether HIAs should be incorporated into EIAs, while the Bhatia/Wernham article seemed more enthusiastic. I was surprised by this since my impression from the conference was that Bhatia was opposed to codification of HIA– perhaps he just wanted to warn people that it should only be used when appropriate.

The case study this week was from the Asian Development Bank on a dam in Laos.

Memo on school siting HIAs from Susan’s student

I didn’t have a chance to mention this, but one of Susan’s students is working on a policy memo on the use of school siting HIA. I asked to take a look and Susan asked for some feedback. I’ve attached the feedback I provided earlier this week below. I asked Susan if could also share with you, and she said that if you had any feedback she’d love to have it– I said I would ask you if had some time to take a look.


Readings, Week Seven

This week had a light reading list. There was one report from Europe, but the link had expired and several Google searches to find the document were not fruitful.

The second reading was an HIA from Oakland by Bhatia & Co. on a 64-acre waterfront development project in Oakland. The Oak to 9th HIA examined the planning process, access to parks & open spaces, pedestrian injuries, air quality, and noise pollution impacts from the redevelopment.

One characteristic of the Oak to 9th HIA that stood out to me was the assessment of the planning process. The business that planned the redevelopment failed to meet public input requirements at several steps, and the report presents a thorough accounting of those failures, including lists of people who submitted public comment. I didn’t expect to see that as part of the HIA– I guess I’ve been envisioning the ideal HIA that happens in concert with the planning process. This was an unexpected use of the tool and a good reminder that the land development process is not always transparent.

Special attention was paid to pedestrian safety because rates of pedestrian injuries were especially high in this area– twice the national limit. HIAs by definition respond to local needs, but I find this element of HIA to be very appealing. My default position is that most U.S.. places in within very broad categories (rural, suburban, big city, low-income) are more similar than different, so I enjoy having my assumptions challenged!

I’ve never thought very much about pedestrian safety before, I had no idea there were so many pedestrian deaths:

Prior to the 1970s, the United States was a world leader in traffic safety. However, over the past three decades, measured by the number of traffic deaths per million vehicles, the United States has slipped to13th place, and is still sinking. Pedestrians account for 11% of all motor vehicle deaths, and in cities with populations exceeding  million, they account for about 35%. Each year, 80 000 to 120 000 pedestrians are injured and 4600 to 4900 die in motor vehicle crashes.

This report also had handy chart on how land-use decisions are made in California– that may come in handy someday!

A few other updates: I emailed Kristin Raab and it looks like we’ll be meeting the last week of April. For the Safe Routes to School HIA, I’ll be streamlining the pathways to three major impacts: physical activity, air quality, and exposure to food marketing and fast food. I’ll spend part of next weekend on the assessment phase to evaluate the potential health impacts, and the weekend after that one the recommendations section.

Readings, Week Six

The focus of this week’s shorter (phew!) list of readings was the “science and art” of impact assessment.

The first article by Brian Cole was a very nice overview of HIA definitions, the key elements of HIA, and the history of different HIA approaches both internationally and within the United States. Cole notes that there are different ways of distinguishing HIAs, but offers his own categories based on the disciplines that they drawn on:

Quantitative analytic HIA (epidemiology, risk analysis, EBP and evaluation)

  • “In practice, the quantitative/analytic approach to HIA can be highly time- and cost-intensive. Time, money, and data limitations often restrict its application to a consideration of single, unmixed, noncumulative exposures, and only one or a few outcomes”

Community-based health promotion (participatory approach)

  • “Most HIAs have some provision for soliciting stakeholder input, but this is particularly emphasized in this approach to HIA, as it is the main input for analysis; facilitating this participation is the primary rationale for conducting a HIA”
  • Evidence may not have as much cache in some social contexts, not replicable, no common metrics, therefore, “This approach to HIA is probably better suited for analyses of local projects, not broad policies and programs that affect larger geopolitical units”

Environmental impact analysis (procedural approach & EBP and evaluation)

  • “The primary strength of the procedural approach to HIA is that the assessment can be performed in a relatively transparent, reproducible manner with methods that are broadly disseminated and understood. In theory, it can be relatively quick and efficient, but in practice agency rules and regulations specifying content and methods in great detail may greatly increase resource requirements for this type of assessment”
  • “There is also some question as to whether these procedural assessments are really used in the decision-making process, or whether they are just conducted to fulfill a bureaucratic requirement.”

I skimmed the next three articles. Mindell and Joffe examined the literature on the health impacts of fine particulate matter—the key takeaway here was that there is no threshold effect for particulate matter impact on morbidity and mortality, and that the long-term effects on health are probably more substantial than the acute effects. The World Bank’s guide for institutional, policy, and social analysis included frameworks and cases studies on analysis in the developing world. The final reading was an article by Oakes & his colleagues—a longitudinal analysis of equity in the siting of hazardous waste facilities. The researchers found that hazardous waste facilities were sited in white, working class neighborhoods, not in low-income, minority neighborhoods, and that there was no white flight after the facilities were built.

The HIA case study this week was an analysis of an Oregon proposal to reduce VMT (vehicle miles traveled) in Oregon’s six Metropolitan Planning Organizations. Human Impact Partners and UpStream Public Health collaborated on the HIA. They focused on analyzing the proposals in Governor Kulongoski’s plan on three indicators: air quality, physical activity, and car accident rates. In their literature review, they found that parking fees are more effective and equitable than driver-related taxes (e.g. congestion taxes) in reducing VMT, and that there is a threshold effect in fuel taxes—the proposed tax was not high enough to have an effect on VMT.

I added this to my mental list of favorite HIAs because the scoping and analysis seemed much more robust than previous HIAs in the reading list. The UCLA menu-labeling HIA, for example, made multiple leaps in logic, and I felt uncomfortable with the results. (I learned at the conference that Arnie changed his mind about menu-labeling legislation when he read the HIA so perhaps I’m being too skeptical!).  I wonder if I feel more comfortable with the Oregon HIA because much of the HIA was based on a literature review, which is a familiar process to me and in the public health research context is an accepted way of assessing the evidence. Both HIAs were equally transparent about their methods and pathways, but in this instance, I felt more comfortable with the science than the art!

RWJF’s Coverage of the HIA conference

On lunch on the first day, I happened to sit next to a woman who writes articles for (Journalists and former journalists have good j-dar :-) ) Here are her two posts about the conference, an interview with James Hodge, who directs the Public Health Law and Policy Program at ASU, and who studied the different legal manifestations of HIA across the country, and with Aaron Wernham, who leads the Health Impact Project for Pew/RWJF, and conducted HIAs as a physician in Alaska.

Conference Blog Post 3: Case Studies

  • UCLA Menu-labeling—influenced governor
  • Funding for Farm to School in OR
  • Lyell/Freeway analysis in SF—led to asking DOT to use more hybrid buses in area, looking at rerouting truck traffic
  • Rachel Thornton, JHU, Baltimore example—addressing alcohol outlet density in land use planning
    • Zoning code in Baltimore from 1971 – gasp from a planner in the audience
    • The built environment was out of sync with the code, the city wanted it to be flexible, to be in sync with the future direction of the city—ie emerging bioscience industry,
    • The group identified potential impacts of the plan, violence/crime was  special concern for Baltimore, also obesity,
    • Found that the strongest predictors in the literature for land-use impacts on health was alcohol density and crime, crime was also a concern for stakeholders. Also looked at food desserts but found that the evidence was mixed so this was not included in the final recommendations
    • Three agencies: health, planning, and police worked together, ongoing relationship
    • Took one year, probably about $230K, 300 page report


  • Brandon Haggerty, Clark County health department: bike and ped plan
    • two stage process, first a rapid HIA, then a more full-fledged HIA. HIA reframed the plan and offered a more robust analysis
    • shifted the plan from focus on recreational bike and pedestrian transport to active commuting
    • health data used in communication of plan, in retrospect would have placed less emphasis on assessment and more on the reporting, in follow-up interviews policymakers didn’t remember that 26% of children are obese, they only remembered obesity: bad.
    • Lots of request for monetizing the impacts—they pushed back because they didn’t feel comfortable making unsupported claims, but they did report the direct medical costs of obesity to the county


  • SANDAG 47th Street station HIA:
    • San Diego unique in that the consolidated agency has authority
    • Used PEQI (pedestrian walking environment w/in one mile of station)
    • Offered training on ?, huge turnout, led to larger community participation in project
    • In future: need more local examples, looking to develop TA program to support HIA at public agencies, also looking at:
      • RCP:  (land-use) occurs at the local level, provides technical assistance but doesn’t make decisions, not federally mandated
      • RTP: (transport) projects for 30-40 years out, updated every 4 years

Future HIAs:

Follow the (federal) money: transport, water, farm bill

Conference Blog Post 2: Ideas & Nuances


Policy-> Proximate Impact-> determinants of health -> health outcomes

First two usually site specific, second two can be based on existing literature

Distinction between policy and project HIAs.

  • Projects
    • physical impacts
    • e.g. for access to parks, joint-use agreements, school siting
    • in UK, found better involvement of communities
    • Policies
      • physical and social impacts,
      • e.g. for living wage and paid leave policies in SF, land use, infrastructure, mass transit
      • more fluid process
      • more difficult to identify contribution to better decision


  • Can take many forms
    • MPOs—Nashville, SD
    • Legislation—MA Healthy Transport Compact
    • Cross-agency collaborations
    • Health department led


  • Bhatia’s words of caution:
    • “In a good planning environment, HIAs are redundant”
    • Our goal was not to introduce a method or a technical process but to improve health, equity and community participation, to improve a political system. When we started we wanted participatory research to inform community organizing, to bring health evidence and lend the authority of the health department to discussions.
    • Learned that: have to be willing to compromise, accept political realities. We let the planners regain control once we gave them the evidence, and that meant that we were asked to come back to the table; we also translated the evidence to the political process
    • HIA exists in a political systems, it’s only policy tool, it may not be the best policy tool in every situation


  • Lea de Broder , Netherlands
    • Debate in Europe:   is HIA advocacy or a science?
    • In Becker’s the Politics of Health Policies  the author states that technocratic ways can divide practitioners
    • Wonderful European lingo: “smoking discouragement” , health as it pertains to “lifestyles, landscapes, and livelihoods”

Community Engagement

  • What do you do if community not eager to participate: Not a problem in Oakland, Human Impact Partners have training, especially helpful for conflict resolution, may also need to educate about HIAs, empowering communities
  • What about undocumented workers? Do they have less political say because they can’t vote? Not sure, but try National Latino Legislators


  • Can appear in different forms:
    • w/in MPOs (Metropolitan Planning Organization): Nashville, SD
    • Legislation: MA, Healthy Transportation Compact
    • Led by non-public health agencies – ie in AK by Dept. of Natural Resources
    • Cross-agency collaboration
    • Timing is everything—if you’re too early the policy may not be fully developed and you won’t know what options to consider, if you’re too late, then planners will have made their decision and they won’t want to change  anything.
    • Build relationships early. HIA can also be a tool to build relationships for future HIAs.


Four groups currently conducting evaluation of HIAs:

  • Group Health Seattle
  • Keisha Pollack, Johns Hopkins
  • Australian group
  • Office of Policy, CDC

Pollock, quoting from National Resource Council report(?) “It is not reasonable to expect decision makers to adopt HIAs widely in the absence of evidence of its effectiveness and value”

In future: Pollock has completed first round of interviews, will be talking to policymakers to see what they felt went well about HIA process

Conference Blog Post 1: Resources & Fun Facts

Fun Facts:

1999: First? HIA by Rajiv Bhatia (SFPH) on minimum wage

2001: RWJF first funding of HIA

2011: Inclusion of HIA in national guidance/recommendations: Healthy People, Let’s Move, Sustainable Communities Partnership, National Prevention Council


~110 HIAs to date

Europe and Australasia have been having international meetings on HIA for over 10 years


6 Universities with HIA courses:

  • UWashington
  • UC-Berk
  • Indiana
  • JH
  • UPenn
  • PSU




  • Environmental Public Health Tracking Network for HIAs
  • Transportation HIA Toolkit (completed), Parks and Recreation (Summer 2012), Housing (Winter  2012)

In future: microsimulation, new data on population within a ½ mile of a school in CDC’s Environmental Public Health Tracking Network


  • – indicators were taken to community members and planners to ensure that the indicators were meaningful and actionable
  • PEQI  : pedestrian environmental quality index—support for safe walking at the neighborhood level
  • Air Quality Measurement and Modeling
    • check out Article 38 of the SF Health Code
    • Pedestrian Injury Forecasting Model – traffic volume strongest predictor in this model

In future: Food Access very difficult to measure, still working on this one. Even if you can map grocery stores, corner stores, and farmer’s market how do you judge cost? Quality? Selection?


  • National Household Travel Survey (NHTS) predictors of trips , online analysis tools

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