Ever wondered what impact building a four-lane highway near a residential neighborhood could have on someone’s health? Perhaps not. But the national conversation is quickly shifting from how to react to health problems to how to prevent them. Wonks call it “health in all policies”. And as states and localities move toward that goal, they have a new tool at their disposal: health impact assessments (HIA’s).

Would that highway increase carbon emissions near family homes? Would the traffic pose a risk to pedestrian traffic? Is there an opportunity to add bike paths or walkways to encourage exercise? These are the kind of questions HIA's can try to answer.

They aren’t yet a common part of public policy: according to a review by the Health Impact Project (a joint venture by the Robert Wood Johnson Foundation and Pew Charitable Trusts) of 30 state and local jurisdictions (plus five American Indian tribes and the federal government for a total of 36), there were only four instances of HIA’s being required by law.

Still, the movement seems to be gaining steam: the inaugural National Health Impact Assessment Meeting was held in Washington, D.C., in early April. More than 400 people -- including public health officials, non-health policymakers and elected representatives -- attended the two-day conference at the Renaissance Hotel, according to the Health Impact Project, which coordinated the event.

Even with that level of interest, there might not need to be a sudden rash of HIA legislation. According to the project’s analysis, HIA’s could be used to satisfy already existing legal requirements in several areas: environmental and energy (22 jurisdictions out of 36); transportation (7); agriculture (7); and waste disposal and recycling (11). Many initial HIA efforts have also been voluntary, reducing the need for new governmental mandates that might be politically unpopular.

'The Healthiest Way Possible'

Transportation offers arguably the most intriguing application of HIA’s. Their use seems fairly intuitive for environmental or waste disposal projects, but the implications are vast if health considerations become a major factor when policymakers decide where to build a highway or how to design a traffic intersection.

“Our goal shouldn’t be to make all transportation projects primarily focused on improving health,” Aaron Wernham, director of the Health Impact Project, said. “Transportation has a different mission. It’s about moving people. But if we can do that in the healthiest way possible, then I think we have a win-win.”

Two states, Massachusetts and Washington, have specifically required HIA’s for transportation projects. The Massachusetts legislature passed the Healthy Transportation Compact in 2009, which requires an assessment to ensure that a proposal will reduce greenhouse emissions, improve access to health-related services for those with limited mobility and expand opportunities for physical exercise through biking or walking.

The state received a grant from the Health Impact Project to develop its HIA model. One project to make use of the HIA process is Grounding McGrath, a plan to lower an elevated roadway along the Route 28 corridor in Somerville, Mass. The project partially arose from the need to allow schoolchildren to walk to school, which was impossible with the raised road. The HIA will consider the effect of motor vehicle emissions being closer to the ground (and therefore the neighborhood) as well as the potential for additional walkways and green space in the area.

The HIA mandate has allowed often-isolated departments like Public Health and Transportation to collaborate on projects, such as Grounding McGrath, in a way they never did in the past, state officials said.

“We’re trying to get all the players involved to fully understand health impacts, both positive and negative,” said Suzanne Condon, director of the bureau of environmental health at the Massachusetts Department of Public Health. “When people don’t consider health, then we end up with consequences later that we all have some responsibility for.”

Washington lawmakers passed a bill in 2007 to mandate an HIA for a specific project: the State Route 520 bridge replacement over Puget Sound near Seattle. The law required the state office of fiscal management to coordinate with affected parties, including the Seattle and King County public health agency, to assess the impact on air quality, greenhouse gas emissions and the overall well-being (physical, mental and social) of the nearby communities.

The findings led to the incorporation of more green spaces, more pedestrian and biking pathways and a greater emphasis on noise reduction in the final product, which is expected to be completed by 2017. "Transportation planners must make decisions that will support individuals and communities in making good healthy choices," David Fleming, director of the Seattle and King County Department of Public Health, and Dennis McLerran, executive director of the Puget Sound Clean Air Agency, wrote in the introduction to the final HIA.

'It's A Stepping Stone'

The long-range goal is that HIA’s would ingrain health considerations into public policymaking. The voluntary efforts of the Nashville Metropolitan Planning Organization (MPO) present an early example of a local government working toward that goal.

With an undesirable health reputation (Nashville has been ranked as one of the 10 most obese cities in the United States), the MPO conducted an initial survey in 2009 of 2,400 individuals (with a focus on low-income, elderly and minority populations -- those with higher proportions of health problems) that resulted in its first regional bicycle and pedestrian plan, said Leslie Meehan, director of healthy communities. It served as a pilot HIA of sorts and the organization’s first foray into the “health in all policies” realm. The MPO is also set to launch a study of 600 individuals who will wear “accelerometers”, which will measure their daily physical activity and amount of energy expended. That data could then be used to inform future policy decisions.

The goals outlined by the community also led to the adoption of the 2035 Regional Transportation Plan in December 2010, which established the area’s goals in merging health and transportation concerns for the foreseeable future. More than half of the scale on which proposed infrastructure projects are judged is based on health impacts (from injury reduction to promotion of physical activity). With an estimated $6 billion at the MPO’s disposal for future projects, the 2035 plan ensured 70 percent of those approved included some kind of active transportation infrastructure, such as walking or biking paths, up from 2 percent in the previous long-term plan.

By responding to their citizens’ desires, Meehan said the MPO has been able to more easily integrate health into the policy conversation. “It’s a stepping stone to get people to think differently,” she said. “When we approached our long-range plan, we didn’t start with this notion of health. We started by asking: What’s your vision of your community?”

Some advocates have suggested that, if all goes according to plan, HIA’s would eventually become obsolete because their functions would be absorbed into all elements of policymaking. That scenario might be a long way off, or even impossible, but it is an ideal worth pursuing, they said, and one that should be amenable to everyone because the benefits are simply practical (think of the effect on states’ ballooning Medicaid expenses).

“The real way to lower health care costs is not by insurance gimmicks or reducing access to care, but by creating a healthier population,” said Paul Jarris, executive director of the Association of State and Territorial Health Officials. “But the issue is that most of the decisions impacting health aren’t made within the health sector. HIA’s are a tool to motivate people to do the right thing.”

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