Health Impact Assessment: A Tool to Help Policy Makers Understand Health Beyond Health Care

Abstract

Health impact assessment (HIA)-a combination of methods to examine formally the potential health effects of a proposed policy, program, or project-has received considerable interest over the past decade internationally as a practical mechanism for collaborating with other sectors to address the environmental determinants of health and to achieve more effectively the goals of population health promotion. Demand for HIA in the United States seems to be growing. This review outlines the common principles and methodologies of HIA and compares different approaches to HIA. Lessons learned from the related field of environmental impact assessment and from experience with HIA in other countries are examined. Possible avenues for advancing both the field and the broader goals of population health promotion are outlined. HIA AS A NEW TOOL FOR AN OLD WAY OF DOING PUBLIC HEALTHFrom the time of Hippocrates public health practitioners have looked to the environment to identify the causes of ill health and for potential opportunities to advance well being. The seminal "Report on a General Plan for the Promotion of Public and Personal Health" to the Massachusetts legislature, authored by Lemuel Shattuck (69) in the mid nineteenth century, and the writings of Rudolf Virchow (72, p. 72) in that same century suggest a continuing recognition of the centrality of social and physical environmental effects on health. Snow's apocryphal removal of well pump handles to stem an outbreak of cholera, Gorgas' efforts to control yellow fever and malaria during the building of the Panama Canal, the dramatic improvements in motor vehicle safety in the United States as a result of improved vehicle standards and roadway infrastructure, and reductions in tobacco use over the past several decades demonstrate the potential of an environmental approach for improving public health. Although a more individualistic approach, emphasizing biomedical and behavioral paradigms, has frequently dominated the field since the mid-twentieth century (72), concern about the environmental determinants of disease remains a vital principal of public health (45). Over the past quarter century the World Health Organization has set forth a number of major declarations and initiatives calling for a return to an environmental approach to improving population health, including the Alma Ata Declaration (82), the Ottawa Charter on Health Promotion (82a), the Jakarta Declaration on Health Promotion (83), the Bangkok Charter for Health Promotion (86), and the Healthy Cities movement (5). Similar declarations have been made at the national level, including most significantly the Lalonde Report (39) in Canada and the Acheson Report (2) in the United Kingdom. Because the ability to modify many of the environmental determinants of disease lies outside the traditional province of public health agencies, intersectoral cooperation in creating healthy public policy (46) has been a common theme throughout these declarations and initiatives. Questions remain, however, about how...

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