Health Impact Assessment: A Tool That Can Build A Healthier America

In December, the Department of Health and Human Services released “Healthy People 2020” — a 10-year blueprint aimed at improving the health of the nation. The plan comes amidst rising rates of many diseases – such as asthma and diabetes — and skyrocketing health care costs.

Now at the dawn of 2011, federal, state and local officials are faced with the tough job of turning the public health goals outlined by that plan into reality.

However, they will almost certainly fail at that increasingly urgent task unless they start factoring health into proposals being considered in non-health sectors like energy, housing, agriculture and transportation.

What does a decision to build a new highway have to do with health?

Plenty, as it turns out.

Depending on how it is planned, a new highway may change levels of air pollutants and the risk of asthma for people living nearby. New traffic patterns may also increase the risk of traffic-related injuries. Furthermore, the roadway might unintentionally cut off an important walking route to and from a transit stop or local school, making it harder for adults and children to get enough exercise.

These are significant health concerns. According to the American Public Health Association, it is estimated that health problems associated with our current transportation system—such as injuries, asthma, cardiovascular disease and premature mortality—may result in over $300 billion in additional costs every year.  This amount includes accident and medical expenses, and lost wages and lost productivity.

Yet officials in transportation and other sectors like energy, agriculture or housing do not routinely identify and address the health implications of their decisions.

One way to address this shortcoming is a powerful approach called a health impact assessment (HIA), which is being used worldwide to identify unintended health risks and unnecessary costs. At the same time, HIAs build in solutions aimed at keeping people healthy.

For example, collaboration between city planners and health officials on an HIA for a proposed housing development in Colorado has led to new measures that will minimize the impact of pollution from local roadways and offer residents greater opportunities for exercise, all with a minimum investment of time and expense.

In New Hampshire, an HIA is being used to inform the difficult choices that the state legislature will need to face in cutting costs to deal with the budget deficit.  For example, how will changes in Medicaid reimbursement levels affect delivery of medical services in the hospital? Or, will decreases in the amount of state tax revenue that is shared with municipalities change welfare program offerings at the local level and will that have unintended consequences for health?

In Atlanta, the regional transportation agency is collaborating with experts from the Georgia Institute of Technology’s College of Architecture to plan updates to the region’s roads, highways and urban centers that will maximize the return on investment for health.  The aim is to minimize air pollution and the risk of injury, create safe places to exercise, and provide better access to services such as clinics and grocery stores, as well as help to relieve congested roadways.

As a doctor, I have seen firsthand the impact that the places we live, work and play can have on our health. I have cared for many diabetics who struggle to follow exercise recommendations because there is no gym nearby and nowhere safe to walk; asthmatics who live in housing with mold and substandard ventilation; and children who live in neighborhoods that have fast food outlets on every corner, but no grocery stores that sell healthy foods for miles in any direction.

In America today, one out of three people struggle with excess weight or obesity. Type 2 diabetes, a deadly disease once seen only in adults, is now attacking our children. Meanwhile, an astonishing one out of four working-age adults suffers from a chronic condition like heart disease or asthma. Many of these diseases are preventable, yet they are increasing at an alarming rate and exacting an enormous cost on our nation.

We cannot afford to delay. Along with many diseases, health-related costs in the United States are growing every year. In order to stem the rising tide of disease and get the best return on our investments in health, we must proactively identify opportunities to prevent illness and fight the spread of chronic diseases in our country.

Many of the Healthy People 2020 objectives will require actions on the part of officials in education, agriculture, transportation, energy and many other areas. An HIA is a practical, effective tool to address that need and factor health into the decision-making process.

Aaron Wernham, M.D., is the director of the Health Impact Project (www.healthimpactproject.org), a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts designed to promote the use of health impact assessment and support the growth of the field in the United States.

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Jonathan, Some comments about NYC life span. 1. Immigrants to NYC are not representative of their countries. They are either well educated or with high enterprise. Immigrants from developing country also have much higher immunity. 2. NY with all its lavish health coverage might be improving life expectancy. 3. Lastly, life expectancy is also a factor of how close you are with your family. Now I do not know about demographics of NYC. Maybe high real estate priceis forcing families to stay together. This article actually also needs to wade into societal issues. American Dream (isolated homes), alcohol celeberated life… Read more »

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As a 30-year veteran of the health care business, I can tell you that asthma and allergy medical claims are larger than most people realize. ER visits, of course, don’t help.
Any reduction in costs could make a big difference.


Looking more systematically at the externalities or unintended consequences of policies on public health is long overdue, so I hope this does get much more traction than it currently has. One Caveat, though: these HIAs must not become contentious instruments using poorly verified or (as Taleb would put it) “fragile” findings. It would be very easy to game the system, either cynically or piously, to get directionally the numbers one wants. So, stick with what is solidly known from multiple, large scale studies with control groups (the gold standard) when you can. On the other hand, just because you can’t… Read more »


Thank you for posting this. Take transportation energy alone (as you allude to broadly). It is argued that we cannot engage in a massive policy shift toward liquid hydrogen fuel because its NOMINAL unit cost is so much higher than conventional petrochemical motor fuel. But (even ignoring the unwarranted assumption of the necessity of the remote, centralized large-scale “refinery” paradigm) the criticism ignores the very real, widespread, and substantial economic externalities of hydrocarbon fuels — e.g., environmental/health degradation, proportion of DoD budget devoted to assuring the continuing flow foreign oil. An honest and thorough accounting (“Impact Assessment”) might make H2… Read more »