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Health impact assessment


FINTAN HURLEY, SALIM VOHRA
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Using environmental health evidence to inform policy development Health impact assessment Definition of health used in HIA The HIA process HIA in the context of other approaches

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An overview of environmental HIA An example: environmental HIA of outdoor air pollution Current trends and future prospects Acknowledgements References

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USING ENVIRONMENTAL HEALTH EVIDENCE TO INFORM POLICY DEVELOPMENT


There are many ways of summarising and communicating scientific evidence for use in policy development when the aim is to protect public health and the evidence concerns risks from exposure to environmental pollutants. In the context of environmental medicine, one long-established approach involves developing health-based guidelines for specific pollutants. Typically, these guidelines are limit values, chosen so that if pollution is maintained at levels below these limits, the consequent risks to the health of even the most vulnerable individuals in the population are low. Setting, implementing and maintaining health-based guidelines has proved very important in protecting human health. The approach has, however, some important limitations. First, it sometimes happens that, where pollutant levels are lower than guideline values, it is considered acceptable to allow a drift upwards towards those guidelines; or, in an equivalent manner, that policies or developments that imply an increase in pollution are considered acceptable as long as guideline levels are not exceeded. This ignores the possibility of effects at concentrations below guidelines, a problem especially with pollutants that have no threshold at population level. Second, health-based guidelines do not per se take account of the difficulties and costs involved in achieving them, and therefore they are not amenable for comparing the costs and benefits of a new proposal. Third, measures to reduce pollution to conform with limits may have other unintended consequences, including health impacts

mediated through other environmental or social determinants of health. Attempts to overcome these limitations have contributed to the development and increased use of other methods of using science to inform the development of policy. One such set of methods is called health impact assessment (HIA).

HEALTH IMPACT ASSESSMENT


Health impact assessment is the systematic prediction of the potential positive and negative health and well-being impacts of new policies, plans, programmes and projects (hereafter referred to as proposals), including how these impacts are distributed across the population.1 It was defined by the Gothenburg Consensus as A combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.2 It works within an explicitly stated ethical framework that promotes an impact assessment that is participatory, equitable, sustainable and ethical in its use of evidence and maximizes health opportunities for the affected population. It also generally provides a set of recommendations and/or a set of mitigation and enhancement measures so that positive health impacts are maximized and negative health impacts minimized within a given population. HIA is therefore about both protecting health by reducing exposures to harmful agents, and improving health by capitalizing on opportunities to promote and enhance health and well-being. HIA is also concerned with the

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inequalities/inequities generated by the uneven distribution of health impacts within an affected population.

DEFINITION OF HEALTH USED IN HIA


HIA tends to use both a biomedical and a social definition of health, recognizing that although illness and disease (mortality and morbidity) are useful ways of thinking about and measuring health, both health protection and health improvement need to be understood in ways that are wider than the reduction of illness and disease. HIA therefore generally uses the World Health Organization (WHO) definition that Health is a state of complete physical, social and mental wellbeing and not simply the absence of disease or infirmity,3 or the more recent WHO psychosocial definition of health: the extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. From this viewpoint health is therefore a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities.4

public health, epidemiological, toxicological and medical knowledge, as well as public and other stakeholders views and experiences. This means it uses both quantitative and qualitative peer-reviewed scientific evidence as well as community surveys and systematically collected and analysed anecdotal evidence based on the experiential knowledge and judgement of stakeholders (communities and professionals).

Rapid and in-depth HIAs


HIAs can generally be characterized as rapid or in depth depending on the level of detail of the analysis, the comprehensiveness of the scientific literature review and the breadth and depth of the community, and other stakeholder, engagement. However, any particular analysis can have both aspects because, although the nine stages outlined above are presented as linear, HIA tends to be an iterative process where findings and issues that emerge in later steps can lead to earlier steps being revisited with the scope and analysis being revised. For example, causal pathways may be identified and a rapid analysis of the important pathways undertaken to provide a first estimate of the likely impacts. This estimate is then refined with a more in-depth analysis of the pathways shown to have an important influence on the final answers, using better and more detailed baseline information and cause-and-effect relationship data. Three practical considerations can and should have a major influence on the degree of rigour of any particular analysis: 1. Proportionality: It generally makes sense to put more resources into HIA where the expected health impacts are large or controversial. 2. Timeliness: Because the point of HIA is to inform the development of a proposal or policy, a timely albeit less in-depth analysis (but one whose strengths and weaknesses have been made explicit) will be more useful than a more comprehensive HIA that misses the decision points of proposal development and implementation. Meeting policy and decision-making deadlines can be a challenge even when a HIA is anticipated and planned well in advance. 3. Limitations of evidence and data: These can be to an extent overcome by making plausible assumptions and then checking how robust or sensitive conclusions are to changes in these assumptions; HIA lends itself well to sensitivity analyses along these lines.

THE HIA PROCESS Key elements of the HIA process


There is a general consensus that the HIA process is made up of nine partially overlapping stages: 1. 2. 3. 4. screening; scoping; baseline data-gathering and community profiling; stakeholder involvement (this can be part of the other stages as well as occurring separately; it tends to involve different stakeholders at different points in time); evidence-gathering and the identification of causal pathways; an analysis of health impacts (identification, assessment of likelihood and magnitude); making recommendations and/or developing a set of mitigation and enhancement measures, as well as how such recommendations/measures can be monitored and evaluated once introduced; writing the HIA report or statement and presenting the findings to decision-makers; follow-up of the HIA recommendations and of the HIA process (monitoring of the health impacts and evaluation of the HIA process).

5. 6. 7.

8. 9.

Sources of evidence used in HIA


HIA uses a range of structured and evaluated sources of qualitative and quantitative evidence that includes

Stakeholder involvement and community engagement


Actively listening to and involving people who may be affected by a proposal is an important part of HIA and its

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HIA in the context of other approaches

ethos of equity, participation, sustainability, accountability and transparency in the use of evidence and analysis. Involving the individuals and groups who are, or are likely to be, affected by a proposal is essential for obtaining a rounded picture of the actual and potential impacts on health and well-being. It can also reduce actual and potential concern, distrust and conflict, and so make an evidence-based decision more likely. Reasons why stakeholders should be, and generally are, actively involved in a HIA, include the following: 1. Affected stakeholders will face the direct positive and negative health consequences. 2. Stakeholders have valuable experiential knowledge that can inform the analysis of health impacts. 3. Not adequately and appropriately addressing stakeholder concerns can lead to them experiencing social and psychological distress. 4. Allowing residents and others to have a voice and influence in decision-making processes reduces the sense of social exclusion, democratic deficit and inequity. A range of community consultation and involvement methods can be used, from workshops and focus groups to one-to-one interviews and public meetings. The key issue is to be clear about the purpose of the activities and to communicate to stakeholders how the consultation findings have been used to inform the HIA.

HIA and evaluation studies


The purpose of HIA is to inform the development of new proposals in advance of their being put in place. Evaluation studies are empirical investigations that aim to assess the actual impacts of proposals that have been implemented; they are an elaboration of stage 9 of the HIA process. It is best that evaluation studies are designed, and baseline measurements taken, in advance of a proposal being put into place (cf. stage 7 of the HIA process). HIA and evaluation studies are therefore different in tone and focus, and they play a different role in policy development and review. Both HIA and evaluation should, however, be considered as part of the overall process of developing a proposal, and there is a close and mutually supportive relationship between the two. For example, some of the data used in the HIA may be relevant to developing the baseline for an evaluation study. In addition, evaluation studies (if properly conducted and sufficiently powerful) will help show to what extent the HIA predictions have in fact been borne out by events (even though evaluation studies rarely aim to cover the full health impacts of a proposal).

HIA and health risk assessment


Health risk assessment is an established term for methodologies that aim to provide a quantitative assessment of the adverse health impacts of population exposure to single or multiple hazards, and in particular environmental and occupational exposure to chemical pollutants released or transferred into the air, water and soil and their direct physical health impacts. HIA includes health risk assessment as one of its component parts (within stages 5 and 6, as listed above). However, HIA is wider than health risk assessment in several ways.

HIA IN THE CONTEXT OF OTHER APPROACHES HIA and other forms of impact assessment
HIA has its roots firstly in the healthy public policy movement of the 1970s and 80s, which recognized that non-health policies, for example housing, transport and welfare, are as important as, if not more important than, healthcare policy as determinants of public health. It has been rooted secondly in the environmental impact assessment movement from the 1950s onwards and its perceived deficiencies in assessing the wider public health impacts of new projects, particularly infrastructure projects in the developing world;5 thirdly in the sociology of health; and finally in epidemiology and quantitative health risk assessment. HIA is increasingly carried out either in conjunction with or by being integrated into other forms of impact assessment at both policy/plan and project/programme levels; these include environmental impact assessment, strategic environmental assessment, sustainability appraisals, equalities impact assessment and policy appraisals.6 This is increasingly being badged as integrated impact assessment or integrated policy appraisal.

It takes a wider view of health. It considers health benefits as well as health hazards. It aims to assess the full health impacts of policies, and not only those which are mediated through changes in chemical and physical exposures. It examines the distribution of health impacts across a population.

Thus, HIA tends to be a broader and more holistic form of assessment that examines not only the effects of pollutants, but also the direct and indirect impacts on the wider determinants of health, for example: employment and economy; housing and shelter; transport and connectivity; learning and education; crime and safety; public and commercial services; social capital and community cohesion; culture, spirituality and faith; arts and leisure; lifestyle and daily routines; governance and institutional structures; energy and waste; and land and spatial factors.

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AN OVERVIEW OF ENVIRONMENTAL HIA Social HIA and environmental HIA


Given its historical roots, it is not surprising that HIA can in practice be seen as the fusion of two broad traditions of assessment environmentally focused and socially focused HIA. Social HIA has roots in the healthy public policy movement, sociology and environmental impact assessment. It tends to take a wide view of what constitutes health and, because of weaknesses in the evidence base, it has a strong focus on qualitative analysis of the wider determinants of health and a strong focus also on community participation, and other stakeholder engagement, as a key part of the process. In contrast, Environmental HIA (EHIA) has a narrower focus, on those health effects which are mediated by the environment and by environmental pollutants in particular, and has closer roots in health risk assessment and epidemiology. Consequently, it tends to interpret health in traditional biomedical terms of adverse consequences death, disease, use of health services, illness and some health-related behaviours such as days off work or off school. The analysis stages tend to be expert driven, especially where there is strong evidence of causal and quantifiable exposureresponse relationships, and the stages are often time-consuming. The relatively strong evidence base for some environment and health pathways brings a danger of undue focus on what is quantifiable, at the expense of downplaying other health effects that are important but unquantifiable. This danger can be reduced through community and other stakeholder consultation, which, for environmentally focused HIA, is undertaken largely in the scoping phase where the question is framed, and in consultation on the results and recommendations, rather than in the intermediate stage of analysis of impacts.7

opposition to each other, with HIA being seen as either of the following: 1. a decision-support tool providing information and advice to the policy and decision-making process (an objective, technical, informing tool); 2. a decision-influencing tool providing support to communities to have their voice, and their views on what decisions should be made, heard within the decision-making process (a community advocacy and empowerment tool). In reality, in most cases HIA is a mixture of the two. It does give voice to the most vulnerable by providing a structured approach to including their views and wishes and focusing on health equity/inequality. However, it also provides an evidence-based and systematic understanding of the potential positive and negative health impacts of the policy or measure under consideration and this implies a role for subject matter experts. Part of the art of HIA is the ability to combine these two aspects in a transparent, credible and robust way. Indeed, from one point of view, there is no need to identify environmental HIA for special attention all that applies to HIA and social HIA generally applies to EHIA also. In practice, however, EHIA has developed relatively independently from the wider socially focused HIA movement, and as noted it has some particular characteristics that give it a distinctive flavour within the HIA field. One such characteristic is a highly developed and often quantitative analysis stage, which will be the focus of much of the rest of this chapter.

A framework for EHIA analysis: the impact pathway or full-chain approach


There have been several attempts to develop a useful conceptual model for tackling the subject matter issues that are central to the analysis stage of EHIA and that form the basis for much EHIA work. The impact pathway8,9 or full-chain approach is one way of systematically describing the various linked stages of an analysis that tracks the fate of pollutants from emissions through to monetary valuation. In terms of human health, this involves tracking the fate of pollutant emissions through a set of stages, for example: 1. from (changes in) policies in various sectors, insofar as they affect the environment; to consequent 2. (changes in) burdens, and emissions, to air, soil and water; to 3. (changes in) pollutant concentrations in microenvironments; to 4. (changes in) the exposure of individuals and populations (by inhalational, dermal and/or ingestional routes); to 5. (changes in) internal dose at target organs in the body; to 6. (changes in) the risks of health effects; to

Environmental justice and health equity


Environmental burdens are often both geographically and socially located, thereby affecting the poorest, most vulnerable and already burdened members of a community or population. There is also some evidence that, over time, this becomes a systematic and institutionalized process that is very difficult to shift. There is therefore a call for both environmental justice and health equity in relation to new proposals. Socially focused HIAs have an explicit value framework, in line with the Gothenburg Consensus, while environmentally focused HIAs tend not to; hence, one of the debates in the HIA community is whether it is the role of HIA to take a more overtly political and social stance, advocating health improvement and reductions in health inequalities/inequities. This has led to two broad stereotypes of how HIA is practised that are often seen in

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An overview of environmental HIA

7. (changes in) health impacts (overall and in subpopulations); to 8. (changes in) the monetary value of health effects The linearity in this list, albeit somewhat artificial, helps to emphasize the importance of looking at the pathway as an integrated whole, focusing on the transitions between various steps of the pathway, as well as on the steps themselves (see also Chapter 1). It is essential to have an alignment between the output of one stage and the input of another. So, for example, in modelling the health effects of environmental tobacco smoke, the concentrationmodellers and health experts need to agree on whether the analysis will be carried out with a simple exposure metric such as non-smoker, living with a smoker, or with a more complex one such as concentration of particulate matter with a diameter of 2.5 m or less (PM2.5), or with both (see also Chapter 7). There may also need to be an alignment in understanding a health end point say, chronic bronchitis or asthma attack between the epidemiological studies that provide evidence for risk functions and the willingnessto-pay studies that underlie monetary valuations. It is important to check that what appears to be the same thing really is, and if necessary to make adjustments in order to ensure alignment. As a broad rule of thumb, it is usually worthwhile spending more time on alignments of this nature, and doing so as early as possible, than might at first sight seem necessary or even reasonable. It helps if the analysis is best done more than once, for example rapidly, to identify alignment issues and dataevidence gaps, and to identify what matters before deciding where to focus the detailed effort. A more realistic and less linear description is given Figure 63.1, from the Health and Environment Integrated Methodology and Toolbox for Scenario Assessment (HEIMTSA) projects representation of the full-chain approach.10 The left-hand side of the diagram is a
Policies and mechanisms

representation of the full chain as described earlier in the text. Note, however, that the estimation of health effects may arise from studies that examine the relationships between health and (1) background concentrations, as with ambient air pollution; (2) exposures, as in most occupational studies; or (3) dose (or biomarkers), as for lead in the blood. It may also not be necessary, or even useful, to work through all stages of the pathway from concentration through to dose. This can also be compared with the Driving ForcesPressuresStateExposure EffectsActions model described in Chapter 1.

Some aspects of implementing a full-chain analysis


THE TARGET POPULATION, INEQUALITIES AND POPULATION DISAGGREGATION

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Underlying the analysis as a whole is the key component of the target population. Logically, this is the entire population whose health may be affected by the proposal under consideration. In practice, some analyses may, in framing the question, decide to focus on a more limited population, for example the effects within a particular region, country or group of countries, where the policy under consideration is targetted. In those circumstances, we think it is important that the wider health effects should at least be indicated. Here as elsewhere, how the HIA question is framed can have a major impact on the methods used and the results.7 The estimation of health effects has three component parts:

exposure (concentration or dose); a risk function (concentrationresponse, exposure response or doseresponse), typically expressed as the
Figure 63.1 Schematic representation of the full-chain approach. (Adapted from Health and Environment Integrated Methodology and Toolbox for Scenario Assessment,10 with permission. )

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SOURCES

Burdens and emissions Pollution in micro environments

People and context: social, economic, behavioural, perceptions of risk

EXPOSURES

Toxicity: % change per unit exposure or dose

Background rates of mortality and morbidity

Dose

Health (disease) impacts

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percentage change in (risk of) a specific health end point per unit exposure (concentration or dose); background rates of that health end point in the target population.

Issues of environmental justice/health equity/inequalities are relevant to all three components. That is, it is likely that there are differences between population subgroups in terms of (1) environmental exposures; (2) risk functions, per unit exposure; and (3) background rates of morbidity and mortality, and that together these differences may imply important differences in health impacts by population subgroup. In principle, the size and nature of such differences should influence the extent to which the population is disaggregated for any particular analysis, for example by age, gender, social class/socioeconomic status, current health status/pre-existing disease, geographical area or other relevant factors. In practice, however, the level of disaggregation is influenced strongly by limitations on resources needed for the analysis, such as data availability.
EXPOSURE ASSESSMENT

There are many definitions of environmental exposures, but they all include the key idea that exposure is a measure of the interaction (usually in a given time period) between people, or populations, and the environment(s) where they spend time. Exposure involves the interaction of two components the state of the environment, and the timeactivity patterns of people in relation to that environment. Note that a policy or measure may affect environmental exposures by affecting either (or both) the state of the environment and how people interact with that environment; and while pollution reduction might be considered the preferred option, there is a role also for the avoidance of exposure. Although the language of exposure and risk function generally carries negative connotations, suggesting adverse health effects, the concept as described here (of an interaction between a population and its environments) may also be life-enhancing. Therefore, for example, exposure may be a measure of proximity or ease of access to greenspace or open space, for recreation, physical activity or conviviality. This very simple overview does not do justice to what in practice may be a very detailed and time-consuming aspect of an analysis, i.e. identifying what microenvironments need to be considered (e.g. at home, at work, outdoors in or near traffic, and outdoors elsewhere) and how the proposal may affect both pollutant concentrations and the timeactivity patterns of the target population and its relevant subpopulations. A fuller development of this area can be found in Chapter 7.
CAUSALITY AND STRENGTH OF EVIDENCE

The various pathways or chains of an analysis carry the implicit assumption that the environmental exposures

being analysed are causes of the health effects being estimated, in the sense that changes in exposures will result in changes in health impacts. The evaluation of causality can be difficult and is best done as a multidisciplinary exercise including as a minimum exposure assessment, toxicology, epidemiology and clinical expertise, even though an elaboration of a full-chain analysis following the acceptance of causality may draw on some of these disciplines much more than on others. Effects should be included if, on the basis of the available evidence, the chains leading to them are more likely than not to express relationships that are causal (the balance of probabilities). This is a weaker criterion than that of beyond reasonable doubt, often applied in science. Some favour it in HIA assessments because it is relevant to the aim of providing best estimates, and thus of giving a fair and unbiased assessment of the overall impacts: restricting assessments to impacts and risk functions that are practically certain gives an analysis that is biased towards underestimating overall health impacts, and so is in practice (although usually not intentionally) antiprecautionary.11 The issue of evaluating strength of evidence in relation to different policy needs has been addressed more systematically and more comprehensively elsewhere.12 Causality is sometimes accepted for a pollution mixture, or for pollution from a source such as road traffic, but the particular agents responsible, or more generally the role of the components of the mixture, may be unknown or contested. This is not necessarily a barrier to HIA. It may be possible to quantify relationships based on proximity to source (the presence or lack of a gas cooker, living or not living with a smoker, or closeness of residence to roads). This gives a crude model in that it does not reflect the effects of changes in intensity of exposure that would follow from reduced emissions without elimination of the source. It is nevertheless a model that may be useful. Alternatively or in addition, one pollutant of a mixture may be taken as a marker of or surrogate for the mixture as a whole, with health effects being estimated for that component and taken as expressing the effects of the mixture as a whole. For example, the health effects of outdoor air pollution as a whole are generally expressed via relationships in PM, represented as PM2.5 and/or PM10. Opinions vary on the extent to which PM measured as PM2.5 or PM10 is the causal agent of the mixture; it is widely accepted, however, that it is the single best marker. It is also possible to quantify in terms of other pollutants, for example nitrogen dioxide, where the associated risk functions are generally understood as expressing the effects of traffic-related air pollution, rather than of whatever causal role nitrogen dioxide as a gas plays within the mixture as a whole. This can work well as long as changes in traffic-related nitrogen dioxide reflect changes in the mixture as a whole. Such quantification would be seriously misleading, however, in estimating the health effects of proposals that reduce traffic-related nitrogen dioxide without concomitant reductions in the other components of the pollution mixture.

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This emphasizes a more general point that there are not any universally best EHIA models. Rather, there are models of different complexity, with different assumptions and different data needs, and different strengths and weaknesses in the context of different applications. We support the concept of fit for purpose, not least because it pushes for early-stage clarification of what the purpose is, what degree of accuracy and precision is envisaged for the EHIA, and whether the resources (evidence, data, time and money) available are at all realistic in relation to the envisaged purpose.
RISK FUNCTIONS

influence on final estimates, more attention on estimating background rates would be worthwhile.
AGGREGATION ACROSS HEALTH END POINTS

Estimates of risk functions vary between studies, and this leads to interesting questions about which functions to use when local estimates (i.e. those relating to the target population of the EHIA) are available, and about the transferability of functions from elsewhere. The key issue is whether the variability between estimates from different times and places arises from real known factors or from the complexity of issues we call chance. If the former, it may be possible to adjust for differences in these factors when transferring relationships from one context to another. If the differences are best understood as chance effects, the use of random effects methods in meta-analyses will give better estimates of effects and of the uncertainties with which they are estimated. In either case, we think that the wider international evidence should weigh strongly relative to a particular, and possibly not large, local study, although stakeholder pressure to use local evidence may be strong. For an informative discussion of these and many other relevant issues, see the reports of two WHO workshops,13,14 the more recent focusing on outdoor air pollution but including many points of wider interest.
BACKGROUND RATES

It is rare that the HIA of a proposal implies effects on only one health end point. In the more usual situation of multiple health end points, there is often an interest in aggregating results across health end points into a single composite index. The two most commonly used approaches are disability-adjusted lifeyears, as used, for example, in the WHO Global Burden of Disease analyses, and monetary valuation.16,17 Insofar as any aggregation of this kind can be done meaningfully, the results facilitate the comparison between studies and between the effects of different measures. Monetary valuation in addition allows a cost benefit analysis of the proposal, which some decisionmakers find particularly informative. When aggregation is used, as it is widely, we recommend that the underlying separate health effects estimates also be presented. This not only increases the transparency of the final aggregated values, but also allows stakeholders to apply their own weighting factors. Indeed, the range and diversity of health effects, and not just their aggregated value, may be a spur to action to protect or improve health.
ISSUES OF SPACE AND TIME

For some health end points, relevant data may be collected routinely to a high standard across the target population, and be available for use. Often, background rates need to be estimated, for example by extrapolating from a small number of locations for which reliable data have been collected as a result of special exercises is specific times and places as, for example, was done by the Air Pollution and Health: A European Information System HIA team with respect to hospital admissions in several European cities.15 Alternatively, it may be possible to get good-quality data on background rates from specific research studies carried out by others. Because the focus here is on a health end point, these studies do not need to be limited to those investigating the environmental factors under consideration in the HIA. In general, both analysts and stakeholders tend to be drawn to paying much more attention to the choice of risk functions than to the estimation of background rates, and while there is some rationale to this in terms of the

Any full-chain analysis needs to consider issues of space and time in an integral way, from framing the question (e.g. what are the boundaries in space and time of the environmental exposures that are considered relevant, of the population at risk, and of the of the health effects?) through to the detailed linkage of information across the full chain. Estimates of one component of the chain (e.g. a dispersion-modelling of pollutants) may be carried out on quite a different spatial scale from estimates of other components (e.g. background rates of morbidity or mortality). However, the full-chain analysis will require linkage of all the data spatially, and it is helpful to be aware of this from the outset. The detailed work of any component may need to be adapted so that the analysis as a whole becomes workable. Similar issues apply to the time dimension, and this is greatly facilitated by going through the full chain more than once, first very approximately and then in more detail. An important issue is the extent to which results may be sensitive to the spatial scale of the analysis; this is an area where sensitivity analyses may be helpful.
REPRESENTATION AND ASSESSMENT OF UNCERTAINTY

Any EHIA, indeed any full-chain analysis, implies uncertainties at different stages and in the final estimated health impacts, whether reported individually or in aggregated form. It is not practicable to pay close attention to all of these. It is, however, both possible and necessary to

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be explicit about what these are, and to get some perspective on which of these matter in terms of their impact on the final answers. This also helps with identifying what aspects of the full chain could most benefit from more attention and improvement. There are many more-or-less sophisticated approaches to the assessment and representation of uncertainty. We suggest that they should begin with identifying and describing the various sources, and with some qualitative assessment of their size and importance to the final answers. This seems an essential precursor to more sophisticated methods, be these qualitative or quantitative, that attempt to assess and aggregate uncertainties across the full chain, for example by assuming particular distributional forms for the individual components, and using Monte Carlo methods to explore how they combine.

There is a very substantial body of research evidence epidemiology, toxicology and human experimental studies for the assessment of causality and for estimating relationships between exposure and the risk of adverse health effects (mortality and morbidity). The main epidemiological studies are based on concentrations of outdoor air, as measured by fixedpoint samplers located at background sites, rather than on personal exposures. This in effect removes one of the steps of the impact pathway and leads to a simpler schematic representation, as shown in Figure 63.2.11

Early HIA analyses of outdoor air pollution: effects of daily variations in air pollution
Early examples of what were in effect this approach were developed by Ostro and colleagues in the early 1990s, in a series of analyses about the effects of air pollution from electricity generation and in burden of disease estimates for the World Bank.18 The basic framework has changed little since then. The essentials of the methodology can be found elsewhere.11,19 Those early analyses were based principally on studies of daily variations in mortality and morbidity. In principle, it was necessary: (1) to construct the full annual pattern of daily concentrations of ambient pollutants, and how these would change with changes to policy; (2) to apply the relevant concentrationresponse functions and background rates in order to estimate daily impacts; and then (3) to aggregate these impacts over days in the year to reach estimated annual impacts. In practice, however, the concentrationresponse functions used were linear, with no threshold, and an equivalent answer could be provided by the simpler method of applying concentrationresponse functions and background rates to annual average (changes in) ambient pollution, and then scaling appropriately.
Figure 63.2 Schematic diagram of the health impact assessment of outdoor air pollution.

AN EXAMPLE: ENVIRONMENTAL HIA OF OUTDOOR AIR POLLUTION Policies affecting outdoor air pollution are amenable to HIA
Some of the history of the development of environmentally focused HIA and several of its interesting characteristics can be illustrated with reference to the HIA of outdoor air pollution, the context within which EHIA is most strongly established both methodologically and in terms of its use in policy development. There are several reasons why the HIA of outdoor air pollution has gained this position:

The impact pathway from emissions to health is relatively simple, with emissions to air and exposure by inhalation (although there are of course major complexities in modelling the fate of relevant emissions to air).

Pollution sources: emissions pathways

Population at risk: overall and subgroups

Backgroung data: morbidity rates

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Incremental pollution and background levels

Concentration response functions: risks as percentage changes per unit of pollutant

VALUATIONS

HEALTH IMPACTS

Benefits of improved air quality

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An example: environmental HIA of outdoor air pollution

The simplification, which is substantial, is a consequence of how the various component parts of the overall HIA process fit together; it is not a consequence of any one part of the process, viewed in isolation. This illustrates the benefits of doing an HIA using the impact pathway approach, not as a once-and-for-all pass through the various stages, but rather as an iterative process, i.e. in outline form initially, and then in more detail as the shape of the component parts becomes evident. This has several benefits:

serious cardiorespiratory disease among those effectively at risk. This debate has not yet been fully resolved.

Some more recent developments: effects of long-term exposures


The emerging evidence in the mid-1990s, from two cohort studies in the USA,21,22 showed associations between longterm exposure to outdoor air pollution, specifically PM, and mortality. Earlier studies had suggested such associations; the cohort studies provided stronger evidence because they adjusted for confounding factors at the individual level. Whether or not these studies expressed a causal relationship was disputed. It was clear, however, that if they did and it is now widely accepted that they do they implied substantially greater public health effects than did the mortality studies of daily variations in air pollution. This was partly because the estimated relative risks of mortality across the adult population were much higher than those implied by time series studies, and partly because the whole adult population and not just those with pre-existing cardiorespiratory disease was considered to be at risk. Together, these implied much greater effects, especially when expressed in terms of accumulated life expectancy rather than attributable deaths. Despite the caveats about causality, the effects of longterm exposure, as expressed via these cohort studies, were included quite soon in some HIA assessments as part of sensitivity analyses or as a central part of the assessment.8,9 With growing epidemiological evidence23 and a better understanding of possible mechanisms, a consensus has emerged that the HIA of outdoor air pollution should include the mortality impacts of longterm exposure as not to do so implies a possibly serious underestimation of mortality impacts. The overall evidence has been reviewed by various expert groups, including the UK Expert Committee on the Medical Effects of Air Pollutants.24 Using the results of cohort studies for the HIA of outdoor air pollution has highlighted a number of methodological issues that have been resolved only in part.25 There are at least three. First is how to express mortality impacts, in terms of life expectancy or as attributable deaths? A simple approach yielding estimates of attributable deaths was used in ExternE,8 and has continued to be used until recently. The use of life tables was proposed by Brunekreef26 and developed and recommended by others, for example ExternE, Leksell and Rabl, and Miller and Hurley.9,27,28 Both approaches were used in the HIA and associated costbenefit analysis of the Clean Air for Europe (CAFE) programme. However, methodological work using life table methods has shown that estimates of attributable deaths which in HIA analyses are treated as reproducible year on year do

It allows aspects of integration to be properly addressed. For example, with ozone, the modelling of ambient concentrations may be in terms of 8 hour daily maximum ozone concentrations, whereas epidemiology uses other metrics, such as 1 hour daily maximum or 24 hour average concentrations. An initial scoping exercise will identify the need to join these up, for example by focusing on concentrationresponse functions in the metric of the 8 hour daily maximum, by carrying out the ozone modelling in the metric of 1 hour daily maximum or 24 hour daily average, or by scaling the relevant concentrationresponse functions according to the average relationships between 1 hour daily maximum, 8 hour daily maximum and 24 hour daily average. Initial scoping should help identify the most important uncertainties and evidence gaps, i.e. those which most affect the final answers; this helps in prioritizing further work. Viewing the process as a whole can lead to simplifications, as described earlier.

This period also saw an important debate about who was at increased risk of mortality from higher daily values of outdoor air pollution, i.e. where the focus was on daily values within the normal range of variation in Europe and North America, rather than during specific episodes of unusually high air pollution. The emerging consensus was that the associated extra deaths attributable to air pollution were among people with already severe (albeit possibly undiagnosed) cardiorespiratory disease. The implication was that, on average, the life expectancy of those at risk was less, and maybe very substantially less, than that of the general population of similar age; air pollution was viewed as bringing forward a death that might in any case have occurred before very long.20 This was helpful in focusing attention on the fact that death is unavoidable air pollution does not lead to extra deaths, but rather it leads to earlier deaths. A complication was that the time series studies that quantified the risk of earlier deaths (attributable to daily variations in air pollution) were not directly informative about the degree of life-shortening. The debate, however, led to a questioning of the practice, until then current, of associating with the earlier (extra) deaths attributable to air pollution a value of a statistical life that ignored the likelihood of pre-existing

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Health impact assessment

in fact change over time, as the different mortality patterns imply differences in the size of the underlying population at risk.29,30 Specifically, if the same population is analysed under two scenarios lower and higher age-specific death rates there will initially be more deaths per year in the population with higher death rates, but the situation will reverse in due course as the size of the surviving population at risk (under higher death rates) decreases more rapidly than when death rates are lower. Currently and in general, HIA analyses of attributable deaths do not take this effect into account. The second issue is the time lag between reductions in air pollution and the associated or consequent changes in risks of mortality a concept sometimes known as cessation lag. It is linked to, but is not identical with, the latency period between exposure to ambient air pollution and the associated risk of mortality. Studies in Dublin31 and Hong Kong32 have shown that substantial reductions in air pollution can have clear and immediate benefits in terms of lower death rates. There may, however, also be delayed effects, for example effects on birth weight or on lung function in childhood, which may affect mortality risks in later life. How cessation lag is treated within a HIA can have substantial effects on the final results, especially if monetary values are linked with health impacts and if the discount rate is large. The final issue is the time frame for an analysis. When an HIA of outdoor air was focused on the effects of daily variations, the associated health effects were more or less immediate, and so there was a concordance between the time frame of emissions and of effects the two could be considered as concurrent, and effects within a year was an unambiguous concept. With the effects of longer-term exposure, however, this identification was broken. It now became necessary to distinguish between (1) the health impacts in a given year, arising from emissions, whenever they occurred, and (2) the health impacts whenever they occur, arising from emissions in a given year. The latter of these is more consistent with the HIA as a prospective exercise, and is what is generally used. There are, however, other time frame issues to consider. While looking at the health effects of emissions in a given year may be helpful, for comparing with the costs of emission control in that same year, there is something artificial about an evaluation focused on one years emissions given that policies to control air pollution are intended to be long-lasting, rather than reverting to the status quo after a single year. Consequently, how the HIA is framed in terms of time scale remains an issue that is very relevant to the analysis and to the results, but which that not have an obvious solution.

Directorate-General for the environment.33 This shows, inter alia, how the methods and results of the HIA and costbenefit analysis were used by the Commission to inform its policy development on outdoor air pollution. Briefly, results showed that the estimated benefits of a 20 per cent reduction in fine particulate air pollution (PM with a diameter of 2.5 m or less [PM2.5]) across the European Union far outweighed the estimated costs. The benefits were largely attributable to the effects on mortality risks of long-term exposure to outdoor air pollution, expressed as PM2.5.

CURRENT TRENDS AND FUTURE PROSPECTS


There is renewed and growing interest in both socially and environmentally focused HIA globally, as policies and measures are developed to tackle two major health issues of the present period the adverse effects of climate change, and of poverty and income inequality. Successfully tackling either of these issues requires policy-makers and others to draw on the main strengths of both traditions that underlie HIA: the strengths of socially focused HIAs in analysing the wider, social determinants of health and giving a voice in decision-making to all stakeholders, particularly those who are socially disadvantaged, and of environmentally focused HIA in providing precise numerical estimates of health impact that can be linked to monetary costbenefit analyses which can support finegrain decision-making between the costs and benefits of a range of proposal options. All HIA, whether socially or environmentally focused, draws on both these traditions and, we see, methodologically, moves towards a convergence, with an increasing focus on quantifying health impacts in socially focused HIA and on including wider health impacts (including positive health impacts) and on community engagement in environmentally focused HIA. Socially focused HIA is reaching the limits of what can be described and analysed qualitatively, and environmentally focused HIA is seeing the limits of focusing on tangible, chemical environmental exposures. This seems to show a coming together of the two approaches and an increasing integration of the methodologies between the two traditions of HIA, a direction that many strongly welcome and support.

ACKNOWLEDGEMENTS
Work on this chapter was supported in part by HEIMTSA, an Integrated Project, funded under the European Union Sixth Framework Programme Priority 6.3 Global Change and Ecosystems, and draws on discussions with many HEIMTSA colleagues, whose help we acknowledge.

HIA of the Clean Air for Europe programme


The HIA within the CAFE programme was carried out as part of a wider costbenefit analysis, commissioned by

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References 11

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16. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global Burden of Disease and Risk Factors. Geneva: World Health Organization, 2006. 17. Hanley NSCL. CostBenefit Analysis and the Environment. London: Edward Elgar, 1993. 18. Ostro BD. Estimating the Health Effects of Air Pollutants: A Method with an Application to Jakarta. World Bank, Policy Research Department Working Paper No. 1301.: World Bank, 1994. 19. Ostro BD. WHO Air Quality Guidelines: Global Update 2005. Geneva: World Health Organization, 2006. 20. Committee on the Medical Effects of Air Pollutants. The Quantification of the Effects of Air Pollution on Health in the United Kingdom. London: HMSO, 1998. 21. Dockery DW, Pope CAI, Xiping X et al. An association between air pollution and mortality in six US cities. N Engl J Med 1993; 329: 17539. 22. Pope CA III, Thun MJ, Namboodiri MM et al. Particulate air pollution as predictor of mortality in a prospective study of US adults. Am J Resp Crit Care Med 1995; 151: 66974. 23. Pope CA III, Burnett RT, Thun MJ et al. Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution. JAMA 2002; 287: 113241. 24. Committee on the Medical Effects of Air Pollutants. Longterm Exposure to Air Pollution: Effect on Mortality. London: HMSO, 2009. 25. Hurley F, Hunt A, Cowie H et al. Methodology for the Cost Benefit Analysis for CAF. Volume 2: Health Impact Assessment. Didcot: AEA Technology Environment, 2005. 26. Brunekreef B. Air pollution and life expectancy: is there a relation? Occup Environ Med 1997; 54: 7814. 27. Leksell L, Rabl A. Air pollution and mortality: quantification and valuation of years of life lost. Risk Analysis 2001; 21: 84357. 28. Miller BG, Hurley JF. Life table methods for quantitative impact assessments in chronic mortality. J Epidemiol Commun Health 2003; 57: 2006. 29. Miller BG, Hurley JF. Comparing Estimated Risks for Air Pollution with Risks for Other Health Effects. IOM Report TM/06/01. Edinburgh: Institute of Occupational Medicine, 2006. 30. Brunekreef B, Miller BG, Hurley F. The brave new world of lives sacrificed and saved, and deaths, attributed to and avoided. Epidemiology 2007; 18: 7858. 31. Clancy L, Goodman P, Sinclair H, Dockery DW. Effect of airpollution control on death rates in Dublin, Ireland: an intervention study. Lancet 2002; 360: 121014. 32. Hedley AJ, Wong CM, Thach TQ, Ma SLS, Lam TH, Anderson HR. Cardiorespiratory and all-cause mortality after restrictions on sulphur content of fuel in Hong Kong: an intervention study. Lancet 2002; 360: 164652. 33. Commission of the European Communities. Commission Staff Working Paper. Annex to The Communication on Thematic Strategy on Air Pollution, and The Directive on Ambient Air Quality and Cleaner Air for Europe. Impact Assessment. COM(2005)446 final. COM(2005)447 final. Available from: http://ec.europa.eu/environment/air/pdf/ sec_2005_1133.pdf (accessed December 13, 2009).)

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Author queries AQ1. Please confirm your affiliations, including position held, institutions and qualifications as youd like them to appear in the book, and please let me know any change of contact details. AQ2. A framework for EHIA analysis, para 2 after list. It helps if the analysis is best done more than once, e.g. rapidly - is this part of the sentence correct? AQ3. Figure 1. Do you already have permission to reproduce this? AQ4. Figure 2. Does this come from reference 11 (in which case a credit line will need to be added to the caption) or is it newly drawn for this chapter? If the former, has permission to reproduce it been obtained? AQ5. Refs 8, 9 and 18. Do you have a place of publication for these? AQ6. Ref 10. Please provide full details of the document that this appeared in. AQ7. Please could you indicate which (if any) of the references are to be annotated as seminal primary articles, or alternatively as key review papers.

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