In 2007, a community developer in Oakland, California, made minor modifications to a planned low-income senior housing complex that benefited residents’ health, generated support from local neighborhood leadership, and garnered recognition for the developer as an innovative company committed to creating healthy neighborhoods. Small design changes opened the door to a healthier living space and, on a larger scale, a new way of thinking about the role that developers can play in a community’s well-being.
The tools used to make these changes went beyond the usual hammers, nails, plans, and building permits. Rather, a small group of public health experts worked with the developer to apply a new planning tool: a health impact assessment, or HIA. HIAs bring together scientific data, public health expertise, business acumen, and stakeholder input to identify opportunities for maximizing health and community benefits when making decisions on policies and projects that would not otherwise focus on health. Examples include land use and transportation plans, educational policies, or—as in the Oakland case—plans for a housing development. Moreover, HIAs identify metrics for health and health-related impacts as a new project or plan is implemented.
A growing body of research shows that the major illnesses facing our nation—such as obesity, asthma, heart disease, diabetes, and injury—are shaped by the conditions in the places where we live and work, and by the policies that shape these conditions. For example, well-designed and properly maintained housing can help prevent asthma and injuries from falls. Transportation projects and land use plans that include safe routes for pedestrians and bicycles can minimize the risk of traffic injuries and allow people to be more active, thereby lowering the risk of obesity and many other illnesses. In addition, education policies that improve academic performance among students lead to higher income, better jobs, and—in turn—longer, healthier lives. Large and untapped opportunities exist for improving health among Americans and addressing skyrocketing medical costs. These opportunities involve bringing attention to health-related concerns when making decisions that shape the world outside the doctor’s office.
The Oakland HIA demonstrated that minor facility modifications could potentially yield significant health improvements. By relocating the main entrance away from the neighboring freeway, for example, noise exposure among residents was reduced—a significant concern for health. Changing the design of windows facing the freeway and installing air filtration lowered the risk of air pollution exacerbating lung and heart problems.
Community developers seek to improve living conditions and economic opportunities in low-income communities, and public health data offer new metrics to measure and demonstrate the value of this work. Conversely, collaborating with developers provides a pathway for public health professionals to effectively address many root causes of illness. The Federal Reserve and the Robert Wood Johnson Foundation’s Healthy Communities Initiative has highlighted the tremendous opportunity for greater collaboration between these fields. Further highlighting the potential, in January 2014, the Commission to Build a Healthier America, a national, nonpartisan commission of public and private sector leaders, recommended that the two fields “fundamentally change how [they] revitalize neighborhoods, fully integrating health into community development.”
Community developers face several important challenges in realizing these opportunities, such as financing, technical and design constraints, and permit requirements. Public health professionals will need to learn how to work within these constraints and offer analysis that is not only rigorous but also timely, in addition to recommendations that are not only based on sound evidence but are realistic and feasible. Moreover, public health analysis can be time-consuming and costly, and with the considerable challenges they already face, developers may be reluctant to add work with the potential to significantly increase costs or create delays. For these reasons, understanding each other’s objectives and constraints, metrics of measurement, and simple analytic tools assessing readily available data sources are essential for widespread collaboration.
This essay explores HIAs as a practical tool to help community developers factor health into their initiatives, catalyze new partnerships between the two fields, and create metrics that measure the value of community development efforts.
Community Development and Health of Americans
Poverty is one of the most important predictors of poor health among Americans. A recent meta-analysis found that 133,000 U.S. deaths per year could be attributed to living below the poverty line, with an additional 39,000 deaths attributed to living in a neighborhood with high poverty rates. Many serious illnesses are more common among low-income Americans including diabetes, coronary artery disease and heart attacks, strokes, asthma, and many types of cancer. Children living below the federal poverty line are seven times more likely to be in poor or fair health—and have higher rates of asthma and many other illnesses—than children in families earning above 400 percent of the federal poverty line. These statistics simply reflect the outcome of economic hardships that low-income Americans face—hardships that community developers work to alleviate every day. As early as the 1800s, physicians recognized that poor-quality and overcrowded housing, insufficient heating in the winter, dangerous work, hunger, and malnutrition contributed to higher rates of illness and death among the poor. Today, low-income families are more likely to live in substandard housing, which exposes them to problems such as pest infestations, mold, poor ventilation, and other hazards that increase their risk of asthma, depression, burns, falls, and other health problems. Furthermore, lacking the money to pay for basic necessities often leads to situations that compromise health: going without prescribed medications, skipping meals, eating unhealthy foods because they are more affordable, or making-do with inadequate home heating or cooling.
As a primary care physician who spent many years working with low-income communities in major cities and in rural Alaska, I learned about these challenges firsthand. I would give my diabetic patients advice about eating more nutritious diets, only to find that the nearest grocery store required an hour-long trip by bus. Furthermore, as I encouraged people to walk more, I learned about the barriers that prevent many people from doing so, including high neighborhood crime rates and six-lane roads with no sidewalks.
By addressing problems such as substandard and unaffordable housing, lack of access to healthy foods, and unmet needs for basic services, community developers in the United States are making a profound yet largely unmeasured and unrecognized contribution to reducing health risks and, quite possibly, the associated medical costs.
Health Impact Assessments
The last 30 years have produced a growing body of public health research on the roots of illness in problems such as poverty, poor education, and substandard housing. These data highlight the need for more attention to health in public policy. In many countries, HIAs have become one of the most commonly used tools to assess these concerns. HIAs are used by government agencies; the private sector, such as oil, gas, and mining companies; and by lenders that finance international development projects, including the World Bank and International Finance Corporation. HIAs first emerged in the United States in 1999, and they have gained considerable momentum in the last decade. In 2007, only 27 HIAs had been undertaken in the United States; by 2013, more than 275 HIAs had been completed or were underway.
HIAs assess the baseline health status of the population that will be affected by a policy proposal. Data obtained from HIAs can be used to better understand the needs and vulnerabilities in the neighborhoods developers serve. To create a profile of baseline health status, HIAs draw on a mix of publicly available data, which are sometimes augmented by surveys. Stakeholder engagement—through community meetings, focus groups, or advisory committees—helps identify the issues of greatest importance to the health of the affected population and aims to facilitate consensus among those with diverse and sometimes conflicting perspectives.
To explore the potential health effects of a proposal, HIAs review available research and employ both qualitative and quantitative methods. Most commonly, the predictions are qualitative: Literature reviews and stakeholder input are evaluated to provide insights on the potential connections between health outcomes and project-related changes, such as housing quality, traffic patterns, and pedestrian infrastructure. Most important, HIAs focus on solutions: They provide evidence-based, practical recommendations for optimizing the effects on health.
In practice, HIAs are typically carried out in six steps: (1) screening, (2) scoping, (3) assessment, (4) recommendations, (5) reporting, and (6) monitoring and evaluation. This framework is routinely adapted to accommodate the available resources and decision timeline. A larger-scale “comprehensive” HIA—undertaken for a new, major oil and gas project, for example—might take longer than a year to complete and may involve multiple analysts. Smaller-scale HIAs are often accomplished with far less time and fewer resources, some in as little as four to six weeks. One county government in Maryland has developed a standardized HIA−based approach in which the health department conducts reviews of new planning proposals with only a few hours of staff time.
HIAs at Work
The following case examples illustrate how HIAs can be applied to the types of initiatives in which community developers often play a leading role.
Planning a Mixed-Income Housing Development
In Colorado, the Denver Housing Authority and its partners are replacing an older, distressed, 250-unit public housing complex with nearly 900 new mixed-income units in the La Alma/Lincoln Park neighborhood near downtown Denver. The Denver Housing Authority and its master planning team created the Mariposa Healthy Living Initiative in 2009, which established physical, mental, and community health as variables for measuring how redevelopment would change the quality of life among residents. The initiative’s responsive and rigorous planning framework advanced broad objectives, including the availability of healthy housing, stewardship of the environment, sustainable and safe transportation, opportunities for social interaction, and a community structure that supports a healthy economy. This extensive framework served as the basis for designers, developers, and practitioners to execute the HIA concept.
The HIA examined the baseline needs and health issues important to current residents. Then, as an integral element of the master planning for the development, the HIA team assessed the health implications of elements of the proposed plan such as building design, road and transit modifications, and pedestrian and cycling infrastructure. The team evaluated the HIA’s options by using a customized version of the “Healthy Development Measurement Tool”—an HIA−based set of health indicators related to elements of the built environment, such as proximity to public transportation, health care, and nutritious food. The tool confirmed that the housing authority’s plan would offer substantial health benefits for Mariposa residents. The HIA also allowed the housing authority to identify specific measures—such as traffic calming at high-volume intersections, safer and more attractive stairways in buildings, and acoustic modifications for housing nearest to the neighboring railway—that would optimize these health benefits. The final design will help to increase physical activity through improved pedestrian and bike opportunities, increase mobility and traffic safety, improve access to healthy foods, increase safety and security, and improve access to health care.
Since the master plan was adopted four years ago, the first phase of construction has been completed and two other sites are now under construction. The housing authority notes that crime rates in the neighborhood have already dropped from 246 per 1,000 people in 2005 to 157 per 1,000 people in 2011.
In 2012, the housing authority launched a new effort to further integrate health into every aspect of implementation by monitoring progress, refining recommendations, and developing implementation plans. An initial progress report updates and refines the previously used health indicators and tracks health-focused initiatives that have been completed. The report informed the further prioritization of new initiatives, focusing on what is important for the health of residents today.
Urban Greenway Design
A nonprofit developer in California used an HIA to develop plans for a new urban greenway with walking and biking trails along an urban transit line. The HIA identified many health benefits. First, a safe place to exercise would fill a critical need in the struggle against rising diabetes and obesity rates. Next, the space would create the opportunity for community members to interact and get to know one another, thereby improving community safety. In addition, less motor vehicle use could improve air quality and health problems among residents such as asthma. Stakeholder engagement during the HIA also identified challenges: Community members were worried about safety along the high-crime sections of the corridor—a concern that the HIA team recognized might decrease the use of the new path. With local residents, the team developed a series of recommendations including improving lighting, controlling access points, and creating a citizen watch group.
The HIA contributed to a plan that was instrumental in the Alameda County Transportation Authority’s decision to grant the developer funds to complete the required environmental impact report. Widely recognized for excellence, the plan received an award in 2009 from the American Planning Association.
In 2009, a multidisciplinary team conducted an HIA to inform planning for the redevelopment of the Page Avenue corridor, an economically distressed neighborhood in St. Louis, Missouri. The HIA was led by Washington University faculty in public health, urban design, public policy, and economic development, and involved extensive engagement of the project’s lead developer; community members; and city, county and state decision makers. The Page Avenue project envisioned a new grocery store, homes, and businesses, in addition to renovated streets, sidewalks, vacant lots, and intersections. The HIA team conducted literature reviews; mapped important neighborhood concerns and assets such as streets, sidewalks, bus stops, and food stores; and spoke with stakeholders through focus groups, resident surveys, and interviews with 20 key city and county decision makers. The team incorporated this information into an assessment of how the proposed redevelopment would affect health through its predicted effects on jobs, housing, recreation, access to goods and services (including nutritious food), pedestrian infrastructure, and neighborhood safety. The team then developed recommendations based on the findings.
In the short term, the HIA resulted in several important outcomes. It raised awareness of the plan’s implications for health among community members and key decision makers including the developer, mayor, and planning and transportation officials. Officials made verbal commitments to improve sidewalks near transit stops, and the mayor and county health department committed to participating on a post-HIA task force. A city initiative to revive fruit orchards and gardens sought to improve local nutrition.
The implementation of the Page Avenue revitalization plan will take place over several years. The HIA has established a starting point for effective collaboration as the project evolves, and it has already contributed to a new culture of health among the stakeholders in which ideas and initiatives to optimize the health benefits of the revitalization have become a priority.
Regional Land Use and Transit Planning
Atlanta was successful in using an HIA as part of planning the BeltLine, a major light-rail system that will link with parks and open space in a ring around the city. The BeltLine involves a complex, multiyear planning effort and coordination among city, county, state, federal, and private sector partners. In 2005, Georgia Tech’s Center for Quality Growth and Regional Development conducted an HIA that continues to benefit the planning process and the area’s residents.
At baseline, the HIA identified higher rates of diabetes, heart disease, cancer, motor vehicle injury, and other health problems in the low-income neighborhoods in the study area. The HIA found major health benefits were likely to result from constructing the BeltLine as initially proposed, but it also identified important areas for improvement in the project. For example, the plan’s focus on transit and trails would increase physical activity (lowering the risk of many illnesses), but the need for these benefits was particularly high in the lower-income southwest neighborhood. Therefore, the HIA proposed adding more acres of parks and better access to trails and sidewalks in this area. The plan would also improve connectivity and thereby increase general access to schools, parks, grocery stores, hospitals, and other amenities that benefit health. To maximize these benefits for the lower-income neighborhoods that had particularly poor access to these amenities, the HIA offered a series of recommendations for location of transit stops and improved connectivity with the regional transit system.
The effects of this HIA continue to evolve as BeltLine planning and implementation progress. Effects to date include a commitment by the mayor to complete the project as quickly as possible given its benefits for health; federal and private sector decisions to award $7 million in grants to clean brownfields and construct green space and trails in low-income neighborhoods; an affordable housing policy for the BeltLine; the addition of health metrics to evaluate BeltLine proposals; and the addition of a public health professional to the advisory committee for the Tax Allocation District that issues bonds to fund BeltLine capital expenditures.
Using HIAs to Advance the Collaboration Between Health and Community Development
The Health Impact Project—a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts—supports using HIAs to integrate health considerations into new plans, projects, and policies. In the area of community development, the project is funding three pilot HIAs and a simultaneous evaluation to adapt and streamline this approach for easier use in community development initiatives. These assessments address decisions that range from local planning to state-level policies:
Community Solutions, a nonprofit organization dedicated to strengthening communities and ending homelessness, is working with an art, design, and planning studio to include health considerations in a neighborhood revitalization and sustainability plan for Hartford, Connecticut’s northeast neighborhood. This plan will offer a blueprint to inform revitalization efforts, which may include improvements to land use, utilities, housing conditions, open space, and access to transportation and healthy food. The HIA will examine how these changes will influence health, and it will provide recommendations to optimize positive health effects.
Health Resources in Action, a nonprofit public health institute, is working with the Massachusetts Department of Public Health and Metropolitan Area Planning Commission on an HIA to inform new rules that will guide future funding for community development corporations under the state’s Community Investment Tax Credit Grant Program. The HIA will offer ideas for health-oriented criteria that the agency can use to screen projects.
The Georgia Health Policy Center is conducting an HIA to examine the 2015 Georgia Qualified Allocation Plan for Low Income Housing Tax Credits. The annual plan is required by the Internal Revenue Service to allocate housing tax credits to state agencies, which then award credits to developers. The project will engage the Georgia Department of Community Affairs, real estate developers, state regional commissions, community representatives, and relevant federal agencies to ensure that all stakeholder perspectives are well represented in the final recommendations.
This community development initiative will create a toolkit to assist developers with integrating health considerations into their initiatives. The toolkit will identify a set of health effects that are commonly encountered, catalogue available sources of health data, provide simple analytic tools, and offer health-based metrics that developers can readily apply to their own initiatives. Using health-based metrics to measure the impact of their work will also help developers better demonstrate the medical cost savings that could accrue from the health benefits produced by their initiatives. The final HIA report and toolkit are expected in fall 2015.
For primary health care providers in low-income communities, the connection between neighborhood and health presents a daily challenge. Too often, we find ourselves needing to add more medications to a patient’s regimen to control asthma or diabetes, when what is really needed is better housing; readily available access to fresh fruits and vegetables; or a safe, pleasant place to exercise. For public health professionals, collaboration with community developers holds promise as a new means to fill a “prescription” for better health. Public health offers a new way to help developers improve the lives and health of the communities they serve and, equally important, a new way to measure the results of their work. With medical care costs now consuming nearly 20 percent of all the goods and services in the United States, finding ways to contain costs is critical. Demonstrating the health-related value of community development initiatives can contribute to a foundation for a more evidence-based conversation about the most effective ways to invest in improving health among Americans.
Realizing the full potential of this partnership will require hands-on experience gained by close collaboration on specific initiatives. At the second national HIA meeting in 2013, councilmember Joe Cimperman of Cleveland, Ohio, told attendees that HIAs “help me win” by ensuring that important concerns have been addressed early-on in developing new policy, and by providing solid data to support new proposals. The examples in this chapter validate the notion that good stakeholder engagement and an eye to improving health can enhance the planning process and build support for new proposals. Moreover, collaboration on an HIA can be an effective way for developers and public health professionals to gain a working knowledge of each other’s fields, identify metrics to measure the health benefits of a well-planned project, and develop actionable recommendations that are both feasible for the developer and good for health.
Dr. Aaron Wernham wrote this essay during his tenure as the founder and director of the HealthImpact Project. He recently left the Health Impact Project to become the CEO of the Montana Healthcare Foundation.
For Further Reading
National Research Council of the National Academies: Improving Health in the United States: The Role of Health Impact Assessment. www.iom.edu/~/media/Files/Activity%20Files/Environment/EnvironmentalHealthRT/2011-Nov-RT/132291.pdf.
The Health Impact Project Web site, www.healthimpactproject.org, offers many resources, including a searchable map, for finding practitioners and funders in a particular area or sector.
Health Affairs, “Health Impact Assessments Are Needed in Decision Making about Environmental and Land-Use Policy.” http://content.healthaffairs.org/content/30/5/947.abstract.
 S. Galea et al.“Estimated Deaths Attributable to Social Factors in the United States. American Journal of Public Health. 2010, 101(8): 1456–65.
 P.Braveman, S. Egerter, C. Barclay. “Issue Brief 4: Income, Wealth, and Health.” Exploring the Social Determinants of Health. (Robert Wood Johnson Foundation, 2011) Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70448.