Health impact assessment: concepts, theory, techniques, and applications.

A few weeks before I received this book for review, two colleagues and I carried out a health impact assessment (HIA) of a major water resource development project in a low-income country in south-east Asia. We screened the several hundred-page-long environmental assessment and management plan, and brought along guidelines, technical briefings, journal articles and other relevant publications. Although this material covered the topic — from how to embark on an HIA to strategies for institutionalizing HIA — the bulk of the documentation lacked significant practical utility in a developing country setting, as it was based on the prevailing environmental, health and sociopolitical landscapes of Australia/New Zealand, Europe and North America. Now along comes Health impact assessment: concepts, theory, techniques, and applications, whose editors teach and carry out research in departments of public health and epidemiology in universities in the United Kingdom. The book points out that HIA is a young field and emphasizes that further progress critically depends on more assessments being performed. Indeed, a literature search that I carried out on Thomson ISI for the term “health impact assessment” in the title generated only 85 hits. The pioneering contributions to HIA were short abstracts published in the chemical literature in the 1980s. The first full papers appeared in 1995 and, subsequently, the number of contributions published every year has increased steadily. The search produced 27 hits for 2003, including 14 in a theme issue on HIA published in the Bulletin. The observation made by Kemm et al. that the HIA community is small is corroborated by the fact that only one of the contributions identified in the literature search had been cited more than 20 times. The editors claim that their book is the first to provide a comprehensive overview of the developments, current concepts, areas of consensus and disagreement, techniques and theories of HIA. This claim is justified by the array of applications that it presents, including HIA of projects (e.g., development and expansion of commercial European airports), of programmes (e.g., campaign to eliminate a non-endemic insect species in New Zealand), and of policies (e.g., proposal to increase the numbers of medical students in the United Kingdom). Hence, the book holds the promise of filling an important gap in the literature. The book’s 36 chapters cover a wide range of applications of HIA, some written by the editors, but most prepared by 52 other contributors. All chapters are concise and referenced. The book has several strengths. First, it is comprehensive and has merit as a stand-alone work; hence, it serves as a most welcome and significant contribution to the growing body of HIA literature. Second, it provides a succinct history of HIA, stresses its conceptual roots either in environmental impact assessment or the promotion of healthy public policies, and emphasizes its values; namely, democracy, equity, ethical use of evidence and sustainable development. Third, it provides a good snapshot of progress made since HIA’s inception approximately 10 years ago, which is illustrated using a host of applications that underscore its thinking from various disciplines. Fourth, it clearly articulates the fundamental characteristics of HIA: it must be – by necessity – carried out prospectively, i.e. before implementing a project, programme or policy; and the results must feed into the decision-making process, so that interventions can readily be modified in order to avoid/mitigate negative health impacts and to enhance positive ones. HIA therefore might become an important tool for building effective bridges between health and other sectors and policy-makers. Fifth, the book is not shy about discussing areas of controversy and campaigns for a more consistent use of terminology. For example, it eloquently argues against the use of “retrospective HIA” and “concurrent HIA”. Arguments for the correct use of other terms appear throughout the book and are tied together in the exceedingly good concluding chapter. Finally, the book provides a sound basis to predict progress, which might therefore stimulate people outside the HIA community to learn more about such assessments and to put them into practice. The book, nevertheless, has several shortcomings. First, it is very much “Eurocentric”. Of the contributors, 89% work in Europe and the majority of case studies pertain to European settings. Second and even more irritating is that all of the 55 contributors live in countries with a high human development index (HDI). According to Human development report 2004, they work in countries ranked between position 1 (Norway) and 27 (Slovenia) on the HDI scale, with more than half of them based in the United Kingdom (HDI rank 12). Some of the authors argue that the lack of capacity for HIA is serious, particularly in the developing world. I would not dispute this claim, but I’m not convinced that not a single expert could be identified there. Hence the book missed an important opportunity to articulate coherently how HIA should build inroads into developing countries, where many large-scale infrastructure developments are under way. Third, I am not sure about the utility of some of the chapters. For example, the important roles played by epidemiology and the social sciences in HIA are made repeatedly throughout the book, hence the two stand-alone chapters on these topics lack specificity. In summary, this book fills a very important gap in the literature, serves as resource for training future assessors, and could become a standard text. Its utility would nevertheless have been improved had the contributors included also those from middle or low HDI countries. It is to be hoped that this shortcoming will be rectified in any second edition. The publication of this book bodes well for the further promulgation of HIA, with health functioning as a cross-cutting issue to build bridges between different sectors and policymakers, a key factor for good governance, and equitable and sustainable development.