Susann Roth, senior social development specialist, Asian Development Bank, argues why a health impact assessment is essential for hard infrastructure projects.

Although I am a medical doctor, I changed my career from a clinician in surgery to public health because I wanted to have impact on people’s lives by preventing diseases, instead of treating sickness, as I would often see patients when it was too late.

The “where” and “how” we live determines our health. We all agree with this. We all want a healthy future for ourselves and for our children. Looking at the bigger picture, we know that sustainable economic development needs healthy populations – especially in this part of the world.

But health is often not valued until it’s too late, when sickness comes. The same occurs in development projects.

Developing Asia is at a crossroads. The region’s rapid economic growth comes with concerns over environmental degradation. Around 27% of diseases affecting Asians are related to the environment, according to the World Health Organization. Throughout Asia’s cities, hundreds of millions of children are exposed to air quality that is dangerous for their health.

Infrastructure projects can affect human health in many ways, creating both risks and opportunities.

For many Asian developing countries, economic development is still based on heavy industry and investments in hard infrastructure that often don’t consider the long-term impacts on human health.

Water contamination with industrial or agricultural waste such as heavy metals, pesticides, and antibiotics can cause hormonal diseases and even cancer. Threats may happen prior or during project implementation, and even long after project termination.

However, unlike environment and resettlement, health is not a traditional safeguard in development projects. It does not get the attention it deserves to ensure that whatever is built contributes to healthier and better lives for everybody.

The best way to think of health during each stage of development is through a health impact assessment (HIA).

Along with sound public health management plans and effective monitoring and mitigation systems, HIA is of utmost importance for preventing and reducing the potential negative health impacts of such projects.

HIA is an established evidence-based method for showing what are otherwise the hidden costs and benefits of infrastructure projects to human health and to the heath sector in general. It is a structured process that combines scientific evidence and community engagement to inform decision-makers about how they can maximize the health benefits and minimize the adverse health impacts of infrastructure development projects.

HIA does not look only at environmental health impacts, but rather assesses community health as a whole. It aims to ensure that benefits of development can be shared more equitably across all affected communities.

It’s important to note that HIA targets in particular the vulnerable groups that carry the brunt of the negative health impacts of development. This reflects the “leave no-one behind” philosophy of the Sustainable Development Goals.

HIA, though, doesn’t come without challenges. For instance, one of the main reasons a health component is often omitted from infrastructure cost-benefit analysis is because of the inherent difficulties in measuring health outcomes. The Disability Adjusted Life Year or DALY, a metric of the disease burden affecting community health, remains poorly accepted outside of the health sector. 

Quantification is usually limited to health outcomes that can be expressed in terms of exposure and disease (dose/response), such as for air or water pollution. Moreover, changes in population health cannot usually be attributed to any single project alone: the longer the trajectory between cause and outcome, the more confounding factors will obscure the cause-effect relationship.

While HIA cannot always draw a straight line between an infrastructure project and a specific health outcome for a defined community, it can ensure that health is on the agenda when the impact of a project is being determined. HIA can also create explicit opportunities to enhance positive health impacts and to avoid, reduce, or mitigate adverse health impacts.

For this to happen, we need to implement three paradigm shifts. First we need to develop more ambitious regional and national level policies and guidelines for HIA. We need to do more than the bare minimum required for HIA in environmental impact assessments. For example, ADB is currently assisting Greater Mekong Subregion (GMS) countries to strengthen HIA policies and guidelines.

Second we must invest in capacity development of communities, civil society, and academia to generate the evidence to support the hypothesis that the cost of not conducting HIA is more expensive in the long term. To help GMS countries achieve this goal, ADB has trained more than 600 experts from public health, environment agencies, academia and private sector on HIA and created an HIA network across the subregion.

And third, we must mobilise more resources for HIA demonstration projects and to implement public health management plans that ensure infrastructure projects have the best possible health outcomes. ADB is working on several demonstration projects that showcase HIA in various sectors throughout the GMS.