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CHAPTER 1
Health impact assessment for sustainable water management: the lay of the land
Lorna Fewtrell, David Kay, Ian Matthews, Jürg Utzinger, Burton H Singer and Robert Bos
BACKGROUND
Health impact assessment (HIA) aims to predict public health issues 'upstream' and hence to influence the decision-making process in development planning (Kemm and Parry 2004). This facilitates the formulation of healthy public policy (HPP), one of the conceptual roots of HIA, and the incorporation of measures for health protection and promotion in proposed policy, projects and programmes. Environmental impact assessment (EIA), with a 35 + year history, is seen as the second conceptual root of HIA (Kemm and Parry 2004). Over the past 20 years, innovation, validation and application of HIA procedures, methods and tools have accelerated, and a number of countries have adopted national HIA policies and strategies. While these countries are mainly found in the industrialized world, recently some of the least developed countries have also adopted HIA policies (e.g. Lao PDR adopted its national HIA policy in March 2006).
In the past, development was generally undertaken without even an informal assessment of possible health impacts. This prior lack of assessing possible health impacts can be explained by the fact that health was considered the exclusive responsibility of the health sector, a view that still prevails in some countries or sectors. As a result, a range of adverse health effects added a preventable burden of ill-health to the lives of vulnerable population groups. Most development also missed opportunities for health promotion that typically present themselves at project planning and design stages. Unintended negative health effects have included such diverse impacts as the spread and intensification of vector-borne disease transmission, particularly schistosomiasis and malaria associated with hydropower projects and irrigation systems (Southgate 1997; Jobin 1999; Scudder 2005; Steinmann et al. 2006), intensification of dengue transmission due to the introduction of storage jars for drinking water in Viet Nam (Vu et al. 1998), arsenic poisoning as a result of using contaminated boreholes for supplying drinking water in Bangladesh (Smith et al. 2000) and the psycho-social disorders resulting from forced resettlement out of reservoir areas or irrigation schemes (Montgomery et al. 1973; Scudder 2005). An example of missed health opportunities in developing countries is that of numerous irrigation schemes developed without including a component to improve access to safe drinking-water and sanitation (Konradsen et al. 1997).
A major feature of large development projects in developing countries (e.g. the construction and operation of hydroelectric power schemes, mining projects and oil and gas pipelines) is involuntary resettlement of entire communities. The number of people involved in involuntary resettlement is estimated to be in the region of ten million persons per year (Goodland 2000). The negative health consequences of such resettlement have been documented in studies dating back 50 years (Scudder 2005) and recommendations that rigorous appraisal of potential health impacts be carried out in the context of resettlement linked to large dams was proposed in 1973 (Montgomery et al. 1973) with repeated admonition to build this into the planning stages of large projects. However, the term HIA was only introduced in the scholarly literature many years later and no systematic follow-up of HIAs in the important context of large dams has been forthcoming. Figure 1.1 underscores the magnitude of the issue, showing the number of large dams constructed in different regions of the world over the past 100 years. Of note, the People's Republic of China is not included in these statistics, although it is estimated that over 50% of the large dams have been constructed in this country alone.
When HIAs have been implemented in connection with large projects in the tropics and subtropics, primary attention is often focused on infectious disease, with little or no consideration given to what is probably the most profound long-term health consequence of resettlement; namely, mental illness (Scudder 2005). Furthermore, HIAs alone cannot deal with long-term health consequences of development projects. If large infrastructure development projects are not accompanied by an ongoing data collection programme and public health management plan capable of being adaptively tuned to local conditions over time, then even the best of HIAs will have limited impact. Discussion of this topic in the context of wealthier countries focuses on government responsibility and legally binding agreements for promotion of health of the public. In most tropical and subtropical regions of the world, there is no legal system with this kind of focus, Brazil being a notable exception, and project development usually involves a three-way tension between international development banks, corporations and host governments. If ongoing health monitoring and implementation of curative and preventive services is not actually written into a concession agreement (CA) between the corporations and the government, there is little hope that HIAs will be anything other than consciousness raisers at the start of a project. Furthermore, addition of health mitigation into the formal CA assumes that:
• some type of HIA was performed prior to the CA negotiations;
• sufficient capacity exists within the host government for long-term implementation of the required mitigation measures; and
• a monitoring and evaluation system of sufficient capacity has been developed in order to identify and evaluate both impacts and mitigation measures.
Basically, HIAs should not be treated in isolation from the long-term follow-up that is needed to mitigate health consequences of development projects. The pressing need for such follow-up is already documented in the analysis of over 50 resettlement cases connected to large dams, many running over multiple decades (Scudder 2005).
With increasing demands for 'sustainable development' (Goodland 1995), and the acknowledgement that the greatest scope for improving public health lies outside the traditional medical profession (which focuses on management of illness) (Lock 2000), HIA has become an important instrument to manage and mitigate possible health implications in advance of any development. Consequently, HPP options can be selected and an intersectoral public health management plan can be integrated into the design, implementation and operation of development projects and programmes. The principles of sustainable development have been summarised as:
• environment;
• equity (i.e. within and between societies); and
• futurity (i.e. inter-generational equity).
Achievement of all three elements in the absence of a strong public health ethos is impossible and this explains the emerging focus on the health dimension in sustainable development policy goals (WHO ECHP 1999; Kemm and Parry 2004; Petticrew et al. 2004).
HIA can provide an estimation of potential health impacts (positive or negative; intended or not; direct or indirect; single, multiple or cumulative). While HIA is predominantly qualitative, for certain issues it is possible to be quantitative with varying levels of uncertainty (Veerman et al. 2005). It can be used to define health safeguards, mitigation measures and health promotional activities for the design, construction and operational project phases (Bos 2006; Chapter 9). Thus, HIA supports minimization of predicted health risks and makes it possible to take optimal advantage of health opportunities.
The enthusiasm with which HIA has been adopted varies. The United Kingdom is a leading nation, certainly in terms of published reports in the peerreviewed international literature. Figure 1.2 is reproduced from a systematic review covering the period from 1976 to mid-2007 which revealed that almost a quarter of HIA-related publications in the peer-reviewed literature focused on the United Kingdom (Erlanger et al. 2008). This imbalance explains the difficulty in sourcing developing country HIA examples for a book of this nature. This issue was noted when critically reviewing a recent textbook on HIA (Kemm et al. 2004); indeed, only one of the 36 chapters has an explicit focus on developing countries and all of the 55 contributing authors are affiliated to highincome nations (Utzinger 2004).
Many countries, however, do have policies and legislation regulating EIA, and such assessments have traditionally included a health component. The scope of health coverage in EIAs tends to reflect its roots in industrialized countries in the 1960s and 1970s, with a focus on pollution, chemical hazards, accidents and injuries (Steinemann 2000). In the United States of America, despite more than a 30 year history of formal EIA legislation, HIAs are only now beginning to be incorporated into the National Environmental Protection Act (NEPA) and relatively few HIAs have actually been performed for any industrial development projects. Furthermore, EIA tends to focus on the physical environment with little or no attention to the cultural, economic and societal aspects of development projects which include equity, health, livelihood and wellbeing. There may also be conflicts of interest between the environment and health sectors (an extreme example would see wetland conservation juxtaposed to wetland drainage for malaria or dengue vector control), and the boundaries set for the scope of an EIA may differ significantly from those required for a parallel HIA.
Kemm and Parry (2004) identify two key features of an HIA, namely:
• it is concerned with the prediction of different options and how these contemplated decisions would affect the health of a population; and
• it is intended to influence decision-making and to assist decision makers.
Therefore, by definition, an HIA needs to be undertaken prior to the implementation of a policy, project or programme. Thus, HIA is predictive. A formidable challenge of HIA with regard to influencing the decision-making process is the limited time available for such development decisions and the notorious lack of high-quality baseline health and socioeconomic data, particularly in developing country settings. One suggestion is for a number of 'off-the-shelf' reviews (Joffe and Mindell 2002; Mindell et al. 2004) to speed up subsequent HIA. The United Kingdom research reported in Chapters 3 to 5 is, in part, a response to this. These desk-based HIAs have been conducted on a hypothetical case-study population.
This Chapter does not set out to reinvent the wheel; there is already good guidance available on how to manage and how to conduct an HIA in a relatively wealthy country setting, including information on suitable stakeholder groups and public engagement (see for example enHealth 2001; Abrahams et al. 2004). Rather, it sets the scene so that the approaches taken in the research reported in subsequent chapters can be contextualised. For those who wish to perform their own HIAs on water management options in the United Kingdom (such as utilising rainwater harvesting and greywater reuse), specific guidance is available (Fewtrell and Kay 2008) in addition to the case study examples outlined in subsequent chapters. In a developing country setting, with the exception of HIA guidelines that have been developed for the oil and gas industry (IPIECA 2005) as a derivative of the HIA carried out for the Chad-Cameroon petroleum development and pipeline project (Jobin 2003; Utzinger et al. 2005), there is little of a general nature to build on that derives from concrete project experience. Lessons from the Nam Theun 2 hydroelectric project in Lao PDR (Chapter 9) represent one place from which to make further progress. Some of these lessons are under consideration in guidelines for HIAs being developed through the International Finance Corporation (IFC).
1.1 ORIGINS OF HIA
Despite its widespread uptake in many industrialized countries, and despite strong pleas made in the 1970s for the need to assess health impacts in the context of large dams and involuntary human resettlement in developing countries (Montgomery et al. 1973), HIA only really emerged in the 1980s. The trigger was a specific concern over the vector-borne disease implications of water resources development and management, specifically irrigation schemes and dams implemented in developing countries. To address this issue, the World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO) and United Nations Environment Programme (UNEP) established a joint Panel of Experts on Environmental Management for Vector Control (PEEM). One of the first panel meetings addressed how vector-borne disease implications of water resources development could be predicted (WHO 1983). Recommendations made at this meeting were followed up with the development of forecasting guidelines, published in their final version in 1991 (Birley 1991).
Despite this chain of meetings, there is a considerable distance between guidelines developed in the context of international organizations and the actual conduct of HIAs on specific projects with a focus on developing countries. Here the HIA experience for the Chad-Cameroon petroleum development and pipeline project (Jobin 2003; Utzinger et al. 2005), the Ahafo gold mining site in Ghana and the Nam Theun 2 hydroelectric project in Lao PDR (Chapter 9) provide a basis for going well beyond broad guidelines and moving to concrete protocols derived from, and improving upon, what has actually been done in the complex triangle of the corporate world, governments and international development banks, that is at the heart of large projects in the tropical regions of the world.
It is also noteworthy that during the 1980s, there was a rapidly expanding interest in EIA, nurtured by a series of articles in "The Ecologist" on the impacts of dams and other major infrastructure development projects in low-income countries. Indeed, there was a growing recognition that, despite the requirement for a consideration of people's health and wellbeing within EIA (NHMRC 1994; Birley 1995; BMA 1998), health only received token attention (Arquiaga et al. 1994; NHMRC 1994; Birley 1995). At the same time, there was an interest in HPP . A landmark event was the 1986 Ottawa Charter on Health Promotion, which spelled out the critical importance of HPP as part of intersectoral approaches to health (Ottawa Charter 1986). The role that HIA could play was realized and enabled through the publication of guidance (PHRB 1994; Putters 1994; DoH 1995). The Bangkok Charter (2006) re-iterated this, with explicit reference to the key-role of equity-oriented HIA.
1.3 DEVELOPING RATIONALE
HIA is still at a relatively early stage of development in comparison with other types of impact assessment, most notably EIA. There is a need, therefore, to strengthen the role of health in various impact assessment processes, such as EIA and strategic environmental assessment (SEA) (Bina 2007), as well as to encourage the development of HIA in its own right. Linked to this, there is also a need to develop criteria to decide on the level of integration between HIA and other types of impact assessment. The bottom line is that further progress on HIA methodologies and tools, underlying processes and integration with other impact assessments will only come about by doing more HIAs (Parry and Kemm 2004; Utzinger 2004). The pressing need of HIA in developing country settings, particularly in the frame of large-scale water resources development and management projects and exploration of other natural resources has been stressed (Erlanger et al. 2008).
Investing in HIA is justified by four compelling arguments: economics, equity, best public health practice and good governance, all of which are required for policy implementation based on principles of sustainable development (Bos et al. 2003).
1.3.1 Economics
The economic argument is perhaps the strongest driver for ministries of finance, developers, local agencies, donor agencies and staff in sectors other than health to engage in HIA. Past experience shows that a lack of consideration of possible health issues in development may result in the transfer of hidden costs to the health sector, which will have to deal with new or increased disease burdens in affected communities. As a consequence, the savings perceived by the project proponent resulting from not doing an HIA are false economies when the issue is considered government-wide and the value of the additional burden on the health sector is included in the analysis. This is clear-cut in some examples, such as the malaria outbreaks in the Gezira irrigation scheme in Sudan, where the army had to be called in to save the cotton harvest, because all agricultural labour was down with irrigation-associated malaria (Bell 1999). Or, in the example of the Accelerated Mahaweli Development Project in Sri Lanka, where 165,000 ha of land were developed for irrigated rice farming accompanied by the settlement of approximately 1 million individuals into the malaria-endemic lowland dry zone in the 1980s. There was a 2- to 5-fold increase in malaria incidence. In one part of the irrigation scheme, the unfortunate combination of intensified irrigated rice production and the promotion of pig rearing, as a second source of income, further led to severe outbreaks of Japanese encephalitis, which forced the government to embark on costly vaccination campaigns (Amerasinghe 2003). Another prominent example is the severe outbreak of intestinal schistosomiasis in the Richard Toll area of the Senegal River basin in connection with the construction and operation of the Diama dam and intensified irrigation (Southgate 1997). Although some kind of HIA had been performed, the risk of schistosomiasis had been underestimated as insufficient attention had been placed on the ecology and possible spread of the intermediate host snails of Schistosoma mansoni in this area.
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