Dear Marc

Thank you – lots to digest – immediate responses

  1. For a more measured description of Swedish experience see “Nilunger, L. et al. Health Impact Assessment: screening of Swedish governmental inquiries. Eurohealth 8 (5):30-32, 2003. Available at
    Discussions/analysis on health equity may use epidemiology but they certainly do not rest on scientific certainty – the principles of fairness and justice and also of a given condition/situation being unnecessary & avoidable quickly lead us away from ‘scientific certainty’.
  2. Yes – I am sure you are right – governance is the issue. I like your point: ‘equity considerations can be darn inconvenient in governance’ – very important. ‘Efficient’ policy-making does not necessarily mean speeding something through.
  3. I may have been guilty of stating the obvious here – interesting that you have a similar experience with regard to civil rights evaluations of metropolitan planning. Same observation could prob be applied to all processes – HIA not immune – the benefit of institutionalising a process is that it reaches further – the loss is that it becomes ossified - reminds me of theme in William Blake’s poetry that organised religion stifles and ensnares humanity … ‘binding with briars, my joys and desires’ [‘The Garden of Love’ at]
  4. Useful – thank you. I will ponder





From: []
Sent: 24 June 2014 15:40
To: Ben Cave
Cc: Elizabeth Murphy; TRB Health and Transportation; Martin Birley; Jenny Mindell; Ben Harris-Roxas (; Alex Scott-Samuel
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Hi Ben, the questions and comments you raise are good ones.  I'd be curious to know more about this:  "Federation of Swedish County Councils included a health screening question on all policies and collapsed under the weight of policies to screen." 

1.  Our definition of health inequities is more civil rights oriented, where disproportionate adverse effects are determined using a preponderance of the evidence, rather than a scientific certainty.  Some adverse effects will be unavoidable, due to business necessity (or physical realities), but can either be mitigated, or a less discriminatory path chosen.  The burden is on the causing institution to justify its actions. 

2.  This is a difficult question:  "can questions about equity be integrated into routine decisions without causing cogs of democracy".  In the US, these questions are not usually integrated into routine decisions, so we don't know the answer by experience.  Rather, as in the recent huge federal bailout statute during the Great Recession, "shovel ready" projects are chosen, which have never been subjected to an equity filter.  So using such a filter might indeed flow down the consideration of projects and cause them to be changed.  But the cog would not be one of democracy, because the communities potentially adverse affected are, or should be, a major consideration in "democracy."  But perhaps you mean "governance" rather than "democracy."  Indeed, equity considerations can be darn inconvenient in governance, particularly where, as in most places in the US, the steering wheel of governance is in the hands of the dominant population.  In the US, the demographics are changing quickly, especially with the rising Hispanic or Latino community, and the power structure has not adjusted yet.  Decisions are still being made to benefit an older Anglo middle and upper class population as a default position.  Tom Sanchez and I discuss some of these governance issues in our book, "Planning as if People Matter: Governing for Social Equity," Island Press, 2012.

3.   Indeed the danger exists that our plan will result in a tick box exercise in some places.  This has been the case, for example, with civil rights evaluations of metropolitan plannings organizations in the US (300+ entities established by statute to plan surface transportation in regions).  Those implementing the plan have to look deeper than the ticks.  Indeed, the Federal Transit Administration has created excellent civil rights and environmental justice guidance for transit providers to accomplish just this.

4.  We should probably have distinguished between inequality and inequity.  This difference came up again yesterday in my class with the Young African Leaders Initiative.  One Fellow made the point that if one person is short and the other tall, inequality would demand that they both be given the same size box to stand on, while inequity would demand that the shorter person be given a bigger box.  Here are a couple of other approaches:

Equality implies the ordering of liberty within society so that the freedom of one person does not infringe on the rights of others, just as liberty implies the right to act in ways permitted to others. The notion that all human beings are entitled to the same human rights without distinction. Equality does not necessarily mean treating people the same but rather taking whatever steps are necessary to promote a more just society for all. Equality does not always mean identical treatment. It acknowledges the possibility of different treatment in particular circumstances (for example the prohibition in some international treaties and covenants on the imposition of the death sentence on those under 18 or on pregnant women). The principle of equality sometimes requires countries to take affirmative action to diminish or eliminate conditions that cause or help to perpetuate prohibited discrimination.

“Equity is really about inclusion. It’s about trying to make sure that we have an economy that can benefit everyone who is willing to work and participate in it.” (Manuel Pastor)  This definition is of course troubled by the inclusion of the work "willing," which resonates with medical treatment concerns about patient compliance, and with people with mental disabilities not wanting to take their prescribed medications.  Todd Litman defines equity as "Equity refers to the distribution of impacts (benefits and costs) and whether that distribution is considered fair and appropriate." But even here, the word "appropriate" is troublesome.  Who determines what is appropriate?  He notes, "There are three major categories of transportation equity.

1. Horizontal Equity

Horizontal equity (also called fairness and egalitarianism1) concerns the distribution of impacts between individuals and groups considered equal in ability and need. According to this definition, equal individuals and groups should receive equal shares of resources, bear equal costs, and in other ways be treated the same. It means that public policies should avoid favoring one individual or group over others, and that consumers should “get what they pay for and pay for what they get” from fees and taxes unless a subsidy is specifically justified.2

2. Vertical Equity With Regard to Income and Social Class

Vertical equity (also called social justice, environmental justice3 and social inclusion4) is concerned with the distribution of impacts between individuals and groups that differ in abilities and needs, in this case, by income or social class. By this definition, transport policies are equitable if they favor economically and socially disadvantaged groups, therefore compensating for overall inequities.5 Policies favoring disadvantaged groups are called progressive, while those that excessively burden disadvantaged people are called regressive. This definition is used to support affordable modes, discounts and special services for economically and socially disadvantaged groups, and efforts to insure that disadvantaged groups do not bear excessive external costs (pollution, accident risk, financial costs, etc.).

3. Vertical Equity With Regard to Mobility Need and Ability

This is concerned with the distribution of impacts between individuals and groups that differ in mobility ability and need, and therefore the degree to which the transportation system meets the needs of travelers with mobility impairments. This definition is used to support universal design (also called accessible and inclusive design), which means that transport facilities and services accommodate all users, including those with special needs." (Todd Litman (2002), “Evaluating Transportation Equity,” World Transport Policy & Practice (, Volume 8, No. 2, Summer, pp. 50-65) While I don't agree with everything Todd says, I sometimes write with him, and he has thought deeply about these issues.

Best regards,



From: "Ben Cave" <>
To: "marcomcast" <>
Cc: "Elizabeth Murphy" <>, "TRB Health and Transportation" <>, "Martin Birley" <>, "Jenny Mindell" <>, "Ben Harris-Roxas (" <>, "Alex Scott-Samuel" <>
Sent: Tuesday, June 24, 2014 6:02:06 AM
Subject: RE: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Dear Marc

Thank you for circulating the memorandum on use of civil rights laws to address health inequities

I’ll be fascinated to see how this approach is received, put into practice and enforced – some observations

1.       From a PH point of view the memorandum introduces a new definition of health equity (para 1) ie “Ethnic and racial health inequities are persistent and pervasive”. Compare with Whitehead (1991) who defines health inequity as differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust - - there are problems with putting Whitehead’s definition into practice. What practical challenges do you envisage to your definition?

2.       The case you make is all encompassing (para 6)  – can questions about equity be integrated into routine decisions without causing cogs of democracy, or in this case of California Endowment Fund, to grind to a halt? [Federation of Swedish County Councils included a health screening question on all policies and collapsed under the weight of policies to screen].

3.       In UK we have Equality Impact Assessment (or had – law has been changed recently by our ‘fair-minded’ Govt) – this was conducted by providers of public services when new or revised services, policies etc were proposed. In principle it is fine however in practice it has become a tick box exercise – legal challenge on EqIAs is, I think, more often on the process than the results ie was a particular group consulted at the appropriate time – not are the findings of the EqIA implemented.

4.       In para 11 you introduce term inequality – the memorandum does not appear to distinguish between inequality and inequity – no real comment here other than to note this change in terminology - in short history of HIA this has long exercised HIA scholars: does HIA address equity etc. My personal opinion is that it does and that there is less difference between the two terms than commonly acknowledged.

That is it, for now!

Best wishes



From: []
Sent: 20 June 2014 19:59
To: Ben Cave
Cc: Elizabeth Murphy; TRB Health and Transportation; Martin Birley; Jenny Mindell; Ben Harris-Roxas (; Alex Scott-Samuel
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Hi Ben, thanks very much for your thoughtful discussion.  I'd appreciate a copy of your talk that you mention at the end.  To help address the question of invoking/using the law in public health studies, please see the attached summary document written by a team from The City Project in response to a request by the California Endowment, on addressing health inequities using civil rights laws.  The Endowment funds HIAs, and is very interested in health issues in California, such as the Affordable Care Act ("Obamacare").  Of course, many of these lessons apply in other states, and have some applicability in countries that have an intensive civil rights/human rights legal enforcement system. 




From: "Ben Cave" <>
To: "marcomcast" <>, "Elizabeth Murphy" <>
Cc: "TRB Health and Transportation" <>, "Martin Birley" <>, "Jenny Mindell" <>, "Ben Harris-Roxas (" <>, "Alex Scott-Samuel" <>
Sent: Friday, June 20, 2014 6:35:12 AM
Subject: RE: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Dear all

I add my voice to the chorus of support – this has been an interesting dialogue.

However … we have deviated from the original challenge that Marc posed, namely the perceived failure of HIA to invoke/use legal definitions. [I have not revisited the original question – probably a mistake – but I think that sums it up].

This is a valid challenge and one to which we HIA practitioners should respond. It is a challenge for Public Health generally.

From my own point of view I think we should use all levers we can to ensure that the recommendations made are irrefutable and are enacted. Invoking a legal duty, where one exists, would seem to be a powerful way of doing this. This applies as much to HIAs as to other engagements with policy (at any level).

Our conversation has ranged from human rights to the legal arguments in planning decisions (my input) to the loan requirements levied by banks for large infrastructure projects.

The final section on humanitarian aid in Haiti is interesting and sadly not surprising (diarrhoeal disease, sanitation and water supply are not fashionable topics that enjoy a high media profile) but as Martin identifies it is not ‘on topic’. In the Haitian example an authoritative statement on the necessity of enforcing building codes would have saved lives. HIA was not needed here.

My decidedly lay understanding is that legal challenge is all about applying the law to a specific case under scrutiny. How can Public Health help with this? A specific instance might be taken to represent the whole but legal challenge is on that specific instance.

There are examples of public health analysis directly being used to formulate policy and to set legal precedent (not the same thing I know) in Health in All Policies with regard to tobacco, alcohol, sugar etc – it is clear that large amounts of political capital are also needed to ensure the law is continuously enforced.

In analysis and recommendations in HIA it is easier to focus on health protecting aspects eg air quality and noise than on soc dets. In the transport example Marc cited (placing a levy on cars entering centre of city [San Francisco]) it would be simpler to get air quality readings for a defined area and show they exceed or meet thresholds. The population is relatively easy to define. The thresholds are clear and sanctions simple to apply. The low-income group suffer – they will be geographically dispersed – the effects will be harder to show and more open to challenge. Solutions to mitigate adverse effects will be complicated and politically challenging.

What happens at a local level on an individual case? I have yet to find a way in which public health can provide the definitive voice on individual cases at local level concerning social determinants of health. We offer broader supporting evidence. We are better at policy level where larger numbers of people are affected. Does this mean we are of less use in individual cases? We can make a strong case if public health colleagues have the time and resources to gather quantitative & qualitative information about people living in a particular area and the likely effects that a change (transport policy, opening of betting shop etc) would have. Would this be enough to set precedent in other cases or would it be too specific? It would be expensive to do each time a legal challenge was mounted

I end with questions – and I welcome all responses. I’d be interested in some overarching/reflective comments from Marc given that he is the instigator of our interaction.

I gave a talk to PH colleagues a while back where I touched on this – please get in touch if you would like copy of text







Ben Cave


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From: []
Sent: 18 June 2014 17:23
To: Elizabeth Murphy
Cc: TRB Health and Transportation; Martin Birley; Jenny Mindell; Ben Harris-Roxas (; Ben Cave; Alex Scott-Samuel
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Hi folks, thanks very much for the kind words.  Attached is the evaluation paper.  As I mentioned to some of you, I also have a paper on social equity impact assessment that might be of interest.  For the bigger issues on planning, governance, and equity, you might want to take a look at Tom Sanchez' and my book, "Planning as if People Matter: Governing for Social Equity," Island Press, 2012.  We also get into some difficult issues like planning ethics.  For those interested particularly in transportation, Tom's and my book, "The Right to Transportation," American Planning Association, 2007, might be of interest.  This book does not have a heavy health emphasis, and predates much discussion of HIAs.  It does include material on the issues of people with disabilities, however, which many analyses, even equity analyses, ignore. 

Best regards,

Marc Brenman



From: "Elizabeth Murphy" <>
To: "TRB Health and Transportation" <>, "marcomcast" <>, "Martin Birley" <>
Cc: "Jenny Mindell" <>, "Ben Harris-Roxas (" <>, "Ben Cave" <>, "Alex Scott-Samuel" <>
Sent: Wednesday, June 18, 2014 9:01:50 AM
Subject: RE: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Thanks so much for sharing this thought provoking and informative discussion with us all.


I am also  interested in reading your paper, Marc. It seems that a number of us are. Perhaps you could share it with the whole group? Thank you!




Elizabeth Murphy

Active Transportation Specialist

Finger Lakes Health Systems Agency

(585) 224-3146 office

(916) 201-1626 cell



From: [] On Behalf Of Salim Vohra
Sent: Tuesday, June 17, 2014 3:17 AM
To:; Martin Birley
Cc: TRB Health and Transportation; Jenny Mindell; Ben Harris-Roxas (; Ben Cave; Alex Scott-Samuel
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA




I would be interested in reading your paper.  Good discussion thank you.





Dr Salim Vohra MBChB MSc PhD

| co-Chair of the Health (HIA) Section of the International Association for Impact Assessment|

| the international association for HIA and IA practitioners, academics and consultants – join today at |

| Public Health By Design, Craneshaw House, Hounslow, London, TW3 1DA |

| email:   mobile: 00 44 7 506 165 506 |


From: "" <>
Date: Monday, 16 June 2014 12:32
To: Martin Birley <>
Cc: Alex Scott-Samuel <>, Salim Vohra <>, Ben Cave <>, Jenny Mindell <>, TRB Health and Transportation <>, "Ben Harris-Roxas (" <>
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Thanks, Martin.  Many of these international principles apply in principle but not in practice in the US; they have little or no legal standing.  Individual organizations could adopt them, and also pursue their own visions, like the Gates Foundation.  The values of a very large and rich organization like Gates can drive international efforts. Gates has been criticized for this; driving out other efforts.

 I wonder about the effectiveness of the work of corporations "ahead of the national government in which project is located."  For example, when I look at sixty years of humanitarian assistance in Haiti, I see almost no progress.  Organizations built medical clinics and hospitals that met no seismic design and construction standards, even though they were on a known earthquake zone, and consequently fell down in the big earthquake a few years ago.  This argues for inclusion of best practices from various forms of infrastructure when HIAs are done. This could be another example of the "silo" or "stovepipe" problem. 

 Another aspect from Haiti is the fact that some otherwise highminded organizations refuse to provide contraception, family planning, and abortion funding, services, or advice due to religious and theological reasons. They thus perpetuate poverty and thus wipe out any progress that may be made in another area.

 A third example those medical people on this discussion know much more about than me-- the lack of education and aid on basic sanitary services in places like Haiti. I watch sophisticated medical services being provided, when a shipload of 50 cent Chinese shovels and soap and instructions about digging pit latrines away from water sources and washing hands could accomplish more in cutting the chain of disease transmission.

 A fourth example from tragic Haiti is the emphasis by some organizations on electronic solutions to "problems," using cellphone and computer networks, for example, when much lower tech solutions are needed.

Sorry to go on like this, but when I look at evaluation of humanitarian operations, I see this sort of thing. If anyone is interested, I have a paper on this subject.




From: "Martin Birley" <>
To: "marcomcast" <>
Cc: "Alex Scott-Samuel" <>, "Salim Vohra" <>, "Ben Cave" <>, "Jenny Mindell" <>, "TRB Health and Transportation" <>, "Ben Harris-Roxas (" <>
Sent: Monday, June 16, 2014 12:06:42 AM
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


It would be great to have your detailed view of how the IFC PF and Equator Principles apply in US in light of what US is and is not signatory to. Also how well IFC addresses civil rights.

Treaties on human rights include the right to health. we have had legal opinion in the past that this is about progressive realization and that decisions by government that would reduce health are then in breach of treaty obligations.

In HIA I'm usually just constructing a justified argument to a corporation who are concerned about their reputation, social license to operate and investment risk rating. They are usually ahead of the national government in which project is located.
I think the IFC PS anticipates your point and expects clients to act even when government is uninterested. It's a loan condition.