Very interesting Marc. I'm not really qualified to comment on the San Francisco HIA because while I understand that San Francisco does have good public transport – which is crucial if cars are banned from cities – i'm not clear how genuinely accessible public transport is to all low income people in the bay area. Also I'm much more red then green!

With regard to caste and class, the UK situation is of course much broader than income and wealth: we have a long tradition of sociocultural discrimination and snobbery - and social status and social connections are crucially important here. Our caste system also includes symbolic elements like peerages, knighthoods and a Byzantine system of various medals and other 'honours'. Professions also play their part, such that getting a medical degree or becoming a religious minister gives you a hike up the caste system.

Best wishes, Alex

On 13 Jun 2014, at 12:42, "" <> wrote:

Thanks, Alex.  Yes, I had a feeling Ben was referring to the situation of African-Americans in the US.  There is a tendency here in the US also to reduce civil rights discussions to an African-American context.  One fascinating difference between US and UK discrimination issues involves the presence of caste issues in the UK.  In the US, we hate to discuss social class.  In the courses I teach on human rights in graduate school, I can get the students to discuss race much more readily than I can class.  Almost everybody, especially our politicians, refers to everyone as middle class.  The 1% and Occupy movements don't even like to talk about the upper class, but rather differentiate by income and wealth. How does this resonate with HIA?  I criticized an HIA done in San Francisco last year or the year before, because it advocated a car cordon scheme in San Francisco, as has been done in a couple of European and UK cites, to keep cars out of downtown. Like other road tolling schemes, this one would have had regressive economic effects on low income people (by charging large amounts of money to bring a car into the City).  But because the bias of the HIA was toward car hating environmentalism, and was based on data/instructions/assumptions provided by institutional car haters/environmentalists, it ignored the idea that historically for some people, cars represent social and physical mobility, and that low income and working class people have far less discretionary income than middle and upper class people.  The class analysis escaped the folks who did the HIA, who are otherwise nice and thoughtful people doing excellent work. 

From: "Alex Scott-Samuel" <>
To: "marcomcast" <>
Cc: "Jenny Mindell" <>, "TRB Health and Transportation" <>,, "Salim Vohra (sal@PUBLICHEALTHBYDESIGN.COM)" <sal@PUBLICHEALTHBYDESIGN.COM>, "Ben Harris-Roxas (" <>, "Ben Cave" <>
Sent: Friday, June 13, 2014 4:26:45 AM
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA

I think your comments are spot on Marc. My view is that most of us who practice HIA in the 'economic north' do so from within the confines of a well protected establishment which while it occasionally gives tokenistic acknowledgement to the issues you describe, continues primarily to focus inwards on promoting, protecting and sustaining itself. I imagine Ben from Australia was referring to the fact that American civil rights have been chiefly developed by the black former slavery population rather than first nation Americans. While this is indeed the case it does not, as you point out, change the situation whereby the massive scale of racism in both countries (and also of course in the UK) means that civil rights and for that matter HIA are crucially important.

This correspondence has been a welcome reminder of the silos in which we all work and I do hope that it will lead to stronger links with groups representing the dispossessed who need us most. 

Best wishes, Alex

On 13 Jun 2014, at 11:56, "" <> wrote:

Thanks very much, Jenny and colleagues, these thoughts are fascinating and helpful. I appreciate the time and energy everyone has taken to participate in this discussion. 


I am troubled by this comment from Australia:  "civil rights as they're construed in the United States have very little relevance in other settings."  In reality, Australia has a robust civil rights legal regime and enforcement system, very similar to (and dare I say, in large part derived from) the US system, with the Australian Human Rights Commission analogous to the US Equal Employment Opportunity Commission. When I search the site of the AHRC, I find no reference to HIA.  So it sounds like the HIA folks and the civil rights/human rights folks in Australia need to be talking to one another.  But beyond that, while not claiming to be an expert on civil rights in Australia, it is clearly wrong to say that "civil rights as they're construed in the United States have very little relevance in other settings." In fact, Australia and the US both have very serious issues with historical maltreatment of indigenous populations; both have disability access and gender/womens issues that are almost identical; both have illegal and legal immigration issues involving people of different races and national origins from the dominant population, including issues of incarceration of undocumented people; and both have changing demographics, with a growing Asian population in Australia, and a growing Latino population in the US.  One area of really big difference is gun control, an epidemic public health problem in the US, and under much more control in Australia.  Even President Obama very recently referred to Australia's progress in that area. 


Best regards,


From: "Jenny Mindell" <>
To: "marcomcast" <>, "TRB Health and Transportation" <>
Cc: "Martin Birley" <>, "Salim Vohra (sal@PUBLICHEALTHBYDESIGN.COM)" <sal@PUBLICHEALTHBYDESIGN.COM>, "Alex Scott-Samuel (" <>, "Ben Harris-Roxas (" <>, "Ben Cave" <>
Sent: Friday, June 13, 2014 2:29:22 AM
Subject: RE: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA

I forwarded this email chain to colleagues who are more active than I am currently in HIA in the UK and elsewhere.

Here are their responses:


Martin Birley:

1. all aspects of HIA need improvement
2. ideally there would be a team with a wide range of expertise, in practice one person often has to cover everything
3. there should be a policy /legislation review and I will take away the need to check that equality legislation is always included.
4. most of my work is ESHIA so I interact with a social assessment team who would be the lead for this aspect
5. equality minority issues are always in my mind but then so are very many other issues
6. I do not favour the fragmentation of HIA into sub fields but equality HIA has received much attentiont in some jurisdictions.
7. international HIA is usually in multiple languages. In the UK we have used Bangladeshi speakers for community surveys, in Tower Hamlets.
8. I've never had to be an expert witness.


Ben Harris-Roxas (Australia):

I agree with everything Martin's said and just add that civil rights as they're construed in the United States have very little relevance in other settings. Human rights, etc is more relevant and there's been quite a lot of thinking done on that, if not much practice. 



Salim Vohra:

This is a very interesting issue that Marc raises.

"Health impact assessment (HIA) has emerged in the U.S. as a promising way to increase social and environmental justice by addressing health equity within transportation planning."

I have always felt the aspirations put on HIA have always been bigger than what it can sensibly achieve.

I don't see HIA as a way of tackling social and environmental justice, it may help provide evidence but on its own its a weak approach because of the context within which it is undertaken and the limitations imposed by the key parties (see next paragraph). It does address health equity but in a narrow sense. It does not often get a say in why a development is located in the place that it is and not another i.e. a poor deprived area compared to a more prosperous one. These are often the default contexts that we have to assume.

I think civil and human rights opens up issues at project level that a) need a broader policy analysis approach e.g. integrated assessment and strategic policy assessment and b) needs political/governmental backing to address or a very sympathetic business or NGO willing to explore their own inadequacies and what it would take to remediate them. This is rare.

As a part-time epidemiologist I would say that it’s great that most epidemiologist don't get up and say that X exposure is definitively causing Y in Z minority groups.

Fintan Hurley at the IOM, talks about balance of probabilities rather than certain evidence (similar to Marc's analogy of the lower buden of proof in different parts of justice systems) as how HIA works and we do in HIA try and say who is likely to be affected the most/most sensitive to impacts.


Alex Scott-Samuel:

My view is that social and environmental justice and human rights are entirely appropriate dimensions with which HIA should engage. As Martin points out, variants on 'health equity impact assessment' have been around for quite a while – and Ben HR of course worked on the original equity focused HIA project. The prominence given to HIA in the Commission on Social Determinants of Health and Marmot reports will hopefully over time increase the engagement of HIA with social equity.
Environmental justice is much more prominent in the US thanks to the very vocal civil rights community. That is no excuse for its inadequate development here: hopefully in the future we will get more HIA folk who are prepared to advocate for those who get dumped with the worst environments and the greatest environmental insults.
As regards human rights, there has as Ben H-R says been a fair bit of thinking about this but not enough action. 

The references below outline the potential for HIA in the context of human rights and of social equity at the global level
O’Keefe E, Scott-Samuel A. Health impact assessment and globalization. In: Kawachi I, Wamala S, eds. Globalization and Health. Oxford: Oxford University Press, 2006, 201-216

·         Scott-Samuel A, O’Keefe E. Health impact assessment, human rights and global public policy: a critical appraisal. Bulletin of the World Health Organization, 2007, 85, 212-17

·         O’Keefe E, Scott-Samuel A. Health impact assessment as an accountability mechanism for the International Monetary Fund: the case of Sub-Saharan Africa.International Journal of Health Services,2010, 40(2), 339-345


Ben Cave:

I agree with the tenor of what has been said by my UK & Oz colleagues and also with the points made by Nicole Iroz Elardo in the separate email thread.


This is a welcome and important question – “(HIAs) rarely contain legal concepts at all”.


HIAs do, try to do, and are expected to do many things. Too many things, I think.


The answers in this email thread illustrate what a small set of academics and practitioners understand it to do: from analysis of potential effects of projects to national and supranational policies/goals.


Ben HR’s typology (2010) - to me more of a spectrum -  can help understand this.


We are all working on different aspects of HIA and share a desire to see health addressed fully and inequalities reduced. As Martin says every aspect of HIA needs to improve – agreed - but so does every aspect of pretty much everything else. So, while we must not be complacent we must not beat ourselves up.


In the field of spatial planning I am always troubled by the failure of public health to attract the attention of the lawyers – when it comes to the crunch point of inquiry our analysis is too easily dismissed. For some time we have made the policy argument that health & wellbeing are important. It gets much harder when we try to see ways in which PH can help planners to support decisions on individual applications. Health protection has long been a tightly regulated field. We are struggling to find ways to enforce the social determinants of health in the courts (leaving aside the question of whether this is desirable).


I think this will change. Experience is growing in one small field and this will begin to set precedents. In England there are an increasing number of planning authorities who are working with PH teams to address issues on the high street that exacerbate ill health and inequality eg proliferation hot food takeways, betting shops, payday loan shops etc. This is Health In All Policies at a very local level. We know these things are mostly bad for health but how can we construct an argument that 1 more takeaway, betting shop etc will affect the health of a particular population. We enter into a complex mix of local economy, political leadership, planning law, competition law, commercial viability etc. Everything is open to challenge at inquiry so it becomes very important to be aware of the legal implications of our advice. I think that public health advice and analysis can play an important role in supporting the planners when making individual decisions and in helping them defend those decisions but it will often be a supporting role. The action of PH teams is important eg showing they are proactively identifying needs and also that they are taking action to address needs – a hot food takeaway successfully challenged a decision to refuse permission. The inspector noted the importance of health and of combatting obesity but also that there was no policy to support this. The inference was that the planning authority was using the obesity argument to stop this development but doing little else to address obesity.


The same observation applies to Environmental Assessment and HIAs. HIAs are rarely tested at inquiry. Health is dealt with easily. In Europe we have failed to establish the way in which health should be addressed in Strategic Environmental Assessment. If the SEA is faulty the so is the plan/programme. As with NEPA, the SEA Directive requires human health to be addressed. This is applied to all plans and programmes that set the framework for planning consent so is a HUGE opportunity for health to get involved ‘upstream’. These documents are constituent parts of plans and programmes. Public health has been silent on this matter, across Europe, and so the assessment is routinely done by environmental scientists with ref to air, water etc. The EIA Directive is now set to change. This applies to projects. Human health will become a core topic. We need to define how this should be addressed.


So to pick up on Nicole Iroz Erado’s point – an HIA might identify potential effects on a particular community – the question then becomes can we frame the (shared) analysis so that our recommendations are robust and defensible at inquiry? Can we elevate our analysis above an eloquent articulation of a particular situation? Do not get me wrong – eloquent articulations are important and contribute to longer term goals but the aim has to be ensure that effects are addressed in that situation there and then. At the moment I agree with Marc Brenman’s observation that examples where we do this are rare. This criticism applies as much, if not more, to public health as it does to HIA.


Marc & Nicole, and Oz & UK colleagues, I’d be happy to continue talking/sharing thinking on this so please do not hesitate to get in touch


PS here are refs to 2 recent reports where we have advised planning & public health teams on the particular question of betting shops, pay day loan shops etc.
1.       R. Pyper and B. Cave. Health evidence base for emerging policy concerning retail provision. Ben Cave Associates Ltd for NHS Haringey.  2012.
2.       R. Pyper and B. Cave. Betting, borrowing and health: health impacts of betting shops and payday loan shops in Southwark. Ben Cave Associates Ltd for LB Southwark. Appendix 9, 2014.


From: []
Sent: 10 June 2014 19:09
To: TRB Health and Transportation
Cc: Mindell, Jenny
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


Here's what I said:  "HIA's rarely address Title VI of the Civil Rights Act of 1964 or the environmental justice executive order. They rarely contain legal concepts at all. HIA's are usually conducted by public health people, who have no background in social equity or civil rights. They often perform with an environmentalist bias...much HIA work is conducted solely in English, and the limited English proficiency needs of various demographic groups are not addressed."  My comments were focused on the US, where the webinar under discussion is occurring.  But prove me wrong in the UK.  Quote some HIAs in the UK that discuss the Equality Act (which is under fire in the UK by the Conservative Party) or the equivalent, and environmental justice, and use the languages preferred by demographic groups.  This is more than "awareness," since awareness doesn't cure much of anything.  I'll be happy to be proved wrong and would love to use those good HIA examples. 


In recent work with The City Project in Los Angeles, as funded by the California Endowment, we observed that even those public health organizations and medical professionals who work with minority health disparities rarely engage civil rights law to help solve the challenges.  Various professions just seem stuck in their silos.  And don't get me started on trying to use epidemiologists as witnesses in environmental just cases.  I've never found one who would testify that X environmental insult caused Y adverse effect on a given minority or low income community.  They insist upon a scientific standard of proof, which is way higher than the administrative civil rights standard of proof of a preponderance of the evidence. 

Marc Brenman


From: "Jenny Mindell" <>
Sent: Tuesday, June 10, 2014 1:58:44 AM
Subject: Re: [H+T--Friends] H+T--Friends Digest, Vol 38, Issue 4 - HIA


We may like the concept of evidence-based decision-making but  being realistic, political (including planning) decisions are based on a whole range of things.
So most people now aim for 'evidence-informed decision-making', for which HIA is well-suited.
It would be daft to think that planners (or others in local, regional or national government) consider only health when making their decisions.
But the more that the decision-makers are involved with the HIA process, the more likely they are to engage with the recommendations produced.
And I am very surprised by the statement that public health professionals are unaware of social equity or civil rights.  Certainly not the case in the UK.  And HIA, as accepted across Europe and I thought worldwide, considers both the health impacts and their distribution across the population.


Dr Jennifer Mindell
Clinical senior lecturer
Health and Social Surveys Research Group
Research Department of Epidemiology and Public Health
1-19 Torrington Place
London WC1E 6BT


Tel. 020 7679 1269 (Internal x41269)
Survey doctor: 07770-537238
Fax 020 7813 0242
Web: IRIS web page


Journal of Transport and Health:




Message: 1
Date: Sat, 7 Jun 2014 12:29:58 +0000 (UTC)
Subject: Re: [H+T--Friends] webinar on Health Impact Assessment (HIA)
        in Transportation Planning
To: TRB Health and Transportation <>
Content-Type: text/plain; charset="utf-8"


Who is putting on this webinar? It appears to be something called IBPI. "The Initiative for Bicycle and Pedestrian Innovation is an exciting center for research and learning that is focused on bicycle and pedestrian travel. IBPI?s aim is to advance bicycling and walking as integral elements of the transportation system in Oregon?s communities." Where's the neutrality and objectivity?


In regard to this statement, "Health impact assessment (HIA) has emerged in the U.S. as a promising way to increase social and environmental justice by addressing health equity within transportation planning," much HIA work does not adequately address social equity and EJ issues. For example, HIA's rarely address Title VI of the Civil Rights Act of 1964 or the environmental justice executive order. They rarely contain legal concepts at all. HIA's are usually conducted by public health people, who have no background in social equity or civil rights. They often perform with an environmentalist bias (see "bicycle innovation" above), which often is in tension with the needs of low income communities and communities of color.


As to this, "It also augments community and stakeholder engagement by providing a forum - usually through an advisory committee - where stakeholders can identify and deliberate about health interests related to the target plan. While HIA advisory committees are diverse by design," much HIA work is conducted solely in English, and the limited English proficiency needs of various demographic groups are not addressed. Another concern with "advisory committees" is that fact that they only provide "advice" which the "planning" entity is not obligated to pay any attention to. A colleague who leads an immigration advocacy group told me a couple of years ago, "I no longer serve on advisory committees because they don't make policy or control anything."


Marc Brenman