Public Health Impact Must Be Part of Policy Decisions, Says Former CDC official

Andrew Kitchenman | May 11, 2015 | Health Care
NJ native says health-impact statements are key to making smart choices that can affect an entire community

Richard Jackson and Denise Rodgers
When Nutley native Dr. Richard Jackson served as the nation’s top environmental health official in the 1990s, he had an experience that crystallized his thinking.

After watching an elderly woman walk along an Atlanta highway on a hot day while he drove to a meeting, Jackson reflected:

“If that poor woman collapses and dies, the cause will be (listed as) heat stroke; it won’t be absence of trees, heat-island effects, ozone levels in the environment, absence of sidewalks, absence of public transportation,” said Jackson. Likewise, if a truck struck and killed her, the cause would be listed as a motor-vehicle crash, not the absence of safe transportation.

Jackson cited this as an example of how public officials should consider the importance of health in making decisions about a wide range of policies. Jackson, a pediatrician, now lives in California, where he serves as a professor at UCLA. He formerly was the environmental health director for the Centers for Disease Control and Prevention.

He spoke recently at the first New Jersey conference on health-impact assessments which is a planning tool that allows local elected officials, planners, builders and residents to consider how land-use decisions will affect health.

Health-impact assessments consider factors such as whether a project will encourage residents to be more physically active by including sidewalks and making it as easy to bicycle as to drive; improve access to healthy food, by offering tax incentives, for example, to food sellers that stock fresh produce; or increase exposure to potentially harmful toxins by locating industrial facilities near homes.

These assessments are generally done by trained professionals, and it can cost a significant amount to gather all relevant data.

Jackson said it’s important for New Jersey to revive a skill that was long a part of the state’s culture: how to build communities that encouraged residents to be physically active and provided access to healthy food. To do that, research points to the need to use health-impact assessments carefully, in a way that involves key decision makers and furnishes data that will usefully inform their decisions.

“Jersey had really robust towns” through World War II, Jackson said, adding that he’s come to believe based on decades of research that communities that are more walkable and designed to bring neighbors together lead to better social connections and a wide range of positive health outcomes.

Jackson added that small decisions can lead to positive health consequences. For example, UCLA ask some vendors to put healthier drinks like water at eye level in soda machines, leading to significant changes in the drinks that students buy.

And Jackson has a suggestion that can be implemented readily. “Every school ought to have a garden, and kids ought to know where food comes from.”

Staff members at Rutgers’ Edward J. Bloustein School of Planning and Public Policy have formed an organization to help conduct these assessments: the New Jersey Health Impact Collaborative.

Four assessments have been recently completed or are currently underway: a potential redesign of a 4.3-mile stretch of Bloomfield Avenue in Essex County; increasing public access to the Middlesex Greenway, a walking and biking path in Metuchen, Edison, and Woodbridge; a stormwater management plan for Hoboken; and a voluntary buyout program for homes on Mystic Island in Egg Harbor Township. The Pew Charitable Trusts and the Robert Wood Johnson Foundation fund the last two.

Jimmy Dills, a research associate with the Georgia Health Policy Center, said it’s important that those who are interested in conducting health-impact assessments carefully consider which projects they’re appropriate for. This process to “screen” projects includes estimating the timeline for when a large project will be completed, so that the assessment can be done in time. In addition, key decision makers must be involved in the process, or it’s unlikely to have much of an effect.

[related]“The goal is to institutionalize the health perspective, not necessarily make the HIA as an end-all, be-all tool,” Dills said.

This pervasive approach to including health in policymaking can be found in some state programs. For example, Shaping NJ, a state Department of Health initiative that funds local projects, has as its motto “to make the healthy choice the easy choice,” state Health Commissioner Mary E. O’Dowd noted.

O’Dowd noted that a growing number of employers are developing clear policies discouraging tobacco use and encouraging their workers to walk.

Jackson sees a growing demand for health-impact assessments and other methods of weighing the health consequences of planning decisions.

Young people “want to be living in lively places where they can walk and meet their life needs, where their kids can be active in their neighborhoods and go about their lives and maybe walk to school,” Jackson said. “And I think from a business proposition, building as if it’s 1965 and everybody’s going to be in the car all the time — that’s over. The country’s too crowded, fuel’s too expensive, there are a lot of reasons why people don’t want that anymore and they really want the neighborhood feel and they want to be active.”

Bloustein School Dean James W. Hughes pointed to evidence that this is occurring — long-growing Monmouth, Hunterdon, Warren, and Sussex counties actually lost population from 2010 to 2014. And the baby boomers, who Hughes described as the most suburban generation, are being replaced in the workplace by millennials– born in the 1980s and 1990s — who “are rejecting plan-vanilla suburban New Jersey,” he said. He summarized the suburban office market as being “massively oversupplied and under-demolished.”

Health-impact assessments can also look to positive examples from the state’s past. Hughes indicated that a New Jersey development from the late 1920s — Radburn in Fair Lawn — is increasingly gaining attention across the country as an example of a neighborhood that encourages healthy behavior by being focused on a series of walking paths that encourage children to walk to school.

Dr. Denise Rodgers, a vice chancellor for Rutgers University’s Biomedical and Health Sciences division, added that the interests of minority and economically disadvantaged groups haven’t been considered when many planning decisions have been made, which has contributed to these groups having poor health outcomes.

“Power plants (and) other more noxious environmental structures are more likely to be located in poor communities, and we also know of many of the struggles that people living in these communities have related to access to high quality, nutritious food at a reasonable cost, (which) is a significant impact on their health,” Rodger said.

“While health impact assessments are important for everyone, potentially they’re even more important for those who are most vulnerable in our society.”

Jackson said that considering health in a broad range of policies can shift how we think about some problems. For example, while the rise of diabetes is currently seen primarily through a medical lens, it can be viewed primarily through an environmental lens by focusing on the suburban building patterns that reduced physical activity and the food policies that made candy and soda the cheapest, most available food in some communities.

“We have medicalized what is in fact environmental disease,” he said.

Jackson encouraged those who attended the conference to think of the growth in the use of health impact-assessments as a long-term project, like reducing smoking and making cars safer.

These culture shifts “take longer than two or three years, they take a generation or two — it does happen,” he said, adding that as a result of better-designed communities, “I expect not to sit in a car and be stressed out for a whole generation like my parents were.”