Consider health in all policies

By Mark B. Horton

What is “Health in All Policies” (HiAP) and what are its implications for public health practice and for policymakers in all sectors of the community?

HiAP is simply the acknowledgement that virtually all policies, programs and services put in place that affect the community as a whole likely will have an impact on the health of the community and its constituents.

It is obvious that policies, programs and services put into place relating to the health care and public health systems have (or hope to have) a direct impact on health. It is also obvious that many other community services that are put in place to serve society’s interest in maintaining and improving the well-being of the community also have a direct or indirect impact on health.

Examples include law enforcement, fire and rescue services, waste and sewage management, regulatory programs that monitor air quality and food safety, the design of consumer products, traffic control, etc.

Not so obvious is that yet other sectors put in place policies, programs or services that have a direct or indirect impact on the community’s health. Here, examples include:

* Agricultural policy (what foods are grown, how and where they are grown, and whether they are subsidized);

* Transportation policy (where and how roads are built, how fast automobiles are allowed to travel on the roads, what other vehicles share right-of-way on the roads, who has access to public transportation and how much it costs);

* Education policy (requiring immunization prior to school entry, providing healthful foods in the school cafeteria); and

* Zoning policy (where commercial and industrial enterprises are located relative to residential areas, where critical community services like hospitals and schools are located).

Health in All Policies has significant implications for the practice of public health. The public health process typically involves the identification and diagnosis of an acute or chronic health condition or threat to the community (e.g., rising levels of obesity or an outbreak of influenza in the community); the development and implementation of a plan to address the condition or threat, which may involve mobilizing health care (e.g., medications) or preventative health (e.g., immunizations) interventions; and the ongoing monitoring of the condition or threat with an eye to ensuring that everyone is benefiting from the plan that’s been put into place and that the impact of the condition or threat on the community has been reduced or eliminated.

This process by its nature focuses on health conditions or outcomes (e.g., deaths from heart disease or HIV/AIDS) and/or risk factors for those conditions or outcomes (e.g., smoking, unhealthy diet, and physical inactivity) that lead to the development of programs that are focused on those conditions or threats, funded and carried out by public health entities or agencies at the appropriate jurisdictional level depending on the scope of the condition or threat.

Through a HiAP approach, we acknowledge that there are social factors (e.g., poverty, unemployment rate) and environmental factors (e.g., access to parks and transportation, community safety) that play a powerful role in determining the degree of likelihood of citizen exposure to an environmental threat or in influencing human behavior.

These social and environmental factors or determinants of health are frequently the result of a broad range of policy decisions, programs or services that have been put into place by many different sectors of the community.

This acknowledgement of the health impact of a broad range of social and environmental health determinants leads to an expanded role for public health. Public health leaders must educate the community about the role of social and environmental factors in determining the health of the community and must bring partners in those various community sectors to the table to develop processes for systematically assessing the health impact of policies, programs and services being considered prior to their being implemented. When these assessments are done formally, we call them environmental impact or health impact assessments.

All sectors of the community need to be made aware of the potential health impact of the policies, programs and services they put into place and evaluate every policy they are considering putting into place through a health lens.

The ultimate goal of a Health in All Policies approach to health, however, is not simply the avoidance of unintended health consequences of policies, programs or services being considered or implemented. Rather, the ultimate goal is for every community sector to be aware of and acknowledge the potential health impact of everything they do, and to adopt as part of its core mission the maintenance and improvement of the health of the community.

— Mark B. Horton, M.D., MSPH, is the state public health officer in the California Department of Public Health.

Special to The Enterprise

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