Practitioner survey of the state of health integration in environmental assessment: The case of northern Canada

Environmental Impact Assessment Review 26 (2006) 410 – 424 www.elsevier.com/locate/eiar

Practitioner survey of the state of health integration in environmental assessment: The case of northern Canada Bram Noble a,*, Jackie Bronson b,1 a

#9 Campus Drive, Department of Geography, University of Saskatchewan, Saskatoon, Saskatchewan, Canada S7N 5A5 b Stantec Consulting Ltd., 100-75-24th Street East, Saskatoon, Canada SK S7K 0K3 Received 1 July 2005; received in revised form 1 October 2005; accepted 1 November 2005 Available online 13 December 2005

Abstract Based on a case study of health integration in Canadian northern EA, this paper further demonstrates the lack of consistent integration of health in EA practice. A survey was administered to northern EA and health practitioners, administrators and special interest groups to assess current northern health assessment practices, the scope of health in EA, EA performance with regard to health assessment and the perceived barriers to health integration. Results suggest that health is currently recognized as an important component of northern EA and is addressed in the majority of cases; however, health is addressed primarily during the pre-decision stages of EA and less often during post-decision follow-up and monitoring. Moreover, when health is addressed, attention is limited to the physical components of health and health impacts due to physical environmental change, with considerably less attention given to the social aspects of health. Results also suggest dissent between EA practitioners, health practitioners and other interests concerning the overall state of health in EA; however, there is consensus on the key challenges to improved integration, namely differences in understanding of the scope of health and expectations of EA to assess health impacts; limited coordination between EA and health practitioners; limited scope and requirements of current EA legislation for health assessment; and the lack of supporting EA methods and frameworks. D 2005 Elsevier Inc. All rights reserved. Keywords: Health integration; Health assessment; Northern Canada; Practitioner survey

* Corresponding author. Tel.: +1 306 966 1899. E-mail addresses: [email protected] (B. Noble), [email protected] (J. Bronson). URL: http://www.arts.usask.ca/geography (B. Noble). 1 Tel.: +1 306 667 2457. 0195-9255/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.eiar.2005.11.001

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1. Introduction Environmental assessment (EA) is argued to be a logical medium to consider the potential impacts of project development on human health (Laws and Sagar, 1994) and, internationally, there is growing recognition of the need for and the benefits of health integration in EA (e.g., Noble and Bronson, 2005; Steinemann, 2000; Banken, 1999). Currently, most EA systems around the world provide for some level of consideration of human health, but it was not until the late 1980s, stemming from a World Health Organization report on the health and safety components of project EAs (WHO, 1987), that health concerns started to receive international attention in EA practice (Banken, 1999). Subsequent studies of the status of health in EA, however, suggested that health continued to receive insufficient attention in the EA process (Sloof, 1995; Davies and Sadler, 1997). The British Medical Association (BMA, 1998), for example, reported that 72% of EAs surveyed in the UK between 1988 and 1994 failed to address human health issues. Similarly, in a review of 42 EAs in the United States, Steinemann (2000) found that more than half contained no mention of health impacts and in the remainder health impacts were inadequately supported by analysis. In Canada, there is limited knowledge of the current state of health in EA. That being said, a number of authors (e.g., Birley, 2003; Kwiatkowski and Ooi, 2003) have suggested a general trend towards an integrated impact assessment that combines environmental, social and health considerations. If this is the case, then one would expect to see evidence of such an integrated approached to health and EA practices in Canada. Accordingly, based on a case study of EA in Canada’s northern regions, this paper further explores the state of health in EA and the principal barriers to improved health integration. While recent studies in Canada have addressed health integration within the context of specific northern project developments, such as Kwiatkowski and Ooi’s (2003) review of Canada’s Ekati diamond mine, there has not been a comprehensive study of the current state of health in EA and, more importantly, the barriers to health integration. In the sections that follow, a brief overview of the research context and methods are provided, followed by a discussion of the study results and broader implications for advancing health in EA. 2. Health integration in EA—the case of Canada’s North The Canadian North is home to environmental, economic, social, political and cultural realities that differ substantially from the rest of Canada. The region is predominately rural and comprised of approximately 53% Aboriginal people, compared to only 3.3% at the national scale. Within the context of this study, these are important demographics for at least two reasons: first, a 1987 Canadian Environmental Assessment Research Council survey of factors that determine how much emphasis is placed on human health in EA found that EAs for projects located in northern rural areas were less likely to address potential health effects than those located in more populated areas of southern Canada (Davies, 1992); and, second, as Aboriginal peoples traditionally depend on the land, for uses such as traditional or country foods, health and well being are closely tied to the state of the environment. Moreover, economic development in the North has traditionally been at social and health cost to northern residents (Young, 1995). Rates of illnesses, for example, such as those tied to economic and resource development initiatives, including disruption and contamination of food sources or substance abuse, typically are higher in the North than in other parts of Canada (INAC, 2003; Health Canada, 1996; O’Neil and Solway, 1990). A survey of the

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state of health in EA is thus timely, as Canada’s North is currently facing unprecedented levels of large scale resource development (Bone, 2003). The focus of this study is on the state of health in EA in Canada’s North, as evidenced by recent large-scale resource development projects; that is, projects that have undergone either a comprehensive study or review panel assessment.2 The geographic extent of the study incorporates the area north of the southern limit of Canada’s discontinuous permafrost zone, encompassing the territories and the northern parts of the provinces. Attention is focused on current health assessment practices, the scope of health, EA performance and the barriers to health integration. While the focus is on Canada’s North, the broader objectives are to further our understanding of the state of health in EA and to identify the barriers to improved health integration. 2.1. Research methods The primary research instrument was a mail-out questionnaire to EA and health practitioners, administrators and special interest groups with experience in northern environmental and health assessment, supplemented by semi-structured interviews with northern community and regional health professionals. Previous studies that have addressed the state of health in EA have largely relied on reviews of project EA reports and impact statements (e.g., Steinemann, 2000; BMA, 1998; Sloof, 1995). While such an approach is accurate to the extent to which health effects are documented in the project impact statements, it does not provide insight as to the potentially different understandings of health in EA; different perspectives on the nature, importance and level of health integration throughout the assessment process; and the main challenges to improved health integration. Moreover, based on Robinson and Bond’s (2003) evaluation of public involvement in the EA process, different stakeholders may have different views and aspirations about health and the EA process. Such views and aspirations need to be examined and understood if the state of health integration in EA is to improve. Project impact statements from nine comprehensive study and review panel EAs in the mining and energy resource sector were used to identify an initial 177 participants, from which an additional 42 potential participants were identified and contacted. From this list, 53 individuals (24%) agreed to participate—representing government EA authorities (n = 21 federal, n = 10 provincial/territorial), consultants and project proponents (n = 14), and First Nations and Aboriginal interests (n = 8). The relatively low response rate is explained in part by the fact that a number of potential participants identified from the project documents indicated that they did not have sufficient northern EA and/or health assessment experience to participate. Of those individuals that did participate, 70% reported over 15 years of experience in EA in both northern and non-northern regions and all had been involved in northern EA in some capacity. The median number of northern EAs in which participants had been involved is 10. The survey was supplemented by semi-structured interviews with health professionals, including individuals from Health Canada, northern environmental and occupational health practitioners, and regional health authorities to ascertain, from a health practitioner’s perspective, the state of health in northern EA. Open-ended questions were used to elicit the views of these 2

A dcomprehensive studyT EA applies to projects with a potential for significant adverse environmental effects or to projects that trigger certain laws or regulations. If it is found that the impacts of a proposed project require further study; the project will cause significant adverse effects; there exists considerable uncertainty; or where public concern warrants it, the project is referred to a dreview panelT for further assessment. See http://www.ceaa.gc.ca/010/basics_e.htm#comp.

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participants based on their experiences with health, EA and northern development. An initial 44 health professionals and experts were contacted, from which 13 semi-structured interviews were conducted. Interview participants were comprised of northern health practitioners (n = 6), northern government health authorities (n = 3) and others with direct involvement in health and northern EA, including Aboriginal representation (n = 4). Survey and interview participants were asked to assess and comment on the importance and current state of health assessment in northern EA, the scope of health impacts in EA, the extent to which health is considered throughout the EA process and the current barriers to better health integration. In order to ensure consistency in the interpretation of health across northern EA jurisdictions, the World Health Organization’s (1987) definition of health was adopted: a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity. The key literature informing the research and questionnaire design includes a recent northern EA and health case study analysis by the authors (Noble and Bronson, 2005), northern impact assessment literature (e.g., Mulvihill and Baker, 2001; Davies, 1992), and literature that seeks to bridge health impact assessment and other forms of project assessment and appraisal (e.g., Kemm, 2004; Birley, 2003; Birley et al., 1998). The following sections summarize the study results and discuss the broader implications for health integration in EA. In order to protect the confidentiality of study participants, only the participant’s organization and general profession are noted. 3. Study results: health and EA practice in Canada’s North Survey participants were first asked to indicate the importance of assessing health impacts in EA. All participants identified health as an important part of EA, with 24 individuals (45%) suggesting that health is dextremely importantT. In order to gain a better understanding of the importance of health specific to northern EA, and to determine whether this reflects the arguments presented in the literature that health may be more important in the North (e.g., FNHIB, 2001; Davies, 1992), participants were asked to compare the importance of human health in EA practice for northern Canada to that of southern parts of the country—that is, EAs conducted south of the discontinuous permafrost zone and in the most populated parts of the country. Fifty-one of the 53 individuals responded to the question, with 51% (n = 26) identifying human health inclusion in EA as dequally importantT in northern and non-northern environments. One senior advisor from Petro Canada, for example, contends human health impacts should be assessed in ball areas we propose projectsQ (Petro Canada Environmental Advisor, pers. comm., 2004). That being said, 47% (n = 24) of survey participants indicated that health should play a dmore importantT role in EAs in the North (Fig. 1). An interviewee from Health Canada, for example, argues that the North is more sensitive to development projects and states: The impact of projects is much greater in the north. The influx of money into northern areas brings social problems such as alcoholism, violence, radical change to traditional ways. Most. . .impact assessments do not look at these issues, yet they could have the most significant impact on the individuals in these areas. (Health Canada, pers. comm., 2004) Another interviewee agrees, suggesting: It [health] is particularly important in the North where human health impacts can be felt much harder on residents not exposed to widespread development. (Indian and Northern Affairs Canada, pers. comm., 2004)

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1

24

26

equally important

more important

less important

Fig. 1. Perspectives on the importance of health assessment in Canadian northern versus southern EA.

The notion that health is an important variable to consider in EA is undisputed; this is confirmed both by recent literature and by the study results. Results also suggest that many participants identify the role of health as considerably more important in northern EA. The question that emerges is whether this perceived importance is reflected in practice. 3.1. Frequency of health assessment in EA Survey participants were asked based on their experience to rate on a seven-point scale dhow oftenT human health impacts are addressed in northern EA. Eighteen participants (37%) suggested that human health impacts are considered dmore than 75% of the timeT for northern development projects. The median response across all participants indicates that human health is considered in EAs 70% (F15%) of the time for northern developments, compared to only 50% (F12%) of the time in southern parts of Canada (Table 1). The results are statistically significant at the 95% confidence interval for the median,3 suggesting that the overall frequency of health integration in northern EA tends to reflect well on its perceived importance. This is consistent with the provisions for health integration as set out under various regional northern EA acts and land claims agreements.4 Maximizing the value added of health in EA requires that health, when identified as a potential project concern, be addressed at each stage of the assessment process from environmental baseline definition to post-decision follow-up and monitoring. Davies and Sadler (1997) agree, suggesting that a truly integrated approach to health in EA could help minimize or even eliminate the potentially adverse health effects associated with project development. Participants were thus asked to indicate how often human health is addressed at each stage of the EA process and the importance of doing so. The results suggest that health is included throughout the EA process, but there is considerable variability from the pre-decision to the postdecision stages. For example, it was found that health is addressed d40–59%T of the time during 3

The 95% confidence interval (CI) for the median is a distribution free statistic and is derived as follows: upper and lower fence = median F (1.58  (H-spread) / Mn). Where the H-spread is the difference between Tukey’s upper and lower hinges, represented by the box and whisker plot, and gives the range covered by the middle half of the data (approximately the 25th and 75th percentile). 4 See, for example, the Mackenzie Valley Resource Management Act (http://laws.justice.gc.ca/en/M-0.2/), Yukon Environmental and Socioeconomic Assessment Act (http://laws.justice.gc.ca/en/Y-2.2/) and the Nunavut Land Claims Agreement (http://laws.justice.gc.ca/en/N-28.7/ and http://www.tunngavik.com/site-eng/nlca/nlca.htm), all of which provide for health considerations as part of impact assessment.

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Table 1 Percentage of time human health impacts are addressed in EA Survey participant groups

All participants Federal authorities Provincial authorities Territorial authorities Consultants/proponents Northern/Aboriginal interests

Northern EA

Southern EA

Median (%)

95% CI

Median (%)

95% CI

70 65 60 50 80 65

64.8–85.1 50.1–79.9 34.4–85.6 29.6–70.4 74.0–86.0 23.8–71.2

50 45 57.5 25 70 67.5

37.4–62.6 24.5–65.5 35.5–79.5 15.0–35.0 55.0–85.0 41.8–93.2

impact prediction (pre-decision), but less than 20% of the time during post-decision follow-up and monitoring (Table 2). Results further suggest a discrepancy between the dfrequencyT and dimportanceT of health assessment across all phases of the EA process. For example, on average, health is reported as assessed less than 60% of the time across all phases of the EA process, but health is rated as dimportantT to dvery importantT in each stage of EA. The most notable difference is once again between the frequencies of health consideration in the follow-up stage in comparison to its perceived importance. Health is identified as dvery importantT in post-project follow-up and monitoring, but is reported as being addressed in follow-up in less than 20% of all cases (Table 2). 3.2. Perspectives on health inclusion A further observation related to Table 2 concerns the different perspectives found to exist between a number of participant groups concerning the importance and practice of health assessment. A cosine h 5 function was used to measure the ddegree of similarityT between groups for both the dfrequencyT and dimportanceT of addressing health at each stage of EA. Table 3 focuses specifically on the frequency (column) and importance (row) of health integration during EA follow-up and monitoring. While no statistically significant differences were found to exist between groups at the 95% confidence interval (Table 4), the results do indicate some level of dissent between participant groups. For example, federal EA authorities and northern Aboriginal and First Nations interests are only 65% similar in their views on the importance of health in EA follow-up and monitoring, with Aboriginal and First Nations interests indicating higher levels of importance for health integration during post-decision analysis. Consultants and proponents and federal EA authorities are found to be least similar in terms of their views on the frequency of health integration during follow-up and monitoring (59% similar). Concerning the perceived importance of health integration, it is the territorial government participants and federal EA authorities that are the least similar at only 61% consensus. Interestingly, territorial government EA authorities and those representing Aboriginal and First Nations interests demonstrate the most similarity in their views, which may, in part, be a reflection of their closer physical ties to the North than, for example, project proponents, federal or provincial governments from the south.

5 Costheta measure of proportionate similarity and is useful method to determine the amount of agreement P (or dissent, similar P 2toP an 2 dindex of dissimilarityT) within a data set or set of group responses. Cosine h (ij) = ( k x ik x jk ) / (M k x ik k x jk ), where x jk = score of participant i in cell k and x jk = score of participant j in cell k.

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Table 2 Frequency and importance of health integration in northern EA EA phase

Project description Baseline description Identification of VECs Impact prediction Determination of impact significance Design of impact management measures Post-project follow-up and monitoring

Frequency of integrationa

Importance of integrationb

Median response (% of all EAs)

CI for median (95%)

Median response (importance)

CI for median (95%)

2 3 3 4 4 3 2

1.51–2.49 2.27–3.73 2.27–3.73 3.27–4.73 2.27–3.73 2.27–3.73 1.51–2.49

5 5 6 6 6 6 6

4.32–5.68 4.54–5.46 4.77–5.23 5.54–6.46 5.54–6.46 5.54–6.46 5.77–6.23

(1–19%) (20–39%) (20–39%) (40–59%) (40–59%) (20–39%) (1–19%)

(important) (important) (very important) (very important) (very important) (very important) (very important)

a The range and confidence interval represent the median response of participants when asked how often (% of all cases) human health or human health impacts are incorporated into each phase of the EA process, where: 1 = 0%, 2 = 1– 19%, 3 = 20–39%, 4 = 40–59%, 5 = 60–79%, 6 = 80–99% and 7 = 100%. b The importance level represents the median response of participants when asked how important it is to consider human health or human health impacts in each phase of the EA process, where: 1 = not important, 2 = slightly important, 3 = somewhat important, 4 = moderately important, 5 = important, 6 = very important and 7 = extremely important.

That being said, dissent was also found to exist within participant groups in the North, particularly between northern health practitioners and EA regulators. For example, an interviewee from a northern health and social services department suggests: The impact of development on health is often overlooked through the EA process, especially north of 608. (Inuvik Regional Health and Social Services Authority, pers. comm., 2004) Whereas another interviewee, an EA analyst with a northern health and social services department contends that human health assessment in northern EA practice b. . .is becoming more recognized as the [North] faces such an increase in development and as traditions by many families are attempted to be maintainedQ (EA Analyst, Government of the Northwest Territories, pers. comm., 2004). In summary, there is agreement that health is important to consider in EA; however, there does not exist a strong consensus as to how often health is actually assessed in practice. 3.3. Scope of health Next, participants were asked to evaluate the nature of health considerations in recent northern EA practices. The survey results are consistent with the literature in that more Table 3 Cosine theta values (measures of similarity) for (a) frequency and (b) importance of health integration during dfollow-up and monitoringT in northern EA (A)

(B) Federal authorities

Federal authorities Provincial authorities Territorial authorities Consultants and proponents Aboriginal and First Nations

73.2% 84.8% 59.4% 87.1%

Provincial authorities

Territorial authorities

Consultants and proponents

Aboriginal and First Nations

68.2%

60.8% 96.2%

94.8% 86.1% 78.3%

65.8% 92.1% 85.2% 85.2%

94.9% 70.7% 76.5%

84.5% 90.4%

94.9%

EA component

Project description

Federal authorities

Provincial authorities

Territorial authorities

Consultants and proponents

Aboriginal and First Nations

Emphasis dtypicallyT given (median, 95% CI)

Emphasis dshouldT be given (median, 95% CI)

Emphasis dtypicallyT given (median, 95% CI)

Emphasis dshouldT be given (median, 95% CI)

Emphasis dtypicallyT given (median, 95% CI)

Emphasis dshouldT be given (median, 95% CI)

Emphasis dtypicallyT given (median, 95% CI)

Emphasis dshouldT be given (median, 95% CI)

Emphasis dtypicallyT given (median, 95% CI)

Emphasis dshouldT be given (median, 95% CI)

2

4

2

4

2

4

3

4

2

4

Baseline description 2.5 VEC identification

2

Impact prediction

2.5

Significance 2 determination Impact management 2 Follow-up and monitoring

2

1.47 2.53 0.00 5.00 1.65 2.35 1.62 3.38 1.65 2.35 1.29 2.71 1.29 2.71

4 4 4 4 4 4

4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 3.66 4.34 4.00 4.00

2.5 2.5 3 3 3 3

1.21 2.79 1.30 3.70 1.32 3.69 1.42 4.58 1.42 4.58 1.02 4.98 0.63 5.37

4 4 4 4 4 4

4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 3.29 4.71

2 2 2 2 2.8 1

1.54 2.46 1.09 2.91 1.09 2.91 1.54 2.46 1.09 2.91 1.63 3.98 0.09 1.91

4 4 4 4 4 4

2.63 5.37 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00

2 2 2 3 3 2

2.05 3.95 1.52 2.48 1.29 2.71 1.29 2.71 2.05 3.95 1.63 4.37 1.29 2.71

4 4 4 4 4 4

3.77 4.23 3.77 4.23 3.77 4.23 4.00 4.00 3.77 4.23 4.00 4.00 3.32 4.68

2 2 2 2 2 1.5

1.60 2.40 1.60 2.40 0.42 3.58 0.82 3.18 0.42 3.58 0.52 3.48 0.32 2.69

4 4 5 5 5 4

3.70 4.30 3.70 4.30 3.11 4.89 4.11 5.89 4.11 5.89 4.11 5.89 3.11 4.89

a Emphasis that is btypically givenQ and bshould be givenQ to human (social) health in comparison to physical (environmental) health factors is assessed on a scale from dextremely less emphasisT = 1, dless emphasisT = 2, dslightly less emphasisT = 3, dequal emphasisT = 4, dslightly more emphasisT = 5, dmore emphasisT = 6 and finally dextremely more emphasisT = 7.

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Table 4 Emphasis given to human (social) health integration compared to physical (environmental) health factors—median responses and 95% confidence intervals by participant groupa

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attention is given to physical health and health impacts due to physical environmental change than to broader social health impacts (Table 5). This is, however, an interesting finding since 91% (n = 48) of survey participants (EA practitioners, regulators, consultants and proponents) indicated that the human (or social) dimensions of health should be given dequal emphasisT to physical (or environmental) health factors. Results indicate a significant difference between the amount of emphasis dtypicallyT given to social and other aspects of human health and the amount of emphasis that it dshouldT receive. This is true across all phases of the EA process. For example, at the 95% confidence interval for the median, there is an expressed view that considerably less emphasis is placed on human health during dproject descriptionT in comparison to the emphasis that it dshouldT receive. The results reflect those of a recent project-by-project analysis of Canadian northern EA by the authors (Noble and Bronson, 2005), in that health in northern EA is typically approached from a physical perspective, often limited to the physical health effects due to environmental change caused by project actions, or limited to those social determinants of health, such as project employment, over which a proponent has direct control. 3.4. Perspectives on the scope of health Different perspectives concerning the scope of health in northern EA were also evident across participant groups (see Table 4). For example, participants from dprovincial governmentsT suggested that the amount of emphasis typically given to human or social health in comparison to physical or environmental health attributes is sufficient in current practice for impact prediction, determining significance, impact management and follow-up. Federal and territorial EA authorities, however, indicated that the level of integration of human health across all stages of EA is significantly less than what is desired. Participants representing Aboriginal and First Nations interests similarly indicated that the consideration of human or social health, in comparison to physical or environmental health, is insufficient across the EA process—with the exception of valued environmental component (VEC) identification. EA consultants and proponents indicate satisfactory treatment of human or social health during project description, determination of impact significance and for impact management. Consistent with previous discussions all survey participants, with the exception of provincial EA authorities, agree that Table 5 Emphasis given to human (social) health integration compared to physical (environmental) health factors—median responses and 95% confidence intervals for all survey participants EA phase

Emphasis dtypicallyT given a

Project description Baseline description Identification of VECs Impact prediction Determination of impact significance Design of impact management measures Post-project follow-up and monitoring a

Emphasis dshouldT be given

Median

95% CI

Mediana

95% CI

Less Less Less Less Less Less Less

1.51–2.49 1.76–2.24 1.76–2.24 1.51–2.49 1.51–2.49 1.27–2.73 1.51–2.49

Equal Equal Equal Equal Equal Equal Equal

4.0–4.0 4.0–4.0 4.0–4.0 4.0–4.0 3.89–4.11 3.77–4.23 4.0–4.0

(2) (2) (2) (2) (2) (1) (1)

(4) (4) (4) (4) (4) (4) (4)

Emsphasis that is typically given and should be given to human (social) health in comparison to physical (environmental) health factors is assessed on a scale from dextremely less emphasisT = 1, dless emphasisT = 2, dslightly less emphasisT = 3, dequal emphasisT = 4, dslightly more emphasisT = 5, dmore emphasisT = 6 and finally dextremely more emphasisT = 7.

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human health is given considerably less emphasis than physical environments during postproject follow-up and monitoring. There is also a general consensus among participants that health should be given at least dequal emphasesT to physical factors in northern EA practice. As Davies (1992) explains, because the North is already a sensitive environment–physically, socially and culturally– development projects need to be assessed within the context in which they are proposed. This requires that EAs integrate the social and cultural complexities of health and the local environment while weighing the economic benefits of project development. A recent study by the Government of the Northwest Territories on the impacts of mining on northern community health and well being, for example, states: Most projects. . .are expected to have beneficial effects on health and well-being because they create jobs and provide other economic benefits that contribute to a better standard of living. . ..They also have the capacity to cause adverse effects on health and well-being at the individual and community level. . ..Social and community health may. . .be affected negatively where individuals face a loss of cultural identity and quality of life, social disruption and violence, and a breakdown of community and family support networks. (GNWT, 2000: 2, cited in MVEIRB’s, 2002 Issues and Recommendations for Social and Economic Impact Assessment in the Mackenzie Valley: 5–6) In principle, bthe impacts to spiritual, cultural. . .and social infrastructure are large compared to environmental impactsQ (EA Consultant, pers. comm., 2004). In practice, there remains considerable dissent as to how much attention such issues actually receive in comparison to physical health and the health effects due to physical environmental change. 3.5. EA performance For those cases where health impacts were included as part of the project EA, participants were asked to evaluate the assessment and management of those impacts. Responses from territorial government participants and EA consultants and proponents suggest that in those cases where health is considered northern EA is performing dabove averageT, in that physical health impacts and health risks are treated as important as other potential project impacts (Table 6). This may be due in part to the recent adoption of a number of northern EA regulations, such as the Table 6 Performance of northern EA in terms of addressing the impacts of development on human health Rating of northern EA performance

All participants (n = 51) Federal authorities (n = 21) Provincial authorities (n = 6) Territorial authorities (n = 4) Consultants and proponents (n = 13) Aboriginal and First Nations (n = 7)

Mediana

95% CI

5 4 5.3 5 5 3

4.56–5.44 3.65–4.35 3.55–7.00 3.42–6.58 3.68–6.32 1.81–4.19

a In terms of addressing the impacts of development on human health, EA practitioners and administrators assigned ratings based on the following definitions: 1 = below average: only specific physical health impacts are addressed; 3 = average: physical health impacts and health risks are assessed; 5 = above average: physical health impacts and risks are treated as important as other potential impacts; 7 = very good: health is broadly defined to include biophysical health as well as social health impacts; 2, 4, 6 = intermediate ratings.

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Mackenzie Valley Resource Management Act and the Nunavut Land Claims Agreement, which have resulted in improvements with regard to incorporating community health and health concerns in northern EA practice (MVEIRB, 2002). However, Aboriginal and First Nations interests consider northern EA to be performing only daverageT, such that only physical health and health risks (e.g., communicable disease or exposure) are typically addressed in EAs. Interviews with northern health practitioners reflect the perspective of Aboriginal and First Nations participants, in that EA is seen as performing only daverageT in terms of health assessment (i.e., social health issues are considered, but they are given significantly less attention than other physical health or environmental project impacts). According to one interviewee: . . .human health issues are not being incorporated very well. There is no evidence of that, not from and Aboriginal worldview or a health stand point. . .There is a perception that companies are doing a better job of including health issues, but how well is unclear. It seems as though it may just be lip service and the focus remains on environmental factors. (Yellowknife Health and Social Services, pers. comm., 2004) 4. Principal barriers to effective health integration The final section of the questionnaire attempted to gain insight as to the principal barriers to health integration in EA. An initial list of barriers was provided to participants based on Trudgill’s (1990) AKTESP (Agreement, Knowledge, Technological, Economic, Social and Political) framework, which identifies a number of common barriers to a better environment. Participants were asked to identify the barriers that are most significant in terms of health integration and to comment on the nature of those barriers (Table 7). For brevity, we highlight here only a select few of these barriers that were identified as most significant and, arguably, common across other EA systems in Canada and abroad. 4.1. Differences in EA expectations and health understanding Different expectations of EA and different understandings of the scope of health may pose significant barriers to effective health integration. In this study, the state of health in EA was assessed based on the knowledge and experiences of EA and health practitioners and other interests that regulate, administer or influence the EA process. The results indicate that health is

Table 7 Barriers to health integration in northern EA Barrier (based on AKTESP)

Median ratinga

Incomplete understanding of the scope of health in EA (knowledge) Absence of standardized EA methods and frameworks for assessing human health impacts (knowledge, technology) Lack of coordination and communication between EA practitioners and health professionals (agreement, social, political) Difficulty obtaining health data (knowledge, technological, social) Legislation too restrictive or insufficient (political) Lack of financial resources for health assessment and data (economic) Limited time frame for health assessment in EA (temporal)

Significant (5) Significant (5)

a

Significant (5) Significant (5) Moderately significant (4) Significant (5) Significant (5)

Participants were asked to rate on a scale of 1 to 7 the significance of each barrier to health integration in northern EA, where 1 = insignificant; 3 = slightly significant; 5 = significant; 7 = extremely significant; 2, 4, 6 = intermediate scores.

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currently recognized as an important component of EA and addressed on average 70% of the time in northern project assessments. That being said, there was considerable variation in participant’s perceptions of the state of health in EA—both in terms of health integration across various phases of the assessment process and the effectiveness of EA in addressing health impacts. For example, territorial government participants and EA practitioners and proponents identified EA as performing above average in terms of health integration, but there was disagreement from Aboriginal and First Nations participants, as well as northern health practitioners, suggesting that health is perceived as neither well incorporated nor well assessed in EA in Canada’s North. Such differences may be due, in part, to different expectations of EA and understandings of the nature of health. For example, notwithstanding the study’s adoption of a common WHO definition of health, the scope of health in Canada’s North, and in particular Aboriginal perceptions of health, goes beyond the accepted WHO definition to include health as balance between humans and their environment (INAC, 2003; O’Neil and Solway, 1990) and places a strong emphasis on community health (Davies, 1992), encompassing such factors as sustaining cultural identity, teachings of traditional values and other social, spiritual and psychological effects (Health Canada, 1999). Practitioners, regulators and health officials must be aware of such differences in EA expectations and understandings of health if health effects are to be adequately addressed in the EA process. 4.2. Coordination and communication A second barrier to health integration concerns the limited coordination among those parties responsible for health and EA. The survey and interview participants agree that those agencies responsible for northern EA do not currently have the capacity or expertise to adequately deal with human health related issues and concerns, and bqualified health professionals neither play a direct role nor have the needed input regarding human health related matters in conducting assessmentsQ (Environment Canada, pers. comm., 2004). This appears to be a common problem across international EA systems (e.g., Birley, 2002; Banken, 1999), thus demonstrating the need for improved coordination between health and EA practitioners and regulators, including proponents and the public. However, when different cultural understandings of the nature of health prevail, the problem of coordination is particularly challenging. This is only exacerbated by communication barriers in health data collection where local languages, for example, such as Inuit or Cree in Canada’s North, are not spoken by health or EA practitioners. A study interviewee from Health Canada (pers. comm., 2004) puts it best in saying that current practice bdoes start to address the integration of human health into EA; however, a simultaneous cultural change is required of practitioners, legislators, administrators, etc.Q if such integration is to be meaningful. 4.3. Scope of EA legislation Third, there tends to be considerable disagreement as to the sufficiency of current EA legislation and its provisions for health assessment. On the one hand, 47% of study participants believe current legislation and regulatory EA requirements for northern health assessment to be sufficient, noting that bthe legislation is fine and clearly allows for addressing health. . .it is the practitioners who have not taken to incorporating it (Environment Canada, pers. comm., 2004). On the other hand, 36% of study participants identified current legislation as dinsufficientT with

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regard to current requirements for health assessment. One participant explains that health effects should be considered a bdirect effectQ of the project and bnot only as an effect resulting from a change to the environment. . .this is why health effects are so often ignored in EA (Parks Canada, pers. comm., 2004). Under current Canadian federal EA legislation, for example, benvironmentQ, means components of the earth including land, water, air, organic and inorganic matter, living organisms and the interacting natural systems of which they are part. However, an benvironmental effectQ means any change that a project may cause in the (physical) environment, and any effect of such change on health, socio-economic and other human environmental components (Canada, 2003, S2(1)(a)(i)). The consideration of a project’s effects on human health is thus required only indirectly, as a result of a physical environmental change. Certainly, no project that has a significant direct, adverse effect on physical health would be allowed to proceed in Canada’s North without proper mitigation; the problem is that other health effects that relate to quality of life, culture or social well being are much less likely to be given equal consideration. A study participant from Canada’s National Energy Board (pers. comm., 2004) emphasizes the value in legislation that is deliberately broad in scope, noting that it benables practitioners to apply the process to a range of development projects and in different contextsQ; however, Davies (1992) argues that the health effects of projects need to be assessed specifically within the context in which they are proposed. More regionalized and context specific EA regulations, such as Canada’s Mackenzie Valley Resource Management Act and the Nunavut Land Claims Agreement, could provide for a more contextually relevant approach to EA and a stronger role for understanding and integrating health and social concerns. An interviewee and EA analyst with the government of the Northwest Territories suggests that under such regionalized legislation practitioners have been more proactive at identifying and acknowledging the significance of human health in EA (EA Analyst, Government of the Northwest Territories, pers. comm., 2004). 4.4. Supporting EA methods and frameworks A final barrier to effective health integration identified by study participants concerns the complexity of health impacts and the availability of supporting EA methods and frameworks. Eyles (1999) suggests that identifying causal links between project actions, environmental change and human health poses a significant challenge to EA practitioners. This was evidenced in the report of the Cluff Lake Board of Inquiry–a panel appointed to review a proposed uranium mine development in northern Saskatchewan–who suggested that it is ba near impossible taskQ to measure the effects of mining operations on an already disordered society (Cluff Lake Board of Inquiry, 1978, p. 174). An interview with a current environmental affairs manager (pers. comm., 2004) representing one of Saskatchewan’s northern uranium mining companies confirms this challenge, suggesting that there are often btoo many confounding factorsQ to tell whether a project will have a direct effect on communities and well being. Rather than focus attention on health impact prediction and managing negative health outcomes, Sloof (1995), in a review of the state of health integration in UK EA practice, suggests the need to focus attention on preventative health strategies as part of project development plans and objectives. The problem, however, is that pre-decision analysis (even if objectives driven) is not a sufficient condition for sound planning and impact management (Arts and Caldwell, 2001, p. 177). In practice, health impacts are often included in EA impact prediction, mitigation and preventative programs (see, for example, Table 2 and Kwiatkowski and Ooi, 2003), but there is an apparent lack of post-decision follow-up and monitoring (Table

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2). As a result, the actual health effects of project developments and the effectiveness of mitigation programs are often unknown. Arguably, based on observations from recent EA follow-up literature (e.g., Noble and Storey, 2005), the limited consideration of health in EA follow-up is not unique to health per se, but rather a function of the lack of follow-up of human and other social impacts in general. If health is to form an integral part of EA, then health must invariably be part of the project assessment, decision-making and monitoring processes. 5. Observations and conclusions Based on a survey of Canadian northern EA and health practitioners, administrators and special interest groups, this paper further demonstrates the lack of consistent integration of health in EA and identifies a number of principle barriers to improved integration. Keeping in mind the northern context and limited nature of the survey, the results suggest that the general trend towards an integrated impact assessment that combines environmental, social and health considerations may not be as forthcoming as suggested by recent literature—at least not in Canada’s North. While health is invariably addressed in EA, it tends to be limited to the predecision stages with considerably less attention to post-decision follow-up and monitoring. As a result, there is often little understanding of the actual health effects due to project development. In addition, health in EA is limited to the physical components of health or health impacts due to physical environmental change with considerably less attention to the social or cultural aspects of health. Notwithstanding the recognized need to include health as part of the EA process, health is addressed significantly less often that what is considered necessary by EA and health practitioners. Finally, different stakeholders appear to have different understandings of the scope of health in EA and different health expectations of the EA process. What is promising, however, is that there is agreement on a number of pressing barriers to health integration including differences in understanding and expectations, limited coordination and communication among EA and health practitioners and the affected publics, narrow scope of EA legislation with regard to defining health impacts, and the need for supporting EA methods and frameworks— particularly at the post-decision stage. Moving toward a more integrated approach will require further investigation as to the underlying nature of these barriers and how they might be addressed. Acknowledgements This research was funded by the Social Sciences and Humanities Research Council of Canada. We also wish to acknowledge those who participated in the survey and interviews. The comments and suggestions of one anonymous reviewer are greatly appreciated. References Arts J, Caldwell P, Morrison-Saunders A. Environmental impact assessment follow-up: good practice and future directions. Impact Assess Proj Apprais 2001;19(3);175 – 85. Banken R. From concept to practice: including the social determinants of health in environmental assessment. Canad J Public Health 1999;90(1);S27 – 30. Birley M. A review of trends in health-impact assessment and the nature of the evidence used. Environ Manag Health 2002;13(1);21 – 39. Birley M. Health impact assessment, integration and critical appraisal. Impact Assess Proj Apprais 2003;21(4);313 – 21. Birley M, Boland A, Davies L, Edwards R, Glanville H, Ison E, et al. Health and environmental impact assessment: an integrated approach. London7 Earthscan and British Medical Association; 1998.

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