Current Global Health Impact Assessment Practice

Mirko Winkler led a team that undertook a survey of 122 HIA practitioners across 29 countries . The findings highlight that:

  • HIA is being used worldwide
  • Capacity is concentrated at the beginner and intermediate levels, though a higher proportion of respondents from Europe reported having more than ten years of HIA experience
  • there is a need for more advanced capacity building and training offerings internationally
  • strengthening the policies and legal frameworks under which HIAs are undertaken remains relevant.
Origin countries of respondents; and the number of respondents per region with corresponding years of HIA practice experience
Regions where HIA assignments were conducted; and fields of HIA application
Types of health assessments conducted; and decision-maker on type of health assessment to conduct

Twenty-four percent of respondents were from the Asia Pacific, and practices across our region are reflected in the overall results.

Health Impact Assessment: A practical guide that I wrote with Patrick Harris, Elizabeth Harris, and Lynn Kemp was identified as the fifth most-used HIA guidance internationally, after WHO guides, Martin Birley’s book on HIA , and the IAIA Best Practice Principles .

In general respondents were split on whether HIA’s use is continuing to increase or has stagnated, a debate that has relevance across the Asia Pacific region. Of particular important to our region, the paper emphasises that:

Finally, there is an increasing recognition of the role that biodiversity and ecosystem services play in the relationship “healthy planet, healthy people”, and the role that impact assessments play. In an outlook for the future, and additionally to providing a framework for safeguarding health in sustainable development, HIA has the potential to be contributory to the operationalisation of “planetary health”.



Harris, P., B. Harris-Roxas, E. Harris, and L. Kemp. “Health Impact Assessment: A Practical Guide.” Sydney: UNSW Centre for Primary Health Care and Equity and NSW Health, 2007.
Martin Birley. Health Impact Assessment: Principles and Practice. London: Routledge, 2011.
Quigley, R., L. den Broeder, P Furu, A Bond, B Cave, and R Bos. “Health Impact Assessment International Best Practice Principles.” Fargo, North Dakota: International Association for Impact Assessment, 2006.
Winkler, Mirko S., Peter Furu, Francesca Viliani, Ben Cave, Mark Divall, Geetha Ramesh, Ben Harris-Roxas, and Astrid M. Knoblauch. “Current Global Health Impact Assessment Practice.” International Journal of Environmental Research and Public Health 17, no. 9 (April 25, 2020): 2988.

Revisiting the 2020 Summit: The renewed urgency for a long-term strategy for Australia’s future

Cover of the Australia 2020 Summit report

I was wondering about the Australia 2020 Summit tonight, prompted by seeing former Prime Minister Rudd on television talking about the Ruby Princess. For those who don’t remember, it was a sort of festival of ideas convened by the still-new Gillard-Rudd government in 2008. It was supposed to shape a long-term strategy for Australia’s future, one that was sadly never realised.

If I’m honest I imagined that the report would be full of naïve assumptions and misguided aspirations (much like Mr Rudd’s comments this evening). The horrors of the summer bushfires and the global COVID-19 pandemic mean we’re living in a world I didn’t imagine even a year ago, even though I’ve been worried about climate change, biodiversity loss, and water scarcity for a while. It must have been inconceivable twelve years ago.

Instead I was surprised by how many of the ideas remain relevant and, by and large, unaddressed. The topics in the table of contents should be part of any long-term strategy we’d develop today, albeit with much greater urgency about climate change.

An example of the ideas captured in the report, this from page 385.

There are even some of my pet topics in the report, like health impact assessments, which I’d entirely forgotten.

A call for health impact statements of all new policies and an audit of the impacts of taxation on healthy, from page 155 in the report.

I won’t attempt to summarise the report. It’s 399 pages, and quite densely packed with ideas. It’s definitely worth reading if you have a chance.

Mostly, I’m left with a sense of sadness about how we’ve wasted the last twelve years. I hope the crisis we face due to COVID-19 forces us to reconsider our direction as a society, and the renewed urgency for a long-term strategy for Australia’s future.

“The first wave hits the poor, the second wave hits the rich”: Lessons from the 1918 pandemic

Black and white interior photograph of workers inside a factory. Men and women are shown, with the women lined up on the right hand side of a long piece of equipment with sloping sides and circular holes in it, perhaps containing sinks, with a man looking over a low wall on the left side of the space. The interior is brick, and there is a mezzanine at the back of the space. There are various pipes, buckets, wooden barrels and crates in the space, with glass plate racking on the right hand side.
Workers waiting to use the ‘inhalatorium’ at the Kodak Australasia Pty Ltd factory in Abbotsford, 1919. The inhalatorium was thought to protect workers from being infected with the influenza during the 1919 Spanish flu epidemic. A zinc sulphate solution was steamed onto the worker’s faces to ‘disinfect’ the workers’ throats and air passages. Staff were given this treatment twice a day for four minutes at a time.
Source: Museums Victoria
Photographer: Unknown
Credit: Courtesy of Kodak Australasia Pty. Ltd.
Terms of use: Public Domain

The poor came down with influenza first and were overall most affected, while the rich with less exposure in the first wave tended to have higher morbidity in the second wave. This finding is concurrent with prior studies documenting that the poor had the highest 1918 pandemic mortality. Although this study could not tease out the mechanisms for the SES crossover in morbidity, results suggest that preparedness plans should consider how (non‐)pharmaceutical interventions can hinder socioeconomic morbidity disparities in future pandemics. Surprisingly however, social inequalities in pandemic outcomes do not form part of the discussion in international preparedness plans for pandemic influenza. This is not conducive to achieving the international goals of eradicating poverty, reducing social inequalities and ensuring good health for all by 2030.


My knowledge about the 1918-1919 influenza pandemic is woeful. I was prompted to learn more by this diagram from the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19), which describes COVID-19 as similarly transmissible to the H1N1 influenza in 1918-1919. I’ve been reading a few articles, keeping an eye out for potential lessons for our looming COVID-19 pandemic.

Source: Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19, p. 11

I’m just beginning to read into the literature. There are some pretty clear lessons—though no thunderclap revelations. These include:

  • Handwashing was effective then and will remain amongst our most effective practices now .
  • There will likely be two or more waves of COVID-19 .
  • In the absence of specific treatments, we’ll have to rely on community mitigation measures to contain the virus, as was the case in 1918 .
  • There is likely to be a social gradient in transmission, i.e. the poor are more likely to get COVID-19, at least at first . This is a concern that some have already flagged in the U.S.
  • If there is a social gradient in the disease, there needs to be a social gradient in our response. The most affected locations and communities should be the focus of the health system’s initial response (we can’t just assume this will be the case). If antiviral therapies are found to be effective, or if a vaccine is eventually developed, consideration should be given to deploying them to poorer areas first .
  • Air pollution may increase the impact of the pandemic (important given the recent bushfires and poor air quality in Australia).
  • We’re much better placed to respond now than health systems were in 1918. Things like intensive care units and protective equipment simply didn’t exist then .
  • The economic impacts of the pandemic will likely have health consequences that dwarf those of the virus itself.

The social impacts of the 1918 pandemic were far-reaching, but also still seem to be poorly understood. “What if” questions abound but are unanswerable. For example, the Indian independence movement was strengthened by the British mishandling of its influenza response in India. Would independence have happened in the same way without the pandemic?

It’s similarly difficult for us to imagine what COVID-19’s far-reaching future social consequences will be.

I’ll keep reading. Your suggestions about good sources are welcome.


Mamelund, Svenn-Erik. “1918 Pandemic Morbidity: The First Wave Hits the Poor, the Second Wave Hits the Rich.” Influenza and Other Respiratory Viruses 12, no. 3 (2018): 307–13.
Jester, Barbara J., Timothy M. Uyeki, Anita Patel, Lisa Koonin, and Daniel B. Jernigan. “100 Years of Medical Countermeasures and Pandemic Influenza Preparedness.” American Journal of Public Health 108, no. 11 (2018): 1469–72.
Wilson, Nick, Osman D Mansoor, and Michael G Baker. “The First Analytic Evidence for Socio-Economic Gradients in 1918 Pandemic Influenza Mortality Rates for New Zealand” 131, no. 1486 (2018): 5.
Clay, Karen, Joshua Lewis, and Edson Severnini. “Pollution, Infectious Disease, and Mortality: Evidence from the 1918 Spanish Influenza Pandemic.” The Journal of Economic History 78, no. 4 (December 2018): 1179–1209.
Martini, M, V Gazzaniga, N L Bragazzi, and I Barberis. “The Spanish Influenza Pandemic: A Lesson from History 100 Years after 1918.” Journal of Preventive Medicine and Hygiene 60, no. 1 (2019): E64–67.
Jester, Barbara, Timothy M. Uyeki, Daniel B. Jernigan, and Terrence M. Tumpey. “Historical and Clinical Aspects of the 1918 H1N1 Pandemic in the United States.” Virology 527 (January 15, 2019): 32–37.
Cristina, Juan, Raquel Pollero, and Adela Pellegrino. “The 1918 Influenza Pandemic in Montevideo: The Southernmost Capital City in the Americas.” Influenza and Other Respiratory Viruses 13, no. 3 (2019): 219–25.

Heatwaves: Changes in frequency and intensity

I’ve found myself thinking a lot about this paper by Herold et al. over the past few days. It describes the far-reaching implications of climate change for health and agriculture across different regions within Australia.

In particular I keep thinking about the implications of these two graphs:

The first graph shows heatwave frequency and the second one shows heatwave amplitude for different Australian cities for the recent past (blue), near-future (green) and far-future (red). Bottom and top of boxes indicate the 25th and 75th percentiles.

NB: For those not familiar with it, heatwave amplitude is a way of measuring and modelling the hottest day of the hottest heatwave within a year. This is different from the other common way of measuring heatwave intensity– magnitude–that looks at the average temperature across all heatwave days within a year. °C2 is a heatwave unit of measurement and isn’t the same thing as degrees Celsius.

There are many impacts and consequences associated with this model, but the frequency and scale of near- and far-future heatwaves alone should terrify us.

Source: Herold, N., M. Ekström, J. Kala, J. Goldie, and J. P. Evans. 2018. “Australian Climate Extremes in the 21st Century According to a Regional Climate Model Ensemble: Implications for Health and Agriculture.” Weather and Climate Extremes 20:54–68.

A neural network defines health as…

One of Mike Lynch’s bot creation is the Glossatory, which generates definitions of words based a recurrent neural network. Mike illustrates some of the more outlandish ones at

a neural net defines AUTHORITY, created by Glossatory/Mike Lynch 2019. Shows a drone-like machine looking over a rough sketch of a village.
a neural net defines AUTHORITY, created by Glossatory/Mike Lynch 2019. Source

The Glossatory is based on a recurrent neural network, which is the type of artificial neural network that’s typically used for machine translation. Mike used a training set of 82,115 definitions that were taken from WordNet. The results are often amusing, frequently incomprehensible, but mostly they’re just odd.

Continue reading “A neural network defines health as…”

Community health workers and data privacy

This is an interesting open access article that brings together two of my pet interests: community health workers and data privacy.

Mobile Health Systems for Community-Based Primary Care: Identifying Controls and Mitigating Privacy Threats

On one hand these type of mHealth platforms allow data collection that’s meaningful to people, as well as services and systems. In developing country contexts this has often never been collected before except through specific population health surveys.

On the other hand, lots of health systems and major philanthropic funders are talking about using this data for linkage and data mining. They’re also talking about developing algorithms to guide care and risk stratification. Again, this is mostly being done with a focus on care in developing countries, but also developed ones too.

I’m ambivalent about this. The potential to actually capture data and to harmonise/minimise variation in care could be quite profound and far-reaching.

I just don’t trust algorithms though, largely because they reproduce our biases. I’m worried that investment might be in device-driven care rather than developing local workforces.

Primary health care provider–focused interventions for improving outcomes for people with type 2 diabetes

In brief

The greatest opportunities to enhance diabetes care in the Australian primary health care setting seem to be:

  1. delivering culturally tailored programs involving community health workers (a strong interest of mine)
  2. incorporating diabetes decision support into practice software.

About the paper

Colleagues at the Centre for Primary Health Care and Equity and I did a rapid review on what works to improve outcomes for people with Type 2 diabetes in primary health care , which is available now.

We identified (1) computerised decision support, (2) feedback and benchmarking on diabetes care quality, (3) culturally tailored programs (usually delivered by community health workers), and (4) enhanced practice nurse involvement in diabetes care as interventions that had a positive impact across several outcome measures. These outcomes included:

  • clinical outcomes (blood pressure, and body mass index, or weight)
  • biochemical outcomes (glycosylated haemoglobin [HbA1c], lipid profile, or renal function)
  • psychological outcomes (anxiety, depression, diabetes-related distress, perceived seriousness and vulnerability, self-efficacy, or self-care)
  • health-related quality of life measures from participant self-report.

The evidence about the use of decision aids (e.g. when to commence statins) was equivocal in terms of their impact on HbA1c, lipid profile and renal function. One high quality integrated care study on a virtual clinic, which brought together nurses, diabetologists and GPs, showed improvements in blood pressure but not renal function. No single intervention improved all the outcome measures that were considered.


Faruqi, N. et al. (2019) ‘Primary health care provider–focused interventions for improving outcomes for people with type 2 diabetes: a rapid review’, Public Health Research and Practice, 29(4), p. e29121903. doi: 10.17061/phrp29121903.

Care of patients with chronic conditions: achievements in Australia over the past decade

Mark Harris, Andrew Knight and I published a paper in the Medical Journal of Australia. It’s an update of a review of the management of chronic conditions in Australia, ten years on. What was surprising to me is that we haven’t made too much progress has in the obvious areas – integrated care, information sharing, multiple provider care plans. Many of the promising activities that have emerged over the past decade have been at the individual and practice level. For example, using peer navigators, and tailoring care to people’s literacy and activation levels.

The table below suggests some potential solutions, but these are only some of them.

ref=””> Some current barriers to optimal management of chronic conditions in general practice[/ca
More info: Care of patients with chronic disease: achievements in Australia over the past decade – The Medical Journal of Australia doi: 10.5694/mja18.00333

Sydney Local Health District EquityFest 2018

Every year Sydney Local Health District holds EquityFest, an event that showcases work being done to address health equity within the District and to consider what else needs to be done. The theme of this year’s EquityFest was “investing in the future – leaving no one behind”. It was an impressive showcase of the diversity of the District, and the work that they’re undertaking to respond to their communities’ needs.

More than that though, it provided a clear statement that equity matters to them as an organisation, something that we almost never see in contemporary Australian social institutions.

Key messages

  • There’s a need to invest meaningful time in understanding lived experience, not just giving lip-service to it through a narrow focus on things like patient experience measures.
  • Reflective and interrogative practices are required, personally and organisationally, to identify biases and to think about who’s excluded in, and through, our activities.
  • We need to think about “soft infrastructure” more meaningfully and systematically in planning (referring to services, networks, and community social assets), and sharing this through networks/backbone organisations.
  • There is a groundswell of interest in equity, but the challenge is developing a shared vision of how to achieve it, being accountable for change, and the related challenge of meaningful engagement.

Opening session

There was a welcome from the Chief Executuve Dr Teresa Anderson and a warm welcome to country by Uncle Allen Madden.

[bctt tweet=”Lessons from #EquityFest: People living in public housing, people who are homeless, people with substance use disorders, sex workers, and people in custody all experience extremely high levels levels of social exclusion” username=”ben_hr”]

A/Prof Jane Lloyd from the Health Equity Research and Development Unit gave an overview of the importance of social inclusion, and the health harms of exclusion. She spoke about who’s excluded in Australia, based on data from the Brotherhood of St Laurence Social Exclusion Monitor. This highlighted that people living in public housing, people who are homeless, people with substance use disorders, sex workers, and people in custody all experience extremely high levels levels of social exclusion.

Peter Jack from Sydney Local Health District spoke about his experiences of working with people in Redfern and Waterloo about health concerns. In discussion with Jane he reflected on life, growing up as an Aboriginal person and the challenges of working with people who are socially excluded in Sydney and Adelaide. The lessons I took from from Peter were the importance of investing time to develop credibility and trust with excluded people, before we try to do anything else.

Zione Walker-Nthenda spoke about the challenges of inclusiion in justice and domestic violence. She emphasised that self-interrogation is important, both organisationally and institutionally, to identify biases and barriers to inclusion. Essentially, that we need to constantly check that we’re not kidding ourselves about how inclusive we’re being.

Join-In and Speak-Out Sessions

There were a series of presentations showcasing work that’s happening. Highlights included Can Get Health, the Waterloo Neighbourhood Advisory Board, Redlink, and Healthy Homes and Neighhbourhoods.


Liz Harris from HERDU presented a framework that emphasised the need to consider place as the dynamic interplay between people and space – meaning the norms, use, services, and culture that make up the bulk of community life. Her critique was that in planning in human services often focuses on “need”, constrained to understanding people in atomised ways, and rarely considers place assets and issues in meaningful ways. She further suggested that more work is required to develop coherent program logic for these activities.

[bctt tweet=”Lessons from #EquityFest: Planning in human services often focuses on “need”, constrained to understanding people in atomised ways, and rarely considers place assets and issues in meaningful ways” username=”ben_hr”]

Hal Pawson from the UNSW Faculty of the Built Environment spoke about the factors that drive locational disadvantage. The drivers he emphasised were:

  • pushing people without resources to the fringes, or less accessible parts of cities
  • the diminishing pool of low cost housing in acccessible areas
  • a political unwillingness to use planning powers to reverse these trends.

Pam Garrett, Director of Planning within SLHD, spoke about the scale and pace of development within the inner west, ranging from Green Square, through to Waterloo/Redfern, Parramatta Road, and the Bankstown line. This represents a challenge in general, but also presents specific challenges to the District to make sure that services are responsive and that health inequalities aren’t exacerbated.

Geoff Turnbull from Inner Sydney Voice and REDwatch emphasised the need to get back to genuine community development, and the need to work in genuine partnership with communities. He emphasised the need to create organisations that bring together interests to have a voice in changes that would affect their suburbs and communities.





Social determinants of health: the 2016 Boyer Lectures

I wrote a piece for Croakey on the first of the 2016 Boyer Lectures, which focus on the social determinants of health. The four Boyer Lectures air weekly from Saturday 3 September 2016 at 1pm on Radio National, or you can subscribe to the podcast.

Norman Swan in conversation with Michael Marmot at the launch of the 2016 Boyer Lectures
Norman Swan in conversation with Michael Marmot at the launch of the 2016 Boyer Lectures (Image credit: ABC)

“One thing leads to another.”

This was the secret of life imparted to Michael Marmot by a patient, and recounted as part of the opening 2016 Boyer Lecture Fair Australia – Social Justice and the Health Gap. It could also be the theme of this year’s lectures.

In his first lecture, Marmot set out a compelling argument for the links between the circumstances of one’s life and work and health outcomes. These circumstances are socially determined and not equally shared, as shown by his foundational research on the social gradient in health.

This is familiar territory for most Croakey readers, and the information wasn’t new. It was well-crafted however, and drew on evidence, comparisons and anecdotes. Marmot led the audience, inexorably, from the problem of health inequalities, to their causes, then to the changes that are required to address them.

One thing leads to another.

The points in the lecture that resonated most with me were:

Health status is a better indicator of wealth than GDP

Marmot cited the example of Costa Rica, who have invested heavily in education. He outlined the benefits this has brought to their health and national development, in ways that aren’t captured by GDP and conventional economic measures alone.

This reminder that health is a meaningful and under-recognised indicator of wealth and assets is timely given the publication of Clare Bambra’s excellent Health Divides: Where you live can kill this week. It’s destined to become a seminal work on the political geography of health, but it also puts forward several creative ways of presenting data on health inequalities.

My favourite idea is a European Health Championship, modelled on the European Football Championship. Health League


In a sporting nation like Australia, this sort of approach could get attention.

Imagine if we competed internationally to have the best health. Imagine if successfully reducing the gap in life expectancy between Indigenous Australians and non-Indigenous Australians became a source of national pride.


Marmot emphasised the role that empowerment, or lack of empowerment, plays in determining people’s health. He drew on the framework for empowerment developed for the WHO Commission on the Social Determinants of Health. This emphasises the need for material, psychosocial, and political empowerment if people are to take control of their health and have the same opportunity for good health.

Using data to drive change

Marmot gave the example of Coventry in the UK, who describe themselves as a “Marmot City”. They have established monitoring and reporting frameworks to drive activity on health inequalities. Accountability has enabled sustained action and a better understanding of the issues.

In Australia, many services have been working on the same issues. South Eastern Sydney Local Health District has incorporated a set of comprehensive indicators of health inequalities into its Equity Strategy. Data enables action to move beyond rhetoric.

A different audience

The value of the Boyer Lectures is not their ability to preach to the converted. It’s about exposing an engaged audience to new ways of thinking about Australia’s future, and in that task last night’s lecture succeeded.

Eva Cox’s 1995 Boyer Lectures on A Truly Civil Society were instrumental in sparking a wave of interest in social capital in the design and evaluation of social support in Australia during the mid ‘90s. Eva herself would say the tide has gone out on social capital, but its impact is still felt.

The research program I manage includes a stream on place-based interventions to address health inequities. As part of this we have collected neighbourhood-level data on trust and social capital in disadvantaged areas in South Western Sydney since 1998. This research can be directly traced back to the agenda set by the 1995 Boyer Lectures, and informs and guides our work to this day.

It’s my hope that this year’s Boyer Lectures may have a similar catalyst effect.

The remaining lectures will focus on the importance of early childhood, our work and living conditions, and the action required by researchers, civil society, and government.

There is a series of articles at The Conversation on the themes covered by this year’s Boyer Lectures, featuring contributions from Sharon Friel and Fran Baum.

Hopefully this will lead to a broader appreciation of the social gradient in health in Australia, and a shared understanding of the case for action.

One thing leads to another.

To coincide with the Boyer Lectures, Croakey has also released a collection of articles on the social determinants of health. Includes contributions from Fran Baum, El Gibbs, Liz Harris, Sharon Friel, Tim Senior, Marie McInerney, Marilyn Wise, Peter Sainsbury, Denis Raphael, Fiona Haigh and many others, including me. Recommended reading.