Major update of the International Best Practice Principles for health impact assessment

Cover of the International Best Practice Principles: Health Impact Assessment document

The International Association for Impact Assessment has published revised International Bets Practice Principles: Health Impact Assessment.

This influential guide has been updated for the first time in fifteen years to reflect the evolution of health impact assessment practice. Mirko Winkler led the revision and the team included Francesca Viliani, Astrid Knoblauch, Ben Cave, Mark Divall, Geetha Ramesh, Peter Furu and I .

Key Citations

The Principles are accompanied by an updated IAIA Key Citations document. This sets out important health impact assessment milestone publications, guidance documents and journal articles .

The new guide complements the findings of the international survey on Current Global Health Impact Assessment Practice that was published last year .


Winkler, M., Viliani, F., Knoblauch, A., Cave, B., Divall, M., Ramesh, G., Harris-Roxas, B., & Furu, P. (2021). International Best Practice Principles: Health Impact Assessment (2nd edition) (Special Publication Series). International Association for Impact Assessment.
Winkler, M., Viliani, F., Cave, B., Divall, M., Knoblauch, A., Harris-Roxas, B., Ramesh, G., & Furu, P. (2021). Key Citations: Health Impact Assessment (Key Citations Series). International Association for Impact Assessment.
Winkler, M. S., Furu, P., Viliani, F., Cave, B., Divall, M., Ramesh, G., Harris-Roxas, B., & Knoblauch, A. M. (2020). Current Global Health Impact Assessment Practice. International Journal of Environmental Research and Public Health, 17(9), 2988.

A framework for preferred practices in conducting culturally competent health research in a multicultural society

It was a real privilege to work with my colleagues Lisa Woodland, Ilse Blignault and Cathy O’Callaghan on this paper.

All research takes place within broader systems of gender and sociopolitical environments [29, 30]. We do not wish to minimize the importance of the social determinants of health in producing and reproducing health inequities [53]. On the contrary, we would argue that cultural differences need to be understood alongside gender, educational status and socioeconomic status [54]. This highlights the importance of a culturally competent research team and community partners in interpreting study results and considering their implications. We are also conscious of the need to recognize the protective aspects of culture. Culture should not be problematized by health services or health researchers. Culture provides shared meaning and identity, as well as enabling mechanisms for material support. Further, culture is not static but ever-changing, as is the multicultural profile of Australian society.

Woodland, L., Blignault, I., O’Callaghan, C., & Harris-Roxas, B. (2021). A framework for preferred practices in conducting culturally competent health research in a multicultural society. Health Research Policy and Systems, 19(1), 24.

I hope it makes a useful contribution to the field, as well as providing a practical set of considerations for people who are planning to undertake research with culturally and linguistically groups.

The enduring nature of systems of oppression

Economic research has shown that the distribution of areas of relative poverty in Peru can be partly explained by the lingering effects of the mita system of forced mining labour that began in 1573 and ceased two hundred years ago .  The mita effect continues to reduce household consumption by around 25% and increases the prevalence of stunted growth in children by 5% compared to the districts in Peru where forced labour was not practiced.

This example, one of many, underlines the immense, enduring impact of the systems of oppression that our world is based upon. It also highlights the urgency of addressing them.


Dell. “The Persistent Effects of Peru’s Mining Mita.” Econometrica 78, no. 6 (2010): 1863–1903.

The harms of shisha use: An issue that isn’t going away

The Cancer Institute NSW released their NSW Smoking and Health Survey, 2019 report last week. It highlights significant progress in tobacco control in NSW – with the exception roll-your-own cigarettes, e-cigarettes and shisha use.

The apparent reduction in shisha use in the 2017 survey may be partially explained by changes in the sampling approach. Another reason was that the question in 2017 made explicit reference to tobacco:

In 2017, however, the wording was waterpipe tobacco or shisha tobacco (i.e. the word tobacco was removed for 2019).

This highlights that people who use shisha may be unaware that it contains tobacco, an issue that we identified in our qualitative research on water pipe use . It also underlines the importance of ongoing campaigns to make people aware of the harms associated with water pipe use, such as the Shisha No Thanks program.

Shisha use is a significant and increasingly widespread tobacco control issue that can no longer be regarded as a niche concern . It needs to be explicitly addressed through all tobacco control activities.


Cancer Institute NSW. (2020). NSW Smoking and Health Survey 2019. Cancer Institute NSW.
Eissenberg, T. (2019). Now is the Time for Effective Regulation Regarding Tobacco Smoking Using a Waterpipe (Hookah). Journal of Adolescent Health, 64(6), 685–686.
Haddad, C., Lahoud, N., Akel, M., Sacre, H., Hajj, A., Hallit, S., & Salameh, P. (2020). Knowledge, attitudes, harm perception, and practice related to waterpipe smoking in Lebanon. Environmental Science and Pollution Research.
Kearns, R., Gardner, K., Silveira, M., Woodland, L., Hua, M., Katz, M., Takas, K., McDonald, J., & Harris-Roxas, B. (2018). Shaping interventions to address waterpipe smoking in Arabic-speaking communities in Sydney, Australia: A qualitative study. BMC Public Health, 18(1).
Romani, M., Jawhar, S., Shalak, M., & Antoun, J. (2020). Waterpipe smoking cessation: knowledge, barriers, and practices of primary care physicians- a questionnaire-based cross-sectional study. BMC Family Practice, 21(1), 21.
Ward, K. D., Kumar, J., Khan, Z., & Jiang, Y. (2019). Characteristics of Waterpipe Health Warning Labels in the United States. American Journal of Health Behavior, 43(4), 858–865.

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”.



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.


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.” New Zealand Medical Journal 131, no. 1486 (2018): 5.
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.
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.