Program on Health Equity & Sustainability

State: CA Type: Model Practice Year: 2007

The Eastern Neighborhoods Community Health Impact Assessment addresses the issue of built and social environments. The overarching goal of the project was to integrate human health needs into San Francisco land use planning via a multi-stakeholder consensus building community engagement process. The ENCHIA process had five broad objectives: 1. Identify and analyze the likely impacts of land use plans and zoning controls on health determinants, including housing, jobs, and public infrastructure; 2. Provide recommendations for land use policies and zoning controls that promote community priorities; 3. Demonstrate the feasibility of health impact assessment methods; 4. Promote meaningful public involvement in land use policy-making by making explicit competing interests and facilitating consensus; and 5. Develop capacity for inter-agency working relationships on health and land use planning.
A Bay Area development boom during the late 1990s and early 2000s resulted in evictions, overcrowding, and migration out of San Francisco for low- and moderate-income residents and light industrial businesses. Cumulatively, gentrification began to affect community composition and created residential-industrial conflicts (i.e., noise and air pollution), among new residents who moved into historically industrial communities. In response, community organizations demanded a Community Planning Process to relieve development pressures and to create a long-term vision for their communities. In January 2002, the Department of City Planning (SFDCP) launched the Eastern Neighborhoods Community Planning Process in the Mission, South of Market, Showplace Square/Potrero, and Bayview/Hunters Point neighborhoods, with the dual goals of rezoning and developing comprehensive Area Plans. Many stakeholders were concerned that the Planning Process would not comprehensively meet social, environmental, and economic priorities. Furthermore, they believed the Planning Process would have adverse affects on health via displacement, stress, noise, job loss, and crowding. Despite community requests, SFDCP was not prepared to include such issues in their plans, nor in the environmental impact assessment (EIA). While acknowledging the health consequences of land use decisions, SFDCP did not believe it was feasible to include health in the EIA because of limited standards for environmental review, limited methods for quantifying health risks and cause-effect relationships, and the widely prevalent view that EIA should only consider direct impacts on the environment. Stakeholders thus approached SFDPH to explore conducting a health impact assessment (HIA) of the Planning Process. Over several months, SFDPH, SFDCP, and community partners envisioned different ways of conducting an HIA. Ultimately, the groups decided that SFDPH would convene and lead an independent HIA process to identify the health and social impacts of the rezoning. The HIA would occur in parallel to developing rezoning and Area Plans, and would complement the EIA. HIA is an established practice in many countries, but an emerging practice in the United States. According to a recent CDC review, there were seventeen HIAs conducted in the U.S. between 1999 and 2006. ENCHIA is a unique process among U.S. HIA case studies in the scope (100 plus indicators) and scale of the evaluation (Citywide land use planning). ENCHIA is also unique among U.S. HIA practice in its use of a Community Council to guide the process, deliberate on evidence, and to develop consensus-based recommendations.
Agency Community RolesA project steering committee representing SFDPH and SFDCP identified forty organizations to participate as potential Community Council members. These groups represented a range of interests that were affected directly or indirectly by the rezoning and planning process. SFDPH staff also invited several city agencies and technical advisors to participate in and support the ENCHIA process by participating in the Council, answering questions regarding agency programs and policies, and sharing agency-specific planning and assessment data. Ultimately, about twenty-five organizations and individuals agreed to participate on the ENCHIA Community Council making a commitment to attend a monthly 2.5 hour meeting over an eighteen-month period. Members of the ENCHIA Community Council represented a number of broad interests, including community planning and design, economic and neighborhood development, environmental justice, homeless, open space, housing, transportation, and bicycle advocacy, low-wage and union workers, food systems, child care and childhood development, non-profit and private developers, property-owners, architects, and small businesses. Early in the process, the Council conducted an “interests” exercise to identify stakeholder gaps in Council membership, and to identify ways to balance those interests. Following this process, staff worked to recruit developers, property-owners, small businesses and resident organizations that represented diverse ethnic and age groups. The ENCHIA process called for a Community Council to determine the content and focus of the HIA. SFDPH would facilitate and staff the assessment process, gather data, conduct research, and produce group products. The Council would deliberate all evidence and products and make decisions using consensus techniques. Over the course of the process, the ENCHIA Council developed ground rules and procedures for participation, dialogue, policy evaluation, policy prioritization, and decision-making.  Costs and ExpendituresNo external funding was used for this practice. Implementation, start-up, and in-kind costs included:$440,000 / 2 years / including external and in-kind costs.  ImplementationThe ENCHIA was an eighteen-month process divided into five distinct stages: visioning, creating community health objectives, identifying measurable indicators and gathering baseline data, developing policies/strategies to advance community health objectives and developing actions/recommendations. Within each stage, specific activities that constituted the ENCHIA process were not pre-determined but adapted to the needs of Council members to achieve process objectives. Developing a Healthy City Vision: Visioning provided an opportunity for participants to express their desires and concerns for the Eastern Neighborhoods, and to identify common ground and potential conflicts among stakeholders.  Creating Community Health Objectives: With a Healthy City Vision established, the group moved on to develop Community Health Objectives that, if achieved, would accomplish the Vision and result in greater and more equitable health assets and resources for San Francisco residents. This translation from Vision to Objectives required the ENCHIA Council to explicitly name the nexus between the needs of health and the actions of City agencies.  Identifying and Gathering Data: The Council next identified Measurable Indicators against which development plans and projects could be evaluated for each Community Health Objective. Council sub-groups working with project staff gathered relevant and available data ranging from traditional outcomes like asthma hospitalizations and injuries to environmental quality measures such as access to parks, proximity to freeways, and affordable housing. Ultimately, quantitative data in the form of maps, tables, and charts were organized into data profiles that described specific neighborhood needs and assets, and highlighted disparities between the Eastern Neighborhoods and the rest of City.  Developing Policy/Design Strategies: After understanding the needs and opportunities reflected in the indicators data, the Council researched and evaluated a series of urban land use, housing, infrastructure, environmental and economic strategies to improve neighborhood conditions. SFDPH staff conducted extensive research and drafted narratives on 27 specific policies that included enumeration of health impacts and discussion of local feasibility and implementation. The Council also developed criteria on which to evaluate policies.  Making Recommendations and Taking Action: The Council integrated the objectives, indicators and policy research into the Healthy Development Measurement Tool to create a standard method that could be used to evaluate development plans and projects prospectively. Indicators provided a broad set of criteria against which to evaluate development plans and projects. For each indicator, a range of development targets--from minimum acceptable to maximum attainable--specified achievable outcomes for development. ENCHIA staff solicited comments from over sixty national technical reviewers and a dozen City agencies. The use and the institutionalization of the Tool in San Francisco land use development was the primary policy recommendation of the Council, and the Council spent its final sessions discussing priority applications, community oversight, dissemination to City leaders, and routes to Tool institutionalization in planning.
Objective 1: Identify and analyze and mitigate the likely impacts of land use plans and zoning controls on health determinants, including housing, jobs, and public infrastructure.  Performance Measures: Completion of council determined process objectives and tasks.  Outcome: Council achieved consensus on of Healthy City Vision, Objectives, Indicators, and policies for land use; ENCHIA process created the Healthy Development Measurement Tool and called for its use as an actionable policy recommendation to achieve the overarching goal.Objective 2: Promote meaningful public involvement in land use policy-making by making explicit competing interests and facilitating consensus.  Performance Measures: Sustained participation; breadth of participation; active participation; establishment of process ground rules;  Outcome: Sustained 2 year participation of Council members; achieved Council consensus on Healthy City Vision, Objectives, Indicators, policies for land use; consensus positions on 3 legislative policies; established all needed process ground rules through consensus process; commitment to application and institutionalization of the Healthy Development Measurement Tool. Objective 3: Develop capacity for inter-agency working relationships.  Performance Measures: New or enhanced inter-agency (public and private) relationships; new partnerships, projects, proposals, advocacy, and research on health and land use issues.  Outcome: Council achieved consensus on of Healthy City Vision, Objectives, Indicators, and policies for land use; ENCHIA process created the Healthy Development Measurement Tool and called for its use as an actionable policy recommendation to achieve the overarching goal.
At the final meeting of the ENCHIA Council, members discussed potential ways to sustain its goals, apply the HDMT to land use plans and projects, and ultimately institutionalize the concept of health review of planning. Council members made the following agreements and commitments: Council members should continue their work together under the auspices of a “Healthy City Council” to guide and direct SFDPH application of the Tool. SFDPH and ENCHIA Council members should develop a phased multi-year plan for Tool implementation with a funding strategy to ensure both public and private agency capacity. SFDPH should retain leadership and oversight in developing, managing, and applying the Tool in order to maintain integrity of its breadth and data quality. Most immediately, the HDMT needed ¡§proof of concept¡¨ through real world applications in order to build the case for broader use and institutionalization of the Tool. SFDPH should implement a comprehensive pilot assessment using the HDMT. ENCHIA should fulfill its initial process goal to conduct an HIA on plans for the South of Market, Mission, and Portrero Hill using the HDMT. Tool application should be one part of a coordinated multi-pronged strategy to support comprehensive and community-responsive land use planning. Based on this discussion, SFDPH is currently implementing the following steps: Maintaining an official role in managing and applying the Tool. Developing a web-based application of the Tool. Convening a sub-group of Council members to review and test the Tool website. Conducting pilot applications to the Executive Park Subarea Plan, the Mission-based People’s Plan, and the Eastern South of Market Area Plan. SFDPH plans to re-convene ENCHIA Council in 4-6 months to review Tool pilot applications and discuss the potential of a Healthy City Council to support SFDPH in applying the Tool.