The inclusion of health in impact assessments: a case study in Geneva, Switzerland

Abstract

The aim of this study is to investigate the integration of the health dimension within existing impact assessments such as environmental impact assessment (EIA), strategic environmental assessment (SEA) and sustainability assessment (SA). This work focuses on the canton of Geneva (Switzerland) and was carried out using the following methodology: a review of the legal texts and the guidelines that underpin the design and methodology of IAs; an analysis of the application of these tools in 37 case studies (11 SEAs and 20 EIAs conducted in Geneva as well as 6 SAs undertaken at national level); and conducting semi-structured interviews with selected professionals who participated in these case studies. Our study reveals serious shortcomings in the consideration of health within the investigated environmental assessments, limited to a simple review of the effects of projects on the determinants of the physical environment as required by the Swiss or local (Geneva) legislations. Regarding SA, our research finds that health is treated superficially and primarily through the analysis of ‘health and safety’ criteria.

Keywords:

• Health inclusion
• environmental impact assessment
• strategic environmental assessment
• sustainability assessment
• Geneva
• Switzerland

1. Introduction

Prospective impact assessment is an approach to estimate and anticipate the consequences of policies, plans, programmes and projects. It is considered as an aid to political decision-making (Stahl 2009). The implementation of impact assessments is increasingly recognized as important for the development of sustainable public policies (Nowacki et al. 2010).

The inclusion of health issues in environmental assessments began in the late 1980s with the publication of a report by the World Health Organization (WHO) on the health and safety component of environmental impact assessments (EIA) (Banken 1999). Since then, the inclusion of health has increasingly become the subject of publications from professionals working in the fields of EIA or strategic environmental assessment (SEA) as well as from health professionals (Arquiaga et al. 1994; BMA 1998; Banken 1999; Steinemann 2000; Mindell and Joffe 2003; Hilding-Rydevik et al. 2005; Wright et al. 2005; Bhatia and Wernham 2008; Fischer et al. 2010; Morgan 2011; Reis et al. 2015).

In the European Union, health issues are one of the aspects to be considered in SEA, based on the SEA Directive (2001/42/EC) and the SEA Protocol. Furthermore, the new EIA Directive 2014/52/EU includes requirements for the consideration of direct and indirect effects of projects on the health of human populations.

In 2001, WHO published a report on health impact assessment (HIA) in connection with SEA, intended for experts involved in negotiations for the development of a protocol on SEA (WHO 2001). At the Fourth Ministerial Conference on Environment and Health (Budapest 2004), ministers and national representatives in charge of environment and health within the WHO European Region expressed their commitment to ‘taking significant health effects into account in the assessment of strategic proposals under the SEA Protocol’ (WHO 2004).

In 2009, WHO organized in Rome an international expert consultation on a topic termed ‘Health and SEA’. This meeting concluded that conducted currently SEAs already considered health aspects but mainly in relation to biophysical impacts. Distributional aspects were rarely taken into account and public health experts were rarely involved in the SEA process (WHO 2010).

This paper aims to contribute to discussions on the integration of health considerations in impact assessments (IA) at the international level through an analysis of the use of IAs in the Canton of Geneva (Switzerland). This work is based on three main steps, as follows.

(1)	A review of the legal texts and guidelines that set up the design and methodology of IAs used in Geneva, for EIA, SEA and Sustainability assessment (SA).
(2)	An evaluation of existing EIAs and SEAs conducted in Geneva as well as SAs undertaken at the national (Swiss) level.
(3)	An interview with experts involved in conducting these assessments.

1.1. The context of EIA, SEA and SA in Geneva

This research focuses on two impact assessments used in the canton of Geneva (EIA and SEA) and one used at the national level (SA). EIA has been defined as ‘a planning instrument for predicting the effects on the environment from altering or building a new establishment’ (Lenzen et al. 2003). SEA has been defined as ‘a decision-making support instrument for the formulation of sustainable spatial and sector policies, plans and programmes, aiming to ensure an appropriate consideration of the environment’ (Fischer 2003). SA is a prospective method of assessment and optimization, for examining the social, economic and environmental effects of policies, programmes and projects (Swiss Federal Council 2012).

EIA has been used in Switzerland since 1988 thanks to the Environmental Protection Act that provides a legal basis for EIA (Mattig et al. 2015). The Swiss Confederation has been considering the introduction of SEA since 1997, but only the Canton of Geneva has a regulatory basis for SEA, which was added to the legislation of the canton of Geneva for EIA (Simos 2006). The canton of Geneva is located in the south-western corner of Switzerland. It has an area of 282 km² and is surrounded on almost all sides by France and bordered by the canton of Vaud to the north-east. The population of the canton of Geneva was around 495’000 at the end of 2016. The implementation of EIA and SEA is managed by the canton’s Office of the environment. There is no legal requirement for SA in Switzerland, neither at cantonal nor federal level. However, some case studies have been conducted at the federal level.

We decided to include SA in this study, even though it has not been used in the canton of Geneva, for two reasons. First, the Federal office for spatial development (FOSD), which in Switzerland is closely related to sustainable development, may at some point require the use of SA (currently done on a voluntary basis) at cantonal level. Second, many professionals involved in developing SA believe that this tool can replace HIA and thereby fulfil the aspirations of health promotion within the context of impact assessments (OFSP 2010).

2. Methods and data

2.1. A review of legal texts and guidelines on EIA, SEA and SA

The documents analysed are the following.

•	The Federal environmental protection act, from which several environmental by-laws and regulations are derived, came into force on 1 January 1985. This text formulates the requirements for the protection of the environment in Switzerland.
•	The legislation for EIA at federal level, which came into force on 1 January 1989, defines projects and activities subjected to EIA and establishes a procedure for conducting EIA (Hertig 2006).
•	The legislation of the canton of Geneva for EIA, based on the corresponding legislation for EIA at federal level, came into force on 21 April 2001. This legal text defines EIA procedure in the canton of Geneva. It also includes requirements concerning the SEA process.
•	Guidance on the design and methodological bases for SA. This document was developed at the federal level (by the FOSD).

The questions used for analysing these texts regarding the inclusion of health are the following.

•	Are health and well-being mentioned?
•	Is there a reference to the determinants of the physical environment?
•	Is there a reference to the socio-economic determinants of health?
•	Is there a reference to lifestyle factors?
•	Does the text contain a requirement for the inclusion of health with a holistic view? In the context of this study, this means, taking into account the physical, socio-economic, and lifestyle determinants of health in the conduct of impact assessments.

The determinants of the physical environment are factors that influence the health status of individuals and the population. They refer to a wide range of factors external to the body of the individual, including the quality of water, air, soil, noise, green spaces, etc. Socio-economic determinants of health are factors such as employment, income, education, housing and social interactions which have a direct or indirect impact on the health of individuals and population. Lifestyle factors also play an important role in determining the health status of individuals (Wilkinson and Marmot 2003; Anctil 2012). For example, a healthy diet and regular exercise have many proven benefits. The list of determinants of health used in our study is shown in Table 1.

Table 1. The list of determinants of health used in our study.

Main categories	Specific categories
Physical environment
	Air
	Noise
	Water
	Soils
	Waste
	Landscapes
	Green spaces
	Energy
	Radiation
Socio-economic determinants
	Employment
	Income
	Working conditions
	Housing
	Social and functional diversity
	Education/Training
	Social interaction
	Safety
	Sense of safety
Lifestyle factors
	Physical activity
	Sedentary lifestyle
	Walking/cycling
	Leisure activities
	Food

This study investigates the explicit inclusion of specific terms and determinants of health in impact assessments conducted in Geneva.

2.2. An evaluation of existing EIAs, SEAs, and SAs

The methodological approach used is inspired by studies conducted in various countries on the inclusion of health in environmental assessments (Steinemann 2000; Alenius 2001; Noble and Bronson 2006; Harris et al. 2009; Kornov 2009; Stahl 2009; Fischer et al. 2010; Douglas et al. 2011).

In June 2012, we wrote to the director of the Office of the environment of the Canton of Geneva to collect the following data:

•	All SEA reports conducted in the canton of Geneva from the beginning (2002) to June 2012 (the date of the request). We received 11 SEAs for review, covering the following planning themes: 5 for combining housing and economic activities; 2 for housing; 2 for regional urbanization; 1 for economic activities; and 1 for industrial areas. The length of SEA reports varies from 19 pages to 210 pages including appendices.
•	All EIAs conducted from 2010 to June 2012 (the date of the request) in the Canton of Geneva. Since many EIAs have been conducted in Geneva, our study wanted to focus on the more recent assessments. We thereby collected 20 recent EIAs covering the following planning themes: 12 for infrastructure/facilities; 4 for housing; 2 for economic activities; 1 for combining housing and economic activities; and 1 for industrial areas. The length of EIA reports varies from 45 pages to 265 pages including appendices.
•	We contacted by telephone the director of the sustainable development division at the FOSD in June 2012, to collect all SAs done in Switzerland from the beginning in 2006 to June 2012. This approach yielded four cases studies. In order to increase the number of cases for the analysis, we continued collecting SAs until 2015, thus obtaining a further two case studies. They cover the following themes: 1 for agriculture; 1 for transport; 1 urban planning; 1 for health; 1 for housing; and 1 for climate and energy. The length of SA reports varies from 7 pages to 128 pages including appendices.

In order to analyse the EIAs, SEAs and SAs regarding the consideration of health, a process was conducted consisting of three main parts.

2.3. Part A

This part focuses on the mention of health, well-being and quality of life in EIA, SEA and SA reports, using the following questions:

•	Are health, well-being and quality of life mentioned in the reports?
•	If so, how many reports mention them?
•	How many times are they mentioned in all the reports?

2.4. Part B

This part focuses on the population group affected by the assessed project and on the consideration of vulnerable groups such as elderly people, persons with reduced mobility and children. The questions related to this part are:

•	Is the population group affected by the assessed project mentioned?
•	Are vulnerable groups mentioned and are their needs taken into account?

2.5. Part C

This part is related to the types of impacts addressed in EIAs, SEAs and SAs and uses the following sets of questions:

2.5.1. Determinants of the physical environment

•	Are determinants of the physical environment mentioned?
•	If so, how many reports mention them?
•	How many times are the determinants of the physical environment referenced in the text of all the reports?
•	How are they addressed in the EIAs, SEAs and SAs?
•	Do the reports describe the link between these determinants and health outcomes?

2.5.2. Socio-economic determinants of health

•	Are socio-economic determinants of health mentioned?
•	If so, how many reports mention them?
•	How many times are the socio-economic determinants of health referenced in the text of all the reports?
•	How are they addressed in the EIAs, SEAs and SAs?
•	Do the reports describe the link between these determinants and health outcomes?

2.5.3. Lifestyle factors

•	Are lifestyle factors mentioned?
•	If so, how many reports mention them?
•	How many times are lifestyle factors referenced in the text of all the reports?
•	How are they addressed in the EIAs, SEAs and SAs?
•	Do the reports describe the link between these factors and health outcomes?

2.6. An interview with professionals involved in conducting the assessments

We decided to carry out interviews with professionals from private companies involved in conducting the environmental assessments (EIAs and SEAs) reviewed in this study, in order to refine the information collected during stages a and b. These interviews help understand the circumstances surrounding the conduct of EIA, SEA and SA, because the respondents provide information that goes beyond what can be gathered during legal text analysis or case study review. Ten private engineering firms were identified. We contacted by phone the directors of the 9 offices for which we could find a valid address and telephone number. Out of the nine persons contacted, two did not return our calls and one declined to be interviewed, saying that his office did not provide such services. Out of the six remaining directors, we interviewed three who also coordinated environmental assessments. The three remaining directors referred us to three professionals involved in the implementation of EIAs and the SEAs whom we subsequently interviewed.

The interviews took place between 19 June and 6 July 2015 in the offices of respondents and each interview lasted about one hour. Interviews were conducted by the main author. The questionnaire is included in Appendix 1.

Regarding SA, in June 2015 we contacted a professional in charge of the development of the tool at federal level but he declined our offer of an interview due to a busy schedule.

3. Results

3.1. A review of legal texts and guidelines on EIA, SEA and SA

3.1.1. The Federal environmental protection act

3.1.1.1. Are health and well-being mentioned?

The word ‘health’ was mentioned once regarding the use of organisms that may cause a danger to human health. ‘Well-being’ was mentioned twice in relation to exposure thresholds for air pollution and noise defined at federal level. It is stated that emissions (concentration of pollutants in ambient air) below these thresholds do not seriously affect the well-being of the population.

3.1.1.2. Is there a reference to the determinants of the physical environment?

‘The aim of this act is to protect people, animals and plants, their biological communities and biotopes against harmful effects or nuisances and to preserve natural resources sustainably, in particular biodiversity and soil fertility’. Harmful effects are understood to be

air pollution, noise, vibrations, radiation, water pollution and other water problems, soil pollution, modifications of the genetic material of organisms or modifications of biodiversity, caused by the construction or operation of facilities, by the handling of substances, organisms or waste, or by the cultivation of the soil.

This definition clearly shows that in this act, the focus is on the determinants of the physical environment.

3.1.1.3. Is there a reference to the socio-economic determinants of health?

The socio-economic determinants of health are rarely mentioned in the Act. The only determinants mentioned are safety (n = 7), education (n = 3) and housing (n = 2).

3.1.1.4. Is there a reference to lifestyle factors?

Lifestyle factors are not mentioned.

3.1.1.5. Does the text contain a requirement for the inclusion of health with a holistic view?

The review of the federal environmental protection act revealed that health is implicitly associated with the risk of degradation of the physical environment such as air pollution, water pollution, soil pollution, noise, vibrations, radiation and waste problems. Health effects are related to the exposure to these pollutants of the physical environment. Therefore, a holistic view of health is not integrated into this Act.

3.1.2. The legislation for EIA at federal level

3.1.2.1. Are health and well-being mentioned?

The review showed that ‘health’ and ‘well-being’ are not mentioned in the legislation for EIA at the federal level.

3.1.2.2. Is there a reference to the determinants of the physical environment?

The determinants of the physical environment are not explicitly mentioned in the Act. However, the text refers to the impact of a project on the physical environment and the issues to be addressed in the EIA process are specified in the federal guidelines for conducting an EIA. These issues are air and climate, noise and vibrations, non-ionising radiation, water, soils, polluted areas, waste, environmentally hazardous substances, dangerous organisms for the environment, major accident prevention, protection against natural disasters, forest, flora, fauna, biotope, landscapes and sites, historical monuments and archaeological sites.

3.1.2.3. Is there a reference to the socio-economic determinants of health?

Socio-economic determinants of health are not mentioned in the act.

3.1.2.4. Is there a reference to lifestyle factors?

There is no reference to lifestyle factors.

3.1.2.5. Does the text contain a requirement for the inclusion of health with a holistic view?

The review of the legislation for EIA at federal level revealed that it contains no requirement for the inclusion of a broad health dimension in the EIA process. Requirements are limited to the analysis of the effects of a project on the physical environment.

3.1.3. The legislation of the canton of Geneva for EIA

3.1.3.1. Are health and well-being mentioned?

‘Health’ and ‘well-being’ are not mentioned in the legislation of the canton of Geneva for EIA.

3.1.3.2. Is there a reference to the determinants of the physical environment?

The determinants of the physical environment are not explicitly mentioned but as in the case of the legislation for EIA at federal level, it can be considered that they are implicitly covered. This can be verified through the review of the EIAs and the SEAs and the interviews.

3.1.3.3. Is there a reference to the socio-economic determinants of health?

Socio-economic determinants of health are not mentioned in the legislation of the canton of Geneva for EIA.

3.1.3.4. Is there a reference to the lifestyle factors?

There is no mention of lifestyle factors.

3.1.3.5. Does the text contain a requirement for the inclusion of health with a holistic view?

It does not require the integration of a holistic view of health.

3.1.4. Guidance on the design and methodological bases for SA

‘Health’ and ‘well-being’ were mentioned in the document, (n = 11) and (n = 4), respectively. Health is investigated through the analysis of ‘health and safety’ criteria. The determinants of the physical environment and the socio-economic determinants of health were also mentioned but in the form of sustainability criteria. Indeed, SA assesses projects on the basis of these criteria.

3.2. An evaluation of existing EIAs, SEAs and SAs

3.2.1. Part A

3.2.1.1. Are health, well-being and quality of life mentioned in the reviewed EIAs, SEAs and SAs reports? If so, how many reports mention them?

‘Health’ was mentioned in more than half of the EIA reports (n = 11). ‘Quality of life’ was mentioned in a limited number of EIA reports (n = 4) and only one mentioned ‘well-being’. Regarding SEAs, ‘health’ and ‘quality of life’ were both explicitly mentioned in more than half of the reviewed reports (n = 7) although the number mentioning ‘well-being’ was small (n = 2). The majority of SA reports mentioned health (n = 5) or well-being (n = 4) whereas a minority mentioned ‘quality of live’ (n = 2).

3.2.1.2. How many times are they mentioned in all the reports?

The number of references made to ‘health’ was high (n = 13) across all EIA reports, but far lower for ‘well-being’ (n = 1) or ‘quality of life’ (n = 4). Across the SEA reports, ‘health’ was also more often mentioned (n = 13), well-being (n = 4) and ‘quality of life’ (n = 20).

The mention of health in these reports refers to the determinants of the physical environment such as air, noise, soils, waste, dangerous organisms for the environment, etc. Some representative statements are: ‘Particulate matter (PM₁₀) has a significant impact on human health’; ‘a level of noise which cannot cause damage to population health’; ‘the presence of ragweed is a serious risk to public health because of its strong allergen’.

The total number of times that the word ‘health’ appears is higher in the SA reports (n = 119) than in the EIA (n = 13) or SEA reports (n = 13). It is the same for the word ‘well-being’ (n = 40) in the SA reports. ‘Quality of life’ was less referenced in comparison with ‘health’ and ‘well-being’ in the SAs (n = 13, against 119 and 40 for health and well-being, respectively). SA analyses projects according to their compliance with federal sustainable development goals. The analysis is done through the sustainability appraisal criteria defined by the Swiss Confederation. There are 15 criteria, divided into three groups of five according to the three pillars of sustainable development (environmental, social and economic). Health is one of the criteria. It is included in the social dimension of sustainable development under the heading ‘health and safety’. Thus, explicit references to health in the SAs that we analysed are related to this heading. In the case of an SA on a transportation plan, health was mentioned in relation to air pollution, noise, safety and transportation modes. Representative statements are: ‘increasing road safety as well as reducing environmental damage contribute to improving health, well-being and safety’, ‘road traffic can affect people’s health and well-being directly (accidents) or indirectly (emissions of substances which are hazardous for the environment)’. Another example is the SA of the partial revision of the Federal Act on urban planning, where health issues were mentioned regarding income and unemployment. Typical quotes are: ‘An additional income can have both positive and negative effects on health: it can be used for better health care as it can be for the purchase or consumption of harmful products for health (e.g. unhealthy foods, etc.). An increase of job security and a reduction of unemployment reduce stress’.

3.2.2. Part B

3.2.2.1. Is the population group affected by the assessed project mentioned?

The population group affected by the project was mentioned in the majority of SEAs (n = 8) and EIAs (n = 15). Analysis of the EIA and SEA reports revealed that the population affected by the project may be mentioned but its needs are not necessarily taken into account in the assessments. All the SAs mentioned the population group affected by the project.

3.2.2.2. Are vulnerable groups mentioned and are their needs taken into account?

No SEAs made reference to vulnerable groups. Persons with reduced mobility are explicitly mentioned in very few EIAs (n = 3), and only in relation to planned parking facilities. Indeed, some parking spaces are reserved for this category of population. However, the conditions of accessibility to these parking spaces are not addressed in the EIAs.

In the SAs, the review showed that vulnerable groups are mentioned and that their needs are taken into account.

3.2.3. Part C

Table 2 summarises reviews on the types of impacts addressed in EIAs, SEAs and SAs.

Table 2. Results of the reviews regarding the types of impacts addressed in EIAs, SEAs and SAs.

Determinant of health	Number of EIA reports (N = 20) explicitly mentioning the determinant of health	Number of SEA reports (N = 11) explicitly mentioning the determinant of health	Number of SA reports (N = 6) explicitly mentioning the determinant of health	Determinant of health	Total number of explicit references to the determinant of health in EIA reports	Determinant of health	Total number of explicit references to the determinant of health in SEA reports	Determinant of health	Total number of explicit references to the determinant of health in SA reports
Physical environment
Air	20	11	3	Water	2324	Water	649	Soils	61
Noise	20	11	2	Noise	1576	Noise	526	Landscapes	49
Water	20	11	4	Waste	1552	Energy	373	Air	36
Soils	20	11	4	Soils	1256	Green spaces	306	Energy	26
Waste	20	11	0	Air	816	Waste	282	Noise	17
Landscapes	19	11	4	Green spaces	444	Soils	233	Water	8
Green spaces	19	11	2	Landscapes	289	Air	212	Green spaces	7
Energy	20	11	4	Energy	247	Landscapes	208	Waste	0
Radiation	20	7	0	Radiation	111	Radiation	37	Radiation	0
Socio-economic determinants
Employment	5	7	5	Housing	374	Housing	150	Income	72
Income	0	1	5	Safety	130	Employment	91	Safety	54
Working conditions	6	0	0	Education/Training	20	Safety	47	Employment	46
Housing	18	11	1	Social and functional diversity	14	Social and functional diversity	17	Housing	43
Social and functional diversity	4	7	0	Employment	9	Education/Training	6	Education/Training	20
Education/Training	11	3	4	Working conditions	6	Income	1	Social interaction	1
Social interaction	0	0	1	Sense of safety	1	Working conditions	0	Working conditions	0
Safety	17	7	5	Income	0	Social interaction	0	Social and functional diversity	0
Sense of safety	1	0	0	Social interaction	0	Sense of safety	0	Sense of safety	0
Lifestyle factors
Physical activity	0	0	1	Walking/cycling	54	Walking/cycling	92	Walking/cycling	33
Sedentary lifestyle	0	0	1	Leisure activities	29	Leisure activities	14	Leisure activities	2
Walking/cycling	11	10	1	Physical activity	0	Food	1	Physical activity	2
Leisure activities	12	4	2	Sedentary lifestyle	0	Physical activity	0	Sedentary lifestyle	1
Food	0	1	0	Food	0	Sedentary lifestyle	0	Food	0

3.2.4. Determinants of the physical environment in the EIAs and SEAs

Are determinants of the physical environment mentioned in the EIAs and SEAs?

If so, how many reports mention them?

How many times are the determinants of the physical environment referenced in the text of all the reports?

Table 2 shows that the determinants of the physical environment were mentioned in all EIAs and SEAs. All EIAs and SEAs mentioned air, noise, water, soils, waste and energy. Water was the most referenced in EIAs (n = 2324, mean = 116.2 references per EIA), followed by noise (n = 1576, mean = 78.8 references per EIA). A similar situation was found for SEAs, with water (n = 649, mean = 59 references per SEA) and noise (n = 526, mean = 47.81 references per SEA) featuring prominently.

How are the determinants of the physical environment addressed in the EIAs and SEAs?

Do the reports describe the link between these determinants and health outcomes?

No EIAs or SEAs made causal links between changes in the environment and health outcomes. Health impacts were never quantified. The references made to health in some EIAs and SEAs regarding the physical environment (as mentioned in Part A) do not constitute an appraisal of health impacts. These IAs only focus on examining the compatibility of a project with the current environmental legislation.

3.2.5. Socio-economic determinants of health and lifestyle factors in the EIAs and SEAs

Are socioeconomic determinants of health and lifestyle factors mentioned in the EIAs and SEAs?

If so, how many reports mention them?

How many times are the socioeconomic determinants of health and lifestyle factors referenced in the text of all the reports?

Table 2 shows that socio-economic determinants of health and lifestyle factors were mentioned less often than the determinants of the physical environment. For example, none of the EIA reports mentioned income, social interaction, physical activity or food. The result was similar with SEA reports, with income and food mentioned only once each, and social interaction or physical activity not mentioned at all. However, all SEAs mentioned housing (n = 150 references, mean = 13.6 references per SEA), most (n = 10) mentioned walking and/or cycling (n = 92 references, mean = 9.2 references per SEA) and more than half (n = 7) contained explicit references to employment (n = 91, mean = 13 references per SEA). In the EIA reports, references were often made to housing (n = 374, mean = 20.7 references per EIA) and safety (n = 130, mean = 7.6 references per EIA); just over half (n = 11) mentioned education or training (n = 20 references, mean = 1.8 references per EIA) or walking/cycling (n = 54, mean = 4.9). Employment was less referenced than in SEAs (n = 9, mean = 1.8 references per EIA).

Social or functional diversity were also mentioned in EIAs (n = 14 references, mean = 3.5 references per EIA) and SEAs (n = 17, mean = 2.43 references per SEA).

How are the socio-economic determinants of health and lifestyle factors addressed in the EIAs and SEAs?

Do the reports describe the link between these determinants/factors and health outcomes?

Some socio-economic determinants of health such as employment and housing are only mentioned in the EIAs and SEAs insofar as to emphasise jobs or apartments provided by the project. As for walking and cycling, they are often mentioned as potential measures to reduce the impacts of motorised traffic, but usually in the form of a general recommendation rather than a detailed list of actions to be undertaken.

No EIAs or SEAs made causal links between changes in the socio-economic determinants of health (or lifestyle factors) and health outcomes.

3.2.6. Determinants of the physical environment, socio-economic determinants of health and lifestyle factors in SA reports

Table 2 shows the number of SA reports mentioning the determinants of health and the number of references made to these determinants in the total text of those reports. Unlike EIAs and SEAs that focus primarily on determinants of the physical environment, in SAs we found a broader distribution of issues addressed, with consideration of all three categories of determinants of health. This can be explained by the fact that SA examines the social, economic and environmental effects of projects.

Only three out of six SAs (1 in transport; 1 in urban planning and 1 in climate and energy) described causal links between changes in the determinants of health and health outcomes. Health impacts were not quantified. No causal link was drawn between changes in the determinants of health and health outcomes in the three others SAs. For example, in an SA on the federal law on second homes, the report stated that ‘in mountain regions, income and employment will decrease slightly in the long term compared to the current state’. It would have been appropriate to analyse the effects of this reduction on health. The report concludes that ‘there will be less pollution due to lower construction activities of second homes’. It would have been interesting to study the health consequences of this.

3.3. An interview with professionals involved in conducting the assessments

3.3.1. Aspects related to quality of life and well-being in EIAs and SEAs

Well-being and quality of life were explicitly mentioned in EIAs and SEAs. By interviewing professionals who were involved in conducting these assessments, it became easier to understand what they meant by ‘a district or a neighbourhood where there is a good quality of life for users’ or ‘an auditory environment that promotes the wellbeing of the population’. The majority of the respondents (n = 5 out of 6) consider that good quality of life equates with compliance with environmental standards (e.g. reduction of noise and air pollution), good public transport connections, energy efficiency, development of outdoor public spaces and green spaces. As regards well-being linked to the auditory environment, respondents said they had examined compliance with federal legislation on noise but did not proceed any further in the assessment of this issue.

It is clear from this information that quality of life and well-being are mentioned in the environmental assessments primarily with respect to environmental standards.

3.3.2. Addressing health issues in EIAs and SEAs

Regarding the consideration of health in environmental assessments, one respondent stated that ‘health is linked to the environment, so for health to be good the environment has to be clean’. Another said that in environmental assessments as they are conducted in Switzerland, there is ‘no chapter purely devoted to health’. Finally, one expert mentioned that ‘these assessments analyze only the impact on the environment, health is not addressed’.

Nevertheless, all respondents agree that the determinants of the physical environment (e.g. air, noise, soil, water, waste) may have impacts on health. They are convinced that when they examine the impacts of a project in accordance with legal environmental requirements, health impacts are indirectly considered. They refer to Article 1 paragraph 1 of the Federal environmental protection act, which states that ‘This act is intended to protect people, animals and plants, their biological communities and habitats against harmful effects or nuisances and to preserve the natural foundations of life sustainably, in particular biological diversity and the fertility of the soil’. For them, this Article implies a consideration of health.

Respondents responded positively when asked whether the threshold values set in federal environmental requirements were designed to protect human health. They refer, for example, to Article 1 paragraph 1 of the Swiss air quality legislation which states that ‘This ordinance is intended to protect human beings, animals and plants, their biological communities and habitats, and the soil against harmful effects or nuisances caused by air pollution’.

3.3.3. Addressing walking/cycling and green space issues in EIAs and SEAs

Most respondents (n = 4 out of 6) mentioned that walking and cycling are indirectly included in EIA or SEA among measures to reduce the impact of road traffic – especially from private motor vehicles – on the environment. These measures are most often declined as actions to be taken or recommendations.

The professionals stated that the topic of green spaces focuses on three target groups: flora, fauna and humans. They added that green spaces are addressed from the perspective of biodiversity, with an ecological approach (what species are present in which area? What trees to plant? Do these species promote biodiversity? etc.). However, physical activity, whose benefits in terms of improving the health status of a population are clearly established, was totally absent from their concerns.

3.3.4. Issues related to housing, social and functional diversity and employment

The respondents explained that housing and employment are explicitly mentioned in EIAs and SEAs because they are included in the baseline data. Such data are used to plot future traffic loads. A link is then drawn with air pollution and noise concerns, as well as with parking issues.

One expert pointed out that reviewing the social or functional diversity of a project area, or detailed analysis of housing and employment issues, is closer to a social impact assessment than to an environmental assessment. He added that environmental professionals might not have the necessary skills for the assessment of such issues. Another expert mentioned that the Office for the environment of the canton of Geneva does not ask for a more detailed analysis of issues related to housing, jobs, or social and functional diversity.

3.3.5. Aspects related to populations and vulnerable groups

The respondents mentioned that an analysis of the needs of the population affected by the project is not considered in the environmental assessment, except for specific issues such as transportation and parking. Several reasons are stated:

lack of skills to address other aspects related to population needs; these activities are not included in the Terms of Reference for conducting an EIA or SEA: the issue of population needs is taken into account in the project itself and not specifically in the environmental assessment.

The interviews also showed that there is no consideration of the needs of vulnerable groups in environmental assessments. For example, in the case of parking, it is mandatory to have a minimum number of spaces reserved for people with reduced mobility and this is mentioned in EIA and SEA reports. However, the problem of the accessibility to these parking spaces for such people is not addressed in EIAs or SEAs. Respondents consider that it is the architects who have to answer this question and not the environmental professionals.

3.3.6. Improving the inclusion of health in EIA and SEA

The proposals made by the respondents to improve the inclusion of health in environmental assessments are the followings: increase interdisciplinary, review legislative acts related to the environment, analyse the true effectiveness of environmental standards (such as threshold values) in terms of public health, train environmental professionals for a better integration of the health dimension in EIA and SEA, integrate an expert with a holistic understanding of issues into the EIA process.

On this last point, respondents had divergent views. Some (n = 3 out of 6) believed that the inclusion of public health professionals in the environmental assessment process might be interesting from case to case, particularly if the project had major potential health impacts. They believed such a measure would help expand the scope of the environmental assessment to health issues. In contrast, others (n = 2) considered that such a measure would complicate the process without providing an effective improvement in terms of health. They warned against a possible negative reaction from architects who might see the involvement of public health professionals as a new constraint.

One respondent suggested that health professionals should be involved at the earliest stage of project development and again just before the assessment step but not during the full duration of the project.

4. Discussion

This is the first time that Swiss environmental legislation as well as EIAs, SEAs and SAs have been reviewed together for their coverage of health issues. Our research, in addition to other studies (Alenius 2001; Hilding-Rydevik et al. 2005; Noble and Bronson 2006; ; Harris et al. 2009; Kornov 2009; Fischer et al. 2010; Fehr et al. 2014), reveals that health is not covered adequately in EIAs, SEAs and SAs conducted in the canton of Geneva (Switzerland).

The Federal environmental protection act implicitly links health to the risks of degradation of the physical environment. It contains no explicit or implicit requirements for the integration of a broad view of health into environmental assessments. The same conclusion has been reached for the legislation for EIA at federal level and the legislation of the canton of Geneva for EIA. To draw a comparison, the National Environmental Policy Act (NEPA), which established a foundation for environmental policy in the USA, adopts a broader view than the Swiss Federal environmental protection act. Indeed, NEPA promotes efforts to prevent or eliminate damage to the environment and biosphere and stimulate the health and well-being of people (Sutcliffe 1995; Steinemann 2000). It explicitly recognizes the interdependence of environmental quality and human health (Morgan 2011) and requires the evaluation of both direct and indirect impacts on health (Bhatia 2007).

Currently, Swiss legislation does not fully reflect the aspirations of the European Union (Directive 2001/42/EC on SEA, Protocol on SEA and Directive 2014/52/EU on EIA), which explicitly require the coverage of health in environmental assessments. Switzerland is not a member of the European Union but has taken up many of its regulatory texts.

This research shows that the implementation of EIAs and SEAs in Geneva perfectly follows current legislative texts. Therefore, health is not interpreted in a broad sense with a focus on addressing determinants of the physical environment. Studies conducted in other countries (Australia, Denmark, Austria, Czech Republic, United Kingdom, Germany, Netherlands, etc.) (Harris et al. 2009; Kornov 2009; Fischer et al. 2010) support this. The purpose of EIA and SEA in Geneva clearly is to examine the compatibility of a project with current environmental legislation. The analysis does not go any further. This indicates the limited vision and strictly administrative framework that has been brought about by current legislation, preventing professionals from going beyond the framework established by law. Rather than stimulating discussions on public health, the legislative framework has become a ‘steriliser’ of thought. Cole et al. (2004) considered that the limited consideration of health effects in EIAs is explained by practical, methodological and legal reasons. They state that it is more difficult to predict health outcomes than emissions and that a narrow interpretation of legislation does not facilitate the integration of health into EIA.

Regarding the inclusion of the socio-economic determinants of health in EIA and SEA, the professionals mentioned that the law does not require them to be covered. They add that they do not have the necessary skills to assess such issues. Some authors have recommended organizing environmental assessments according to an interdisciplinary approach to enable various professionals to review a wide range of environmental issues including health (Bathia 2007; Kornov 2009). In order to achieve the integration of health into EIA, Harris et al. (2009) have suggested building capacity among EIA professionals, for health-related knowledge and tools. Douglas et al. (2011), who studied the range of health issues covered by 62 SEAs in Scotland, suggest that the involvement of public health professionals in defining the scoping of health issues and a better use of health evidence could help improve the quality of SEAs.

Negev et al. (2012) have suggested that HIA can serve to support intersectoral collaboration and to promote health and environmental protection. This raises the question of HIA implementation. Should HIA be conducted as a stand-alone tool or should it be integrated into existing IA tools? This is an important issue, given the current proliferation of IA types and budgetary constraints. Some authors call for integration around the goal of sustainable development (Morrison-Saunders et al. 2014). However, the risk with integration is that health concerns will not be addressed in depth as it might have been the case with a stand-alone HIA. One way to deal with this problem is to involve health professionals during the various stages of integrated IAs.

The success of the integration of health also depends on which determinants are considered. The integration of economic determinants of health can be more challenging than environmental or social determinants, when conflicts arise between health issues and economic interests. This is especially the case regarding aspects related to economic growth (Fischer 2014).

Regarding SA, the transversal character of the tool is certainly present, with an assessment of the effects of a project across the three fields of sustainable development, but health is included as a criterion within the social field that contains other criteria such as education, culture and solidarity. Furthermore, the analysis in terms of health is very brief. Fehr et al. (2014) explain that the inclusion of health within sustainable development tends to be more implicit than explicit. Our study supplies detailed evidence that reinforces this finding by Fehr et al. (2014).

Furthermore, this study demonstrates an inadequate coverage of health issues in EIAs and SEAs conducted in Geneva (Switzerland), that remain focused on the determinants of the physical environment. In SA, we find that health is addressed superficially and mainly through the analysis of ‘health and safety’ criteria.

Beyond the elements mentioned above, the limited inclusion of health in IAs reflects the weakness of intersectoral collaboration among most public administrations in the implementation of these tools (Lock and McKee 2005). Therefore, the construction of a culture of intersectoral approaches regarding health is needed. It will require strong support from decision-makers and awareness raising among actors as to the impact of their decisions and actions on health.

5. Limitations

One limitation of this work lies in the relatively small number of case studies. However, a larger sample would probably not have provided more information because all EIAs and SEAs are conducted in accordance with the procedure defined in the current environmental legislation. Furthermore, our analysis has shown that it is always the same issues that are discussed, those that are layed out in the federal guidelines for conducting an EIA. This document even provides the layout for an environmental impact report. It is important to note that these guidelines contain no explicit reference to health. As for SAs, we reviewed all the case studies conducted from 2006 to 2015 at the federal level, so the sample size could not have been larger.

Our research focuses on the EIAs conducted in the canton of Geneva. We did not analyse EIAs undertaken in the 25 other cantons in Switzerland. However, the Federal Office for the Environment has defined guidelines that the cantonal offices for the environment must all follow for conducting EIAs. Therefore, although practical aspects may vary, there is reason to believe that this case study in the canton of Geneva has general validity for Switzerland.

6. Conclusion

This study documents an inadequate coverage of health issues in EIAs and SEAs conducted in Geneva (Switzerland), which focus on the determinants of the physical environment. It reveals that the implementation of these tools diligently follows the legislative texts that do not contain explicit or implicit requirements concerning the integration of a broad dimension of health in the conduct of EIA or SEA. In SA, health is addressed superficially and mainly through the analysis of ‘health and safety’ criteria. An explicit link between the analysed projects and health impacts is present in only half of the 6 SAs investigated in this research.

Based on our findings, we suggest further research into three areas. First, it is important to study in depth the role of legislative and regulatory texts in promoting or limiting the inclusion of health within EIA, SEA and SA. A legal basis is necessary because it provides the legitimacy to act for health with partners from non-health sectors and allows the creation of solid foundations that can support operational work. Nevertheless, such an inclusion may not be sufficient to integrate health issues into IAs. Second, there is a need to explore the issue of integrating public health professionals into the various stages of EIA, SEA and SA. And finally, further investigation should focus on collaboration between health professionals and impact assessments practitioners. Environmental professionals already involved in using such tools need training in public health in order to improve their understanding of the holistic vision of health and its determinants, and why health issues are relevant to the impact assessment they are working on. However, this will not be enough because health professionals also need to learn about impact assessments methods and processes to facilitate the establishment of a common language with impact assessments practitioners.

Disclosure statement

No potential conflict of interest was reported by the authors.