









































October 2020 Volume  5 Issue 1

HEALTH IMPACT ASSESSMENT AND CITY COUNCIL POLICY: 
IDENTIFYING OPPORTUNITIES TO ADDRESS LOCAL 

SOCIAL DETERMINANTS OF HEALTH & PLACE-HEALTH 
RELATIONSHIPS, 10 YEARS LATER

Ryan J. Petteway, DrPH, MPH; Shannon Cosgrove, MHA

1

Abstract
Background: Health Impact Assessment (HIA) can be used to assess any type of policy/program 
related to social determinants (SDH).  However, local public health departments (LHDs) have 
been slow to adopt formal use of HIA in efforts to address local SDH, even with growing evidence 
linking SDH and place-health relationships. Ten years ago, we completed a review of Baltimore City 
Council policies to advance this conversation within the LHD. Our goal here is to revisit this review 
and, again, outline a process by which LHDs can: a) monitor local policies in regard to SDH and b) 
identify opportunities for potential HIA use.

Methods:  We reviewed all policies introduced into Baltimore City Council in calendar years 2008 
and 2009 to identify and assess those with potential health impacts. We then categorized these 
policies as: a) “explicitly health-related” or b) “related to SDH.” We then tabulated the number and 
sub-types of these policies that were referred to the LHD legislative director for review/comment, 
i.e. submission of formal LHD assessment/comment for the legislative record.

Results: We assessed 597 total policies. In total, 89 policies (15%) were identified as “explicitly 
health-related,” 34 (38%) of which were referred for LHD review/comment. In addition, 208 policies 
(35%) were identified as “related to SDH,” 13 (6%) of which were referred for LHD review/comment. 
Overall, 297 (50%) policies were identified as having potential health impacts, 47 (16%) of which 
received LHD review/comment.

Conclusion: This policy review effort represents a potentially replicable process to identify HIA 
opportunities, and potential launch point for health-in-all-policies efforts. In Baltimore, this review 
work facilitated dialogue with Baltimore City officials and led to the LHD’s first HIA grant.

Keywords: health impact assessment, social determinants of health, health in all policies, local 
health departments, place and health, policy



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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Background

Health Impact Assessment, Social 
Determinants of Health, and Place
The World Health Organization recognizes 
that “the social determinants of health are 
mostly responsible for health inequities” (WHO, 
2016). The distribution of social determinants 
of health, or SDH, is largely determined by 
policy decisions, and experts emphasize the 
importance of understanding that “every 
aspect of government and the economy 
has the potential to affect health and health 
equity” (WHO, 2008, p.10). As such, leading 
public health organizations have increasingly 
turned attention towards addressing factors 
that shape the social, economic, political, and 
environmental conditions in which we live, learn, 
work, play, and age (CDC, 2015; DHHS, 2011; 
NACCHO, 2011; Prevention Institute, 2008; 
Ramirez et al., 2008). In focusing attention on 
addressing SDH, local health agencies have 
begun developing public health strategies that 
engage policies and practices that traditionally 
have been viewed as “non-health” related, 
including those concerning transportation, 
housing, zoning, education, and land use 
(BARHII, 2015; BPHC, 2015; Schaff et al., 2013; 
Schaff & Dorfman, 2019). 

One analytic tool that has facilitated this work 
is Health Impact Assessment, or HIA (Bhatia, 
2011; Harris-Roxas et al., 2012; Heller et al., 
2014). HIA is commonly understood as: 

Use of HIA has been increasing in the US 
(Dannenberg et al., 2006; Ross et al., 2014), 
with recent reviews showing that they have 
been conducted on a wide range of projects and 
policies (Bourcier et al., 2015; Dannenberg et al., 
2014; Dannenberg et al., 2008; NCHH, 2016). 
However, HIA is not used regularly at local levels 
to assess potential health impacts of policy 
decisions as part of standard practice.  Rather, it 
is used mostly on a voluntary basis by only a few 
city/county agencies, usually in collaboration 
with non-profits, universities, and the private 
sector. For example, based on our 2016 review 
of publicly available data tracking all HIAs 
conducted in the US, just 53 city/county health 
agencies had served as the lead/authoring 
partner for an HIA since 1999, with 90 total HIAs 
completed among them. This represents just 
2% of the 2,532 city/county agencies defined 
by the National Association of City and County 
Health Officials as local health departments, or 
LHDs (NACCHO, 2013). Based on a more recent 
review of these data (Health Impact Project, 
2020), 71 city/county LHDs—3% of all LHDS—
have now served as lead/authoring partner, with 
134 total HIAs completed among them. San 
Francisco Department of Public Health has led 
the way, serving as a lead partner on at least 
19 HIAs. Douglass County Health Department, 
NE has been a lead partner on at least 9 HIAs, 
and a handful of other LHDs have served as a 
lead on at least three HIAs, including Maricopa 
County Department of Public Health, (AZ), Los 
Angeles County Department of Public Health, 
and Ingham County Health Department (MI).

With a growing appreciation for how “place” 
matters for health (Acevedo-Garcia et al., 2014; 
Diez Roux & Mair, 2010; Kawachi & Berkman, 
2003; PolicyLink, 2007; RWJF, 2008, 2011), one 
would expect LHDs to actively pursue tools 
and strategies that hold potential to address 

“a systematic process that uses an array of data 
sources and analytic methods and considers 

input from stakeholders to determine the 
potential effects of a proposed policy, plan, 

program, or project on the health of a population 
and the distribution of those effects within the 
population.” (National Research Council, 2011, 

p.5)



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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elements of local built, social, economic, and 
political environments. A core feature of HIA is 
that it can be used to assess any type of policy, 
program, project, or plan, including zoning, land 
use, community development, and housing—all 
elements, for example, that shape distributions 
and patterns of place-based SDH exposures, 
experiences, and opportunities (Braunstein 
& Lavizzo-Mourey, 2011; Frank et al., 2006; 
Maantay, 2001; Northridge & Sclar, 2003; Pastor 
& Morello-Frosch, 2014; Rogerson et al., 2014; 
Wernham, 2011; Wilson et al., 2008).  Thus, by 
its very nature, HIA is a tool designed to address 
local SDH, improve place, and promote health 
equity (Heller et al., 2014; PolicyLink, 2013).  

HIA, SDH, and Place: A Baltimore Story
Despite connections between HIA, SDH, and 
place-health relationships, LHDs have been slow 
to adopt the formal use of HIAs or incorporate 
the application of its core components and 
principles in the policy development process. 
Baltimore City Health Department (BCHD) 
was one such LHD.  A 2010 report on health 
inequities revealed that, like many large cities, 
Baltimore has far to go to achieve health equity 
(BCHD, 2010). Moreover, a 2011 report focused 
on SDH and health at the neighborhood-level 
revealed significant inequities within the city 
(BCHD, 2011). For example, compared to other 
communities, predominantly black and high-
poverty communities have up to 3 times as 
many liquor stores, 4 times as many tobacco 
stores, 35 times as many vacant buildings, 
2.5 times as many vacant lots, and 3 times 
as many fast-food and carry-out restaurants 
(Petteway, 2012).  Within this SDH context, 
the report uncovered a 21-year gap in life 
expectancy between the city’s most- and least-
healthy neighborhoods. Another report in 2012 
demonstrated a strong connection between 
historic patterns of racial residential segregation 
(e.g. from redlining), persistent poverty, and 
health (Joint Center, 2012). These reports make 

it abundantly clear that place (and how it is 
“made”) matters for health, and that addressing 
SDH is integral to any strategy to achieve health 
equity. Moreover, inequities in these social and 
environmental conditions are shaped by local 
policy and practice decisions, and accordingly 
could benefit immensely from HIA.

Two Baltimore projects that have employed 
HIA include The Redline Project, related to the 
proposed development of a new light-rail transit 
route (Ricklin, 2008), and TransForm Baltimore, 
related to a comprehensive zoning code re-
write (Thornton et al., 2013).  A third HIA related 
to a proposed community redevelopment 
plan, the Downtown-Westside Redevelopment 
Implementation Plan, was completed in 2014. 
However, while HIA is not entirely foreign to 
Baltimore City, to date there is no standard 
HIA process to evaluate the potential health 
impacts of local policy decisions.  Moreover, 
currently there is no general process established 
to ensure health is considered from the very 
beginning of the policy development process, 
e.g. a health in all policies (HiAP) approach 
(Rudolph et al., 2013). The work presented here 
describes an attempt to move the needle in this 
regard, and could prove particularly timely given 
the iterative releases of updated Neighborhood 
Health Profiles (BCHD, 2017), which continue 
to highlight the importance of examining local 
policy roots of place-based SDH inequities in 
Baltimore City. 

Building Momentum Towards HIA Through 
Local Policy Reviews: Revisiting a Baltimore 
Study
In this paper, we revisit and present findings 
from a policy review of City Council policy for 
Baltimore City for calendar years 2008 and 
2009. We completed this work ten years ago 
with the following goals in mind: 



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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1. Ascertain the amount, types, and 
magnitude of policies that may potentially 
impact the health of Baltimoreans, i.e. 
a low-level “screening” of all policies 
introduced

2. Identify policies that were referred to the 
Baltimore City Health Department (BCHD) 
for review and those that were not

3. Identify gaps in BCHD referral patterns, i.e. 
what kind of policy does BCHD not receive 
that could have potential health impacts?

4. Outline replicable processes that LHDs can 
use to monitor SDH policies and explore 
potential HIA opportunities

We have previously shared the results of the 
2008 review with various LHD officials and 
practitioners (Petteway, 2010). We shared 
both the 2008 and 2009 reviews within the 
LHD and with various Baltimore City officials 
as part of our efforts to scale-up and deepen 
local efforts to address local SDH, and to build 
interest and capacity for HIA and, potentially, 
HiAP. These reviews were foundational in local 
efforts related to addressing SDH and led to the 
BCHD’s first HIA grant in 2011. We revisit this 
work now as an opportunity to again highlight 
it’s potential value in outlining a way forward 
for LHDs to make inroads towards HIA use 
and HiAP considerations in local practice to 
address SDH and place-health relationships. 
Given the pace at which public health discourse 
regarding SDH and health equity has grown over 
the last decade, we believe this “excavation” of 
sorts could present as timely and potentially 
instructive.

We briefly describe the review process and 
present summary review data. We then discuss 
major findings, limitations, and potential 
practice impacts and implications for LHDs.

Methods
 
Legislation Search
For the 2008 policy review, the online legislative 
database for Baltimore City Council was 
searched for Resolutions and Ordinances with 
legislative file numbers beginning with “08.” In 
addition to an overall search, separate searches 
were performed for legislation sponsored by 
each of the 15 active City Council members 
for both types of legislation, and by legislative 
status. Only legislation introduced between 
1/1/2008 and 12/31/2008 was included for the 
2008 searches. All searches were performed 
between 2/25/2009 and 4/15/2009. This 
same procedure was repeated for 2009 City 
Council policy using “09,” with all searches being 
performed between 4/1/2011 and 6/24/2011.

Legislation Review and Classification
Summaries for all policies, including both 
Resolutions and Ordinances, were evaluated to 
ascertain basic degree of health-relatedness. 
Entire legislative files were read only if health-
relatedness of summary content was unclear 
or insufficient to make a determination. Polices 
that were determined to be health/safety-
related—directly or indirectly, and regardless 
of magnitude or degree of explicitness—were 
collated, re-evaluated, and categorized based on 
if they were: a) Explicitly Health/Safety-Related, 
or b) Related to SDH. Policies categorized as 
“explicitly health/safety-related” (EHR) explicitly 
mentioned health, safety, and/or health-related 
topics (e.g. asthma, smoking, trans fats), or 
otherwise pertained to matters commonly 
recognized as being related to health/safety 
(e.g. child welfare, firearms, sanitation, animal 
control) (see Table 1).

Policies involving topics commonly considered 
SDH, or that influence SDH (directly or 
indirectly), were categorized as Related to SDH.  
Considerations for which policies constituted/



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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affected SDH were rooted in SDH literature and 
core guiding documents within health equity 
and HIA work (PolicyLink, 2007; Ramirez et 
al., 2008; RWJF, 2008; WHO, 2008). These 
included policies that are traditionally outside 
the scope of “health” policy, e.g. policy regarding 
homelessness, parks, green buildings, affordable 
housing, transportation, vacant housing/
lots, living wages, zoning and community 
development (see Table 1). 

Legislation that was reviewed and did not fall 
into the EHR or SDH categories was excluded 
in the remaining analysis. The EHR and SDH 
policies were then sorted based on their 
current or final legislative status: Enacted 
(for Resolutions), Adopted (for Ordinances), 
Withdrawn, Failed, or In Committee. These 
categorized and sorted policies were then 
compared to a list of policies that were 
forwarded from City Council to BCHD for 
comment and review of potential health 
concerns. These policies were forwarded at the 
discretion of each City Council subcommittee, 

i.e. committee members determined whether or 
not formal assessments/comments would be 
sought from various agencies for each pending 
policy, including BCHD. Policy review results 
were then tabulated—stratifying by year, type 
of policy, EHR or SDH, policy status, and BCHD 
review status.  

Findings Summary

We identified and assessed 179 Resolutions 
and 418 Ordinances—597 total policies—across 
the 2008 and 2009 calendar years (Figure 1). 
Again, a total of 89 policies (15%) were identified 
as “explicitly health-related,” 34 (38%) of which 
were referred for LHD review. 208 policies 
(35%) were identified as “related to SDH,” only 
13 (6%) of which were referred for LHD review. 
Overall, 297 (50%) policies were identified as 
having potential health impacts, only 47 (16%) 
of which were reviewed and commented on 
for potential health considerations by BCHD 
(Figure 2). 



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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2008 & 2009 Resolutions
BCHD 

Reviewed
Ordinances

BCHD 
Reviewed

R&D
BCHD 

Reviewed

Total 2008 and 
2009

181 433 614

Total Reviewed
(on file)

179 418 597

Total Health/
Safety-Related

93 (52%) 16 (17%) 204 (49%) 31 (15%) 297 (50%) 47 (16%)

Explicitly Health/
Safety

44 (47%) 13 (30%) 45 (22%) 21 (47%) 89 (30%) 34 (38%)

Related to SDH 49 (53%) 3 (6%) 159 (78%) 10 (6%) 208 (70%) 13 (6%)

Figure 1: Summary of 2008 & 2009 Polices Referred for Health Review

Figure 2: Summary of 2008 & 2009 Polices Referred for Health Review

Figure 1: BCHD is Baltimore City Health Department. Note that a total of 17 policies were not on file in the database and 
were therefore not included in this review.

Figure 2: BCHD is Baltimore City Health Department. Note that a total of 17 policies were not on file in the database and 
were therefore not included in this review.

2008-2009 Resolutions & Ordinances

Total Health/Safety-
Related

Explicitly
Health/Safety

Related to SDH



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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Table 1: 25 Illustrative Examples of Policies Reviewed & Categorized for Potential Health 
Impacts

Table 1 provides an illustrative overview of the 
types of policies that were identified as having 
potential health impacts, distinguishing those 
that were “explicitly health-related” and those 
that were “related to SDH.” Table 2 highlights 

some major SDH-related policies that were 
not reviewed for potential health impacts, thus 
representing significant missed opportunities to 
potentially improve place-health relationships in 
the city.

Illustrative Examples of Policies Reviewed & Categorized for Potential Health Impacts

Policy Category Policy 
Type Policy Topic Status1 BCHD-

Reviewed

Explicitly 
Health-

Related (EHR)

Resolution Asthma Awareness Month acknowledgment Adopted No

Resolution
Baltimore Green Week acknowledgment: Healthy 

Cities & Healthy Lives
Adopted No

Resolution
Informational Hearing; Public Wellness and Disease 
Prevention Program; request for BCHD to discuss 
available practices/resources for Baltimore City

Adopted Yes

Resolution
Informational Hearing; Vector Control; request for 

City Council briefing on effectiveness of efforts
Adopted Yes

Resolution
Investigative Hearing; Decommissioning, 

Dismantling, and Closure of Hazardous Material 
Sites

In 
Committee

Yes

Ordinance
Trans Fats; exempting certain bakeries from the 
provisions governing food containing trans fat

Enacted Yes

Ordinance Repeal ban, sale of contraceptives to minors Enacted Yes

Ordinance
Zoning ; Conditional Use; Nonprofit Home and 
Transitional Housing Facility for the Care and 

Custody of Homeless Persons
Enacted Yes

Ordinance

City Streets - Bike-Safe Grates; requiring that all 
City street paving and repaving contracts require 

that drainage grates be installed in a bike-safe 
alignment

Enacted No

Ordinance
Flavored Tobacco Wrappings; Sale or Distribution; 

prohibiting the sale or distribution of flavored 
tobacco wrappings

Enacted Yes

Ordinance
Tobacco Products; strengthening the prohibition 

against the sale or transfer of unpackaged 
cigarettes

Failed Yes

1At time of review



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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Illustrative Examples of Policies Reviewed & Categorized for Potential Health Impacts

Policy Category Policy 
Type Policy Topic Status1 BCHD-

Reviewed

Explicitly 
Health-

Related (EHR)

Ordinance
Baltimore City Sustainability Plan; establishing a 

Sustainability Plan for the City of Baltimore
Enacted Yes

Ordinance

Food Service Facilities - Suspension or Non-
renewal of Licenses; authorizing the suspension or 
non-renewal of a license for a food service facility 
that has received multiple environmental or civil 

citations

Enacted Yes

Related to 
SDH

Resolution
Urging Baltimore City Public Schools CEO to 

adopt Non-Violent Conflict Resolution Curriculum 
(Education)

Adopted No

Resolution

Informational Hearing; Revocation of Federally 
Subsidized Housing Assistance; to keep housing 

free of “criminals” and those “associated with 
criminals or persons with criminal intent” (Housing; 

Criminal Justice)

Adopted No

Resolution 
Celebration/acknowledgment of Bike to Work Week 

(Transportation)
Adopted No

Resolution
Task Force on Noise Laws and Enforcement 

(Environment)
Adopted No

Ordinance
Plastic Bags; imposing a surcharge on certain bags 

provided by dealers to customers (Environment)
Enacted Yes

Ordinance
Zoning ; Conditional Use; Nonprofit Home and 
Transitional Housing Facility for the Care and 

Custody of Homeless Persons (Housing)
Enacted Yes

Ordinance
Urban Renewal; Greenmount West (Community 

Development)
Enacted No

Ordinance
Zoning; Condition Use; Incinerator (Community 

Development)
Enacted No

Ordinance Speed Monitoring Systems (Transportation) Enacted No

Ordinance

Planned Unit Development; The State Center, 
Transit Oriented Development Business Planned 
Unit Development (Transportation; Community 

Development)

Enacted No

Ordinance
Transit and Traffic; Bike Lanes for the purpose of 

allowing the creation of bike lanes (Transportation)
Enacted No

Ordinance
Westport Waterfront Development District 

(Community Development)
Enacted No



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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Table 2: 25 Missed Opportunities to Inform Policy Decisions Related to SDH: Illustrative 
Examples of Place and Health-Impacting Policies Not Reviewed by BCHD

25 Illustrative Examples of Place and Health-Impacting Policies Not Reviewed by BCHD

Policy Type Year Policy Topic Status2 

Resolution 2008

Informational Hearing; Revocation of Federally Subsidized 
Housing Assistance; to keep housing free of “criminals” and 

those “associate with criminals or persons with criminal intent” 
(Housing; Criminal Justice)

Adopted

Resolution 2008
Allowing students to use MTA transfers until 8PM on school 

days (Education; Transportation)
In 

Committee

Resolution 2008
Request for State Legislation; increase penalty for all 

felony gun crimes (Criminal Justice)
Adopted

Resolution 2008
Request for development & implementation of gang-

related violence training for Baltimore City Public School 
teachers (Education; Criminal Justice)

Adopted

Resolution 2009

Baltimore City Youth Development Task; establishing a 
citywide task force to provide substantive direction on 

how to expand and allocate resources on positive youth-
centered activities (Education; Community Development)

Adopted

Resolution 2009

Requesting the Baltimore City Police Department to 
implement online reporting systems to disclose the final 
internal investigation results of officer-related shootings 

provide a greater level transparency to the citizens of 
Baltimore (Criminal Justice)

Adopted

Resolution 2009

Informational Hearing; inviting the Baltimore Police 
Commissioner to report to the City Council on the recent 

mass dismissal of internal misconduct cases (Criminal 
Justice)

Failed

Resolution 2009

Request for Budget Action; requesting the Mayor 
to restore funding for recreation centers, childcare 

centers, Police Athletic League Centers, and City pools 
(Recreation; Education)

Adopted

Resolution 2009

Informational Hearing; requesting the Senior Vice 
President of Customer Relations and Account Services 
for BGE to report to the City Council on efforts to help 
low-income customers manage energy costs (Energy 

Security)

Adopted

2At time of review



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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Policy Type Year Policy Topic Status2 

Ordinance 2008

City Trees; extending certain laws for the protection of 
trees along public ways to apply also to trees in parks, 

squares, and other public places (Natural Environment; 
Climate)

Enacted

Ordinance 2008
Planned Unit Development; The State Center, Transit 

Oriented Development Business Planned Unit 
Development (Transportation; Community Development)

Enacted

Ordinance 2008
Planned Unit Development; The State Center, Transit 

Oriented Development Business Planned Unit 
Development (Transportation; Community Development)

Enacted

Ordinance 2008
Westport Waterfront Development District (Community 

Development)
Enacted

Ordinance 2009 Urban Renewal; Harlem Park II (Community Development Enacted

Ordinance 2009 Urban Renewal; Park Heights (Community Development Enacted

Ordinance 2009
Urban Renewal; Greenmount West (Community 

Development
Enacted

Ordinance 2009
Zoning; Conditional Use Permit; Incinerator (Zoning; Land 

Use)
Enacted

Ordinance 2009 Speed Monitoring Systems (Transportation) Enacted

Ordinance 2009 Urban Renewal; Belair-Erdman (Community Development Enacted

Ordinance 2009
Urban Renewal; Reistertown Plaza Transit Station 

(Transportation; Community Development)
Enacted

Ordinance 2009
Bike-Safe Grates; requiring that all City street paving 

and repaving contracts require that drainage grates be 
installed in a bike-safe alignment (Transportation)

Enacted

Ordinance 2009
Transit and Traffic; Bike Lanes for the purpose of allowing 

the creation of bike lanes (Transportation)
Enacted

Ordinance 2009
Land Bank Authority; for the purpose of establishing 

the Land Bank Authority of Baltimore City (Community 
Development)

Withdrawn

Ordinance 2009
Newly Constructed Dwellings; reauthorizing and 

extending for a certain period the property tax credit for 
newly constructed dwellings (Community Development)

Enacted

Ordinance 2009

Downtown Management District; extending the Downtown 
Management District to encompass an area bounded by 
Franklin Street to the north, Howard Street to the east, 

Saratoga Street to the south, and Eutaw Street to the west 
(Community Development)

Enacted



Health Impact Assessment and City Council Policy Petteway; Cosgrove

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Discussion: Implications for Policy and 
Practice
There are perhaps three major takeaways from 
the work we summarized here. First, based 
on our review, BCHD reviewed/commented 
on just 16% of potentially health-impacting 
policies introduced during 2008 and 2009 
calendar years (Figure 2). In other words, an 
overwhelming majority—84%—of Baltimore 
City Council policies with the potential to impact 
health were not reviewed accordingly. Moreover, 
BCHD was much more likely to review policies 
with explicit connections to health—reviewing 
38% of EHR policies vs. just 6% of SDH 
polices (Figure 2). This means that dozens of 
opportunities to address local SDH were missed 
(see some major examples in Table 2). Overall, 
the pattern of BCHD reviews during these two 
years suggests a pronounced “downstream” 
perspective regarding what constitutes “health” 
policy, e.g. policies related to tobacco, trans fats, 
vector control, and contraceptives (Table 1).

Second, BCHD reviews of policy were 
proportionately similar between resolutions 
(17%) and ordinances (15%) (Table 1). 
Resolutions tend to be more symbolic and 
affirmational gestures towards policy values 
and priorities, or requests for additional 
information regarding topics that might 
eventually become a policy priority. They do 
not in themselves constitute true policies in 
the manner traditionally understood within the 
scope of HIA and HiAP, as they do not change 
laws, budgets, or practices in ways that would 
fundamentally alter the lived contexts of health 
opportunity. This suggests, perhaps, a need 
to better prioritize review energies such that 
more substantial policies, i.e. actual laws, are 
subjected to more frequent and rigorous review/
comment for health—particularly given the 
extent to which major SDH-related ordinances 
were enacted into law without BCHD review or 
comment (Table 2). 

And third, from our review, it was clear that most 
of the major policies that fundamentally alter 
place-based contexts of health opportunity 
and risk were not reviewed, many of which 
were related to zoning, urban renewal, and 
community development (Table 2). Critically, 
many of these un-reviewed policies directly 
affected the neighborhoods experiencing the 
highest burden of health inequities, e.g. Park 
Heights, Greenmount, Harlem Park (BCHD, 
2011, 2017)—communities in which the 
distribution of health opportunities and risks 
has been historically shaped by mechanisms 
of structural racism, like redlining (Joint 
Center, 2012). There is quite literally no point 
in completing future iterations, for example, of 
the Neighborhood Health Profiles if the policies 
responsible for (re)producing, maintaining, or 
exacerbating the inequities revealed in these 
reports continue to be developed and enacted 
without application of a critical health lens. This 
suggest a critical need to develop mechanisms 
so that such polices (e.g. urban renewal, 
community development) are routinely reviewed 
in light of potential health impacts—even in the 
absence of HIA resources. Reviews like the one 
discussed here could be used to contextualize 
the outcomes data made available by an 
increasing number of tools/platforms (CDC, 
2020; NAPHSIS, 2020; PolicyMap, 2020; RWJF, 
2020), and perhaps allow for more robust and 
locally actionable assessments of place-health 
relationships, drawing from—and enhancing the 
geographic resolution of—legal epidemiology 
approaches in public health (Burris et al., 2016; 
Ramanathan et al., 2017).

This review also had several limitations worth 
noting here. First, we relied on a publicly 
accessible policy database to identify policies 
in each of the years included in our review. 
As indicated in Figure 1, a total of 17 policies 



Health Impact Assessment and City Council Policy Petteway; Cosgrove

12

were not on file in the database and we were 
thus unable to include them in our review. This 
review, while still rather extensive, is incomplete. 
Second, we relied on a generally imprecise 
process for categorizing policies in regard 
to their health-relatedness. As noted above, 
we relied on our knowledge of SDH and the 
guidance of core documents related to SDH 
and HIA in developing our broad categories of 
“explicitly-related to health” and “related to 
SDH.” Moreover, we did not complete inter-
rater reliability testing as part of the policy 
categorization process, primarily because our 
intention was to simply complete a rough/
cursory examination of what the LHD was 
reviewing and not reviewing. We were aiming for 
a quick process that could be applied/adapted 
in the practical contexts of local practice, 
wherein many LHDs, like BCHD, do not have 
the staff resources or technical capacity to 
more formally structure and evaluate policy 
categorizations. We thus approached the two 
years of policy as a sort of test of concept/
process, with the intention to enhance/refine 
in future iterations. We do not discount that 
separate reviewers more than likely would have 
made different category allocations for some 
policies, and likely would have included/retained 
additional policies at the health-relatedness 
categorization stage (we excluded 300 policies). 
Given that we were indeed hoping from the 
outset to explore/arrive at a process that other 
LHDs could potentially follow/replicate, formally 
assessing policy categorization reliability from 
the beginning would have afforded greater 
technical guidance for uptake elsewhere.

And third, we also acknowledge that our 
decision to use two discrete categories—EHR 
and SDH—presumes that each is mutually 
exclusive, even though, in effect, many policies 
have direct health connections and indirect 
impacts via various SDH mechanisms. Even 
so, we believe these categories afforded us 

sufficient direction to complete what we 
intended as a cursory/exploratory review and 
assessment of policies. And we accordingly 
believe that our general process remains 
transferrable if not fully replicable with the 
enhancement of inter-rater reliability testing.

It’s important to note here that while this review 
was partly intended to reveal the potential 
vitality of HIA as a tool to assess local policy, it 
was mostly a way to demonstrate the need to 
simply consider the potential health impacts 
of ‘non-health’ policies, i.e. policies that are/
affect SDH.  Conducting an infinite number of 
HIAs is obviously not a viable goal or solution.  
Accordingly, we approached this review as a 
means to use the discourse and lens of HIA as a 
vehicle to open discussions regarding long-term, 
proactive approaches to promote health equity 
within and through standard policy processes, 
similar to efforts undertaken elsewhere (Den 
Broeder, 2003; Gagnon & Michaud, 2008; 
Wernham & Teutsch, 2015). Thus, we considered 
the broader aims of this work to support 
progress towards:

1. Developing a replicable process through 
which local policies possessing the ability 
to significantly impact the health are 
identified and referred for LHD review

2. Expanding the scope of ‘health’ policy to 
include all policies that shape residents’ 
built, social, and economic environments 
and opportunities, including those related 
to zoning, community development, 
land use, transportation, education, and 
housing, i.e. moving LHD review of polices 
closer to HiAP

As noted above, LHD engagement and uptake 
of HIAs has been remarkably limited, and in 
the absence of either interest, resources, or 
capacity to conduct HIAs, LHDs might benefit 
from more rudimentary—but ultimately, more 



Health Impact Assessment and City Council Policy Petteway; Cosgrove

13

foundational—tools and processes. At the 
time of our review, the health review process in 
Baltimore was not proactively led by LHD staff. 
Rather, City Council committee members made 
determinations regarding which City agencies 
should review/comment on each policy (e.g. 
the Education subcommittee sending school/
education-related policies for review by 
Baltimore City Public Schools leadership). Our 
review makes it clear that such a process is 
insufficient. Moreover, it suggests that real-time 
tracking/monitoring of policy by LHD staff is a 
viable and more robust way to ensure a health 
lens is applied. The work presented here, we 
believe, highlights the potential value of local 
policy reviews as a low-cost “screening”-like 
process for LHDs. Such reviews can serve as 
a tool to identify the most significant policies 
in need of detailed LHD review as they are 
introduced. In this way, the reviews serve as 
a sort of gateway tool to identify potential 
HIA opportunities (should resources become 
available) and as a model process to move 
towards HiAP within local government, with 
every policy given at least a cursory examination 
in regard to health equity implications. 

In an absence of such a review process in 
Baltimore City for 2008 and 2009, several 
significant polices were approved without any 
analysis of potential health impacts—failing 
to even be referred to BCHD for a cursory 
review, comment, or sign-off (Table 2). 
Examples range from transportation policy for 
public school students and energy security 
for low-income residents, to transit-oriented 
development projects and protecting city tree 
canopy, to the aforementioned community 
development policies. And, given the emotional 
and psychological health toll that deaths at 
the hands police #FreddieGray #KorrynGaines 
have on families and entire communities 
(Bor et al., 2018), it’s worth noting that there 
was an entire collection of policies related to 

police (mis)conduct and criminalization that 
went unreviewed for potential health impacts, 
including policies that investigated the mass-
dropping of police misconduct cases and called 
for greater transparency regarding officer-
involved shootings and misconduct (Table 2). 
As previously noted, these sorts of policies 
would not have been referred automatically to 
BCHD for review. Someone would have had to 
have been proactively monitoring all policies 
as they were introduced, then flagged them 
for review. The fact that these policies were 
not referred to BCHD, and the fact that BCHD 
staff either did not see them or feel the need 
to review/comment on them, speaks rather 
poignantly to the myopic tendencies of LHDs 
in regard to health equity efforts, often failing 
to see the nuanced structural factors driving 
community and population health risks and 
outcomes.  

Certainly, not all of the 297 policies we 
identified as having potential health impacts 
needed a detailed review. Indeed, many did 
not appear to need much more than a simple 
acknowledgment, e.g. dozens of zoning policies 
that modified basic elements of property lines 
or rights of way. On the other hand, there were 
dozens of policies that could have benefitted 
from and been potentially strengthened by a 
more health-conscious review, some of which 
possessed the ability to alter the landscape of 
place-based opportunities and risks for years to 
come. We believe this could have been averted 
with a basic commitment to more closely 
monitor policy development activities across 
all sectors of local government. In this light, this 
review could serve as a potential model process 
for LHDs to move in that direction—generally, 
the direction of an HiAP orientation and practice 
among LHD leadership and legislative/policy 
directors.



Health Impact Assessment and City Council Policy Petteway; Cosgrove

14

Conclusion

The review presented here represents a 
potentially replicable process to monitor policy 
with potential health impacts and can serve as 
a starting point to identify HIA opportunities, or 
as a foundational process for HiAP. In Baltimore, 
this work facilitated dialogue around HIA with 
key City officials, including focused discussion 
with various City Council members on how to 
incorporate the principles and core philosophy 
of HIA into City policy development processes. 
These discussions strengthened rapport 
between the LHD and City Hall and engendered 
additional support/motivation to formally 
pursue HIA. This work led directly to the first 
HIA grant for the City health department, which 
improved prospects for integrating HIA into 

standard practice, and led to completion of at 
least 2 HIAs between 2011 and 2015. Moreover, 
this work was a key element to development/
framing of two major LHD reports: one 
highlighting neighborhood SDH for the first 
time (the 2011 Neighborhood Health Profiles), 
and the other outlining the City’s strategic 
plan/vision for health (Healthy Baltimore 
2015)—which was the first official LHD report 
to mention HiAP as policy priority. Other LHDs 
might benefit from engaging in similar review 
processes to facilitate movement towards HIA 
and HiAP as part of standard practice to address 
local SDH, improve place-health relationships, 
and promote health equity.



Health Impact Assessment and City Council Policy Petteway; Cosgrove

15

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CORRESPONDING AUTHOR
Ryan J. Petteway, DrPH, MPH
Assistant Professor
Portland State University
OHSU-PSU School of Public Health
petteway@pdx.edu

CHIA Staff:

Editor-in-Chief 
Cynthia Stone, DrPH, RN, Professor, Richard M. Fairbanks School of Public Health, Indiana 
University-Purdue University Indianapolis

Journal Manager 
Angela Evertsen, BA, Richard M. Fairbanks School of Public Health, Indiana University-Purdue 
University Indianapolis

Chronicles of Health Impact Assessment Vol. 5 Issue 1 (2020) DOI: 10.18060/24320
© 2020 Author(s): Petteway, R.; Cosgrove, S.
       This work is licensed under a Creative Commons Attribution 4.0 International License

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Acknowledgment: This article’s publication was funded by the Portland State University Open Access 
Article Processing Charge Fund, administered by the Portland State University Library."

mailto:petteway%40pdx.edu?subject=
https://doi.org/10.1377/hlthaff.2011.0050
https://doi.org/10.1097/PHH.0000000000000130
https://doi.org/10.1089/env.2008.0506
http://www.who.int/social_determinants/sdh_definition/en/
http://www.who.int/social_determinants/sdh_definition/en/

