New International Consensus on Health Impact Assessment more

Correspondence 100 0001 seems to require further support. We declare that we have no conflicts of interest. *T Hoppitt, M Calvert, H Pall, H Rickards, C Sackley t.j.hoppitt@bham.ac.uk University of Birmingham, Birmingham B15 2TT, UK (TH, MC, CS); Queen Elizabeth Hospital, Birmingham, UK (HP); and Birmingham and Solihull Mental Health NHS Trust, Birmingham, UK (HR) 1 2 Rawlins M. Huntington’s disease out of the closet? Lancet 2010; 376: 1372–73. Harper PS. The epidemiology of Huntington’s disease. In: Bates G, Harper P, Jones L, eds. Huntington’s disease, 3rd edn. Oxford: Oxford University Press, 2002. Wexler A. Stigma, history, and Huntington’s disease. Lancet 2010; 376: 18–19. James CM, Houlihan GD, Snell RG, Cheadle JP, Harper PS. Late-onset Huntington’s disease: a clinical and molecular study. Age Ageing 1994; 23: 445–48. Morrison PJ, Johnston WP, Nevin NC. The epidemiology of Huntington’s disease in Northern Ireland. J Med Genet 1995; 32: 524–30. 3 4 were in pain, seven of whom also showed a disturbance in sensorydiscriminative aspects of pain. Of the 11 patients, only three were receiving analgesics (2 × 25 mg/day tramadol, 3 × 500 mg/day paracetamol, and 4 × 500 mg/day paracetamol). However, near maximum scores on pain scales indicated that pain treatment was inadequate. Touch and temperature applied to the forearm were distorted in two and three patients, respectively. We argue that deafferentiation might cause “central pain”,5 for which paracetamol is inappropriate and the tramadol dose too low. Since pain in Huntington’s disease can go unnoticed, we should take time for tea with these patients instead of simply passing by. We declare that we have no conflicts of interest. 5 *Erik Scherder, Monique Statema eja.scherder@psy.vu.nl Department of Clinical Neuropsychology, VU University Amsterdam, 1081 BT Amsterdam, Netherlands 1 2 3 Wexler A. Stigma, history, and Huntington’s disease. Lancet 2010; 376: 18–19. Rawlins M. Huntington’s disease out of the closet? Lancet 2010; 376: 1372–73. Abbruzzese G, Berardelli A. Sensorimotor integration in movement disorders. Mov Disord 2003; 18: 231–40. Albin RL, Young AB. Somatosensory phenomena in Huntington’s disease. Mov Disord 1988; 3: 343–46. Scherder EJ, Sergeant JA, Swaab DF. Pain processing in dementia and its relation to neuropathology. Lancet Neurol 2003; 2: 677–86. Alice Wexler1 and Michael Rawlins2 emphasise the stigmatisation and isolation of patients with Huntington’s disease, to the extent that even the general practitioner is sometimes not informed of the diagnosis. This omission could result in crucial medical information going unnoticed. In passing, a frequent observation is that patients with Huntington’s disease drink tea while it is still too hot, at first sight without signs of discomfort or pain. Little is known about somatosensory functioning and pain in Huntington’s disease. Studies with sensory-evoked potentials report a disturbance in the cortical processing of somatosensory information (deafferentiation).3 The sole clinical study (1988) describes two patients with Huntington’s disease and severe pain.4 We examined 19 patients with Huntington’s disease who lived in nursing homes—a setting associated with undertreatment of pain in dementia. Pain was assessed by visual analogue scales and an affective verbal pain descriptor scale. Sensorydiscriminative aspects of pain were assessed with a pinprick. 11 patients 1464 4 5 sector. Krieger and colleagues omit to note that the International Finance Corporation is a government-owned entity. Demand by governments for the accountability of financial institutions has been a driver for the private sector’s use of impact assessment, including HIA. The interplay between public and private sectors has led to guidance for, and commissioning of, HIAs. Krieger and colleagues also do not acknowledge their role in writing the International Finance Corporation guidance for HIA.3 The environmental health areas framework4 and the social determinants of health5 are not incompatible approaches. Public health is best served by acknowledging the dynamic between environmental and social factors, and reflecting this in integrated analysis—an approach common to most HIA practice including that articulated by the environmental health areas framework. Krieger and colleagues write that the operationalisation of HIA is the key. We state that transparency, accountability, and having a wide scope are also crucial to achieving the promise of “tangible results” from large projects. We do not agree with Krieger and colleagues’ Comment, but welcome their contribution. We call on them, and others, to come together to develop a post-Gothenburg international HIA consensus that moves the field forward. We have done HIA-related work for the private sector, various government agencies, development banks, and multinational organisations, and have served as experts at WHO. New international consensus on health impact assessment Gary Krieger and colleagues (June 19, p 2129)1 present a polarising narrative, pitting themselves, as private sector consultants, against health impact assessment (HIA) as conceptualised in the Gothenburg Consensus. Krieger and colleagues represent one perspective among HIA practitioners, who all share a commitment to the protection and enhancement of health and wellbeing.2 The private sector’s use of HIA has not evolved independently of the public *Salim Vohra, Ben Cave, Francesca Viliani, Ben F Harris-Roxas, Rajiv Bhatia salim.vohra@iom-world.org Centre for Health Impact Assessment, Institute of Occupational Medicine (London Office), Research House Business Centre, London UB6 7AQ, UK (SV); Ben Cave Associates, Leeds, UK (BC); International SOS, Copenhagen, Denmark (FV); Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, Australia (BFHR); and San Francisco Department of Public Health, San Francisco, CA, USA (RB) 1 Krieger GR, Utzinger J, Winkler MS, et al. Barbarians at the gate: storming the Gothenburg consensus. Lancet 2010; 375: 2129–31. www.thelancet.com Vol 376 October 30, 2010 Correspondence 2 3 4 5 Harris-Roxas B, Harris E. Differing forms, differing purposes: a typology of health impact assessment. Environ Impact Assess Rev (in press). IFC. Introduction to health impact assessment. Washington, DC: International Finance Corporation, 2009. Listorti JA, Doumani FM. Environmental health: bridging the gaps. Washington, DC: World Bank, 2001. WHO. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: Commission on the Social Determinants of Health, 2008. Authors’ reply We appreciate the points offered by Salim Vohra and colleagues. Yet we strongly disagree with their perspective, justified on the following grounds. First, our Comment was centred on the need to clarify important distinctions between private sector projects and government-sponsored policies, programmes, and projects, which are currently being conflated. The field of health impact assessment (HIA) is being wrapped in a cloak of aspirational social determinants rhetoric, which fosters a misperception of universality of this framework and its implementation. The social determinants movement has an important objective to identify and potentially alleviate social inequalities. Although worthy, this is not the role and responsibility of a private company. Our key point is to recognise the aspects of a project that the private sector can directly affect. As part of a project, key core competencies (eg, engineering and logistics) of the private sector can be selectively focused to avoid or mitigate negative health effects and enhance positive ones. The International Finance Corporation (IFC) HIA toolkit recognises the link between broadly defined environmental health and the burden of diseases in the developing world.1 It therefore builds on pioneering work by the World Bank,2 supported by contemporary HIA in developing countries.3,4 We believe that it is a mistake to embed HIA for large industrial projects, and subsequent local community follow-up, in a discussion of social issues that no www.thelancet.com Vol 376 October 30, 2010 private-sector project can realistically and sustainably manage. Second, Vohra and colleagues reveal a misreading of the development of the Equator Principles, which are a voluntary set of standards for the identification, assessment, and management of social and environmental risk in project financing. Describing the history of the Equator Principles as a “demand” by governments for financial institutions’ “accountability” is simply not correct.5 Third, our group was indeed commissioned by the IFC to develop technical guidance for HIA. We stated in our conflict of interest statement that we had done work for “the private sector, development banks, and multinational organisations”. We apologise if this did not explicitly mention the IFC. Similar to other private sector and multinational organisations, IFC has a rigorous process for vetting and reviewing guidance materials. Our contribution went through exhaustive stakeholder consultation and extensive review by IFC’s in-house technical experts and IFC retained editorial control of the process and final product. Finally, we agree that transparency, accountability, and having a wide scope—along with operationalisation—are key issues to move the field of HIA forward. A post-Gothenburg international HIA consensus is critical, but this requires clarity about the distinctions between HIAs done as part of nationally focused government initiatives, and those accompanying private-sector projects with only local community effects. We have done work for the private sector, development banks, and multinational organisations, including the IFC, and have served as experts on WHO committees and for other international organisations. Swiss Tropical and Public Health Institute, 4002 Basel, Switzerland (JU, MSW); NewFields LLC, Pretoria, South Africa (MJD); and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA (BHS) 1 Prüss-Ustün A, Bonjour S, Corvalán C. The impact of the environment on health by country: a meta-synthesis. Environ Health 2008; 7: 7. Listorti JA, Doumani FM. Environmental health: bridging the gaps. http://www. worldbank.org/afr/environmentalhealth (accessed Aug 25, 2010). Krieger GR, Balge MZ, Chanthaphone S, et al. Nam Theun 2 hydroelectric project, Lao PDR. In: Fewtrell L, Kay D, eds. Health impact assessment for sustainable water management. London: IWA Publishing, 2008: 199–232. Winkler MS, Divall MJ, Krieger GR, Balge MZ, Singer BH, Utzinger J. Assessing health impacts in complex eco-epidemiological settings in the humid tropics: advancing tools and methods. Environ Impact Assess Rev 2010; 30: 52–61. Heal GM. When principles pay: corporate social responsibility and the bottom line. New York: Columbia University Press, 2008. 2 3 4 5 Regulating medical tourism We were interested to read Priya Shetty’s World Report examining the booming medical tourism industry in India (Aug 28, p 671).1 The Lancet is to be commended for bringing attention to this issue. It is of the utmost importance that trends in medical tourism be watched closely given the implications for patients’ health and safety2,3 and for health systems more broadly.4 Shetty places significant focus on the need to regulate the medical tourism industry in India. We would like to note that additional, complementary regulatory guidelines are also needed in patients’ home countries. Several prominent source countries for medical tourists, such as Canada and Australia, currently have no national or regional guidelines for patients or clinicians on their involvement in medical tourism, which is concerning. Such guidelines are needed to ensure that patients’ health and safety is prioritised, that adequate health-system responses are in place, and that risks to patients and others are minimised. Those aimed at patients could also incorporate some ethical buying guidelines. 1465 Gary R Krieger, *Jürg Utzinger, Mirko S Winkler, Mark J Divall, Scott D Phillips, Marci Z Balge, Burton H Singer juerg.utzinger@unibas.ch NewFields LLC, Denver, CO, USA (GRK, SDP, MZB); Department of Epidemiology and Public Health,