Abstract:

The use of Health Impact Assessment (HIA) in the establishment of an urban protected area can enhance the positive impacts and mitigate the negative impacts resulting from its implementation. Brazil hosts some of the most important biodiversity hotspots in the world and the HIA may benefit biodiversity and human health. These areas are commonly created without any preceding survey to assess their impacts on health. Protected areas located in urban zones are essential to maintain environmental balance and quality of life in cities. It promotes positive impacts on health, providing ecosystem services and salutogenic benefits. However, they can generate negative impacts such as the violation of human rights, property speculation, spread of vectorial diseases, and psychosocial stress. Based on the identification of the potential impacts of urban protected areas on health and best practices, this qualitative and exploratory study justifies the use of HIA in urban protected areas, especially in the Brazil, and indicates the main elements for the construction of a methodological approach to contribute to the Sustainable Development Goals and one of its alternatives, the Buen Vivir approach.

Keywords:
Health Impact Assessment; Protected Areas; Urban Zone; Community Participation

Resumo:

O uso da Avaliação de Impacto à Saúde (AIS) na criação de uma área protegida urbana pode potencializar os impactos positivos e mitigar os impactos negativos resultantes de sua implementação. O Brasil abriga alguns dos mais importantes hotspots de biodiversidade do mundo e a implementação da AIS pode beneficiar tanto estas áreas como a saúde humana. As áreas protegidas urbanas são comumente estabelecidas sem qualquer avaliação prévia de seus impactos na saúde e são essenciais para manter o equilíbrio ambiental e a qualidade de vida nas cidades. Além disso, as áreas protegidas impactam positivamente a saúde, fornecendo serviços ecossistêmicos e benefícios salutogênicos. Contudo, podem gerar impactos negativos, como violação de direitos humanos, especulação imobiliária, disseminação de doenças vetoriais e estresse psicossocial. Com base na identificação dos impactos potenciais das áreas protegidas urbanas na saúde e nas melhores práticas para aplicá-las, este estudo qualitativo e exploratório justifica o uso da AIS em áreas protegidas urbanas, especialmente no Brasil, e indica os principais elementos para a construção de uma abordagem metodológica que contribua com os Objetivos de Desenvolvimento Sustentável e uma de suas alternativas, a abordagem Buen Vivir.

Palavras-chave:
Avaliação do Impacto na Saúde; Áreas Protegidas; Zona Urbana; Participação da Comunidade

Resumen:

Usar la Evaluación del Impacto en la Salud (EIS) para crear un área protegida urbana puede potenciar los impactos positivos y mitigar los impactos negativos resultantes de su implementación. En Brasil se pueden encontrar algunos de los hotspots de biodiversidad más importantes del mundo e implementar la EIS puede beneficiar tanto estas áreas como la salud humana. Las áreas protegidas urbanas, en general, se establecen sin cualquier evaluación previa de sus impactos en la salud y son esenciales para mantener el equilibrio ambiental y la calidad de vida en las ciudades. Además, las áreas protegidas tienen un impacto positivo en la salud, proporcionando servicios ecosistémicos y beneficios salutogénicos. Sin embargo, pueden generar impactos negativos, como la violación de los derechos humanos, la especulación inmobiliaria, la propagación de enfermedades vectoriales y el estrés psicosocial. Con base en la identificación de los posibles impactos de las áreas protegidas urbanas en la salud y en las mejores prácticas para aplicarlas, este estudio cualitativo y exploratorio justifica el uso de la EIS en áreas protegidas urbanas, sobre todo en Brasil, e indica los elementos principales para construir un enfoque metodológico que contribuya a los Objetivos de Desarrollo Sostenible y una de sus alternativas, el enfoque Buen Vivir.

Palabras-clave:
Evaluación del Impacto en la Salud; Áreas Protegidas; Zona Urbana; Participación de la Comunidad

Introduction

Protected areas are the main tool for in situ biodiversity conservation policies and for the preservation of cultures, territories, and traditional populations ¹1. Bensusan N. Conservação da biodiversidade em áreas protegidas. Rio de Janeiro: Editora FGV; 2006.^,22. Dudley N, editor. Guidelines for applying protected area management categories. Gland: International Union for Conservation of Nature and Natural Resources; 2008.^,33. Barretto-Filho HT. Notas para uma história social das áreas de proteção integral no Brasil. In: Ricardo F, editor. Terras indígenas e unidades de conservação: o desafio das sobreposições. São Paulo: Instituto Socioambiental; 2004. p. 53-63.. Biodiversity, a key environmental determinant of human health, can provide health protection against the spread of infectious diseases, as well as offer a better quality of life for the areas under their influence ⁴4. Keesing F, Ostfeld RS. Is biodiversity good for your health? Science 2015; 349:235-6.^,55. Naidoo R, Gerkey D, Hole D, Pfaff A, Ellis AM, Golden CD, et al. Evaluating the impacts of protected areas on human well-being across the developing world. Sci Adv 2019; 5:eaav3006.^,66. Ellwanger JH, Kulmann-Leal B, Kaminski VL, Valverde-Villegas JM, Veiga ABGD, Spilki FR, et al. Beyond diversity loss and climate change: impacts of Amazon deforestation on infectious diseases and public health. An Acad Bras Ciênc 2020; 92:e20191375.. Protected areas are essential since their restricted exploitation conserves biological systems, maintaining ecosystem services and options for future sustainability that might otherwise be depleted, degraded, or destroyed ⁷7. Romanelli C, Cooper D, Campbell-Lendrum D, Maiero M, Karesh WB, Hunter D, et al. Connecting global priorities: biodiversity and human health: a state of knowledge review. Geneva: World Health Organization/Convention on Biological Diversity; 2015.. These areas are also the subject of various economic development policies ⁸8. Pope J, Wessels J, Douglas A, Hughes M, Morrison-Saunders A. The potential contribution of environmental impact assessment (EIA) to responsible tourism: the case of the Kruger National Park. Tour Manag Perspect 2019; 32:100557.^,99. Alberts RC, Retief FP, Cilliers DP, Roos C, Hauptfleisch M. Environmental impact assessment (EIA) effectiveness in protected areas. Impact Assessment and Project Appraisal 2021; 39:290-303.. However, their establishment can threaten rights and livelihoods of people, allowing access for some but excluding others, generally the poorest ¹⁰10. Irving MA. Áreas protegidas e inclusão social: uma equação possível em políticas públicas de proteção da natureza no Brasil? Sinais Sociais 2010; 4:122-47.^,1111. Abacheba MA. Review on impacts of protected area on local communities' livelihoods in Ethiopia. Journal of Resources Development and Management 2017; 39:8-13.. In this sense, there are many controversies about these areas since they can have positive or negative impacts on human health, depending on how they are implemented ¹²12. Andam KS, Ferraro PJ, Sims KRE, Healy A, Holland MB. Protected areas reduced poverty in Costa Rica and Thailand. Proc Natl Acad Sci U S A 2010; 107:9996-10001.^,1313. Oldekop JA, Holmes G, Harris WE, Evans KL. A global assessment of the social and conservation outcomes of protected areas. Conserv Biol 2016; 30:133-41.^,1414. McKinnon MC, Cheng SH, Dupre S, Edmond J, Garside R, Glew L, et al. What are the effects of nature conservation on human well-being? A systematic map of empirical evidence from developing countries. Environ Evid 2016; 5:8.^,1515. Terraube J, Fernández-Llamazares Á, Cabeza M. The role of protected areas in supporting human health: a call to broaden the assessment of conservation outcomes. Curr Opin Environ Sustain 2017; 25:50-8..

Although the role of protected areas in supporting human health is well understood ¹⁶16. WHO Regional Office for Europe. Nature, biodiversity and health: an overview of interconnections. https://www.who.int/europe/publications/i/item/9789289055581 (accessed on 17/Nov/2022).
https://www.who.int/europe/publications/... , few policy implementation tools effectively use it to inform development decisions for protected areas aimed at ensuring human health and biodiversity conservation that is compatible with socioeconomic development ⁹9. Alberts RC, Retief FP, Cilliers DP, Roos C, Hauptfleisch M. Environmental impact assessment (EIA) effectiveness in protected areas. Impact Assessment and Project Appraisal 2021; 39:290-303.. Impact assessment tools, such as the Health Impact Assessment (HIA), support decision-makers in analyzing the positive and negative impacts of interventions, and their consequences for policies, programs, and services, in urban and rural areas ¹⁷17. Winkler MS, Viliani F, Knoblauch AM, Cave B, Divall M, Ramesh G, et al. Health Impact Assessment international best practice principles. Fargo: International Association for Impact Assessment; 2021. (Special Publication Series, 5)..

However, there are no specific guidelines or impact assessment tools that consider health in the establishment of protected areas. Even with the increasing use of other instruments, such as the Environmental Impact Assessment (EIA) and the Strategic Environmental Assessment (SEA), these tools only focus on issues such as public exploitation of natural resources; not however, addressing the full range of social determinants of health ¹⁸18. Eve E, Arguelles F, Fearnside P. How well does Brazil's environmental law work in practice? Environmental Impact Assessment and the case of the Itapiranga Private Sustainable Logging Plan. Environ Manage 2000; 26:251-67.. They may include, at best, the dimensions of quality of life and well-being. In this sense, we defend using the HIA for the establishment of protected areas since these areas are commonly created and managed without any type of study that comprehensively assesses the impacts on health and socio-biodiversity ¹⁹19. Jones N, McGinlay J, Dimitrakopoulos PG. Improving social impact assessment of protected areas: a review of the literature and directions for future research. Environ Impact Assess Rev 2017; 64:1-7..

The use of a methodological approach that emphasizes human health impacts for the areas of influence of a protected area is urgent. Biodiversity loss and wildlife markets increase the risk of disease spillover from wildlife to human populations, and the emergence of many of the new scourges of our times, such as HIV, Ebola, Nipah, SARS, H5N, and COVID-19, can be attributed to increased human impacts on nature ²⁰20. Corlett RT, Primack RB, Devictor V, Maas B, Goswami VR, Bates AE, et al. Impacts of the coronavirus pandemic on biodiversity conservation. Biol Conserv 2020; 246:108571.^,2121. United Nations Environment Programme; International Livestock Research Institute. Preventing the next pandemic: zoonotic diseases and how to break the chain of transmission. Nairobi: United Nations Environment Programme/International Livestock Research Institute; 2020.. These issues are also strongly influenced by the climate crisis ²²22. Convention on Biological Diversity. Global Biodiversity Outlook 5. Montreal: Convention on Biological Diversity; 2020., which is a major driver of emerging and reemerging infectious diseases ²³23. Barcellos C, Hacon SS. One and a half degrees. So what? Cad Saúde Pública 2016; 32:e00212315..

These impacts may be even greater in megadiverse countries such as Brazil, especially in cities and their limit, where urban sprawl leads to biodiversity loss by habitat fragmentation, while socioeconomic inequality increases. Studies in several countries show that 50% or more of the regional or even national biological community is found in cities, despite the intense transformation of the natural environment ²⁴24. Convention on Biological Diversity. Panorama da Biodiversidade nas Cidades. Montreal: Convention on Biological Diversity; 2012..

Brazil, a large-sized country, is at the top of the 18 megadiverse countries, with about 15 to 20% of the world’s biodiversity. It presents six terrestrial biomes with their respective ecosystems, namely the Amazon, Caatinga, Cerrado, Atlantic Forest, Pampas, and Pantanal, three large marine ecosystems ²⁵25. Ministry of the Environment and Climate Change. Brazil: 6th National Report to the Convention on Biological Diversity. Brasília: Ministry of the Environment and Climate Change; 2020., and a great sociocultural diversity, expressed in several ethnic groups and indigenous peoples, quilombola communities, riverines, and traditional agricultural producers, present in urban and rural areas ²⁶26. Joly CA, Scarano FR, Bustamante M, Gadda TMC, Metzger JPW, Seixas CS, et al. Brazilian assessment on biodiversity and ecosystem services: summary for policy makers. Biota Neotrop 2019; 19:e20190865.. The Atlantic Forest and the Cerrado are global biodiversity hotspots ²⁵25. Ministry of the Environment and Climate Change. Brazil: 6th National Report to the Convention on Biological Diversity. Brasília: Ministry of the Environment and Climate Change; 2020.. These biomes are located in the regions with the largest urban populations, in the Southeastern Brazil, where the Atlantic Forest predominates, and with the highest growth rate of urbanized areas (in the case of Cerrado) ²⁷27. Ojima R, Martine G. Resgates sobre população e ambiente: breve análise da dinâmica demográfica e a urbanização nos biomas brasileiros. Ideias 2012; 3:55-70.^,2828. Instituto Brasileiro de Geografia e Estatística. Contas de ecossistemas: o uso da terra nos biomas brasileiros 2000-2018. https://www.ibge.gov.br/geociencias/informacoes-ambientais/estatisticas-e-indicadores-ambientais/28920-contas-de-ecossistemas.html?edicao=28921&t=acesso-ao-produto (accessed on Jun/2023).
https://www.ibge.gov.br/geociencias/info... .

In Brazil, it is estimated that more than 61% of the population is concentrated in urban areas ²⁹29. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2020. https://censo2022.ibge.gov.br/panorama/?utm_source=ibge&utm_medium=home&utm_campaign=portal (accessed on Jun/2023).
https://censo2022.ibge.gov.br/panorama/?... . The country’s rapid and unplanned urbanization has led to the emergence of informal settlements inside and around cities. Such settlements occupy riverbanks, hillsides, and wasteland, often with industrial environmental liabilities and fragile soils ³⁰30. Joppa LN, Loarie SR, Pimm SL. On population growth near protected areas. PLoS One 2009; 4:e4279.^,3131. Pitt B, Boulle T. Growing together: thinking and practice of urban nature conservators. Cape Town: SANBI Cape Flats Nature; 2010.. Most of Brazilian urban agglomerations are located within or on the outskirts of protected areas, with poor sanitation and infrastructure, high levels of air pollution, lack of urban planning, and poor mobility. Moreover, violence and traffic accidents have led to a decreased quality of life and biodiversity loss ⁷7. Romanelli C, Cooper D, Campbell-Lendrum D, Maiero M, Karesh WB, Hunter D, et al. Connecting global priorities: biodiversity and human health: a state of knowledge review. Geneva: World Health Organization/Convention on Biological Diversity; 2015.^,3232. Trzyna T. Urban protected areas: profiles and best practice. Gland: International Union for Conservation of Nature and Natural Resources; 2014. (Best Practice Protected Area Guidelines Series, 22).. Populations living in these areas face a triple burden of disease, which further increases health inequities ³³33. Frenk J, González-Pier E, Gómez-Dantés O, Lezana MA, Knaul FM. Comprehensive reform to improve health system performance in Mexico. Lancet 2006; 368:1524-34.^,3434. Marinho FM, Passos V, Malta DC, Barbosa FE, Abreu DMX. Burden of disease in Brazil, 1990-2016: a systematic subnational analysis for the Global Burden of Disease Study. Lancet 2018; 392:760-75..

As the population of Brazil and the world becomes more concentrated in urban areas ³⁵35. United Nations. World urbanization prospects 2018: highlights. New York: Population Division, United Nations; 2019., human activities, such as consumer demand for food, water, and other natural resources, will also become more concentrated in these places. Global and local environmental changes, including climate change and biodiversity loss due to urbanization, and pressures on the natural environment, such as increased energy consumption and greenhouse gas emissions, deforestation, land degradation, and severe water stress, have multiple impacts on human health.

Given this scenario and the increase in social inequality in countries such as Brazil, it is important to focus on how to make cities more resilient, integrating research on poverty, food and water security, and ecosystem services. The HIA is the appropriate tool for intersectoral and multidisciplinary action, linking issues of climate change, air quality, and health risks and impacts to urban planning and management. Therefore, the use of the HIA in the establishment of protected areas in Brazilian urban and periurban areas can contribute both to mitigating and adapting to these local and global environmental changes, as well as to social inclusion and sustainable development, in the search for Buen Vivir [good living] goals and the achievement of international agreements such as the Sustainable Development Goals (SDGs) ³⁶36. Nações Unidas. Agenda 2030 para o Desenvolvimento Sustentável. https://brasil.un.org/pt-br/91863-agenda-2030-para-o-desenvolvimento-sustentável (accessed on Oct/2019).
https://brasil.un.org/pt-br/91863-agenda... .

HIA for protect areas in Brazil

HIA is a practical approach used to assess the potential health effects of a policy, program, or project on a population. Recommendations are made to decision-makers and stakeholders, to maximize positive health effects and minimize negative health effects of proposals, and their application in different economic sectors by using quantitative, qualitative, and participatory techniques ³⁷37. World Health Organization. Health impact assessment: technical information. https://www.who.int/health-topics/health-impact-assessment#tab=tab_1 (accessed on Oct/2019).
https://www.who.int/health-topics/health... . Studies show that the distribution of HIA is unevenly distributed worldwide due to contextual differences and forms of application ³⁸38. Thondoo M, Rojas-Rueda D, Gupta J, De Vries DH, Nieuwenhuijsen MJ. Systematic literature review of health impact assessments in low and middle-income countries. Int J Environ Res Public Health 2019; 16:E3306.^,3939. Drewry J, Kwiatkowski R. The role of Health Impact Assessment in advancing sustainable development in Latin America and the Caribbean. J Environ Health 2015; 77:16-21.^,4040. Abe KC, Miraglia S. Health Impact Assessment (HIA) in Brazil and Latin America: an essential tool for projects, plans and policies. Interface (Botucatu) 2018; 22:349-58.. It is already well established as an autonomous process in some developed countries but is still poorly recognized and practiced in most low- and middle-income countries such as Brazil ⁴¹41. Pereira CAR, Périssé ARS, Knoblauch AM, Utzinger J, Hacon SS, Winkler MS. Health impact assessment in Latin American countries: current practice and prospects. Environ Impact Assess Rev 2017; 65:175-85..

Winkler et al. ⁴²42. Winkler MS, Furu P, Viliani F, Cave B, Divall M, Ramesh G, et al. Current global health impact assessment practice. Int J Environ Res Public Health 2020; 17:2988. have found an upward trend in the use of HIA worldwide, with a several types of HIA and applications in different fields. However, the barriers to using HIA remain the same as those reported in previous studies: limited technical experience for practice; insufficient knowledge of HIA among decision-makers and public healthcare professionals; lack of HIA or health policies and regulations in other types of impact assessment. There is a clear understanding of the need to invest in capacity building for HIA, particularly in low- and middle-income countries ³⁸38. Thondoo M, Rojas-Rueda D, Gupta J, De Vries DH, Nieuwenhuijsen MJ. Systematic literature review of health impact assessments in low and middle-income countries. Int J Environ Res Public Health 2019; 16:E3306.^,4141. Pereira CAR, Périssé ARS, Knoblauch AM, Utzinger J, Hacon SS, Winkler MS. Health impact assessment in Latin American countries: current practice and prospects. Environ Impact Assess Rev 2017; 65:175-85.. The authors point to the fundamental role of the World Health Organization (WHO) and the International Association of Impact Assessment (IAIA) in guiding the dissemination of the methodology, identifying good practices and the need to train the global network of impact assessment professionals ⁴²42. Winkler MS, Furu P, Viliani F, Cave B, Divall M, Ramesh G, et al. Current global health impact assessment practice. Int J Environ Res Public Health 2020; 17:2988..

Protected areas have not yet been the subject to HIA, but we found some HIA experiences in urban parks and green areas in Europe, Canada, and the United States ⁴³43. Santana P, Santos R, Costa C. Walkable urban green spaces: health impact assessment in Amadora, Portugal. In: Schrenk M, Popovich VV, Engelke D, Elisei P, editors. CITIES 3.0 - smart, sustainable, integrative strategies, concepts and technologies for planning the urban future. Sitges: Real Corp Tagungsband; 2009. p. 579-85.^,4444. Kang E, Park HJ, Kim JE. Health impact assessment as a strategy for intersectoral collaboration. J Prev Med Public Health 2011; 44:201-9.^,4545. American Planning Association. A Health Impact Assessment of the Lawrence Green Streets Program. Lawrence: American Planning Association; 2017.^,4646. Fischer TB, Jha-Thakur U, Fawcett P, Clement S, Hayes S, Nowacki J. Consideration of urban green space in impact assessments for health. Impact Assessment and Project Appraisal 2018; 36:32-44.^,4747. Buregeya JM, Loignon C, Brousselle A. Contribution analysis to analyze the effects of the health impact assessment at the local level: a case of urban revitalization. Eval Program Plann 2020; 79:101746.. Nevertheless, other assessment tools and environmental studies have been used in protected areas implementation, such as the EIA, SEA, Social Impact Assessment (SIA), and Millennium Ecosystem Assessment (MEA) ⁴⁸48. World Health Organization. Learning from practice: case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2022.^,4949. Millennium Ecosystem Assessment. Ecossistemas e o bem-estar humano: estrutura para uma avaliação. http://www.millenniumassessment.org/documents/document.63.aspx.pdf (accessed on 12/Mar/2019).
http://www.millenniumassessment.org/docu... . Studies have qualitatively assessed the impacts of protected areas on the well-being and quality of life of populations, but there are few prospective and quantitative studies assessing these impacts ⁹9. Alberts RC, Retief FP, Cilliers DP, Roos C, Hauptfleisch M. Environmental impact assessment (EIA) effectiveness in protected areas. Impact Assessment and Project Appraisal 2021; 39:290-303.^,1818. Eve E, Arguelles F, Fearnside P. How well does Brazil's environmental law work in practice? Environmental Impact Assessment and the case of the Itapiranga Private Sustainable Logging Plan. Environ Manage 2000; 26:251-67.^,5050. Pullin AS, Bangpan M, Dalrymple S, Dickson K, Haddaway NR, Healey JR, et al. Human well-being impacts of terrestrial protected areas. Environ Evid 2013; 2:19.. SIA has been used in protected areas implementation, particularly where traditional communities are involved ⁵¹51. Vanclay F, Esteves AM, Aucamp I, Franks DM. Social impact assessment: guidance for assessing and managing the social impacts of projects. Fargo: International Association for Impact Assessment; 2015..

Although HIA is not mandatory in Brazil, the Brazilian government published an HIA methodology guide for the environmental licensing process of large projects in 2014 ⁵²52. Departamento de Vigilância em Saúde Ambiental e Saúde do Trabalhador, Secretaria de Vigilância em Saúde, Ministério da Saúde. Avaliação de impacto à saúde: metodologia adaptada para aplicação no Brasil. Brasília: Ministério da Saúde; 2014., based on a joint effort between the Brazilian Ministry of Health and the Brazilian Ministry of Environment and Climate Change. However, HIA has only been developed in research institutions, where technical and scientific debates on how to make the tool applicable in Brazil are held. Some authors argue that it should be integrated into the EIA process, while others argue that HIA should be an autonomous process ⁵³53. Balby CN. Avaliação de impactos à saúde: desenvolvimento internacional e perspectivas no Brasil [Master's Thesis]. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2012.^,5454. Silveira M, Fenner ALD. Avaliação de Impactos à Saúde (AIS): análises e desafios para a vigilância em saúde do Brasil. Ciênc Saúde Colet 2017; 22:3205-14.. Although the health component is explicit in the EIA, as an element of the socioeconomic dimension, and in urban management instruments, studies show that, despite the conceptual presence of health in these instruments, few elements and tools for its implementation can be found ⁵⁴54. Silveira M, Fenner ALD. Avaliação de Impactos à Saúde (AIS): análises e desafios para a vigilância em saúde do Brasil. Ciênc Saúde Colet 2017; 22:3205-14.^,5555. Hacon SS, Périssé ARS, Simos J, Cantoreggi NL, Winkler MS. Challenges and prospects for integrating the assessment of health impact in the licensing process of large capital project in Brazil. Int J Health Policy Manag 2018; 7:885-8.^,5656. Miraglia SGEK, Abe KC, editors. Avaliação de Impacto em Saúde (AIS): estudos de casos. São Paulo: Secretaria de Educação a Distância, Universidade Federal de São Paulo; 2019..

Brazil has little experience with HIA, mainly for environmental liabilities of large capital projects ⁴¹41. Pereira CAR, Périssé ARS, Knoblauch AM, Utzinger J, Hacon SS, Winkler MS. Health impact assessment in Latin American countries: current practice and prospects. Environ Impact Assess Rev 2017; 65:175-85.^,5555. Hacon SS, Périssé ARS, Simos J, Cantoreggi NL, Winkler MS. Challenges and prospects for integrating the assessment of health impact in the licensing process of large capital project in Brazil. Int J Health Policy Manag 2018; 7:885-8.. Recently, HIAs on air pollution and other rapid HIAs in the urban context have been published ⁵⁶56. Miraglia SGEK, Abe KC, editors. Avaliação de Impacto em Saúde (AIS): estudos de casos. São Paulo: Secretaria de Educação a Distância, Universidade Federal de São Paulo; 2019.. In Brazil, there are examples of SEA and SIA in federal protected areas ⁵⁷57. Marinelli CE, Creado ESJ, Leuzinger M, Irving M, Weigand JR, Mora SA, et al. Avaliação de impactos sociais de áreas protegidas no Brasil: caminhos e desafios. https://www.wwf.org.br/?30664/Avaliacao-de-Impactos-Sociais-de-Areas-Protegidas-no-Brasil-caminhos-e-desafios (accessed on 26/Sep/2019).
https://www.wwf.org.br/?30664/Avaliacao-... . Jones et al. ¹⁹19. Jones N, McGinlay J, Dimitrakopoulos PG. Improving social impact assessment of protected areas: a review of the literature and directions for future research. Environ Impact Assess Rev 2017; 64:1-7. recommend the use of this tool in the implementation of protected areas, as the creation of a new structure for the management and regulation of natural resources generates conflicts and imposes social impacts on local communities and other users. In the Brazilian environmental licensing process, the protected areas can be the subject of an EIA if they directly affect their area or can become beneficiaries of environmental compensation funds. This is also the case for projects financed by the International Finance Corporation (IFC), which uses HIA as the structuring centerline for its Performance Standards in Social and Environmental Sustainability. Performance Standard 6 provides guidelines for biodiversity conservation, considering the ecosystem services approach and adaptive management of mitigation measures ⁵⁸58. International Finance Corporation. Padrão de desempenho 6. Conservação da biodiversidade e gestão sustentável de recursos naturais vivos. Washington DC: World Bank; 2012.. Similarly, in the process of land regularization, the Brazilian Forest Code ⁵⁹59. Brasil. Lei nº 12.651, de 25 de maio de 2012. Dispõe sobre a proteção da vegetação nativa; altera as Leis nºs 6.938, de 31 de agosto de 1981, 9.393, de 19 de dezembro de 1996, e 11.428, de 22 de dezembro de 2006; revoga as Leis nºs 4.771, de 15 de setembro de 1965, e 7.754, de 14 de abril de 1989, e a Medida Provisória nº 2.166-67, de 24 de agosto de 2001; e dá outras providências. Diário Oficial da União 2012; 28 may. requires the definition of legal reserve areas and permanent conservation units, also required in urban management, by the Neighborhood Impact Study, demanded by the Brazilian City Statute ⁶⁰60. Brasil. Lei nº 10.257, de 10 de julho de 2001. Regulamenta os arts. 182 e 183 da Constituição Federal, estabelece diretrizes gerais da política urbana e dá outras providências. Diário Oficial da União 2001; 11 jul..

Ultimately, if the assessment aims to mitigate human health impacts, either directly by the enterprise/policy or indirectly by the loss of ecosystem services, EIAs should be reformulated to consider health with the various social and economic dimensions ¹⁸18. Eve E, Arguelles F, Fearnside P. How well does Brazil's environmental law work in practice? Environmental Impact Assessment and the case of the Itapiranga Private Sustainable Logging Plan. Environ Manage 2000; 26:251-67.. HIA is a model that allows for the integration of health, human well-being, and social determinants in their interrelationships with other dimensions of object analysis. Due to its principle of equity and, therefore, its distribution of impacts among vulnerable groups regarding gender, age, ethnicity, and socioeconomic status ⁶¹61. Harris-Roxas B, Harris E. Differing forms, differing purposes: a typology of health impact assessment. Environ Impact Assess Rev 2011; 31:396-403., it requires close participation of the affected populations, as well as other social actors. In this sense, this impact assessment model should be more widely used in Brazil. The epidemiological and exposure studies offered by HIA are essential in the context of multiple epidemics, which is characteristic of Brazil. Therefore, it is closer to the objectives of sustainable development, mainly to assess the relationship between biodiversity and health in urban areas.

HIAs conducted in developed countries, although they include social participation as part of the assessment process ³⁸38. Thondoo M, Rojas-Rueda D, Gupta J, De Vries DH, Nieuwenhuijsen MJ. Systematic literature review of health impact assessments in low and middle-income countries. Int J Environ Res Public Health 2019; 16:E3306.^,6262. Den Broeder L, Uiters E, Ten Have W, Wagemakers A, Schuit AJ. Community participation in Health Impact Assessment. A scoping review of the literature. Environ Impact Assess Rev 2017; 66:33-42., do not give as much emphasis to this issue as is necessary for peripheral countries, such as Brazil. These countries are characterized by social inequality and poverty, where several social determinants of health simultaneously affect vulnerable populations, requiring a deepening of social participation and equity ³⁸38. Thondoo M, Rojas-Rueda D, Gupta J, De Vries DH, Nieuwenhuijsen MJ. Systematic literature review of health impact assessments in low and middle-income countries. Int J Environ Res Public Health 2019; 16:E3306.^,6161. Harris-Roxas B, Harris E. Differing forms, differing purposes: a typology of health impact assessment. Environ Impact Assess Rev 2011; 31:396-403.^,6363. Winkler M, Divall M, Krieger G, Balge M, Singer B, Utzinger J. Assessing health impacts in complex eco-epidemiological settings in the humid tropics: the centrality of scoping. Environ Impact Assess Rev 2011; 31:310-9..

Potential impacts on human health on urban protected area

Protected areas located in urban and periurban areas are essential for maintaining the environmental balance, and quality of life in cities. They promote positive health impacts, ecosystem services, and salutogenic benefits, such as thermal regulation, control of microclimates, surface runoff, noise reduction, air quality, maintenance in water resources, modulation of infectious diseases. Moreover, protected areas allow the preservation of historical, social, and cultural values and assets, and creation of opportunities for education, sport and leisure, economic, employments, income, and ecotourism, which are crucial for long-term urban sustainability ⁶⁴64. Amato-Lourenço LF, Moreira TCL, De Arantes BL, Da Silva Filho DF, Mauad T. Metrópoles, cobertura vegetal, áreas verdes e saúde. Estud Av 2016; 30:113-30.^,6565. Campos RBF, Castro JM. Áreas verdes: espaços urbanos negligenciados impactando a saúde. Saúde Transform Soc 2017; 8:106-16.^,6666. Shanahan DF, Bush R, Gaston KJ, Lin BB, Dean J, Barber E, et al. Health benefits from nature experiences depend on dose. Sci Rep 2016; 6:28551.^,6767. Berghöfer A, Mader A, Patrickson S, Calcaterra E, Smit J, Blignaut J, et al. TEEB manual for cities: ecosystem services in urban management. Geneva: The Economics of Ecosystems and Biodiversity; 2011..

Strong evidence indicates positive associations between biodiversity and psychological and physical well-being ⁵5. Naidoo R, Gerkey D, Hole D, Pfaff A, Ellis AM, Golden CD, et al. Evaluating the impacts of protected areas on human well-being across the developing world. Sci Adv 2019; 5:eaav3006.^,1313. Oldekop JA, Holmes G, Harris WE, Evans KL. A global assessment of the social and conservation outcomes of protected areas. Conserv Biol 2016; 30:133-41.^,1616. WHO Regional Office for Europe. Nature, biodiversity and health: an overview of interconnections. https://www.who.int/europe/publications/i/item/9789289055581 (accessed on 17/Nov/2022).
https://www.who.int/europe/publications/... ^,6868. Buckley R, Brough P, Hague L, Chauvenet A, Fleming C, Roche E, et al. Economic value of protected areas via visitor mental health. Nat Commun 2019; 10:5005., as well as between ecosystem diversity and immune system regulation ⁶⁹69. Aerts R, Honnay O, Nieuwenhuyse AV. Biodiversity and human health: mechanisms and evidence of the positive health effects of diversity in nature and green spaces. Br Med Bull 2018; 127:5-22.. In some places, physicians recommends to patients to spend some in natural areas ⁷⁰70. Maretti CC, Barros M. Ao desejar saúde, deseje áreas protegidas. O Eco 2020; 27 jan. https://www.oeco.org.br/colunas/claudio-maretti/ao-desejar-saude-deseje-areas-protegidas/.
https://www.oeco.org.br/colunas/claudio-... . Protected areas have these beneficial effects and are potentially able to influence the formation of citizens by environmental education and health promotion actions, strengthening the political empowerment for the local management of public goods ²⁸28. Instituto Brasileiro de Geografia e Estatística. Contas de ecossistemas: o uso da terra nos biomas brasileiros 2000-2018. https://www.ibge.gov.br/geociencias/informacoes-ambientais/estatisticas-e-indicadores-ambientais/28920-contas-de-ecossistemas.html?edicao=28921&t=acesso-ao-produto (accessed on Jun/2023).
https://www.ibge.gov.br/geociencias/info... ^,2929. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2020. https://censo2022.ibge.gov.br/panorama/?utm_source=ibge&utm_medium=home&utm_campaign=portal (accessed on Jun/2023).
https://censo2022.ibge.gov.br/panorama/?... ^,7171. Quintas JS. Por uma educação ambiental emancipatória: considerações sobre a formação do educador ambiental para atuar no processo de gestão ambiental. In: Quintas JS, editor. Pensando e praticando a educação ambiental na gestão do meio ambiente. 3rd Ed. Brasília: Instituto Brasileiro do Meio Ambiente e dos Recursos Naturais Renováveis; 2006. p. 13-21.. Economic assessments of green spaces and protected areas in cities worldwide have found that nature “saves” billions of dollars in healthcare services ⁶⁶66. Shanahan DF, Bush R, Gaston KJ, Lin BB, Dean J, Barber E, et al. Health benefits from nature experiences depend on dose. Sci Rep 2016; 6:28551.^,7272. MacKinnon K, van Ham C, Reilly K, Hopkins J. Nature-based solutions and protected areas to improve urban biodiversity and health. In: Marselle M, Stadler J, Korn H, Irvine K, Bonn A, editors. Biodiversity and health in the face of climate change. Cham: Springer; 2019. p. 363-80., promotes ecotourism ⁷³73. Young CF, Medeiros R, editors. Quanto vale o verde: a importância econômica das unidades de conservação brasileiras. Rio de Janeiro: Conservação Internacional; 2018., and improves food security ⁷⁴74. Harvey CA, Komar O, Chazdon R, Ferguson BG, Finegan B, Griffith DM, et al. Integrating agricultural landscapes with biodiversity conservation in the Mesoamerican hotspot. Conserv Biol 2008; 22:8-15..

Conversely, if abandoned by public authorities, urban protected areas can negative affect health and the environment. As an example, we can cite deforestation and environmental degradation, which alters the hydrological and biochemical cycle of several micronutrients, along with air quality, which leads to thermal inversion and heat islands phenomena, increasing the risk of disease ⁷⁵75. Feitosa RC, Wilkinson S. Green roofs and green walls and their impact on health promotion. Cad Saúde Pública 2018; 34:e00003618.. Other negative impacts are related to violations of rights, land grabbing, real estate speculation, conflicts over land and water use, water and sanitation-related diseases, vector-borne diseases, psychosocial stress, and violence. This overlook on urban protected areas also contributes to the development of chronic noncommunicable diseases that overburden healthcare services and the economy ¹¹11. Abacheba MA. Review on impacts of protected area on local communities' livelihoods in Ethiopia. Journal of Resources Development and Management 2017; 39:8-13.^,1616. WHO Regional Office for Europe. Nature, biodiversity and health: an overview of interconnections. https://www.who.int/europe/publications/i/item/9789289055581 (accessed on 17/Nov/2022).
https://www.who.int/europe/publications/... ^,6464. Amato-Lourenço LF, Moreira TCL, De Arantes BL, Da Silva Filho DF, Mauad T. Metrópoles, cobertura vegetal, áreas verdes e saúde. Estud Av 2016; 30:113-30..

These areas are under strong pressure from urbanization and exploitation of natural resources (mining, energy transmission networks, agribusiness, livestock farming), infrastructure works, and the conflicts between land use and livelihoods. At the same time that protected areas act as a harmonious space for recreation and quality of life, they can also be a source of environmental injustice and an instrument of alienation and exclusion of indigenous peoples, quilombolas, and rural communities, as well as migrants and other vulnerable groups in the cities ¹⁰10. Irving MA. Áreas protegidas e inclusão social: uma equação possível em políticas públicas de proteção da natureza no Brasil? Sinais Sociais 2010; 4:122-47.^,7676. Cardoso TM, Eloy L, Barretto Filho HT, Silveira PCB. Apresentação do Dossiê: Antropologia das Áreas Protegidas e da Sustentabilidade. Anuário Antropológico 2020; 45:11-24.^,7777. Acselrad H. Meio ambiente e justiça - estratégias argumentativas e ação coletiva. In: Acselrad H, Pádua JA, Herculano S, editors. Justiça ambiental e cidadania. Rio de Janeiro: Relume-Dumará; 2004. p. 23-39.. Disputes over claims to traditional territories, landless and homeless occupations, evictions, and the exclusion of protected areas, that can reduce poverty ¹²12. Andam KS, Ferraro PJ, Sims KRE, Healy A, Holland MB. Protected areas reduced poverty in Costa Rica and Thailand. Proc Natl Acad Sci U S A 2010; 107:9996-10001.^,7878. Turner WR, Brandon K, Brooks TM, Gascon C, Gibbs HK, Lawrence KS, et al. Global biodiversity conservation and the alleviation of poverty. Bioscience 2012; 62:85-92., or increase it ⁷⁹79. Brockington D, Wilkie D. Protected areas and poverty. Philos Trans R Soc Lond B Biol Sci 2015; 370:20140271..

Other conflicts concern the alliances of corporate capital, the consequent possibilities of “green grabbing”, which exacerbate the existing problems of land grabbing ³²32. Trzyna T. Urban protected areas: profiles and best practice. Gland: International Union for Conservation of Nature and Natural Resources; 2014. (Best Practice Protected Area Guidelines Series, 22).. There are innumerable processes of speculation and real estate valuation in urban and periurban protected areas, leading to gentrification, when the population living in or close to the area is displaced, that is, another form of social exclusion ⁸⁰80. Bidou-Zachariasen C, editor. De volta à cidade. Dos processos de gentrificação às políticas de "revitalização" dos centros urbanos. São Paulo: Annablume; 2007..

For all these reasons, it is crucial to recognize that health depends on the socioeconomic context, which will determine how biodiversity conservation is conducted. Protected areas can have different restrictive uses, ranging from the complete exclusion of human activities to the sustainable exploitation of natural resources. They also vary in shape, size, isolation, and type of management ²2. Dudley N, editor. Guidelines for applying protected area management categories. Gland: International Union for Conservation of Nature and Natural Resources; 2008.^,8181. Brasil. Lei nº 9.985, de 18 de julho de 2000. Institui o Sistema Nacional de Unidades de Conservação da Natureza e dá outras providências. Diário Oficial da União 2000; 18 jul.. All these characteristics affect both biodiversity and health impacts in different ways ¹³13. Oldekop JA, Holmes G, Harris WE, Evans KL. A global assessment of the social and conservation outcomes of protected areas. Conserv Biol 2016; 30:133-41.^,1515. Terraube J, Fernández-Llamazares Á, Cabeza M. The role of protected areas in supporting human health: a call to broaden the assessment of conservation outcomes. Curr Opin Environ Sustain 2017; 25:50-8.. For example, a study on protected areas in the Brazilian Amazon found that the incidence of malaria, acute respiratory infections, and diarrhea was significantly and negatively correlated to the area under strict environmental protection. On the other hand, sustainable-use protected areas may increase malaria since they increase exposure to mosquitoes ⁸²82. Bauch SC, Birkenbach AM, Pattanayak SK, Sills EO. Public health impacts of ecosystem change in the Brazilian Amazon. Proc Natl Acad Sci U S A 2015; 112:7414-9..

The impacts of protected areas on health can be direct or indirect, local, or global, within or outside the areas. Most health impacts are expected at the periphery of the protected area, where a buffer zone is needed. A seminatural buffer zone has been advocated by Terraube et al. ¹⁵15. Terraube J, Fernández-Llamazares Á, Cabeza M. The role of protected areas in supporting human health: a call to broaden the assessment of conservation outcomes. Curr Opin Environ Sustain 2017; 25:50-8. to provide more co-benefits for both health and biodiversity. The emphasis placed on these buffer zones is even more important in urban areas since they regulate the impacts of land use, mitigate the effects of climate change ⁸³83. Ferreira P, van Soesbergen A, Mulligan M, Freitas M, Vale MM. Can forests buffer negative impacts of land-use and climate changes on water ecosystem services? The case of a Brazilian megalopolis. Sci Total Environ 2019; 685:248-58., provide recreational and public spaces, and protect priority areas for biodiversity conservation.

In this review, we highlighted the challenge of identifying and characterizing health impacts associated with protected areas. Moreover, we considered the potential health impacts resulting from the establishment of generic urban and periurban protected areas, based on the HIA scope definition approach. This methodology defines the baseline basic health situation of the population groups that will be affected by the project, considering both health outcomes and socioeconomic determinants. It is based on data from literature, health systems, and dialogue with stakeholders ¹⁷17. Winkler MS, Viliani F, Knoblauch AM, Cave B, Divall M, Ramesh G, et al. Health Impact Assessment international best practice principles. Fargo: International Association for Impact Assessment; 2021. (Special Publication Series, 5).. These data are organized and classified in a causal diagram (Figure 1), which helps to visualize how the different factors change the environment and affect health, the hypotheses to be investigated, and the multiple causes of an outcome. This analysis is useful to guide the analytical dimensions and activities of an HIA for protected area, and to identify the positive impacts that can be enhanced, and the negative impacts that can be avoided or minimized.

Figure 1 shows that impacts occur at different phases of the establishment of a protected area (creation, implementation, and management), which, in turn have different factors that change the environment, and these factors can lead to health outcomes and determinants. Each phase can impact on different directions and magnitudes, depending on how the process is conducted. Generally, impacts on the creation phase are related to the political arena. What impact will environmental studies have? How much money must be invested? Who will be able to participate in the process? The positive impacts are related to the activation of the network, an opportunity to initiate a shared management, socio-environmental and health diagnosis, knowledge of the territory, and allocation of environmental compensation resources. The negative impacts are linked to the exclusion of the population affected by the process, real estate speculation, and expectations of the proposal that create uncertainty.

Generally, the implementation phase can have the most negative impacts: increased resettlement, expropriation, spatial segregation, restricted access to and use of natural resources, and higher infrastructure costs. In the management phase, the impacts are likely to be more positive, considering an ideal scenario, with broad social participation, combined with local development projects that can have a positive impact on quality of life of the local population and the maintenance of ecosystem services. On the other hand, this phase may involve a loss of livelihoods and identity for local people. However, the nature and aspects of the impacts will depend on the way that the protected area is established and the involvement of the local population in determining the distribution of health risks and of access to natural resources. In this regard, local actors must include their demands in the process, to avoid territory loss, spatial segregation, gentrification, increasing social inequality, and health inequities.

The main elements for the construction of HIA for urban protected areas in Brazil

It is estimated that the Brazilian protected areas, legally designated by the public authorities, occupy more than 37% of the national territory, considering the conservation units, indigenous lands, quilombola communities, and agrarian reform settlements. However, protected areas in Brazil present a scenario of poor effectiveness, being created for reasons other than conservation itself ⁸⁴84. Vieira RR, Pressey RL, Loyola R. The residual nature of protected areas in Brazil. Biol Conserv 2019; 233:152-61.^,8585. Oliveira U, Soares-Filho BS, Paglia AP, Brescovit AD, Carvalho CJB, Silva DP, et al. Biodiversity conservation gaps in the Brazilian protected areas. Sci Rep 2017; 7:48691.. In many cases, they are constructed to mitigate environmental liabilities for strictly political interests, generating the so-called “paper parks” ⁸⁶86. Eklund J, Cabeza M. Quality of governance and effectiveness of protected areas: crucial concepts for conservation planning. Ann N Y Acad Sci 2017; 1399: 27-41.^,8787. Terborgh J, van Schaik C. Porque o mundo necessita de parques. In: Terborgh J, van Schaik C, Davenport L, Rao M, editors. Tornando os parques eficientes: estratégias para a conservação da natureza nos trópicos. Curitiba: Editora UFPR/Fundação O Boticário; 2002. p. 25-36. The lack of environmental studies to support the creation and management plan of protected areas, as well as the lack of participation of the local population, partly explain this scenario ⁸⁸88. Pinto LP, Costa C. Unidades de conservação municipais do cerrado. Belo Horizonte: Instituto Internacional de Educação do Brasil/Ambiental 44; 2019.^,8989. Schramm A, Fenner ALD. Arena política do Parque Canela de Ema em Sobradinho II, Distrito Federal. Comun Ciênc Saúde 2017; 28:359-70.. Furthermore, this situation is aggravated in Brazil due to the inapplicability of laws and the relaxation of environmental and social policies.

The process of creating protected areas in Brazil implies prior environmental studies to characterize the situation of the physical, biological, and socioeconomic environment of the area, followed by the indication of the type and the polygonal proposal of the protected area. Therefore, when it is carried out, it involves an impact assessment, but only a simple diagnosis. An impact assessment analyzes (in terms of its nature, shape, duration, scope, cumulative and synergistic properties, magnitude, importance, and likelihood of occurrence), proposes mitigation and compensation measures, and monitoring programs. Box 1 shows a script to guide the elaboration of an HIA approach for the establishment of Brazilian urban protected areas. Some considerations on the elements that characterize it:

• The HIA of a protected area is, at the same time, an assessment of a policy, project, and program. The administrative act of creation alone will not cause direct health impacts, but this act will trigger projects and programs necessary for the establishment of the protected area, which will cause other impacts.

• The establishment of a protected area is a political intervention that regulates access to natural resources in the area. It is a distributive and regulatory policy, and therefore highly conflictual and often expensive. Therefore, HIA should consider the conflicts of interest between private rights and the social function of the property.

• Retrospective and prospective HIA requires understanding the current problems in the area, defining the health baseline of the community around the protected area, identifying trends in the main morbidities, anticipating scenarios, proposing monitoring and sustainability plans for the protected area, and conducting longitudinal studies.

• It must use the science of conservation biology, the adaptive management approach, and ecosystem assessment, focusing on human well-being as the goal of conservation. Uncertain scenarios of global change, multiple epidemics, and social inequality must also be considered.

• The issues of the right to the city; housing and land; mobility; water, food, and nutrition security; air pollution; and climate change should be considered in relation to integrated health impacts in the context of multiple risks. It should be integrated with the watershed plans, sustainable development projects, agroecology, family farming, and traditional knowledge.

• It must be a tool for the potentially affected population to address the social determinants of health, providing evidence that leads to social inclusion programs, land regularization, employment, and income, in a Buen Vivir perspective.

• Obtain primary, qualitative, and quantitative data, which is essential in the current scenario of uncertainty and information overload that hinders access to reliable data. Active methodologies for the collection of qualitative data by gathering the voice of the affected populations ⁹⁰90. Lewin S, Glenton C. Are we entering a new era for qualitative research? Using qualitative evidence to support guidance and guideline development by the World Health Organization. Int Health 2018; 17:126..

• Communication as a transversal axis for HIA. Develop different strategies for each group of social actors and produce informative materials to broaden the social engagement and reach of the evaluation.

• Identify and strengthen the local experience, skills, and competences of local actors, especially those who are living inside and on margins of protected areas for their management. Actors must be involved in the entire assessment process, from the drafting of the terms of reference, and must have deliberative power.

This approach is considered action research since it supports the solution of local problems, while it is increasing the knowledge of the actors involved and producing science. The assessment should use a set of mixed methods, such as qualitative (interviews, participatory planning workshops, and social cartography) and quantitative methods (a cross-sectional study or home-based survey and an ecological study, that is, a correlation between environmental and health variables), as well as tools that recognize uncertainties and assess resilience ⁹¹91. The Conservation Measures Partnership. The open standards for the practice of conservation. Version 3.0. http://cmp-openstandards.org/ (accessed on Apr/2020).
http://cmp-openstandards.org/... . The whole process must be led with network of local actors and support of local volunteers, based on the principle of citizen science and institutional partnerships. The profile of the recommended technical team is composed of the local community, high school students, community health agents, managers, institutions, epidemiologists, sanitary, ecologists, social scientists, and communication professionals.

Figure 2 provides a graphical summary of the proposal presented in this study, namely the need to use HIA in the establishment of an urban protected area, to enhance the positive impacts and mitigate the negative impacts arising from its implementation. In the figure, human health impacts occur in the border between urbanized and biodiversity conservation units. Emphasis should be placed on monitoring the response of biodiversity to human disturbance within protected areas, as well as on the periphery of protected areas and buffer zones, and on understanding how this, in turn, affects different dimensions of human health in different types of protected areas, according to the specificities of regional biodiversity ⁹²92. Terraube J, Fernández-Llamazares A. Strengthening protected areas to halt biodiversity loss and mitigate pandemic risks. Curr Opin Environ Sustain 2020; 46:35-8.. We highlight the importance of social participation of stakeholders and affected people in urban planning instruments. Following our model can contribute to the achievement of the SDGs and one of its alternatives, the Buen Vivir approach ⁹³93. Acosta A. O Bem Viver: uma oportunidade para imaginar outros mundos. São Paulo: Autonomia Literária/Elefante; 2016..

Conclusions

This study aimed to justify the use of HIA in urban protected areas, especially in the Brazilian context. The synthesis of the literature on the subject helped to identify significant elements to support an HIA approach to urban protected areas, allowing to improve the processes of establishment of these areas to make the conservation of biodiversity compatible with human health and well-being. The potential for using HIA in urban protected areas is evident but remains to be explored to help address the most pressing global issues of climate, health, social, and environmental crises. The COVID-19 pandemic provides an opportunity to reaffirm the role of protected areas in reducing the risk of further zoonoses and supporting human health ⁸⁷87. Terborgh J, van Schaik C. Porque o mundo necessita de parques. In: Terborgh J, van Schaik C, Davenport L, Rao M, editors. Tornando os parques eficientes: estratégias para a conservação da natureza nos trópicos. Curitiba: Editora UFPR/Fundação O Boticário; 2002. p. 25-36, and to establish protected areas in a context of urban expansion, which requires studies leading to urban planning integrated on biodiversity management and implementation of surveillance systems for early detection of emerging infectious disease events. This may also be an opportunity for the health sector to act in a different direction, triggering the self-organization of vulnerable urban populations to resist the loss of rights and health inequalities. The main limitations of this study are the lack of studies that provide data on biodiversity, health monitoring in remote, periurban, and urban areas, in addition to case studies of HIA for protected area. It is also limited by ideological bias, but justified by the context of social inequality, and needs to be validated with local actors and experts. Finally, it is necessary to institutionalize HIA in Brazil.

Acknowledgments

We are grateful to the Oswaldo Cruz Foundation (Brazil) for the financial support of the research and to Professor PhD Mirko Winkler (Swiss Tropical and Public Health Institute, Switzerland), for his advice in defining the study.

References

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