When most people think about health inequality, they usually focus on lack of access to doctors or health insurance. They don’t often consider how the city is constructed or the availability of transportation, food, and housing — factors that can have just as much impact on someone’s well-being as affordable medical care. “Living conditions shape health, and for many people their living conditions include daily experiences of economic hardship, exposure to environmental hazards, social exclusion, and other stressors,” says Mariana Arcaya, an assistant professor in MIT’s Department of Urban Studies and Planning (DUSP). “Planning is the field that has the toolbox to address those problems.”
In a new graduate-level course this past spring, Healthy Cities: Assessing Health Impacts of Policies and Plans, Arcaya introduced students to one of the tools in that toolbox: Health Impact Assessment (HIA), a systematic approach to analyzing the health implications of policy decisions, plans, and other proposals under consideration by non-health sectors. “HIA helps decision-makers and communities think together about policies and plans that might have no obvious relationship to health on the surface, but are fundamentally important to how people live,” she says.
Arcaya has long operated at that intersection. In 2012, she used the HIA methodology to assess the impact of a proposal by the Massachusetts Bay Transportation Authority (MBTA, also known as “the T”) to balance its budget by raising fares and reducing service on public transit. Arcaya and several colleagues at the Metropolitan Area Planning Council (MAPC) looked at the likely effects of the proposal on air pollution, physical activity, fuel costs, and automobile crashes, among other things. They concluded that the health, social, and financial costs of the fare increase and lessened service would far exceed the budgetary shortfall.
“The main takeaway was that although we primarily think of the T as a transportation resource, it’s also a public health resource and should be valued as such,” she says.
While HIAs hold great promise, says Arcaya, she worries that they could be implemented in a way that is removed from community concerns. “When you have a handful of well-resourced groups that are the only ones conducting HIAs, they can end up playing a gatekeeper role and having an outsized influence on the types of topics that are examined through a health lens,” says Arcaya. She and collaborators at the MAPC hoped to expand local capacity to integrate health considerations into planning and policy decisions in other ways. “Our model this year was to engage with community groups on the ground on the issues they care about and then match them with students who wanted to get hands-on HIA training.”
Funded by the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts, her course did just that, working with two community groups on issues that don’t immediately seem related to health. Students worked with Lowell, Massachusetts-based UTEC to examine a proposed state law to expunge juvenile criminal records; the second study, conducted with Boston-based City Life/Vida Urbana, focused on a city council ordinance that would prevent evictions except for “just cause” (rather than, for example, a property owner wanting to drive out tenants to renovate and charge higher rent).
To gauge the impact of the policies, the students first researched the science and social science literature, then engaged residents in local communities to understand the potential for the two proposals to affect people’s lives. In both cases, they found important public health effects associated with the policies. Having a criminal record, for example, can lead to difficulty finding jobs or housing, and can influence how youth perceive that they are seen by society. “Barriers to economic self-sufficiency, a lack of safe and decent housing, and feeling discriminated against or excluded from your community can be damaging to health,” says Arcaya.
In the case of evictions, the stress of being uprooted and worrying about continuity with a job or a child’s school can lead to mental and physical health effects. In addition, says graduate student Jennifer Hiser, her group’s conversations with community members found that the very possibility of eviction can affect people’s well-being in negative ways. “The anticipation of eviction is not something that is usually considered, but it’s really huge for folks,” says Hiser. “When we heard over and over from community members how important that was, we realized it was a relevant issue.”
Hiser, who has worked on similar issues in the past with a project in the Bronx, New York, called Healthy Buildings, found the HIA techniques helpful. The recommendations they generate and the way they help frame concerns offer the public a means to consider the impact of policies on real people, backed by the rigor of scientific research. “The tools can be used to evaluate, but also to articulate information to the public,” she says.
Students in both groups pulled the information into what Arcaya calls a “rapid HIA” — the best assessment the class could make after two months of research — and they have released their expungement study findings publicly (see the report), with the report on eviction to be released at the end of the summer. Arcaya hopes that the reports can inform upcoming debates on these issues in city hall and the state house by highlighting what is at stake for citizens.
For students, Arcaya aims for the course to expand the notion of what a city planner can influence. “The goal isn’t just to explore these particular issues of criminal justice or eviction,” says Arcaya. “It’s about when our students go out into the world as planners and are in a position to affect change — for what and to whom are they accountable? It should be something more than just the aesthetic quality of the built form, or the efficiency with which people move through space. It should also be about making sure that everyone has a fair shot at keeping themselves and their families healthy, because health is fundamental to your capacity to do everything else you want to do with your life.”