Marnie Purciel-Hill

Marnie Purciel-Hill
Senior Research Associate
marnie[at]humanimpact.org

Marnie Purciel joined Human Impact Partners in November 2009. She has dual master’s degrees in urban planning and public health from Columbia University. Marnie’s research uses spatial data to examine the implications of the built environment, including land use, transportation, urban design, and housing, for physical activity, diet, and other aspects of health. Prior to joining Human Impact Partners Marnie worked with the Built Environment and Health group at the Institute for Social and Economic Research and Policy at Columbia University. Her experience includes the development and validation of observational and geographic information system (GIS) protocols for the measurement of urban design in New York City and the development of a research design for understanding farmers’ markets as a strategy for increasing access to healthy food. Marnie conducted fieldwork for a food availability survey in New York City and used GIS to characterize and examine disparities in access to urban food and retail. She also provided teaching assistance for several introductory GIS courses at Columbia University and prior to entering graduate school, while at Samuels & Associates, she gained experience with qualitative data collection and analysis.

The Greater Health Impacts of the Affordable Care Act

My son had an accident and broke his leg and I found a lump for which a routine biopsy was needed.

When these things happened to my family, I was relieved I had health insurance to help meet our medical needs. But it’s been an expensive and confusing experience – even quality health insurance coverage (procured through my partner’s employer) is proving inadequate at sparing my family the negative health effects of high medical bills. It made me wonder – how has the expansion of health insurance through the Affordable Care Act impacted peoples’ economic security? How much farther do we have to go to ensure that people can access health care without significant financial stress?

While our health issues were serious enough to require treatment, they were not unusual. I had to spend $1,500 (after insurance paid what they would) to discover my lump was, thank goodness, totally fine from a cancer perspective. Not so, from a financial perspective. Then recently, my son was playing with his cousins, fell, and broke his leg. Not sure what the total bill for this is going to be yet, but I’m guessing it also will be around $1,000 after insurance. In the health insurance world, these are probably considered moderate costs for a “consumer” who also pays health insurance premiums every month. But for a household with a tight and perpetually stretched budget like ours, this extra expense causes a great deal of stress.

This financial stress has a number of additional impacts to our family’s health and well-being. My partner and I have to make decisions about the things we will forgo in order to pay these bills. These are not fun conversations and I could see how over time they might end up putting too much stress on a relationship. For couples that separate, there is a cascade of health effects that happen: isolation, depression, anxiety, and negative impacts on children are well documented in the research.

There’s also research that looks at the long-term “economic scarring” that happens (such as during a recession) when families have to make tough choices about spending money on basic needs and medical bills, rather than on things like educational achievement, investments, or starting a small business. When scores of families are forced to make these trade offs (such as during a recession) our whole economy suffers. Our current system of health insurance not only does not protect people’s right to be healthy and productive, but when one of us gets sick or injured in the current system, we all pay.

In HIA, we seldom look at the health impacts of health care policy. We usually focus our policy efforts more upstream, and think of health care as a safety net after upstream efforts have failed. Health care becomes relevant when we aren’t able to change the unhealthy places where we live, work, go to school, and play. Yet through my personal experiences with the financial burdens of health care, I am gaining a different perspective on the greater health impacts of inadequate health insurance. It’s informing my research on the health impacts of financial stress through a new HIA project in our Economic Security Program that I’m leading with our partners, ISAIAH, in Minnesota.

Although the ACA represents a leap forward, we still have a long way to go towards ensuring everyone has health care that doesn’t come with a heavy dose of financial stress. I believe that health care could and should be considered a human right rather than a commodity, as it is now. We should all have the ability to be healthy and lead productive lives, without living in fear of having an accident, or being stricken with an unwanted illness and not being able to afford diagnosis and treatment. We are still far from this ideal.

Making a List, Checking it Twice

Although Health Impact Assessments are great tools for analyzing the health impacts of development and other urban planning initiatives, they can be long and resource-intensive. HIA is not always the best tool, especially when project proponents and public health practitioners participate early on or arrive very late in the planning process. So among planning departments there has been a lot of recent interest in healthy development checklists as alternative approaches to data collection and analysis to ensure health and equity are considered in decision-making.

A healthy development checklist includes a list of indicators of health and well-being tied to development, and a set of associated criteria meant to evaluate proposed policies, plans, and projects. Many jurisdictions have created indicator systems – measures that can be used to capture the status of social and environmental conditions – but not all of these have criteria against which specific development proposals can be evaluated. So a checklist is an indicator system, but not all indicator systems are checklists.

The San Francisco Department of Public Health has applied a healthy development checklist to planning activities such as public housing redevelopment, pedestrian and bicycle planning, and several specific area plans. Examples of outcomes of these checklist applications include greater community involvement in plan development, potential mitigations and design strategies, and policy and implementation recommendations to better account for health.

Before jumping in, jurisdictions considering developing a checklist should also consider the process, benefits, and challenges of creating an indicator system. HIP produced this resource for the San Diego Association of Governments. It provides a review of several jurisdictions’ experiences with indicator systems and offers some approaches that may prove useful for those considering developing a healthy development checklist.

There are, however, additional considerations that checklist developers and users need to be aware of. In theory, a checklist can be a useful collaboration tool for public health and planning practitioners to ensure health goals are included in development, but keep the following questions in mind:

  • Who develops the checklist? Is the process collaborative? Which priorities are reflected in the checklist? The development of a checklist involves selecting domains of interest, ways of measuring these domains via indicators, determining the health and equity objectives that the indicators reflect, and criteria to gauge whether an indicator will meet stated objectives. Who is involved in the checklist decision-making process will influence the objectives and criteria expressed by the checklist – and ultimately, what value they have to the larger community.
  • Which domains and indicators should be included? To be inclusive, a range of perspectives should be sought. But ultimately, the priorities should reflect human needs – an underlying set of values determined by collaborators. Resist the urge to include the easiest indicators, or all indicators you can think of, in the checklist. Some of the most important things to include relate to what people need to live and be productive members of society – a living wage, education, and freedom from injustice and violence.
  • Will data be available for all the important indicators? There is a good chance that for at least some indicators, data will be hard to come by, which will affect your budget, process, and analysis or interpretation. A collaborative process can help to overcome this challenge because affected communities can be included in data collection and interpretation. Be creative and, wherever possible, make plans to accommodate additional data collection efforts for hard-to-reach but important indicators.
  • What is the process for applying the checklist to proposals? Who will be included? Will the community have input into in the process of interpreting the data, deciding whether criteria and objectives are met, and what should be done if they are not? Make these decisions up front and include them in instructions that accompany the checklist – otherwise, its value as a tool will be limited.

Most importantly, uphold the values of HIA – equity, democracy, sustainable development, ethical use of evidence, and a comprehensive approach to health – in developing and applying a healthy development checklist. Using these values will help ensure that the checklist and its application advance not just the technical goal of considering health, but the ethical and just goal of creating healthy communities.

Practitioner or Renaissance Woman?

I’m in the final stretch of completing a Health Impact Assessment, and I’m struck by how many different skills are needed to do it right. Our model at Human Impact Partners – combining rigorous research, evidence-based analysis, community participation and a strong focus on equity – requires HIA practitioners to master an array of roles:

  • Project manager. Every successful project has a strong manager. A typical HIA must be coordinated with a variety of stakeholders, cover a range of topics, and be done on time (often more quickly than you’d ideally like). As project manager, you outline the tasks, who’s responsible for them, and how long each task should take to stay on time and budget. You coordinate with all team members and partners so everyone is clear about the plan. Throw in a changing timeline and super-busy community partners, and your management skills are really tested.
  • Technical expert. HIA is inherently multidisciplinary, so you’ll need to learn about the subject of your study. You may be unfamiliar with your target, available policy options, your partners’ positions, or the broader political context. You may need to explore a social determinant of health you’ve never researched before, such as critical race theory, cross-race understanding, or parental deportation. By the end, after doing a literature review, sourcing and analyzing the data, and communicating to partners about what you found, you’ll be an expert in something new.
  • Meeting facilitator/public speaker. These skills come into play as you uphold the values of democracy and equity. Stakeholder engagement is critically important; to do this, you’ll need to communicate about your HIA, get people engaged in the process, and facilitate input from stakeholders in a public forum. You’ll need input and agreement on your scope, the impacts you’re predicting and the recommendations you are making. It helps if you’re comfortable in front of a group and have creative ways to keep people engaged.
  • Diplomat. One of the most difficult tasks is prioritizing and limiting your research while still responding to stakeholder and partner concerns. For many HIAs, you can’t examine everything, and to attempt too much means compromising depth for breadth. It takes diplomacy to be strategic with the most compelling findings and recommendations while striking a balance between what your partner wants and what the budget allows.
  • Research designer and analyst. To recognize and analyze the pathways through which your proposal may impact health requires an understanding both of how individuals respond to changes in their environment and how on a larger scale those changes influence an entire population’s behaviors, outcomes and inequities. You start by conceiving the impact pathways. Then you must identify indicators and measures of behavioral, social, and environmental factors. After you and others on the team collect and analyze the data, you still must visualize how you’re going to present it.
  •  Communications expert. Communications are the icing on the cake. The final report is a record of all your efforts, presented for the affected populations, collaborators, decision-makers, journalists and the public to see. As editor of the report you must be strategic about what you include, exclude, and highlight and how you disseminate the results so your HIA has an impact.

You may not be an expert in each of these skills, but being an HIA coordinator does require familiarity and some level of proficiency in all of them. This incredible variety is one of the reasons I love my job. It is never routine, you’re always learning, and you bring people together through the very important shared value of health.

Are Community Diversity and Social Cohesion at Odds?

I once lived in an apartment building in New York City with a remarkable diversity among tenants’ age, income, racial and ethnic background, family structure and sexual orientation. I was close to some of my neighbors, less so to others. But this was my community, and it profoundly influenced my feelings on the value of differences, my idea for the kind of community I want to live in and the policies I want to shape society.

So I was unsettled by reading Richard Florida’s post on The Atlantic’s Cities blog, discussing research that raised troubling questions about whether integration and social cohesion can coexist. Zachary Neal and Jennifer Watling Neal of Michigan State used computer simulations to model more than 20 million virtual “neighborhoods” and concluded that we can’t expect integrated communities to also be socially cohesive.

Florida reports they found that “the more diverse or integrated a neighborhood is, the less socially cohesive it becomes, while the more homogenous or segregated it is, the more socially cohesive.” According to the researchers, integration “provides opportunities for intergroup contact that are necessary to promote respect for diversity, but may prevent the formation of dense interpersonal networks that are necessary to promote sense of community.”

To health impact assessment practitioners, such findings are challenging, to say the least. In HIA, social cohesion is a key determinant of health that can be affected by a broad range of policies, such as housing, transportation, and safety. Likewise, racial/ethnic and economic integration are thought to create a path to greater understanding and increased social equity, which in turn have health benefits. If we have the opportunity to get to know more people with different backgrounds, this can lead to greater empathy and may prevent against the adoption of policies that disproportionately harm some members of society.

How do we reconcile these findings that pit social cohesion against integration? Do we have to choose between them? Are they in competition with each other? It is not that simple, as the researchers and the blog author note. Florida says integration and social cohesion may be hard to achieve in small communities, but a diverse metropolis – a federation of neighborhoods, each with its own identity but also strong cohesion – is what you find in vibrant cities like New York or Toronto.

Personally I don’t think these findings mean we have to sacrifice the benefits of either goal. We just need to work to understand the underlying social processes that lead to a realization of the good that comes from integration and social cohesion. Such research can help build a narrative around how cities grow and change, and what we can or can’t expect such change to accomplish. This research really underscores for me that HIA practitioners have an obligation to dig into this question and understand its nuances so we can achieve integration and social cohesion in the places and communities in which we work.

The Health Benefits of Marriage Equality

In the fervid debate over marriage equality, there’s one perspective not often mentioned: public health. We all know relationships and family are cornerstones of health, but what does research say about how denying a large portion of our population the right to marriage is actually denying them a health benefit. How might same-sex couples and their children be healthier if they had the right to wed?

A couple of caveats. First, this is not a thorough review of the literature on the topic. Second, I recognize that not everyone chooses to get married, and that many who want to marry still haven’t found that certain someone. This is not to say that anyone who hasn’t entered into the institution is at risk, health-wise. Likewise, there are many, many people who are married, yet not satisfied, so this is not to say that just because you sign the contract, you reap the health benefits. Certainly, an unhappy marriage can be harmful to a person’s health and wellbeing. But what benefits accrue to those who do want it and are successful at it?

The research clearly shows that marriage has health benefits. Married men and women who are satisfied with their relationships enjoy better physical and mental health compared to unmarried people. They live longer and are less likely to suffer from long-term illness and disability. Interestingly, studies show that men benefit the most.

There is also something about being married – not just being in an intimate relationship – that has this effect because cohabitating couples don’t see the same health benefits as married couples. You may wonder if this is because healthier people are more likely to get married, but researchers have ruled this out.

So what’s going on? One factor is that society has assured married people will have access to government benefits, rights and privileges – tax breaks, employee benefits, death benefits, entitlement programs. Married couples get greater economic and financial security than unmarried people, and that produces better mental and physical health outcomes.

Spouses also have other rights that can serve as buffers to stressful life events. For example, marriage can help ease the psychological stress associated with the death of a spouse. A surviving spouse has the automatic right to make funeral arrangements, receive any inheritance, and obtain death benefits and bereavement leave.  All of these reduce the chances that this difficult time will harm the health of the surviving spouse.

Because marriage requires commitment, and the ritual that often accompanies it involves family and friends, it provides a unique component of social support and integration. Married adults receive more support than unmarried adults, especially from parents. This leads to better coping mechanisms and financial security and therefore health benefits. Further, the public commitment acts as a deterrent to dissolving the relationship in the face of challenging times and may mean that a couple overcomes barriers and makes it to a better state of being in the long run.

What about the children of same-sex couples – how does denying marriage to their parents affect them?  Studies show that having two parents is better for children than having a single parent. Children from single-parent families are more likely to experience health problems like accidents, injuries and poisonings and are more likely to drop out of high school. Single parents are also more likely to be impoverished, which affects their children’s health.

However, what we really want to know is whether being raised by two unmarried parents is any better or worse for a child than being raised by two married parents, sexual orientation aside (Studies also find that children raised by same-sex couples are no worse off in terms of mental health or social adjustment than those raised by heterosexual couples).

I am hesitant to offer conclusions from the literature comparing child outcomes by family structure because there are limitations to these studies. There are other factors to be considered besides family structure, such as poverty and the quality of relationships and I wouldn’t want to simplify the issues. However, I do think it stands to reason that if the contract of marriage affords a couple increased social and financial stability their children’s health and wellbeing will also benefit.

This is a complicated issue and more research could be done. But we already know enough to say that that by denying couples the right to marry we are essentially denying them and their children better health.

Citations available upon request

The first Annual HIPpy Awards: 2012 in Review

It’s the end of the year, which of course means “best of” lists.  Nationwide, more than 20 HIAs were completed in 2012 — seven by Human Impact Partners:

  • Farmers Field, a proposed football stadium in downtown LA.
  • Marin Housing Code Enforcement Policy, a housing policy to improve tenant health and well-being.
  • Oakland Bus Rapid Transit, a transportation proposal connecting Oakland to San Leandro.
  • Rental Assistance Demonstration Project, a federal housing policy proposing to privatize public housing.
  • School Discipline Policies, alternative approaches to harsh school discipline policies such as “zero tolerance.”
  • University of Southern California Specific Plan, a land use expansion plan around USC in Los Angeles.
  • Wisconsin Treatment Alternatives to Prison, a policy proposing to fund alternatives to incarceration.

May I have the envelopes, please…

Best stakeholder engagement. The Farmers Field and USC Specific Plan HIAs included intensive participation from affected community residents. The model was unique in that community residents – who are typically disenfranchised from such politicized processes – were brought together, listened to and became leaders of these HIAs.

Best innovation in HIA processes. It is really difficult to have meaningful stakeholder participation when you have only two months to conduct your entire HIA. To overcome this challenge the above two HIAs tried out a new model for engaging stakeholders with a very tight HIA timeline. Both HIAs were completed in less than three months. One-day scoping meetings were held on weekends early in the process, HIP summarized the literature and collected baseline data independently, then regrouped stakeholders and subject matter experts for a second two-day meeting to consider findings and come to consensus on recommendations. This HIA process was a huge success in bringing community priorities into a fast-moving debate from which they had previously been excluded.

Most effective communication. The Wisconsin Treatment Alternatives to Prison HIA used a communications strategy that garnered a flurry of media attention, including more than a dozen news reports – one the lead story on the front page of the Wisconsin State Journal – and a letter to the editor printed in the New York Times. The governor of Wisconsin even commented on the HIA when asked about the policy publicly. WISDOM, our HIA partner, had an ongoing and well-organized campaign around this issue with which we were able to integrate. We also invested additional time and resources to focus on clarifying and simplifying the messages of the HIA so they were easier for the media and our partners to utilize.

Best HIA outcome. While we still don’t know the outcomes of several of the HIAs we completed, the Farmers Field HIA contributed to an amazing win for our partner, LA CAN. The proponents of the stadium project agreed to settle a lawsuit filed by the Coalition and individual LA CAN members and supporters that secured for them a wide range of community health benefits. A fantastic outcome of the Housing Code Enforcement HIA is the commitment from multiple Marin County jurisdictions to amend their housing inspection policies so that tenant health and well-being could be better protected.

Best new policy target. With so many HIAs focusing on land use and built environment policies, we welcome the School Discipline Policies and the Wisconsin Treatment Alternatives to Prison HIAs to the mix. Education has strong and clear benefits for long-term health. This HIA helped insure children are not denied their right to an education because of harsh and often discriminatory discipline policies. The Treatment Alternatives to Incarceration HIA furthered the understanding of incarceration’s negative impacts on health, and advanced alternative ways of protecting the health of individuals, their families, communities and even state budgets.

Special mention: catching a public agency’s eye. Perhaps an accolade we shouldn’t be proud of, but the fact that the Rental Assistance Demonstration (RAD) Project HIA ruffled some feathers at the U.S. Housing and Urban Development Department shows this HIA prompted a discussion about HIA research findings. See dueling op-eds on the topic in Politico and The Huffington Post.

Best university collaboration. Of course student contributions to HIA projects are nothing new, but we’d like to give a shout out to the involvement by UC Berkeley students in the Oakland Bus Rapid Transit HIA. Without you this project would have been half the project it ended up being.

It is also worth mentioning a few other HIAs that made a splash in 2012.

Most innovative reporting. The Bernalillo County, New Mexico Place Matters team created a whole web site (not just a page where you can download a written document) to report on their Second Street HIA—a first for HIA practice. Not only is the site well designed, but the information is simple and accessible. The web site also makes it so easy for people to get involved in future work with the PM team.

Most effective, efficient quantitative analysis. The folks at the Boston Metropolitan Area Planning Council, in their work with the Harvard and Boston University Schools of Public Health, broke the record for the shortest full HIA report with their HIA of the MBTA’s proposed service cuts and fare increases for the T. Twenty pages including references! It is remarkable how they do this while still including a solid, compelling quantitative analysis of the health and economic effects of the public transit proposal.

Best (maybe only) inclusion of an evaluation. This team of HIA overachievers, the Kansas Health Institute, actually included a process and an impact evaluation in their HIA report on the Potential Health Effects of Casino Development in Southeast Kansas. I challenge you to find another HIA that can make this claim.