How Public Health Methods Can Bolster Socially Conscious Urban Development

A site plan of the P3 parcel in Roxbury, Boston, showing existing and potential open spaces.

Open spaces at the P3 Parcel in Roxbury, Boston. Image courtesy Boston Planning & Development Agency.

Cities today are faced with complex challenges that require careful decisions about the future of the built environment. Development projects hold the potential to strengthen communities by helping to combat inequality, repair a legacy of environmental racism, improve health outcomes, and adapt to a changing climate. Developers, designers, and city officials alike need sophisticated tools and methodologies to ensure that projects can positively impact their communities while meeting the needs of all stakeholders.

In cities such as Boston, public review processes already exist that aim to foster conversation about the costs and benefits of new development; however, these processes can be slow and contentious. The field of public health offers new tools and insights that can help city leaders, community members, and designers understand the full range of impacts that a given project might produce. Adele Houghton, president of Biositu LLC and instructor at the Harvard T.H. Chan School of Public Health, has been working to bridge these fields for much of her career, most recently by applying a technique known as health situation analysis to real estate development. While pursuing a doctorate at the School of Public Health, Houghton collaborated with Matthew Kiefer, Lecturer in Real Estate at Harvard’s Graduate School of Design. Their work resulted in the recent article “How Real Estate Development Can Boost Urban Health,” published in the Stanford Social Innovation Review.

Houghton and Kiefer spoke with the GSD’s William Smith about how health situation analysis can be a tool for aligning with the needs of communities, the business aims of real estate developers, and the mandates of city agencies charged with overseeing equitable development.

How did this project come about?

Matthew Kiefer The article grew out of a collaboration between Adele and me in a class I taught at the GSD last year called Developing for Social Impact. The premise of the course was to harmonize purpose and profit in real estate development and harness economically feasible projects to accomplish social and environmental goals. We used active Boston development sites as case studies, and student teams working on one site got very interested in the health situation analysis that Adele introduced.

Adele Houghton I reached out to Matthew because I was interested in the dual business model he presented through the course. I was a Doctor of Public Health (DrPH) student at the time, studying at the T.H. Chan School of Public Health. The DrPH degree is designed for mid-career professionals who want to translate research into action in the field. In my case, as an architect who has specialized in green and healthy building for about 20 years, I returned to school to learn how to apply public health methods to the design and real estate development process.

In architecture school you spend a lot of time learning about design, building codes, building engineering, and building systems. The business side is focused on how to create a firm; I wish I had learned more about real estate development. As part of my DrPH, I wanted to learn more about how real estate development happens: how you choose a site, how you decide what its highest and best use is, how you finance it. Matthew’s course did that—and brought environmental, social, and governance (ESG) considerations into that financial calculation.

How does public health relate to real estate development?

AH The work we do as architects and developers affects not just the people inside the building, but also the surrounding neighborhood. Our colleagues in the urban planning and community planning departments are learning about those systems, but architectural design often focuses exclusively inside the property line.

When I pivoted to studying public health about 15 years ago, it was to learn more about methods and data sets that would allow architects and developers to fill in some of the gaps in the site assessment process. I wanted to look not just at how a project site connects to utilities, or whether we need to include a sidewalk along the edge of the site, but really at how a site leverages its surroundings to create a positive ripple effect in the community.

The core of your method is health situation analysis. Could you explain what that entails?

AH The methodology takes data sets and makes them actionable by providing design strategies that a developer or an architecture team could use in response to the conditions in the surrounding neighborhood.

Health situation analysis is already used by local health departments to assess what’s going on in a community and create an evidence-based plan for what to do about it. For example, the Covid-19 pandemic started in clusters around the country. We weren’t sure what it was. We weren’t sure how it was going to impact the community. We didn’t know who was going to be most impacted. Health situation analysis allowed local health departments to understand what was happening and make best use of their resources by implementing the smallest number of interventions—while ensuring that those interventions were not in conflict with each other.

We regularly do site assessments at the start of every design and real estate project. By incorporating health situation analysis into that process, we can pull together data sets to understand the demographics on and around the site, the environmental conditions, and the prevalence of underlying health conditions. For example, an elderly person exposed to a heat wave or power failure is at higher risk of going to the hospital than a younger, healthier person. Health situation analysis helps us tailor the design of an individual real estate project to support the health needs of vulnerable groups inside the building and in the surrounding community so it can have the biggest possible positive impact across multiple priorities–whether environmental, social, or financial.

What kinds of data sets do you look at?

AH When we perform a health situation analysis, we sift through publicly available data sets and look for trends in an entire population–whether inside the building or in the surrounding neighborhood.

We can divide the data sets we look at into three different groups. The first is called social determinants of health: factors outside a person’s own body that can influence their health. Most of that data comes from the US Census. Some people in our community are at higher risk of negative health outcomes because of their age—particularly young children and the elderly—or because they have less robust immune systems, such as cancer patients. We particularly assess factors related to how our society is set up—such as differences in access to health care, to clean air, to education, and healthy housing across income levels and the legacy of racist land use policies like redlining. Over time, those differences lead to disparities in health outcomes, and even in life expectancy. The social determinants of health help us understand which groups of people in the building and surrounding neighborhood are more likely to have a negative health outcome, say, if they’re exposed to a lot of air pollution, heat, or flooding.

The second category of data is community health indicators that are influenced by the built environment—such as asthma rates, cancer rates, mental health, and obesity rates. Every year, the Centers for Disease Control and Prevention (CDC) conducts representational surveys at the national level and then creates estimates at the census-tract level about the prevalence of those health risks.

The third data set relates to the health effects of climate change, and that’s mostly taken from an index created by the Federal Emergency Management Agency (FEMA). It combines a list of about a dozen natural disasters with social determinants of health to analyze the vulnerability of a census tract to each hazard.

Combining these three types of data sets, we end up with a mosaic picture of a neighborhood’s current health conditions and potential risks that could be modified through design.

An aerial view of the Nubian Square area of Boston.
The context for the P3 Parcel in Roxbury, Boston. Image courtesy Boston Planning & Development Agency.

The paper describes three components of a design process that includes health situation analysis. You define these as data analysis, community engagement, and cost-benefit analysis. How do these aspects fit together?

MK Our article applies this methodology to the public approval process that every real estate development goes through. The larger the development, the more rigorous the approval process and the greater the opportunity to affect public health positively or negatively. Health situation analysis helps you understand how all the publicly available data applies to your site. That leads to decisions about how to design your project. And it can lead to changes in everything from building design, to programming, to mitigation commitments surrounding your site.

Health situation analysis is also a useful way to frame communications with neighbors and with community members who participate in the approval process, allowing you to explain why you’re designing the project the way you are. We use the example of a building that has reduced carbon emissions to adhere to a city-wide net zero mandate. If I’m living a block away, how much do I care about that city-wide mandate? But if there are high asthma rates in the neighborhood, and maybe my child has asthma, then the effect of the project on asthma rates might be a better frame for helping me evaluate the project. Health situation analysis is a way to ground those community discussions that every real estate development project has anyway in data that is specific to the neighborhood and informs the community engagement process.

Of course, the real estate developer’s primary objective is not to address public health in the neighborhood; it’s to develop a feasible project and in the process take prudent measures to address public health effects. How do you figure out whether given measures are sensible when you’re trying to harmonize those two objectives? Cost-benefit analysis is the standard way to do it. How much is it going to add to the capital or operating cost of the project and what benefits will it produce, even if those benefits flow to others?

It may be that the developer bears the cost while the benefits flow to the neighbors. But, if the developer is trying to make the case for density on the site, for public approvals, for financing from mission-oriented investors who care about social impact, then health situation analysis is a useful mechanism to test the efficacy of the measures the developer is proposing.

AH What you’re doing inside the property line is creating value beyond the property line. Health situation analysis helps expand the value proposition and answer the question: How could the developer and the design team benefit from providing benefits to the surrounding community?

How do you see health situation analysis mitigating broader housing problems specifically?

AH I’m talking right now to two city housing authorities that are interested in the idea of health situation analysis. They’re thinking about how a development project fits into larger systems, whether they’re environmental systems, social systems, or economic systems.

They consider questions beyond design and construction, such as: What do you do after the building is constructed? How is it operated? A lot of the benefit to the community happens after the building is operational. Affordable housing has to be an affordable place to live once you’re in it. It also has to be well-maintained with amenities like childcare facilities, a playground, maybe even a pharmacy or a primary care facility. We can’t think about housing as just the dwelling. It needs to be thought of as fitting into a larger system. Health situation analysis allows for that conversation to happen in a structured, data-driven way.

MK You could apply the health situation analysis methodology to any kind of project, but it’s particularly powerful for housing. In Boston and many cities with strong economies, housing attainability is a significant issue for many households. In Boston we’re creating jobs faster than we’re creating housing units for the people who are taking those jobs. That drives up prices for middle-income households, young families, first time home-buyers. Health situation analysis doesn’t solve that problem, but it can help overcome barriers to housing production by situating the public review and community-engagement processes in an evidence-based framework that communicates how a project is going to benefit a neighborhood. If this were adopted more broadly, it could help to ease the production of more housing to satisfy rising demand.

Your paper focuses on a case-study development site in Boston called P3. How were you able to apply the health situation analysis method in that instance?

MK P3 is a large publicly owned site in the Roxbury neighborhood of Boston. It was cleared in the urban renewal era and has sat mostly unused ever since. It’s near Nubian Square, the heart of Boston’s African-American community, and across from a major transit node. The Boston Planning and Development Agency was doing a development competition—they’ve since designated a developer. So it was a fruitful case study site in my Developing for Social Impact course.

AH Boston is a great place to do this kind of project because it has an open data portal that has information on a wide range of topics related to the environment, social services, and demographics as well as a lot of qualitative information—interviews with residents in the Boston area. But the data sets are not interconnected. By doing the health situation analysis for P3, I was able to explain how that particular parcel situated within its census tract in Roxbury could help the city or at least the neighborhood address its high vulnerability to heat and its high vulnerability to flooding. The corner of the site is also located at an intersection with a high incidence of pedestrians and cyclists being injured by cars. It’s a place where a lot of elements intersect, but their relationship with each other is not obvious if you only look at each set of information separately.

The students in Matthew’s course picked up on how important it is to see the larger system. Matthew also made sure that the students had access to community members representing residents as well as businesses and institutions that were important in the neighborhood. There’s a real concern in Roxbury about displacement. The health situation analysis and conversations with the community helped students answer the question: How do you redevelop this important large site in a way that is responsive to the needs of the people that are already in that neighborhood, and help to bring jobs and economic opportunity and additional housing for them, while also recognizing that this could be an economic draw for other people in Boston?

Beyond the classroom, how have you been able to translate health situation analysis into real-world action?

AH I’ve been consulting throughout my career at Harvard. My dissertation, which was funded through the AIA Upjohn Research Initiative, was a proof-of-concept pilot working with three active real estate projects: one in Albany, New York; one in Buffalo, New York; and one in Waterford, Virginia. The health situation analysis is part of a larger engagement I call The Alignment Process, which uses health situation analysis as the first step in a multi-stakeholder conversation seeking common ground across three groups who often do not see eye to eye in the development process: the real estate development team, neighborhood residents and businesses, and local officials.

At the end of the process, stakeholders from all three pilots had co-developed aligned visions for their projects, as well as supportive design strategies. The process also produced metrics that the different stakeholder groups could use to keep track of the project and hold each other accountable to the actions to which they had committed to make sure that the project would achieve the agreed-upon vision.

One of my goals coming out of the pilot is to train designers, real estate professionals, local officials, and community groups so that The Alignment Process, and health situation analysis specifically, become standard practice. To that end, I have released a playbook walking stakeholders through the process step-by-step. With funding from the Boston Society for Architecture, Caroline Shannon (another GSD and Harvard Chan alum), and I recently ran the first two train-the-trainer workshops on this topic in Massachusetts. I’m also actively fundraising to turn the process of generating a health situation analysis, the data part of The Alignment Process, into an automated tool so that any designer, real estate team, community group, or municipality could make use of this approach.

MK One of the great virtues of the tool is that it brings stakeholders together. I sometimes describe the public approval process as a three-legged stool. The first leg of the stool is the proponent: the real estate developer or sponsor of the project, whether for-profit or nonprofit. Community stakeholders are the second leg of the stool. There are many community stakeholders and they have different viewpoints, but all of the outside parties affected by decisions about the project are part of the approval process. And the third leg of the stool is the public agency that approves the project. We try to make clear in the article that The Alignment Process generates benefits for all three of those legs of the stool.

It may be most obvious how the community members would benefit from health situation analysis. But project sponsors can also benefit by using it as an organizing framework for their mitigation decisions and discussions with project neighbors. It helps rationalize the approval process and can also benefit the way they do business and build relationships with their lenders and investors as well as their neighbors beyond the project.

The public agency also benefits. The approval process is often very contentious and it’s ultimately the public agency that needs to make a decision about whether to issue a permit. We live in a time of eroding faith in government as an effective agent of positive social change. In this environment, The Boston Planning and Development Agency—the agency most involved in development decisions for large projects—is eager to reach a successful resolution of development approvals, both so that worthy projects go forward, and to demonstrate its own effectiveness as an arbiter and decisionmaker on behalf of Boston’s citizens.

GSD How did the GSD facilitate this research?

AH It was an incredible experience for me as both an architect and doctoral student at the School of Public Health to be so welcomed at the GSD and basically recruited by Matthew as both a student and a teaching fellow in the course. The faculty here recognize their students’ strengths and the fact that so many students are experts in fields outside of design. They see that there’s an opportunity to incorporate broader fields of knowledge into the discussion around design. My more recent research on transdisciplinary curricula at the intersection of climate change, health, and equity reinforced my personal experience in Matthew’s course. There are very few schools that can provide this level of transdisciplinary education, and Harvard is at the top of the list, both in terms of having that capacity and actually starting to use it.