We caught up with our postdoctoral researcher and public health expert Helen Cole to talk about what she’ll be working on with her new JCI grant, what she’s learned about healthcare inequities in cities, and what problems makes her the angriest.
In your last profile, you were working on the GreenLULUs project and evaluating the effect of U.S. healthcare system restructuring with your colleague Emily Franzosa. Tell us where that has led you up until now.
I’d say there are two main projects that I’m working on now, in various phases of completion. It’s always hard not to start new things when I notice something that I think needs to be studied. This happens a lot since I study urban health inequity, and live in a city—there’s new material everywhere I look and in almost every conversation I have with my friends, colleagues, and neighbors!
I’ve recently dedicated a lot of time to understanding how urban greening and gentrification, the core concepts studied in the Greenlulus project, impact– sometimes in complicated ways– the health of urban ways. Back in 2019, I led an article that examined the unequal health benefits of exposure to green space in New York City. My more recent publications go deeper into this issue by looking at the multiple and overlapping exposures that marginalized residents living in gentrifying neighborhoods are facing and which contribute to inequities in urban health outcomes. Most recently, related to my past work on green gentrification and health, last Fall, Margarita Triguero-Mas and I received some funding from the Barcelona city council to do a project which we called FEMPUBLICBCN. We’re studying how use and perceptions of public space among women and non-binary people in Barcelona have changed since before the pandemic. We are also curious about how perceived changes in tourism, which all but disappeared during the pandemic, and gentrification in their neighborhoods have impacted their use of public space. This study is a lot of fun because one of the neighborhoods we are studying is my own neighborhood, Sant Antoni.
With my colleague, Emily Franzosa, I have been working on the last few years developing a concept which we call “healthcare gentrification”, or the ways in which changes in healthcare systems themselves may exclude some patients (mostly lower income, minority or un- or under-insured patients, in the context of the US) while providing new forms of care through private for-profit entities often aimed at private insurance holders or those who can pay out of pocket. We have completed a pilot study to try to understand how this process, which we see as happening along side and entangled with neighborhood gentrification, affects equity in access to healthcare in 4 cities in the US. We are currently analyzing the data and writing up the results, which is taking longer than we’d hoped of course!
Can you talk a little bit about the JCI grant you just obtained and what you will do with it?
Having funding from the Juan de la Cierva Incorporation grant, which funds my position and provides a small amount of seed funding, has been a great opportunity to pursue some of my research interests that diverge from, but also build on, the work I’ve done over the past five years with the lab. This includes furthering the work that I’ve been doing with Emily, my BCNUEJ colleague Margarita Triguero-Mas, and new collaborations with researchers from the Center for Demographic Studies (CED-UAB), the Agencia de Salut Publica de Barcelona, the University of Michigan (USA), Drexel University (USA), and others I’ve gotten to know during my time in Barcelona.
In general, the overarching theme of my work has to do with urban health inequities, and thinking about health equity in the context of uneven urban development, patterns of segregation, and especially of changes occurring in cities overtime (gentrification, specifically) that have implications for determining who has access to resources and healthy places to live, and who doesn’t. I also think about how urban planning decisions and policy making have affected urban health equity.
Aside from these projects, what are you working on next?
Well, one thing I’ve been thinking about is expanding my research on healthcare to other settings and thinking more about healthcare in the context of other urban changes and urban planning strategies. Inequity in access to healthcare is a huge problem in the US due to the lack of public system for healthcare, but it’s also starting to take a toll in Europe. Since 2008, healthcare systems in Spain and elsewhere have been increasingly underfunded, and at the same time privatization of different parts of these systems is increasing, and these changes have implications for equity in access care in urban areas.
It is interesting to me how city planning officials talk about health, often without mentioning healthcare itself. As cities continue to focus on tactical urban interventions like green infrastructure, justified as methods of improving the health of citizens, essential healthcare services are crumbling. As these services don’t fit well into the economic model followed by cities as they focus on policies that will make them more attractive to new wealthy residents, or more competitive on the international stage as a healthy, pleasant place to live, these basic healthcare services are still important and especially so for certain more vulnerable or marginalized communities like the elderly, people with chronic illnesses or disabilities, pregnant people, minorities and those with low incomes.
I’m hoping to keep working on this topic and to find some funding for a bigger project by the time my JCI grant finishes in 1.5 years.
It seems like you have several different interests. How do you decide on what to study next?
A wise professor once told me that the best thing to research is whatever makes you the angriest. Part of my current interests come from the failures in testing that I’ve com across in my past research. For instance, from 2010 to 2016, I managed several randomized control trials that aimed to test behavioral interventions for blood pressure control and to encourage older Black men to get screened for colorectal cancer. These studies were community-based (i.e., were conducted in real world conditions, not a laboratory) and we followed the participants over 6 months. Despite that I have a master’s degree in health behavior and health education, our experience with these studies led me to understand the limits of these types of interventions and the many other important factors determining the health of urban residents.
Managing the implementation of such interventions for older Black men in New York City really taught me how complex environments are. In epidemiology, and public health, we often try to control this complexity by using statistical models and flat measures of urban context (like poverty level, level of education, etc.). I think this strategy detracts from the strength of public health as a real-world science. We should embrace complexity rather than trying to control it!
I should mention that, despite the odds against the men in our study, like unstable housing, having a history of incarceration, poverty, exposure to systematic and interpersonal racism, and many others—one of the interventions actually did work well: a patient navigation program to help men get screened for colorectal cancer which affects Black men more than others. You can read about it here.
My interest in healthcare also came from a long-ago job I had as a young Master’s in Public Health grad. I was project manager for a study on access to healthcare among low income older adults, also in New York City. To me, healthcare is one of the most basic necessities in maintaining a healthy population, and one that is often ignored. And that makes me angry; that this basic necessity is beyond reach for so many people. Most research on access to healthcare either considers the characteristics of patients (like their age, health status, income, etc.) or characteristics of healthcare facilities (like their location, type of care provided, etc.). But again, in the complex context of cities, this is not enough.
Lastly, I get ideas from conversations I’ve had with colleagues, or with my friends or neighbors. In 2018, I wrote a blog post for BCNUEJ about the town where I was born. Isabelle, our director, asked me to add a sentence or two about how gentrification might affect healthcare… and that was the start of my work with Emily. The work I’ve done on the GreenLULU’s project also sent me to three cities in the US to interview people for the project. What a gift. I’ll be researching for years to come for sure.
__
Helen Cole, a native of Arkansas, is a postdoctoral researcher and co-coordinator of urban environment, health and equity at BCNUEJ, focusing on the relationship between gentrification and health. Read some of her blog posts here.
Interview by Ana Cañizares
