Improving accessibility to radiotherapy services in Cali, Colombia: cross-sectional equity analyses using open data and big data travel times from 2020.

In this study, we evaluated and forecasted the cumulative opportunities for residents to access radiotherapy services in Cali, Colombia, while accounting for traffic congestion, using a new people-centred methodology with an equity focus. Furthermore, we identified 1-2 optimal locations where new services would maximise accessibility. We utilised open data and publicly available big data. Cali is one of South America's cities most impacted by traffic congestion. METHODOLOGY: Using a people-centred approach, we tested a web-based digital platform developed through an iterative participatory design. The platform integrates open data, including the location of radiotherapy services, the disaggregated sociodemographic microdata for the population and places of residence, and big data for travel times from Google Distance Matrix API. We used genetic algorithms to identify optimal locations for new services. We predicted accessibility cumulative opportunities (ACO) for traffic ranging from peak congestion to free-flow conditions with hourly assessments for 6-12 July 2020 and 23-29 November 2020. The interactive digital platform is openly available. PRIMARY AND SECONDARY OUTCOMES: We present descriptive statistics and population distribution heatmaps based on 20-min accessibility cumulative opportunities (ACO) isochrones for car journeys. There is no set national or international standard for these travel time thresholds. Most key informants found the 20-min threshold reasonable. These isochrones connect the population-weighted centroid of the traffic analysis zone at the place of residence to the corresponding zone of the radiotherapy service with the shortest travel time under varying traffic conditions ranging from free-flow to peak-traffic congestion levels. Additionally, we conducted a time-series bivariate analysis to assess geographical accessibility based on economic stratum. We identify 1-2 optimal locations where new services would maximize the 20-min ACO during peak-traffic congestion. RESULTS: Traffic congestion significantly diminished accessibility to radiotherapy services, particularly affecting vulnerable populations. For instance, urban 20-min ACO by car dropped from 91% of Cali's urban population within a 20-min journey to the service during free-flow traffic to 31% during peak traffic for the week of 6-12 July 2020. Percentages represent the population within a 20-min journey by car from their residence to a radiotherapy service. Specific ethnic groups, individuals with lower educational attainment, and residents on the outskirts of Cali experienced disproportionate effects, with accessibility decreasing to 11% during peak traffic compared to 81% during free-flow traffic for low-income households. We predict that strategically adding sufficient services in 1-2 locations in eastern Cali would notably enhance accessibility and reduce inequities. The recommended locations for new services remained consistent in both of our measurements.These findings underscore the significance of prioritising equity and comprehensive care in healthcare accessibility. They also offer a practical approach to optimising service locations to mitigate disparities. Expanding this approach to encompass other transportation modes, services, and cities, or updating measurements, is feasible and affordable. The new approach and data are particularly relevant for planning authorities and urban development actors.

Improving spatial accessibility to health care services in Cali, Colombia: stakeholder assessment of an innovative platform.

Objectives: To (i) ascertain stakeholders' perceptions of the contextual factors and resources necessary to successfully implement the AMORE platform, a tool that provides accessibility assessments for health care services, considering factors such travel time and traffic conditions, and (ii) identify potential barriers to and facilitators for enhancing spatial accessibility to health care services within the Colombian urban context. Methods: In this qualitative study, semi-structured interviews were conducted with a purposive sample of seven key stakeholders. The sample was drawn from individuals involved in development of policies in Colombia, service providers, and users, among others, who had expertise in the field. Interviews were conducted until saturation was reached. Results: The participants had positive views on the appearance of the AMORE platform, highlighting its user-friendly visualization. Suggestions were made about the variables used in the dashboard, the implementation of the platform, potential usage areas, and barriers and facilitators to implementation and use. Barriers included economic, political, and personnel challenges, while facilitators included creating a minimum viable product at a low cost and building interinstitutional and international cooperation. Conclusions: Innovations such as the AMORE platform have the potential to support decision-making processes across various sectors, including public policies and internal processes within private organizations, academia, and the community. However, implementing such a tool has financial, contextual and environmental challenges. The study identified key factors that were considered prerequisites for successfully implementing the AMORE platform in Colombian cities.

Why and how has the United Kingdom become a high producer of health inequalities research over the past 50 years? A realist explanatory case study.

BACKGROUND: Evidence on health inequalities has been growing over the past few decades, yet the capacity to produce research on health inequalities varies between countries worldwide and needs to be strengthened. More in-depth understanding of the sociohistorical, political and institutional processes that enable this type of research and related research capacity to be generated in different contexts is needed. A recent bibliometric analysis of the health inequalities research field found inequalities in the global production of this type of research. It also found the United Kingdom to be the second-highest global contributor to this research field after the United States. This study aims to understand why and how the United Kingdom, as an example of a "high producer" of health inequalities research, has been able to generate so much health inequalities research over the past five decades, and which main mechanisms might have been involved in generating this specific research capacity over time. METHODS: We conducted a realist explanatory case study, which included 12 semi-structured interviews, to test six theoretical mechanisms that we proposed might have been involved in this process. Data from the interviews and grey and scientific literature were triangulated to inform our findings. RESULTS: We found evidence to suggest that at least four of our proposed mechanisms have been activated by certain conditions and have contributed to the health inequalities research production process in the United Kingdom over the past 50 years. Limited evidence suggests that two new mechanisms might have potentially also been at play. CONCLUSIONS: Valuable learning can be established from this case study, which explores the United Kingdom's experience in developing a strong national health inequalities research tradition, and the potential mechanisms involved in this process. More research is needed to explore additional facilitating and inhibiting mechanisms and other factors involved in this process in this context, as well as in other settings where less health inequalities research has been produced. This type of in-depth knowledge could be used to guide the development of new health inequalities research capacity-strengthening strategies and support the development of novel approaches and solutions aiming to tackle health inequalities.

Slum Health: Arresting COVID-19 and Improving Well-Being in Urban Informal Settlements.

The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.

Ethnicity and Health in Colombia: What Do Self-Perceived Health Indicators Tell Us?

OBJECTIVE: To compare self-perceived health indicators between ethnic groups in Colombia. METHODS: Cross-sectional study with data from the 2007 National Public Health Survey (ENSP-2007). Data from 57,617 people ≥18 years were used. Variables included: belonging to an ethnic group (exposure); self-rated health; mental health problems, injuries for accidents/violence (outcomes); sex, age, education level and occupation (explicative/control). A descriptive study was carried out of the explicative variables, and the prevalence of the outcomes was calculated according to ethnicity, education level and occupation. The association between the exposure variable and the outcomes was estimated by means of adjusted odds ratios (OR) with 95% CI using logistic regression. Analyses were conducted separately for men and women. RESULTS: The prevalence of outcomes was higher in people reporting to belong to an ethnic group and differences were found by sex, ethnic groups and health outcomes. Women from the Palenquero group were more likely to report poor self-rated health (aOR 7.04; 95%CI 2.50-19.88) and injuries from accidents/violence (aOR 7.99; 95%CI 2.89-22.07). Indigenous men were more likely to report mental health problems (aOR 1.75; 95%CI 1.41-2.17). Gradients according to ethnicity, education, occupation and sex were found. CONCLUSIONS: Minority ethnic groups are vulnerable to reporting poor health outcomes. Political actions are required to diminish health inequalities in these groups.

Dynamic measurements of geographical accessibility considering traffic congestion using open data: a cross-sectional assessment for haemodialysis services in Cali, Colombia.

Background: Many cities with traffic congestion lack accessibility assessments accounting for traffic congestion and equity considerations but have disaggregated georeferenced municipal-level open data on health services, populations, and travel times big data. We convened a multistakeholder intersectoral collaborative group that developed a digital, web-based platform integrating open and big data to derive dynamic spatial-temporal accessibility measurements (DSTAM) for haemodialysis services. We worked with stakeholders and data scientists and considered people's places of residence, service locations, and travel time to the service with the shortest travel time. Additionally, we predicted the impacts of strategically introducing haemodialysis services where they optimise accessibility. Methods: Cross-sectional analyses of DSTAM, accounting for traffic congestion, were conducted using a web-based platform. This platform integrated traffic analysis zones, public census and health services datasets, and Google Distance Matrix API travel-time data. Predictive and prescriptive analytics identified optimal locations for new haemodialysis services and estimated improvements. Primary outcomes included the percentage of residents within a 20-min car drive of a haemodialysis service during peak and free-flow traffic congestion. Secondary outcomes focused on optimal locations to maximise accessibility with new services and potential improvements. Findings were disaggregated by sociodemographic characteristics, providing an equity perspective. The study in Cali, Colombia, used geographic and disaggregated sociodemographic data from the adjusted 2018 Colombian census. Predicted travel times were obtained for two weeks in 2020. Findings: There were substantial traffic variations. Congestion reduced accessibility, especially among marginalised groups. For 6-12 July, free-flow and peak-traffic accessibility rates were 95.2% and 45.0%, respectively. For 23-29 November, free-flow and peak traffic accessibility rates were 89.1% and 69.7%. The locations where new services would optimise accessibility had slight variation and would notably enhance accessibility and health equity. Interpretation: Establishing haemodialysis services in targeted areas has significant potential benefits. By increasing accessibility, it would enhance urban health and equity. Funding: No external or institutional funding was received.

Grassroots innovation practices for social transformation of the health and well-being in a self-built settlement in Medellín-Colombia.

Grassroots innovation generates possibilities for the informal and collective production of the territory that the city itself denies, from bottom-up solutions for sustainable development and consumption, which respond to the local situation, interests, and values of the communities involved. This paper aims to identify how grassroots innovation practices take place and are shaped in 'El Faro', a self-built settlement at the urban border of the city of Medellín; and how these have allowed the social transformation of health and well-being. This was done from a qualitative approach with an interpretative scope, under the case study methodology. 'El Faro' is a space built by its inhabitants, in a process that they have called "dignity and resistance", becoming the promoter of what we identify as four 'grassroots innovation practices' developed around three main issues: community water management, artistic training and the creation of community public spaces. This process has allowed them, from the capacity of agency, to understand their poverty situation and face it, modifying the conditions that reproduce it and responding to unsatisfied basic needs, based on innovative solutions that guarantee conditions of life with dignity and well-being. Likewise, it generates mechanisms that reduce inequality because the community becomes the main driving agent for the construction of the city and the transformation of the health-disease process, through its community assets.

A Scoping Review about Migrants' Oral Health in South-South Contexts.

OBJECTIVE: To gather the available scientific evidence about the oral health of migrants in south-south contexts. METHODS: A scoping review methodology was applied through a comprehensive search in databases of scientific and grey literature: PubMed/Medline, Scopus, LILACS, EMBASE, Google Scholar and the International Centre for Migration, Health and Development. A descriptive analysis of the characteristics of the selected studies was conducted. RESULTS: The search yielded 23 papers. Seventeen studies (17/23, 73.9%) were conducted on the Asian continent and 91.3% (21/23) were cross-sectional. Studies were focused on oral health problems such as dental caries and periodontal disease with diverse findings when comparing immigrants with natives. Some studies found poor oral health indexes in migrants. Migrants face barriers to dental health services. Other oral health variables addressed in the studies were oral health-related quality of life, beliefs, knowledge and practices in oral health. Determining factors related to oral health were evidenced, such as migration status, sociodemographic, cultural, psychological, living, economic and material conditions, social support, oral health practices and previous oral and general health status. Studies reported conceptual and methodological gaps and limitations that must be considered when interpreting the results. CONCLUSION: According to the scientific evidence, immigrant populations in south-south migratory contexts show poor oral health indicators, and this translates into social vulnerability in this group. Further research is needed to increase the scientific body about the social and contextual determinants in oral health and understanding of the social construction of this phenomenon.

The case for planetary health prevention.

The lack of preparedness and the adoption of a reactive approach underlie many mistakes in handling the COVID-19 pandemic. We need a vision with a proactive approach to planetary health prevention, that is suited for addressing the neglected systemic determinants of health which generate disease, inequality and environmental degradation, and capable of anticipating known and unknown risks, and foreseeing possible threatening scenarios. To achieve a healthy, equitable and sustainable future, it is time to make health prevention planetary.

What do we know about the impact of economic recessions on mortality inequalities? A critical review.

Historically, there has been a debate on the effects of recessions on population health, and especially on mortality and its distribution across different social groups. This paper contributes to this discussion by means of a critical review of the research on the impact of economic recessions on mortality inequalities in the period 1980-2020. We analyzed 19 studies according to their mortality outcomes, socioeconomic indicators, design, analysis, and main findings. Twelve studies focused on European countries or urban areas, two on Asian countries, two on Russia, one on Asia and Europe, one on the USA, and one in Somalia. Five articles included cross-country comparisons (four between European countries or cities and one between Asian and European countries). The Great Recession of 2008 was the most researched economic crisis, followed by country-specific crises in the 90s, the fall of the Soviet Union, and some crises during the 80s. Most studies (n = 15) showed an overall or partial increase in mortality inequalities after an economic recession. However, two papers found a decrease in mortality inequalities due to the worsening of the health of the upper and middle classes, one article found a decrease in inequalities due to a general improvement in population health, and a study found a "slow-down" effect of pre-existent mortality inequalities.

Dynamic accessibility by car to tertiary care emergency services in Cali, Colombia, in 2020: cross-sectional equity analyses using travel time big data from a Google API.

OBJECTIVES: To test a new approach to characterise accessibility to tertiary care emergency health services in urban Cali and assess the links between accessibility and sociodemographic factors relevant to health equity. DESIGN: The impact of traffic congestion on accessibility to tertiary care emergency departments was studied with an equity perspective, using a web-based digital platform that integrated publicly available digital data, including sociodemographic characteristics of the population and places of residence with travel times. SETTING AND PARTICIPANTS: Cali, Colombia (population 2.258 million in 2020) using geographic and sociodemographic data. The study used predicted travel times downloaded for a week in July 2020 and a week in November 2020. PRIMARY AND SECONDARY OUTCOMES: The share of the population within a 15 min journey by car from the place of residence to the tertiary care emergency department with the shortest journey (ie, 15 min accessibility rate (15mAR)) at peak-traffic congestion hours. Sociodemographic characteristics were disaggregated for equity analyses. A time-series bivariate analysis explored accessibility rates versus housing stratification. RESULTS: Traffic congestion sharply reduces accessibility to tertiary emergency care (eg, 15mAR was 36.8% during peak-traffic hours vs 84.4% during free-flow hours for the week of 6-12 July 2020). Traffic congestion sharply reduces accessibility to tertiary emergency care. The greatest impact fell on specific ethnic groups, people with less educational attainment and those living in low-income households or on the periphery of Cali (15mAR: 8.1% peak traffic vs 51% free-flow traffic). These populations face longer average travel times to health services than the average population. CONCLUSIONS: These findings suggest that health services and land use planning should prioritise travel times over travel distance and integrate them into urban planning. Existing technology and data can reveal inequities by integrating sociodemographic data with accurate travel times to health services estimates, providing the basis for valuable indicators.

Dynamic geographical accessibility assessments to improve health equity: protocol for a test case in Cali, Colombia.

This protocol proposes an approach to assessing the place of residence as a spatial determinant of health in cities where traffic congestion might impact health services accessibility. The study provides dynamic travel times presenting data in ways that help shape decisions and spur action by diverse stakeholders and sectors.  Equity assessments in geographical accessibility to health services typically rely on static metrics, such as distance or average travel times. This new approach uses dynamic spatial accessibility measures providing travel times from the place of residence to the health service with the shortest journey time. It will show the interplay between traffic congestion, accessibility, and health equity and should be used to inform urban and health services monitoring and planning. Available digitised data enable efficient and accurate accessibility measurements for urban areas using publicly available sources and provide disaggregated sociodemographic information and an equity perspective. Test cases are done for urgent and frequent care (i.e., repeated ambulatory care). Situational analyses will be done with cross-sectional urban assessments; estimated potential improvements will be made for one or two new services, and findings will inform recommendations and future studies. This study will use visualisations and descriptive statistics to allow non-specialized stakeholders to understand the effects of accessibility on populations and health equity. This includes "time-to-destination" metrics or the proportion of the people that can reach a service by car within a given travel time threshold from the place of residence. The study is part of the AMORE Collaborative Project, in which a diverse group of stakeholders seeks to address equity for accessibility to essential health services, including health service users and providers, authorities, and community members, including academia.

What key conditions and mechanisms generate health inequalities research in different contexts? Study protocol for two realist explanatory case studies.

Evidence on health inequalities has grown in recent decades, however, the capacity to generate health inequalities research is uneven, worldwide. A recent bibliometric analysis found notable inequalities of the global production of health inequalities scientific research across countries. What determines the capacity to produce high volumes of health inequalities scientific research, in different settings? What mechanisms are involved? To answer these questions requires in-depth knowledge on the health inequalities research production process, in different settings. We plan to conduct two realist explanatory case studies, to understand why and how particular settings (e.g. the United Kingdom and the city of Barcelona) have generated high volumes of health inequalities research over past decades, and identify the potential key contextual conditions and causal mechanisms involved. This study protocol outlines the rationale and methodology involved, highlights the strengths and limitations of the approach, and provides guidance on how to overcome certain operational challenges and ensure validity of research findings. Valuable learning may be derived from these case experiences, with implications for research, policy and practice. This work can serve as a tool for researcher and planners to guide the development of further case studies to evaluate health inequalities research capacities in other settings.

Health Inequalities in the Time of COVID-19: The Globally Reinforcing Need to Strengthen Health Inequalities Research Capacities.

The full impact of coronavirus disease 2019 (COVID-19) is yet to be well established; however, as the pandemic spreads, and early results emerge, unmet needs are being revealed, and pressing questions are being asked about who is most affected, how, where, and in what ways government responses might be exacerbating inequalities. A number of scholars have called for more in-depth critical research on COVID-19 and health inequalities to produce a strong empirical evidence based on these issues. There are also justifiable concerns about the scarcity of health-equity actions oriented analyses of the situation and calls for more empirical evidence on COVID-19 and health inequalities. A preliminary condition to establish this type of information is strong capacity to conduct health inequalities research. Worldwide, however, this type of capacity is limited, which, alongside other challenges, will likely hinder capacities of many countries to develop comprehensive equity-oriented COVID-19 analyses, and adequate responses to present and future crises. The current pandemic reinforces the pending need to invest in and strengthen these research capacities. These capacities must be supported by widespread recognition and concern, cognitive social capital, and greater commitment to coordinated, transparent action, and responsibility. Otherwise, we will remain inadequately prepared to respond and meet our society's unmet needs.

[Community health assets mapping in a slum in Medellin (Colombia)]. / Mapeo de activos comunitario para la salud en un asentamiento informal de Medellín (Colombia).

OBJECTIVE: To describe how the community from El Faro neighborhood identifies its community assets, uses them to face life's challenges through the capacity of collective agency; and by generating community development processes, applying the salutogenic theory that considers people as active subjects, with the capacity to conserve and generate health and well-being, through the use of their own resources called health assets. METHODS: A map of community assets was made in 2018 in el Faro neighborhood, an informal settlement of Medellín, Colombia, following the phases recommended by other authors and from a qualitative, participatory approach that delves into the health situation of the community. RESULTS: In this process were identified 12 individual community assets, 12 collective, 13 institutional and 10 in the environment. The main community asset among the 47 described was community participation, from the agency capacity, mainly of its leaders who participating in their own organizations encourage development, identity construction and well-being. CONCLUSION: Asset mapping has served to identify intangible assets for the community and, in turn, this recognition has been useful in strengthening the agency's capacity for community development. This is a territory transformed by community reflection processes allowing to understand situations of exclusion and poverty, seeking to create a more livable place and developing a community capacity to solve their own problems, through solidarity and community support.

Coronavirus disease 2019 and slums in the Global South: lessons from Medellín (Colombia).

The coronavirus disease 2019 (COVID-19) pandemic is hitting the world's most vulnerable people hardest, primarily the communities living in slums in the Global South. Lockdown, handwashing and social distancing are impossible privileges for many urban dwellers - measures which make structural inequities more visible, exacerbating racial, gender and class differences. There are many social determinants of health to explain these inequalities that trigger a high prevalence of infectious and chronic diseases. In Medellín (Colombia), it is a challenge to cope with this crisis, especially when the resources and aid provided by the government and institutions are limited. Yet, an organized social response is happening in some communes and slums, with high community participation, as a potentially effective key to control the pandemic. Once the emergency is over, communities in slums will have to face the social and economic reactivation, and effectively react to the multiple social and psychological consequences, new waves of COVID-19 or other pandemics.

A Qualitative Study of the Health Perceptions in the Venezuelan Immigrant Population in Medellín (Colombia) and Its Conditioning Factors.

This study explored the general and oral health perceptions in the Venezuelan immigrant population in Medellín (Colombia) and its conditioning factors. A qualitative study involving Venezuelan immigrants ≥18 years with a minimum stay of six months in Colombia was conducted. Dentists, dental students, and other health professionals also participated. Semi-structured interviews (n = 17), focus groups (n = 2), and key informants' interviews (n = 4) were utilized. The interviews and focus groups were recorded and transcribed for later narrative content analysis. A high degree of vulnerability of participants was found due to the precarious living conditions from the premigratory moment and the lack of job placement possibilities at the time of settling in Colombia, where the migratory status played a fundamental role. Among the perceived needs, the mitigation of noncommunicable diseases stood out. Poor mental health symptoms (depression and anxiety) were perceived, and oral health was not a priority. Barriers to accessing health and dental care were found. The migrant condition was found to be a determinant that affected physical, mental, and oral health and the provision of health care. This situation is of interest to the construction of public health policies that guarantee access to fundamental rights.

Urban Transformations and Health: Methods for TrUST-a Natural Experiment Evaluating the Impacts of a Mass Transit Cable Car in Bogotá, Colombia.

Background: Cable cars provide urban mobility benefits for vulnerable populations. However, no evaluation has assessed cable cars' impact from a health perspective. TransMiCable in Bogotá, Colombia, provides a unique opportunity to (1) assess the effects of its implementation on the environmental and social determinants of health (microenvironment pollution, transport accessibility, physical environment, employment, social capital, and leisure time), physical activity, and health outcomes (health-related quality of life, respiratory diseases, and homicides); and (2) use citizen science methods to identify, prioritize, and communicate the most salient negative and positive features impacting health and quality of life in TransMiCable's area, as well as facilitate a consensus and advocacy-building change process among community members, policymakers, and academic researchers. Methods: TrUST (In Spanish: Transformaciones Urbanas y Salud: el caso de TransMiCable en Bogotá) is a quasi-experimental study using a mixed-methods approach. The intervention group includes adults from Ciudad Bolívar, the area of influence of TransMiCable. The control group includes adults from San Cristóbal, an area of future expansion for TransMiCable. A conceptual framework was developed through group-model building. Outcomes related to environmental and social determinants of health as well as health outcomes are assessed using questionnaires (health outcomes, physical activity, and perceptions), secondary data (crime and respiratory outcomes) use of portable devices (air pollution exposure and accelerometry), mobility tracking apps (for transport trajectories), and direct observation (parks). The Stanford Healthy Neighborhood Discovery Tool is being used to capture residents' perceptions of their physical and social environments as part of the citizen science component of the investigation. Discussion: TrUST is innovative in its use of a mixed-methods, and interdisciplinary research approach, and in its systematic engagement of citizens and policymakers throughout the design and evaluation process. This study will help to understand better how to maximize health benefits and minimize unintended negative consequences of TransMiCable.

What the Puerto Rican hurricanes make visible: Chronicle of a public health disaster foretold.

García Márquez's novel, "Chronicle of a Death Foretold", narrates the multiple strands of a story leading up to a murder in a small Caribbean village. The novel shows both the incredulity of those who do not believe it possible that this tragic death could occur, and the impotence of those who see it coming but can do nothing to prevent it. Something akin to this double incapacity seems to be occurring today in Puerto Rico. In September 2017, the passage of Hurricanes Irma and María caused a public health disaster with large-scale death and destruction. Paradoxically, this catastrophe has made visible the need to evaluate the critical socio-environmental situation of this country, and to analyse the underlying social factors contributing to the problems caused by the hurricanes. Why did neither the US nor the Puerto Rican government react as expected when faced with such a serious situation? For decades, this country has been suppressed by colonial domination, exploitation of the workforce, and health discrimination. It has been a "laboratory", where colonial practices have institutionalized social control, racism, and inequality, with profound negative effects on society, quality of life and health equality. Poverty and unemployment have always been very high, and thousands of families live in precarious housing situations. Additionally, current labour reforms imposed as part of a neoliberal agenda, are eroding the job security and protections of the working population, while education, health, housing, pensions, energy, and land are being progressively privatized. What are the root causes of this situation? What future does the country await? To answer these questions, critical and comprehensive scrutiny of history showing what the hurricanes have helped to make visible is required. This shows that neoliberal colonialism has shaped the social features behind the principle health and inequality problems of the Puerto-Rican population.