The AMORE Project: counteracting the effect of traffic congestion on travel to health care services when travel time is critical

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Luis Gabriel Cuervo, main researcher of the AMORE project. Credit: Jhon Gamboa, Communications Office, Faculty of Engineering. 

The AMORE project focuses on counteracting the effects of vehicular congestion on travel times to critical health services. This project seeks to reduce travel times, especially during peak congestion hours, to improve the welfare and economy of those who require urgent medical attention or those who need repeated access to long-term outpatient services. The ultimate goal is for the population of Cali to gain access to services in reasonable times and without incurring economic hardship.  

In medical emergencies where every minute counts, delays in essential care can have serious consequences, such as complications, sequelae, slower recovery, or even death. For example, a delay in care for a heart attack, stroke or arrhythmia can be fatal. For this reason, it is essential that patients arrive promptly at the specialized center that offers the necessary treatment. 

For patients who rely on prolonged outpatient treatments, such as hemodialysis, rehabilitation, or cancer treatments such as chemotherapy or radiation therapy, travel time is equally important. Repeated trips to these services represent costs that can drain family resources and affect their quality of life. 

Colombian experts have consolidated an international collaborative group and have developed a new methodology to measure the impact of traffic on access to health services. This methodology reunites open data with information on services, housing and population and integrates it with big data on travel times provided by mobile applications.  

Thus, you can:

(1) measure travel times from each neighborhood to the service with the shortest travel time, and reflect this in heat maps (choropleths) by travel time. These maps are adjusted for the level of traffic and the resulting travel times, and present those of the population that can reach the services by travel time. This is done using simple descriptors. For example, the number of people, women or children under five who can reach a high complexity emergency department in 15 minutes or less. These graphs and statistics are easy to understand and share, facilitating dialogue between those who contribute to urban and service planning. They are also presented on interactive web-based platforms, allowing parameters to be modified and scenarios to be explored, letting the data speak for itself.  

(2) Anticipate the impact of adding services in one or two sectors of the city that would optimize accessibility, achieving the greatest benefit for the entire population, providing a general idea of the demand that the new services may have, and reflecting the expected benefit in the color map and descriptive statistics. 

In addition to clearly illustrating travel times, the colors seek to facilitate a common goal among all parties: to strive for a green city, i.e., one in which all residents have services within reach in reasonable times.  

Chart provided by AMORE project. Data available in: Dynamic Measurements of Geographical Accessibility Considering Traffic Congestion Using Open Data: A Cross-Sectional Assessment for Haemodialysis Services in Cali, Colombia. The Lancet Regional Health - Americas 34 (Junio 1, 2024): 100752. 

The methodology, aimed at improving intersectoral cooperation, was tested in Cali with the participation of experts in public health, civil engineering and geomatics from the Universidad del Valle.  

During the XXVI Health Research Symposium, organized by the Universidad del Valle, on October 18, the forum "Let's position Cali at the forefront of the WHO's strategic approach to urban health" was presented, where the project's findings were presented. In this session, public servants, academics, researchers, patients and civic organizations discussed how the results of the study can help create a more equitable and health-oriented city for all. 

This session brought together public servants, academia, researchers, patients and civic organizations involved in urban planning and services to explore how to leverage the results of the study in creating a more equitable and health-oriented city for all.  

The project data are particularly relevant to the Land Use Plan under review, as they propose practical solutions to improve travel times to health services. With heavy traffic, most Cali residents cannot reach a highly complex emergency service in less than 15 minutes, especially from outlying areas and the east of the city. Accessibility to hemodialysis or radiotherapy services is also low for much of the population, including the vast majority living in low-income housing. However, the situation could improve dramatically with the strategic addition of services. 

Accessibility to highly complex emergency services within 15 minutes. Source: Fuente: 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. BMJ Open 12, no. 9 (sept 1, 2022): e062178.

The resonance of an ailment. Origin of the project 

"They (the cars) always used to come in here, but since they uncovered these streets, and you can see that it is very ugly, sometimes I have to go all the way down, and they wait for me there. But when it rains it (the streets) gets very slippery and they can't get in. I have to walk one, two, three, almost four blocks," Margarita Gómez, an elderly woman with short hair who lives in the La Arboleda neighborhood, in the 18th commune, southwest of Cali, tells members of the PopuLab, created in 2022 between the Universidad del Valle and the Secretary of Social Housing and Habitat with the purpose of documenting the living conditions of inhabitants of marginalized areas in the city in the areas of urban territorial peace, integral habitat improvement, mobility and zero waste.  

Due to her chronic illnesses, Margarita must attend hemodialysis and cancer treatment sessions several days a week in centers that involve long trips. According to her, public transportation is not an option, as she is unable to travel long distances and, as Populab's documentary illustrates, the poor condition of roads and pedestrian areas limits her mobility options.  

For transportation, she must use cabs. "I travel by cab. It's 25,000 pesos a day, round trip. There is a man who always transports us. That's, I should say, horrible. Because it doesn't give you the (financial) capacity. Many times you don't have what you can afford and you have to pick him up any way you can, because you can't miss a dialysis," he says in the interview recorded in 2022, in which it was estimated that she spends 90% of a monthly minimum wage on transportation.  

Her situation, as well as that of many patients with chronic diseases who require specialized services in the city of Cali, translates into a deterioration in the quality of life of their families, since in many cases they do not have the economic means to pay these expenses, and the indirect expenses also affect their caregivers. 

The AMORE project has been an interdisciplinary effort led by researcher Luis Gabriel Cuervo, corresponding member of the Colombian Academy of Medicine. The publications have had contributions from local stakeholders and organizations such as ProPacífico, users of the services, public officials, and experts in various disciplines who contribute from Spain, the United States, Peru, Canada and Colombia, as part of his doctorate in Biomedical Research Methodology and Public Health, which is directed by Ciro Jaramillo Molina, professor and researcher at the School of Civil Engineering and Geomatics of the Universidad del Valle, and co-directed by Eliana Martínez Herrera, professor and researcher at the National School of Public Health of the Universidad de Antioquia. 

Born under the name AMORE (Analysis with Macrodata to Orient Equity Results), the project has published studies of three services which demonstrate the usefulness of its novel methodology applied to the analysis of highly complex emergency services, hemodialysis, and radiotherapy. On this occasion, the International Journal for Equity in Health published the results focused on radiotherapy patients in the city, which closes a cycle of research and opens the door for decision-makers to have tools with which to improve health equity for these patients, and for complementary research to be developed and built upon.  

DSTAM model applied to radiotherapy patients 

"His initiative was basically to address the perspective of equity in the provision of priority health services in the city of Cali. Particularly to establish a relationship or association with the characteristics of urban mobility for people to access these facilities and services," says researcher and professor Ciro Jaramillo Molina.  

According to him, each of these research projects within the AMORE project, in addition to focusing on a different service, revealed contrasts between areas in the city, population groups, and traffic congestion levels, raising proactive possibilities aimed at reducing the inequalities evidenced by the project. 

As in its two previous studies, the project made use of its web platform, used to integrate sources of information open to the public and researchers (such as the DANE population census, for 2018), which served as the basis for the comparison of the Traffic Analysis Zones (TAZ), and the specific location of the population centroids of the spatial unit (the point where the population of the area to be analyzed is concentrated), in such a way that the transportation times at specific times could be specified, according to the congestion in the streets or the distance between the patient's place of residence (in this case of radiotherapy) and the care centers that offer these specialized services in the city of Cali. 

The Colombian National Registry of Health Service Providers was used to locate these service centers, and the following operators were found along the north-south corridor of Cali: two at the Imbanaco Medical Center; four in the west of the city; and one in the south, at the Fundación Valle del Lilí. 

These evaluations, technically known as "dynamic spatiotemporal accessibility measurements" (DSTAM), were conducted at two points in time: July 6-12 and November 23 and 29, 2020, via the Google Distance Matrix API, which allowed the research team, supported by data analytics company iQuartil SAS, to obtain real-time data on the expected travel times for each of those dates.   

The use of the census allowed the research team to focus on equity, presenting the demographic characteristics of the population and the socioeconomic characteristics of the dwellings. This revealed contrasts between population groups, and how this impacted their access to service delivery in the case of radiotherapy, as in the case of Mrs. Margarita Gómez: 49% of the population lives in low-income housing, mostly located in the east, northeast and western Andean slopes of the city, facing long commuting times. 

For the researcher and professor of the School of Civil and Geomatics Engineering, Ciro Jaramillo Molina, this was an opportunity to enrich the research. According to him, when referring to equity, scientific literature speaks from two perspectives: vertical equity and horizontal equity. The second deals with how an analyzed study area behaves, in variables that do not consider the differences of the people who may live in those places. Vertical equity, on the other hand, allows it to observe these differential factors. "When Luis Gabriel takes the DANE microdata and analyzes all the variables that are possible to analyze within the project, we can go further. We talk about gender, ethnicity, socioeconomic factors, marital status, and so on. So that allows us to establish differences between collectives," he says. 

Measurements of this type, which took demographic characteristics of the population as a reference, enriched the analysis carried out by the AMORE team, as researcher Luis Gabriel Cuervo says: "Here we are showing with data and images that there are great inequalities. People with fewer resources and greater vulnerability have to pay more to access services. This, known as the inverse care law, leads to the most vulnerable populations incurring higher out-of-pocket expenses to access services". 

The benefits of the tool in visualizing possible solutions 

The analysis independently identified two locations where new services would maximize accessibility in the city, using a threshold of a 20-minute drive from home to care centers with the shortest travel time. 

The simulation established that accessibility could increase from 30.8% to 61.6% (in the July measurement) and from 60.4% to 91.5% (in the November measurement) with these two additional locations. In other words, 702,618 residents would be added to the 20-minute range during hours of vehicle congestion. 

The sites where optimize accessibility would be in the La Alianza neighborhood, to the northeast, and Rodrigo Lara Bonilla, to the southeast of Cali. The predictions made in November pointed to neighboring locations to these, in the Los parques de Barranquilla neighborhood, in the northwest, and in Los Comuneros III, in the southeast, indicating that, although there were variations in traffic, the recommended sectors did not vary notably, since the sectors identified in July and November are contiguous, and give a general idea of the areas to be considered. 

For researcher and professor Ciro Jaramillo Molina, these kinds of proposals are aimed at providing evidence to decision-makers in the region, who, based on these studies, can consider the impact that the installation of new services or the repowering of existing services could have. "If a study like these appears, where it can be supported, from a technical point of view, that using new equipment or upgrading existing services generates a substantial benefit, planning mechanisms can be established to be able to implement it. This seems to me to be very important: to not only diagnose, but also to present practical proposals," he says. 

According to him, this project is aimed at evaluating the problems derived from mobility and linking them to equity from a more comprehensive perspective, so that the departmental administration can take ownership of its results and begin to use this methodology for future land-use plans that are expected to be carried out in the city of Cali in the coming years. 

The city: the impact on social, political and academic issues 

"There is a saying that comes from African countries that says, if you want to go fast, you go alone, but if you want to go far, you go in a group. And that has been fantastic, because many of the solutions came from having diversity in the team and the people informing it who came from different disciplines and sectors, bringing different perspectives. Everything has been achieved based on the enthusiasm and commitment to improve equity and accessibility in Cali. In four years, this project has brought together half a hundred volunteers. It was done without external funding. We did not receive scholarships or economic incentives", says researcher Luis Gabriel Cuervo, regarding the publication of this third and last report, which closes the research cycle of the AMORE project, and leaves the future work for entities and citizens in charge of developing policies on mobility and accessibility to work together for a less inequitable city, and opens a line of interdisciplinary research. 

For his part, researcher and professor Ciro Jaramillo Medina celebrates that, as part of the work and commitment of researcher Luis Gabriel Cuervo, links between different sectors of society, beyond academia, are now being facilitated to continue contributing to the work on mobility. "Some scientific and academic collectives have appeared that work on the subject. They have invited us. A domino effect has been generated, a snow wave that is very interesting," he says, commenting on possible collaborations in studies at universities at the international level. 

As for daily life on the streets, where mobilizing to be attended to as patients with a chronic condition continues to represent an immense challenge, voices join the results of this study, as a way to encourage the change they require, in order to improve their living conditions. This is the case of Justiniano Arias, a man of mixed race complexion and reduced mobility in his lower limbs.  

Justiniano lives in the Pampas del Mirador neighborhood, also in commune 18 of the city of Cali, and he tells PopuLab members that, due to his condition, he always needs someone's help to get around the streets of his neighborhood, pushing his wheelchair, because there are many places where traffic is very difficult due to the poor condition of the roads. In addition, some of the streets are quite steep, which prevents him from climbing them. Cars are not always a solution: in many cases, when they see his condition, they prefer not to stop, or they do not have the space to carry the wheelchair. Transportation requires him, as it does Margarita Gómez, a significant amount of his income. 

"It has to improve 100% (the transportation service), just as they improve it in the city of Cali (the metropolitan area, where most of the health services for patients dependent on hemodialysis and radiotherapy, as well as emergency services, are concentrated). Because this is another face of the city of Cali, where we are confronted daily with these barriers, which are not given importance because they are not people with disabilities," he says when asked what he would say to the public administration. 

The work carried out by the interdisciplinary team led by researcher Luis Gabriel Cuervo and professors from Universidad del Valle is, in this sense, an opportunity to think of a city that proposes alternatives to improve the quality of life of its citizens, regardless of where they live or the resources they have. 

If interested in being in touch with the PhD's student or any further information about the investigation, please write the Faculty of Engineering Communications Office: comunicaingenieria@correounivalle.edu.co.