Bridges - Global Urban Lab 2016 -2017

G U L

BRIDGES VOL. IV 2016-2017

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5 16 24 32 I. THE HIDDEN DANGERS OF CHAGAS DISEASE A Comparative Analysis of Infectious Disease Policies in Houston and Barcelona

II. UNIVERSAL HEALTHCARE COVERAGE: A Comparative Analysis of the Healthcare Systems in Spain and the United States

Caroline H. Lee

Justin Onwenu

III. RECONSTRUCTIVE SURGERY For Survivors of Female Genital Cutting

IV. EXPLORING ENTREPRENEURSHIP

A Comparative Policy Analysis of Houston and Barcelona Dylan Dickens

Aislyn Orji

56 Copyright 2017 Rice University. All rights reserved. No parts of this publication may be reproduced, stored in or introduced to a retrieval system, or transmitted, in any form, or by any means, without the prior written permission of Rice University’s School of Social Sciences. Requests for permission should be directed to ipek@rice.edu.

Ipek Martinez, Director of Gateway Eugenia Georges, Ph.D., Faculty Director, GUL Barcelona Victor Gimenez Aliaga, Ph.D. Candidate, Instructor, GUL Barcelona Christina Tan, Duncan ‘20, Designer, GUL Bridges

VII. LAND USE AND INFRASTRUCTURE Houston and Barcelona: Land Use and Transportation Infrastructure Through the Lens of Sustainability Claire Casey

40 48 V. MEGA-EVENTS, MEGA-PROBLEMS Analyzing Recent Developments of “Mega-events” in Houston and Barcelona

VI. THE HOUSING FINANCIAL CRISES The Financial Crisis and Cultures of Housing in Houston and Barcelona Taylor Morin

Noah Reich

67 78 86 VIII. DEVELOPING PUBLIC SPACE Houston and Barcelona: Topdown and Bottomup Approaches to Developing Public Space

III. CITIES OF REFUGE A Comparison and Contrast of NGOMunicipal Relations and Broader Political Contexts

Tim Wang Colton Cox

Amy Kuritzky

IV. CHALLENGES OF A GRAYING POPULATION A Comparative Analysis of Spain and the United States

HEALTHCARE I. THE HIDDEN DANGERS OF CHAGAS DISEASE Caroline Lee II. UNIVERSAL HEALTHCARE COVERAGE Justin Onwenu III. RECONSTRUCTIVE SURGERY Aislyn Orji

I. THE HIDDEN DANGERS OF CHAGAS DISEASE healthcare EXECUTIVE SUMMARY

A Comparative Analysis of Infectious Disease Policies in Houston and Barcelona

Chagas disease is a neglected tropical disease that is endemic to 21 Latin American countries. Across the world an estimated total of 6-8 million are infected, and Chagas disease causes around 12,000 deaths per year.

Despite the disease’s significance, a majority of countries have inadequate policies to screen for and treat infected patients. Especially in non-endemic countries, the lack of public health policies perpetuates social inequalities faced by immigrants and other critical populations, while creating a hidden burden of Chagas disease. Both Spain and the United States are non-endemic countries with documented Chagas cases, high rates of immigration from endemic countries, and varying levels of attention given to the disease.

This research study comparatively analyzes Chagas disease in Barcelona, within the autonomous community

of Catalonia, and in Houston, within the state of Texas. The paper compares the different factors impacting Chagas disease in Barcelona and Houston and the policies regulating surveillance, screening, prevention, and clinical treatment. While Barcelona provides innovative approaches to maternal testing and treatment, there are areas of policy improvement in both cities.

INTRODUCTION

Chagas disease is a potentially debilitating and deadly disease that is consistently unaddressed by medical and public health officials, despite its associated morbidity and mortality.

The burden of the disease is further exacerbated by a lack of accurate knowledge and awareness from health workers and the general public.

Chagas disease is officially classified as a Neglected Tropical Disease (NTD) by the World Health Organization and as a Neglected Parasitic Infection

(NPI) by the US Centers for Disease Control and Prevention. These diseases are inadequately addressed chronic infections associated with marginalized communities afflicted with poverty, primarily in but not limited to low-income countries (Hotez, 2014).

Chagas disease, or American Trypanosomiasis, is a chronic infection caused by the protozoan parasite Trypanosoma cruzi. This parasite may be transmitted to humans and over 150 domestic animals by triatomine “kissing bug” vectors, a subfamily of reduviidae bugs. Triatomine bugs are nocturnal and live in cracks of walls or ceilings. These bugs may spread the disease by biting a human and subsequently defecating near the site of the bloodmeal. Transmission occurs when the fecal matter is rubbed into the bite location or mucous membranes, such as the eyes or the mouth (Rassi Jr et al., 2010). There

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are also several other modes of disease transmission. This includes vertical transmission, where an infected mother’s infant develops symptomatic or asymptomatic congenital T. cruzi infection. Meta-analysis has shown that congenital transmission rates range from 0.75-28.6% with a total pooled rate of 5% (Howard et al., 2013).

Additional forms of transmission include blood transfusions, organ donations, laboratory accidents, and

“Chagas disease also poses a significant public health hazard to non-endemic countries.” oral transmission due to ingestion of contaminated food or liquids (Shikanai-Yasuda & Carvalho, 2012).

Patients initially develop acute Chagas disease when infected, which typically lasts for a period of 2-4 months with high levels of T. cruzi parasitemia. Most patients are asymptomatic during the acute phase but some may develop fever, chagoma, or inflammation at the site of inoculation, enlarged lymph nodes, splenomegaly, or a Romaña sign, unilateral swelling around the eye, a characteristic sign of a Chagas infection. Severe acute disease only occurs in <1% of infected patients, and so most are completely unaware of their condition. When untreated, patients develop chronic infections.

Of chronic Chagas patients, up to 40% of patients develop potentially fatal cardiovascular or gastrointestinal complications such as cardiomyopathy, arrhythmias, megaviscera, or polyneuropathy. Severe cardiac disease leading to sudden death or heart failure is the major cause of death associated to Chagas (Perez-Molina et al., 2012).

Diagnosis of Chagas disease is

determined by confirming exposure risk with two parallel serologic tests including ELISAs, immunofluorescence assay, or indirect hemagglutination.

Treatment is strongly recommended for all patients with acute, congenital, and reactivated infections. Treatment should also be offered for adults 1950 years old with chronic infections but lacking symptoms of advanced heart disease, as medication is shown to slow the progression of Chagas cardiomyopathy and mortality. Other cases should have optional treatment, especially adults over the age of fifty, as there aren’t sufficiently validated benefits. However, pregnant women and those with severe liver or kidney complications should avoid treatment due to possible complications. There are currently only two treatment drugs with validated efficacy, benznidazole and nifurtimox. Of the two drugs, benznidazole is considered a front-line treatment due to having more tolerable side effects. Unfortunately, both drugs have to be taken for 60-90 days and have adverse effects such as weight loss, nausea, vomiting, and insomnia.

Due to the length of treatment and side effects, both medications may discourage patients from undergoing treatment. However, when taken properly, 60-85% of acute phase patients and 90% of congenitallyinfected infants treated in their first year are successfully treated (Bern et al., 2007).

Since no vaccine currently exists to prevent Chagas infection, vector control and screening of at-risk populations have been the primary forms of disease control. Concentrated efforts in Latin American countries, including housing improvements and insecticides spraying, have drastically decreased Chagas infections. The “Southern Cone Initiative” in 1991 was an intergovernmental approach coordinated by the Pan American Health Organization (PAHO). This successfully promoted elimination of vector transmission in Uruguay, Chile, and many parts of Brazil and Argentina. Other countries also involved included Paraguay, Bolivia, and Peru. With the decrease in vectorial

transmission, focus on preventing non-vectorial transmission rose to importance. In 2004, PAHO’s advisory group emphasized that congenital transmission is the major persistent method of continuing infection amongst populations once vector and transfusion transmissions have been addressed (Cevallos, 2014).

Especially due to globalization and immigration, Chagas disease also poses a significant public health hazard to non-endemic countries. The United States, followed by Spain, is the most common destination for Latin American immigrants. However, it’s important to emphasize that while immigrants from endemic areas are populations of high concern, other modes of transmission put other communities at risk that should not be forgotten. Blood-borne transmission is a major route of infection that can quickly spread through a population.

Also, due to the likelihood that that many Chagas infected infants present as asymptomatic, without constant screening the true extent of congenital Chagas disease is likely underreported and undertreated (Gascon et al., 2009).

Overall, Chagas disease presents a significant health challenge, yet with the proper policies, the needs of at-risk individuals can be addressed.

ISSUE STATEMENT

Chagas disease is an infectious disease that is consistently neglected by health and medical officials, despite infecting 6-8 million individuals worldwide (WHO, 2017). While in the past the disease was mostly limited to the 21 endemic countries of Latin America, Chagas has since become a prevalent issue in several other countries. Globally, the annual burden attributed to Chagas disease is $627.46 million in healthcare costs and 806,170 Disability-Adjusted Life Years (DALYs).

This burden is caused substantially from cardiovascular disease-induced early mortality and associated lost productivity. The significance of the actions of non-endemic countries are essential, as more than 10% of the healthcare-related costs are from the United States and Canada alone (Lee

et al., 2013).

The United States is the most common destination for Latin American immigrants, followed by Spain. In non-endemic areas, the disease disproportionately affects Latin American immigrants and other impoverished individuals, further exacerbating social inequalities and health disparities. Major systemic issues prevent at-risk individuals from receiving necessary screening and treatment. This includes lack of health access, inadequate screening, difficulties receiving treatment, and associated social stigma. In many countries, the lack of awareness of the disease from the general public and healthcare workers further exacerbates the problem, causing many cases to go undiagnosed and untreated.

Comprehensive health policies implemented in countries of concern, in endemic and non-endemic areas, will drastically reduce global transmission rates. These health policies should target vulnerable populations, prevent different modes of transmission, and educate health workers in contact with at-risk patients. This research study is innovative, as the first comprehensive analysis of Chagas disease in two settings facing uniquely different problems, accompanied with an evaluation of their related policy approaches.

RESEARCH METHODOLOGY

This research utilized a mixed-methods approach to inform the state of current scientific research, expert opinions/ recommendations, and countryspecific health policies. An extensive literature review and analysis was conducted to inform background information about recent developments in international Chagas epidemiology, control, and policies. Academic journal articles from PubMed, JSTOR, and infectious disease journals served as the foundation of the information.

Quantitative methodology was used to analyze statistical data, primarily using government data and academic papers summarizing public health or clinical data. Qualitative interviews with experts on Chagas disease and

Latin American migration were conducted to understand the social context, background on the policy implementations, and to gather opinions on essential issues facing both settings.

In-person recorded interviews were conducted on-site in the cities of both Houston and Barcelona with academic and medical experts in the fields of tropical medicine, public health, demography, anthropology, and communication.

The experts involved in this study included: 1. Paula Stigler-Granados PhD, MSPH; Assistant Professor at The University of Texas Health Science Center; 2. Ana Requena Mendez MD; Medical Research Fellow at ISGlobal; 3. Javier Sancho Mas; Communication Officer of the Chagas Initiative and Chagas Coalition at ISGlobal; 4.

Leonardo de la Torre Avila; Research Assistant at ISGlobal; 5. Andreu Domingo Valls PhD; Deputy Director & Associate Professor, Centre for Demographic Studies at Universitat Autònoma de Barcelona; 6. Juan Galeano PhD; Research Assistant, Centre for Demographic Studies at Universitat Autònoma de Barcelona

FINDINGS

To understand and effectively compare both settings, it is essential to understand the epidemiology of the disease, at-risk Latin American populations, standards of care, and the current policies in both Houston and Barcelona.

Chagas Epidemiology in Houston According to estimates by the Centers for Disease Control and Prevention (CDC), by multiplying seroprevalence to immigrant populations, more than 300,000 people with T. cruzi infections live in the United States (CDC, 2016).

Unfortunately, this estimate is subject to variable factors such as the lack of uniformity of transmission across a country’s population and differences of immigrants compared to the national population (Bern, 2009). No concerted

large scale surveillance testing has been organized by Texas or other states at risk to accurately assess the scale of the issue (Hotez, 2013).

One aspect that differentiates Houston from the disease in Spain is that there is risk of local transmission of Chagas disease in the United States.

The entire Southern half of the United States, south of Pennsylvania with 28 states total, has triatomine bugs.

Texas, New Mexico, and Arizona have the highest diversity and density of triatomines. Recent research has found that over 50% kissing bugs submitted from the public are infected with the parasite that causes Chagas disease (Texas A&M, 2016). However, it has also been observed that the general public often confuses triatomines with other similar bugs. Traditionally the entire United States is considered a non-endemic area. However, due to the abundant vectors and established canine, domestic, and peridomestic cycles, some researchers have designated the disease as endemic to Texas, especially for canines (Sarkar et al., 2010).

While triatomines infected with Chagas disease have been observed in Texas since the 1930’s, the first local transmission was documented in 1955, in Corpus Christi, with a second pediatric case in Houston following soon after (Garcia et al., 2015). In 2013-2014, there was a total of 351 cases of Chagas disease in animals, from one-fourth of the counties in Texas, suggesting local transmission across the state. The same year also had 39 human cases of Chagas disease.

Of those cases, 61.5% of infections were due to immigration or travel and 30.8% of infections were locallyacquired (Texas Health and Human Services, 2017a). Within Texas, counties of concern exist mainly in the mid-Southern regions of the state. Houston’s Harris County is also included with other high-risk counties due to the high population density (Sarkar et al., 2010).

Additionally there has been important data regarding congenital and blood transfusion infection rates in Houston and Texas. Serological testing of

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expectant mothers in Houston was first conducted in 1993-1996 and then again in 2011-2012. The initial study in Houston confirmed a seroprevalence of 0.3% out of 3,765 Hispanic and non-Hispanic women, with 3.5 times higher infection rates in Latin American women (Pentima et al., 1999). The follow-up study at Houston’s Ben Taub General Hospital, studied 4000 deliveries where 75% of the women were born in Latin America.

The study found a similar frequency of Chagas disease in the mothers of 0.25%. All interviewed infected women had previously lived in rural Mexico or Central America. While the prevalence was low, targeted perinatal screening was demonstrated as useful for at-risk populations (Edwards et al., 2013). As all infected women were Hispanic, accounting for Hispanic women only, the rate of Chagas disease was slightly higher at 0.294%. Blood donor screening has shown positive donors from 109 different ZIP codes and a prevalence of 0.01-0.4%. An overall estimate is that 1 per 6,500 Texans have Chagas disease (Garcia et al., 2015).

Due to the proximity to Latin America and high rates of immigration from endemic countries, imported cases due to migration or travel are still of primary concern. Therefore, it is essential to examine immigration patterns and numbers in Houston.

Houston is the most diverse metropolitan area in the United States. 1.4 million of the 6.3 million in Houston are foreign-born individuals, a total of 22.2%. Latinos comprise of 36% of the total population, with Mexico and Central America as the main regions of origin for immigrants.

Mexico alone represented 45% of the total immigrants in Houston, around 600,000 people. The other 212,000 Latin American immigrants mostly originate from El Salvador, Honduras, Guatemala, Colombia, and Venezuela, all in the top 10 countries of origin for immigrants except for Venezuela. Applying the estimated T. cruzi prevalence estimates from PAHO, by accounting for the six top Latin American countries, there is an estimated total of 12,204 Latin

COUNTRIES OF ORIGIN: Houston Immigrants, 2008-2012

Mexico Non Latin-American Countries El Salvador Honduras Guatemala Colombia *not pictured: Venezuela, 0.83%

Figure 1. Chart of the Major Countries of Origin for Foreign-Born Immigrants in Houston, with Emphasis on Latin American Countries 2008-12 (adapted from Capps et al., 2015) American immigrants with a positive Chagas infection in Houston. This number drastically underscores the amount of underreporting of Chagas infections due to the lack of comprehensive screening.

Chagas Epidemiology in Barcelona

Spain, while far from endemic regions and areas of local transmission, is a major hub for Latin American immigration. Between 2001 to 2008, Latin American immigration rose 5-times to over 2 million immigrants.

Using the same methodology as for the United States, by multiplying seroprevalence to immigrant populations for the country of Spain, there is an estimated 47,743 Chagasinfected population in Spain (Gascon, 2010).

There are several Spain-wide and Barcelona-specific studies on Chagas disease prevalence for congenital and blood testing. In 2004, a congenital infection of Chagas disease was discovered in Barcelona. This case, in addition to several others, have since then have been recorded, detailed, and reported (Muñoz, 2007; Riera et al., 2006). A large-scale study in two Barcelona university hospitals

tested 1350 pregnant women from Latin American countries. The study showed an overall seroprevalence of 3.4% in the pregnant women and a rate of vertical transmission of 7.3%.

Of the participants seroreactive to T. cruzi, an overwhelming majority, 91%, originated from Bolivia (Muñoz et al., 2009a). This shows that there is a large at-risk population of pregnant Bolivian women in Barcelona, and how congenital screening can have significant effects.

Within Barcelona, there have also been studies of Chagas disease in adult Latin Americans outside of the pregnant population. These studies do not have adequate comparative studies from Houston, reflecting the lack of routine screening of adults in the United States. During a period of 3 years, out of 500 Latin American immigrants in two Barcelona imported disease centers, 41% were infected

by T. cruzi and of those patients, 19% had cardiac conditions and 9% had digestive disorders. Once more, Bolivian immigrants had the highest frequency of Chagas disease (Muñoz et al., 2009b). The high seroprevalence rate matches another study performed in Madrid for 1146 Latin American

COUNTRIES OF ORIGIN: Barcelona Immigrants, 2015

Non Latin-American Countries Ecuador Peru Argentina Colombia Bolivia

Figure 2. Chart of the Major Countries of Origin for Foreign-Born Immigrants in Barcelona, with Emphasis on Latin American Countries 2015 (adapted from Centre d’Estudis Demogràfics, 2015) patients, showing 31% positive serology. The high prevalence compared to previously referenced studies is hypothesized to be attributable to the high number of Bolivian patients from rural areas with previous vector exposure and selection bias due to being a referral center (Pérez-Ayala et al., 2011). A study in a primary care setting of Latin American immigrants, instead of a specialized center, showed more generalizable rates with a 2.87% prevalence over 766 patients (Roca et al., 2011).

Regarding blood transfusions, a study of 1770 at-risk donors confirmed the need for the testing of blood donations.

There was an overall 0.62% positive serology, with the highest rate of 10.2% in donors from Bolivia. Additionally, one donor was a Spanish citizen who had lived in a Chagas endemic country, who wasn’t categorized as “at-risk” based on the screening protocol (Piron et al., 2008). Since screening of blood donations was implemented, the Spanish Ministry of Health reported in 2009 that overall 0.46% of the tested donations were positive for T. cruzi (Angheben et al., 2015).

Spain’s role as a destination for Latin American immigrants is

essential in understanding their involvement in the global landscape of Chagas disease. Barcelona has a robust immigrant population, with 353,000 individuals of the 1.6 million population categorized as foreignborn, a total of 22.1%. This number is almost identical to the 22.2% foreignborn population in Houston. A large portion, 47.7%, of the foreign-born population were from Latin American countries. The major countries these Latin American immigrants originated from were Ecuador, Peru, Argentina, Colombia, and Bolivia, all in the top 10 countries of origin (Centre d’Estudis Demogràfics, 2015). The same estimated T. cruzi prevalence estimates from PAHO were applied to Barcelona’s 2015 Census data. Accounting for the top Latin American countries, there is an estimated 2,534 Latin American immigrants with positive Chagas infections in Barcelona. However, studies suggest that the PAHO estimates are significantly lower than the actual prevalence of Chagas disease in migrants, especially from Bolivia and Paraguay. Instead, 4.2% of Latin American immigrants in European countries may be chronically infected with Chagas disease (Requena-Méndez

et al., 2015). Using this percentage, 7,072 Barcelona immigrants may be affected.

In both cities, Latin America is the major geographic region where immigrants originate from. Compared to Houston’s Latin American immigrant population, there aren’t many from Mexico, El Salvador, Honduras, and Guatemala in Barcelona. However, large populations from Ecuador, Peru, Argentina, and Bolivia are not seen in Houston. Chagas Disease prevalence based only off immigration and countries-of-origin seroprevalence rates, shows an estimated 2.42% of the Latin America population in Houston should be T. cruzi seropositive and 1.50% of the Latin America population in Barcelona. These numbers are again likely underestimates due to the lack of accounted local transmission rates and the higher percentage of Bolivian immigrants shown to have Chagas disease. However, it provides a good basis of understanding about the scope of the issue and the need to implement targeted screening and treatment.

Screening Policies in Houston Within Houston, screening guidelines follow United States and Texas policies.

Currently all pregnant women, atrisk individuals, and infants are not mandatorily offered serological testing to determine if they have Chagas disease. All of these tests are according to the physician’s discretion. However, due to physician misinformation and lack of awareness, it is unlikely significant active screening occurs for these populations.

In the United States, serological screening of blood donations has significant coverage, of 75-90% of the total blood supply. The US Food and Drug Administration (FDA) licensed the serological test and began widespread usage in January 2007, which in a year and a half detected more than 500 confirmed positive donations.

This test is not mandated by the FDA and is voluntary by blood banks and centers (Bern et al., 2008). A FDA committee in 2009 voted in favor of a selective strategy where one negative test for Chagas would allow future

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blood donations without any further testing or questions regarding the risk of newly acquired infections (Center for Biologics Evaluation and Research FDA, 2010). These FDA guidelines are simply recommendations and “do not establish legally enforceable responsibilities.” Therefore, significant variability is introduced by blood banks.

For example, some may choose to screen all donations indiscriminately, only donors who lived in and/or traveled from endemic countries, or all donors once and then never again.

For organ donors, there are only provisional recommendations in place for the country and universal testing for T. cruzi is only implemented in Los Angeles and Miami, but not in Texas.

The CDC recommendations from the Chagas in Transplant Working Group decided there was insufficient evidence for universal screening and advised that a minimum testing based on birth in Latin America to be implemented. However, similar to blood screening, the lack of clear guidelines likely leads to a lack of consistent serological testing, even for at-risk donors. Advisors recommended no heart transplants from Chagas donors and that other organs should be considered based on anticipated immunosuppression and the urgency of transplantation (Chin-Hong et al., 2011). However, due to lack of formal regulation, it is unknown if proper care or procedures take place regularly.

There currently is no national efforts for surveillance of Chagas disease as there is no requirement by federal law to report active cases and “no plans to add Chagas disease to the list of diseases which are nationally notifiable” (CDC, 2015). However, the Texas Department of State Health Services does include Chagas disease on the state mandated list of diseases to be reported, within 1 week of the encounter (Texas Health and Human Services, 2017b).

Screening Policies in Barcelona In Barcelona, the most prominent screening policy is the recent implementation of an innovative

screening program aimed at reducing congenital transmission. In January 2010, the Public Health Agency of Catalonia (ASPCAT) implemented a novel program targeting pregnant Latin American women during antenatal appointments. The program was implemented in response to the predicted cost-effectiveness of screening all at-risk newborns and the estimated number of 7-16 infected newborns a year (Sicuri et al., 2011; Soriano-Arandes et al., 2014; A. Requena-Méndez, personal communication, March 13, 2017).

All pregnant women during their first trimester are offered screening for Chagas disease if they are from an endemic country, born to a Latin American mother, or are Spanish with history in endemic areas for more than one month. Once two positive serological tests are confirmed, the women will be offered treatment for Chagas disease after they stop breastfeeding. When infants are born to T. cruzi positive mothers, they are screened within the first 48 hours with microhaematocrit tests, no matter if symptomatic or not. Treatment is started for positive infants, mostly with benznidazole according to WHO recommendations. Negative infants or those who didn’t get tested in the first 48-hours receive follow-up until nine months when then get IgG serological tests to confirm status. Siblings of newborns to positive mothers will also offered screening and treatment.

Finally, all positive cases are reported for epidemiological surveillance to the Microbiological Reporting System of Catalonia (Basile et al., 2011). Besides Catalonia, the autonomous regions of Galicia and Valencia have also implemented congenital screening (Requena-Méndez et al., 2014).

Regarding blood donation screening, the European Union’s legislation requires complete rejection of blood donation from a person with a previous history of blood donation (European Union, 2004). This protocol, while important, is not comprehensive.

The EU’s legislation does not include active screening of blood donations of at-risk individuals, and likely

misses many cases of Chagas disease from asymptomatic individuals with unknown statuses. However, in Spain, the country instituted its own mandatory screening in 2005 for atrisk individuals. Blood banks currently use screening questions to identify atrisk donors to undergo screening for Chagas. Those classified as at-risk were either born in endemic areas, born to mothers native to endemic areas, or recipients of blood transfusions from endemic areas. For solid organ transplants, the EU directive does not address Chagas disease. In Spain, all at-risk donors are tested, and then organ recipients are monitored for the disease if receiving it from a T. cruzi positive donor (Requena-Méndez et al., 2014).

For screening migrant populations in Barcelona, there are several locations that provide regular screenings, such as the tropical medicine unit at Barcelona’s Hospital Clínic. Here innovative approaches exist, such as the option to contact family in Bolivia with referrals to free screening locations in Bolivia (L. de la Torre Avila, personal communication, March 13, 2017).

Medical Care in Houston In the United States, once a patient is identified as positive, they must undergo significant steps before even obtaining medical treatment. In the United States, the anti-parasitic drugs are not yet approved by the FDA. This means the medicines are only available from the CDC for use under investigational protocols for compassionate treatment. The overseeing physician must complete and become IRB-approved before the administration of the drugs (FDA, 2016). This lengthy process discourages physicians from screening and treating positive patients (P. Stigler-Granados, personal communication, March 31, 2017).

Due to the healthcare system in the United States, a major barrier to care is the issue of health care access and uninsurance. Around 10.9% of the population lacks health insurance, an issue even larger among immigrant

populations (Gallup, 2016). Nearly half of noncitizen immigrants, 45%, and 65% of undocumented immigrants, of which over 81% are Latin American, lack health insurance. Additionally, it’s hard for immigrants to get affordable insurance, as the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) restricts legal immigrants from receiving Medicaid during their first five years of residence (Derose et al., 2007).

Issues such as socioeconomic and language barriers further reinforce lack of health access for immigrants and marginalized populations, preventing necessary care and screenings.

Another major barrier to care is the documented lack of physician awareness associated with Chagas disease. Especially in high-risk areas, with high Latin American immigration and documented local transmission, lack of proper health worker knowledge can be particularly disastrous and contributes to persistent underdiagnosis and lack of treatment. A survey initiated from the CDC showed significant knowledge deficits from physicians regarding the risk about Chagas disease. Many physicians, 29-60%, never even considered the risk of Chagas disease for their patients and 27-68% were not confident in their current knowledge of the disease (Stimpert & Montgomery, 2010).

While there was a knowledge deficit across all medical specialties, Obstetrician-Gynecologists (OB/ GYNs) had the most substantial lack of awareness (Stimpert & Montgomery, 2010). Despite Chagas disease’s link to congenital transmission, many OB/GYNs demonstrate a lack of any knowledge of the disease and its congenital transmission. A survey of OB/GYNs showed that 68.2% possessed “very limited” knowledge of Chagas Disease, 91.2% did not even know that there was a risk of congenital transmission, and the large majority of physicians of 77.9% “never” considered testing and diagnosing patients from endemic country (Verani et al., 2010). Due to the substantial mortality of the disease

and the nearly guaranteed success rate of treatment of infants in the first year of life, Chagas screening is essential for newborns. The lack of OB/GYN awareness, is a concerning statistic indicative of the lack of screening for at-risk families. While efforts, such as the Texas Chagas Taskforce, are being made to educate physicians in Texas, significant knowledge gaps remain (P. Stigler-Granados, personal communication, March 31, 2017).

Medical Care in Barcelona In Spain, the National Health Service provides universal coverage with free healthcare to all citizens at the point of care. Undocumented migrants also have access to health services, which was reinstated after comprehensive care was revoked in 2012 due to austerity measures (Gray & Ginneken, 2012; Badcock, 2015). The presence of universal free healthcare allows citizens, immigrants, and undocumented migrants to receive necessary care and screenings. This also facilitated the implementation of congenital screenings, as all pregnant immigrants should attend antenatal consultations without issue, creating almost guaranteed coverage.

For treatment in Spain, currently benznidazole is available to physicians through the ministry of health and directly from specific hospital pharmacies (Gascon, 2010).

Due to the accessibility of healthcare in Barcelona, the major barriers to care lay outside of accessing the health care system. Many Latin Americans face Chagas-related stigma, such as an association of the disease with poverty and filth, causing many to ignore possible infections and avoid testing.

The beliefs of the migrants’ countries of origin, in addition to lack of disease knowledge and of its prevalence, contribute to migrants not asking for Chagas testing for themselves (Ventura-Garcia et al., 2013; Navarro et al., 2011). Physician awareness is lesser barrier in Spain. Research has shown a much better knowledge base in Spain than physicians in the United States, who mostly had limited knowledge of the disease. When asked specific

questions to physicians about Chagas disease such as about geographic distribution, transmission, and diagnosis, there was a mean of 73.9% correct responses among physicians (Muñoz-Vilches et al., 2013).

CONCLUSION

Both Houston and Barcelona have significant populations affected by Chagas disease, yet evidenced by Figure 3, the two cities have key difference in their approaches to controlling the disease. Although there is local transmission of Chagas disease in Texas, in both cities immigrants from endemic countries are still the key at-risk population. Both cities have nearly identical foreign-born population percentages, 22.1-22.2%, with Latin America as the major region where immigrants arrive from. Due to the differences in population size, Houston has approximately 340,000 more Latin American immigrants.

While both cities have many Latin American immigrants, they have distinctly different countries of origin. Houston immigrants primarily originate from Mexico, El Salvador, Honduras, Guatemala, and Colombia.

However, Barcelona immigrants come from Ecuador, Peru, Argentina, Colombia, and Bolivia.

Studies have shown slight differences in Chagas disease prevalence in the two cities, which may be caused by the different immigrant groups. Also, Texas has local transmission, that Catalonia does not, which contributes to 30.8% of the Chagas infections in the state. Risk of congenital infection is higher in Barcelona, attributable to the high positive seroprevalence of Bolivian women. In Barcelona, the prevalence is around 3.4% in pregnant women, compared to 0.25-0.3% in Houston. Blood transfusion screening have found similar results in both locations, 0.62% and 0.01-0.4% in Barcelona and Houston respectively.

Houston has no official legislative policies on screening blood donations, organ donations, or pregnant women with risk of congenital transmission. However, 7590% of blood donations centers screen

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all donations once, with one negative result exempting the donor from any additional testing. Chagas-positive patients must have their physician undergo CDCâ&#x20AC;&#x2122;s Investigational Drug Protocol to treat patients with benznidazole or nifurtimox. This is an additional barrier for physicians to screen and treat patients. Other major barriers to care for patients in Houston is the lack of physician awareness, healthcare access for individuals, especially low-income immigrants, and associated stigma of Chagas disease.

Across specialties, many United States physicians, 29-60%, had never considered the risk of Chagas disease for their patients. This knowledge deficit was especially prominent among OB/GYNs. Despite the risk of congenital transmission of Chagas disease, 91.2% of OB/GYNs were unaware that there was even congenital transmission. Healthcare access for underserved populations is a major barrier to care, as many uninsured individuals only seek emergency instead of preventive care, due to costs and access. Without improved healthcare for these populations, more stringent screenings will not be enough and at-risk populations will still be unable to get proper care.

In Barcelona, there are instituted policies and legislation regarding blood transfusion, organ donation, and congenital screening. For blood transfusions and organ donations, atrisk donors are screened for Chagas disease if they are 1. born in endemic areas, 2. born to mothers from to endemic areas, or 3. recipients of blood transfusions from endemic areas. When organs are transplanted from positive donors, the recipients are monitored for Chagas disease. In addition, all at-risk pregnant women get screened for Chagas disease and the infants born to positive mothers are monitored for disease for 9 months.

For treatment, benznidazole is offered free of charge, due to Spainâ&#x20AC;&#x2122;s universal health care system, at select hospitals and clinics. Due to existing screening and treatment programs in Spain, the largest barrier to care is diseaseassociated stigma that prevents many migrants from seeking necessary

screening or care.

POLICY RECOMMENDATIONS

In order to protect individuals at-risk of contracting Chagas disease or living with the disease, public health policies should address screening, treatment, and education. Compiling data for both cities on current policies and issues in addition to a comprehensive review of the existing literature and interviews with experts, the following policy recommendations are made according to the areas of most urgent concern: Houston Policy Recommendations 1. Targeted Physician Training The immense lack of physician awareness about Chagas disease puts many lives at-risk, especially since there is in-state local transmission and a large population of potentially infected people in Houston. This knowledge gap leads to a cycle of a deficit of screenings and undertreatment. In Houston alone, there are 818,000 immigrants born in Latin American countries endemic for Chagas disease (Capps et al., 2015). There are thousands of residents predicted to have chronic infections that may lead to fatal heart and gastrointestinal conditions.

Educating physicians about specific at-risk populations and the disease is the first step to making sure that screening efforts are made during any points of contact for those 1. Born in endemic Latin American countries, 2.

Born to mothers from Latin American countries, 3. Travelers who have spent significant time in endemic countries, and 4. Other at-risk populations such as hunters, the homeless, and those with subpar living conditions. Efforts should be made to support existing initiatives, such as those of the Texas Chagas Taskforce, and implement physician training in Houston. Physicians who should especially receive training are those who frequently work with atrisk populations, physicians at public hospitals or clinics, and OB/GYNs.

2. Expand Treatment Accessibility The highly administrative steps physicians must undertake to obtain Chagas treatment for patients may discourage physicians to actively screen for Chagas disease or treat positive patients. Under the CDC Investigational Drug Protocol, all suspected cases must undergo consultations with the CDC and paperwork for the physician to distribute investigational drugs.

FDA approval leading to the wider availability of benznidazole and nifurtimox would be ideal to remove treatment barriers. In the meantime, there should be a collective effort among physicians in areas with the likelihood of Chagas-infected patients, such as Houston, to expand treatment accessibility. This should include an identification of specific centers, such as travel or infectious disease clinics, and physicians who can or already have undergone the necessary protocols to distribute anti-parasitic medications when necessary. A concerted plan of referrals and treatment locations will facilitate necessary care for both the patients and the physicians in charge of their care.

3. Congenital Screenings for At-Risk Population The lack of congenital screening policies is an immense area of improvement in the United States and in Houston. Currently, blood and organ screenings are present for many donations, but there is no policy targeting congenital transmission.

Screening all at-risk pregnant women and the infants of positive women has been demonstrated to be costeffective and feasible, as seen by the implementation in similar settings in Europe and research studies (Sicuri et al., 2011). Although the disease may be perceived as relatively rare, the estimated annual cases is similar to other rare diseases that other newborns get routinely screened for.

In Texas, all infants are required to be screened for a total of 53 disorders with

POLICY

BARCELONA

HOUSTON

BLOOD TRANSFUSION

At-risk donors screened, including those 1. born in endemic areas, 2. born to mothers native to endemic areas, 3. recipients of blood transfusions from endemic areas

• No legislative policy • ●Most blood clinics screen all donations, FDA recommends one negative results sufficient for all future donations

ORGAN DONATION

At-risk donors tested, organ recipients are monitored for the disease if receiving from a positive donor

• No legislative policy • CDC recommends screening Latin American born immigrants

All pregnant Latin American women screened during antenatal care, plus the newborn of positive mothers & siblings

None

Free of charge, benznidazole available at select clinics

CDC Investigational Drug Protocol to obtain benznidazole or nifurtimox

CONGENITAL SCREENING

TREATMENT MAJOR BARRIERS TO CARE

Associated stigma

• Lack of physician awareness • Healthcare access • Associated stigma

Figure 2. Comparison of different policies regarding screening, treatment, and barriers to care in Barcelona and Houston. significant morbidity and mortality, but not Chagas disease (Texas Health and Human Services, 2017c). For example, one core conditions in infant screenings is Phenylketonuria, which has an estimated 215 cases in the United States (Verani et al., 2010).

Chagas disease in Houston is shown to have a 0.25-0.30% prevalence in

mothers and with an approximate 5% congenital transmission rate, so several of the 63-315 congenital Chagas cases should come from Houston each year (Bern et al., 2009). The implementation of congenital screening for all at-risk mothers and their newborns will both identify women positive for T. cruzi but also remove the potential for

congenital transmission.

Barcelona Policy Recommendations

1. Integrate Screenings of the Migrant Latin Americans into Primary Care Screening Latin Americans during primary care visits is cost-effective, calculated with a 4.2% prevalence of Chagas disease among migrants and

chagas disease //

13

an estimated treatment efficacy of 20 or 50% (Requena-Méndez, 2017). By ensuring that all at-risk populations are screened for the disease, it will confirm that the majority with infections will get proper care. While congenital screenings are helpful and essential, there are still many people who are possibly infected but are missed by only consistently testing mothers and infants. This includes all immigrant men and non-pregnant age women from endemic countries. Implementing regular screenings during any points of contact during primary care, is both feasible due to the universal health care system, and effective at targeting the existing burden of Chagas disease in Barcelona. This can drastically benefit many patients who maybe already suffering from complications.

Many adult patients with Chronic Chagas disease in Barcelona’s Unitat de Salut Internacional Metropolitana Nord also presented with Chagas Cardiomyopathy. 49% of patients had significant electrocardiogram or echocardiogram changes, which is significant cause of concern. The majority of patients were at risk of developing organ complications and the most common ECG alteration, a right bundle branch block, has a 20% associated-mortality over six years (Valerio et al., 2011). A primary care screening system will help catch these cases and reduce related mortality and morbidity.

2. Broaden At-Risk Definition and Screened Populations To comprehensively reach all at-risk of a Chagas infection, there should be amendments to the current screening policies. A study of T. cruzi in Spanish blood donations detected a positive case that wouldn’t have gotten categorized as “at-risk” according to the screening methodology used.

The donor had lived temporarily in an endemic country, but since he was a Spanish citizen not born to a foreign-born mother from an endemic

area, his positive case would have gone unnoticed (Piron et al., 2008).

Therefore, all definitions of “at-risk” cases should include those 1. Born in endemic Latin American countries, 2.

Born to mothers from Latin American countries, 3. Travelers who have spent more than one month in endemic areas, and 4. Recipients of blood/ organs from donors from endemic countries. Additional policies should expand the screened population to ensure complete coverage. This should include a regular protocol to offer screening referrals to the immediate family of women tested in the congenital screening program.

Also, to combat disease stigma and increase public awareness, community health approaches can be effectively implemented in the Latin American community for Chagas disease (Soriano-Arandes et al., 2014). Through this approach, public awareness can be reinforced while increasing screening coverage throughout the city.

ACKNOWLEDGEMENTS

This research would not be made possible without the expertise from the following people who provided invaluable guidance. The author would like to acknowledge the numerous experts interviewed for the project.

Dr. Nia Georges and Víctor Giménez Aliaga provided essential background on Barcelona, research methodology assistance, and writing suggestions.

Additionally, Ipek Martinez provided invaluable coordination, support, and mentorship.

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ajtmh.2010.09-0543

MEET THE AUTHOR Caroline Lee (’19) is a student studying Cognitive Sciences and Policy Studies who is particularly interested in global health and health policy. She is especially passionate about researching health disparities related to immigrant populations, especially how the issues relate to public health policies. In the summer of 2016, Caroline researched novel diagnostic technologies for detecting Chagas disease at the Johns Hopkins Bloomberg School of Public Health. Here she became interested in the complexities of Chagas disease, which she further explored through independent research in Rice’s Global Urban Lab. “The Hidden Danger of Chagas Disease: A Comparative Analysis of Infectious Disease Policies in Houston and Barcelona” aims to analyze Chagas disease in two non-endemic settings, related to Latin American immigration, and what policy recommendations should be made in both the United States and Spain.

chagas disease //

15

II. UNIVERSAL HEALTHCARE healthcare INTRODUCTION

A Comparative Analysis of the Healthcare Systems in Spain and the United States

The Spanish healthcare system is continuously ranked one of the best in the world (most recently rated top 10 by the World Health Organization).

What makes this system great is that it guarantees universal coverage and no upfront costs for patients (other than small cost for prescriptions).

According to the World Bank, the United States spends over 17% of its GDP on healthcare while Spain only spends 9%.1 While the US outspends all other countries and also achieves worse health outcomes and lower life expectancy, the Spanish system is able to provide care for all at lower costs while also providing great quality care. With such a stark difference between these systems it is important to identify the merits and pitfalls of both healthcare systems. Therefore, this paper will serve as a comparative investigation into the healthcare policies and the actual implementation

of “universal” care. Healthcare access/ disparity, quality of care, and cultural influences on public policy will be used as metrics of evaluation with the ultimate goal of providing a comprehensive and holistic review of both systems.

METHODS

This report examines the standing of each healthcare system by reviewing relevant literature and speaking with health policy experts and physicians.

In recent history (over the past 20 years) healthcare has been an extremely prevalent topic of discussion within the US. Because of this, there has been a large body of work aimed at evaluating the strengths and pitfalls of the United States’ system.

Additionally, this discussion has prompted many hospitals to become more heavily engaged in healthcare policy. MD Anderson’s Institute for Cancer Care Innovation is one example

of this increased interest. Since I worked there for over 7 months I leveraged my relationships to speak with many healthcare policy experts as well as physicians/surgeons. In total I spoke with Dr. Thomas Aloia (surgical oncologist), Dr. Thomas Feeley (head of the Institute for Cancer Care Innovation and anesthesiologist) as well as Alexis Guzman and John Calhoun (Project Managers with extensive healthcare policy exposure).

In my analysis of the Spanish healthcare system I interviewed Dr. Joan Benach who is a researcher and professor at the University Pompeu Fabra. He also works within UPF’s Johns Hopkins Public Policy Center. I also spoke with Miguel Burriel, a researcher at UPF who specializes in research concerning the Catalan Hospital System. In my research concerning the Spanish healthcare system I also relied heavily on my conversations with (English speaking) locals and other experts in

Figure 1. Dramatic increase in healthcare coverage following the creation of Medicare & Medicaid and the enrollment of the ACA other areas of Barcelona culture/policy in order to gain more perspective on perceptions of the Spanish Healthcare system. In my literature review, I relied heavily on peer reviewed articles and translated pieces of legislation regarding the Spanish Healthcare system.

Overall, this paper features a mixture of direct quotes from my interviews (most interviews were recorded and subscribed), general sentiments from my experts, and information from primary/secondary sources.

ACCESS TO CARE

One of the most important metrics for evaluating the success of a healthcare system is access to care. Access can be looked at in a few contexts. From a societal level, health policy and health financing impact a community or countries access to care; whereas, health insurance status, income, and availability of care/clinics/hospitals impact healthcare access on a smaller scale.

Access to Care in the United States

In the United States, healthcare insurance status largely determines your access to care. With the passage of the ACA and its repeal likely on the horizon, it is important to understand the historical context of health

insurance policy in the United States.

The figure above2 outlines the percent of Americans without health insurance from 1963 through 2014. The United States last saw the most dramatic cuts in the number uninsured following the creation of Medicare and Medicaid in 1965. Medicaid began as a welfare program for the poor as a portion of Lyndon Johnson’s Great Society agenda. As a federal program it pushed states to match federal funds in order to provide healthcare access for poor families. However, Medicare began slightly differently. While Medicaid was considered a minor program, legislators and citizens alike considered Medicare as the most important expansion of healthcare in the 20th century as it guaranteed healthcare for citizens aged 65 and older. After their initial passing, Medicare and Medicaid saw insurance coverage increase in the following decade as life expectancy increased (thereby increasing the number of 65+ individuals) as well as the expansion of Medicaid and Medicare to people with disabilities. However, from the 1980’s to the passage of the ACA uninsured rates remained largely unchanged.

Decreasing the number of uninsured individuals was the major goal of the ACA, which expands Medicaid coverage to many low income individuals (of states that have accepted this expansion) and provides subsidies

for people below 400% poverty.

Previously, with many patients above the Medicaid poverty threshold but still unable to afford private insurance there were many gaps between the public and private insurance systems.

Thus, one of the ACA’s main purposes has been to expand coverage for many of these gap patients. The majority of ACA enrollment began in January of 2014 and led to significant decrease in uninsured rates (as observed in Figure 1). At the end of 2015, the number of uninsured nonelderly Americans was 28.5 million, a 12 million decrease compared to 2013 figures.3 Additionally, healthcare clinics in states that expanded Medicaid reported a 36% increase in Medicaid patient visits corresponding to a 40% decrease in uninsured patient visits, while centers in states that opted out of Medicaid expansion reported a 16% decline in rate of uninsured patient visits with no change in Medicaid patient visits.4 Thus, in examining the United States healthcare system from the perspective of Affordable Care Act and uninsured rates, the ACA has successfully expanded coverage.

Healthcare Disparities While there have been recent strides to expand healthcare access within the United States, there are still many health disparities that exist on racial and socioeconomic lines in particular.

From 2010 to 2015, the percentage of people under 65 who were uninsured decreased for all poverty status and racial/ethnic groups (17.5% in 2010 to 10.3% in 2015). However, as Dr. Feeley stressed in our discussion, it’s one thing to have access, what we should be concerned about is access to affordable care.” 5 He pointed to the fee for service payment model as one of the main barriers for true widespread access to affordable healthcare.Fee for service is a payment model where services are paid for piece by piece; meaning, every pill, MRI, physician examination is itemized and billed for.

He emphasized that instead of being focused on treating a patient for a disease or ailment through the entire treatment cycle (which may include

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imaging, drugs and examinations) doctors are incentivized to only focus on generating revenue by charging for every single thing. Overall, this model has a lot to do with the rising rates of healthcare costs in the US and addressing barriers to access to care will have to also highly consider the role payment models play.

Additionally, while these dramatic decreases have been experienced by the entire US population, blacks and Hispanics were more likely to be uninsured than whites. The figure below, from a verified metadata analysis, emphasizes that disparities in healthcare access still persist on socioeconomic and racial lines.6 Even when they possess insurance, many in communities of color continue to face a variety of cultural, geographic and linguistic barriers to accessing care. In particular, the National Center for Health Statistics conducted a study aimed at identifying health disparities.

They found that after adjustment for age and sex, the percentage of persons with a usual place to go for medical care by race and ethnicity was 82.1% for Hispanic persons, 88.6% for nonHispanic white persons, and 86.0% for non Hispanic black persons.7 While this disparity seemed to be narrowing over time, minority communities still find it significantly more difficult to go to the doctor when compared to other populations. Spatial accessibility measures include travel barriers to visit health care facilities (travel distances/ time for example). Residential segregation, the spatial separation of racial groups that often leads to the development of neighborhoods with fewer resources, is one driver for this spatial access disparity. One study helped contextualize this conclusion by finding that individuals living in areas of metropolitan Detroit with greater black/Latino segregation had less access to mammography and a significant increase in the risk of late diagnosis of breast cancer.8 Residential segregation’s impact on communities’ access to healthcare facilities is important because early detection and regular checkups with physicians is so important in catching signs of many

Figure 2: Displaying healthcare access racial disparity diseases early.

Linguistic barriers may also help explain Hispanic health access disparity. One study examined this question by investigating Hispanic/ white health disparities in children and stratified data by immigrant status and English proficiency. They found that access to care disparity is largely driven by that portion of the Hispanic population that is newly-arrived to this country or does not speak English primarily in the household.9 These findings are consistent with other research that concluded that there is a need for health care services to be provided in a multi-language platform and for outreach efforts to inform the non-English-speaking Hispanic and health professional community about language resources and how to utilize them in health care settings.10, 11 In my conversations with Ms. Guzman and Mr. Calhoun I also found that spatial isolation and linguistic barriers were also extremely prevalent in the city of Houston. With the largest medical center in the world it can be easy to assume that everyone in the city has tremendous access to care (especially if they are insured).

However, as I discovered Houston is extremely divided into neighborhoods.

The experience of an individual on the “East End” of Houston compared to Fifth Ward or West University communities are all dramatically

different. Even when assuming equal levels of insurance status, access to the Texas Medical Center is extremely different across these communities.

Some areas of Houston have regular bus service with great access to the Light Rail that leads directly into the TMC, while others are completely isolated. Similar to the discussion that has become more prevalent in recent history concerning “food deserts” many areas of Houston (and other cities) have “healthcare deserts” that continue drive health disparities on socioeconomic and racial lines.

Access to Care in Spain Spain has been a parliamentary monarchy since 1978 and the political organization of Spanish government is highly decentralized with 17 autonomous regions. The health system is universal coverage funded from taxes and is mostly controlled within the public sector. Healthcare access is free of charge at the point of delivery (but funded through taxes) with the exception of pharmaceuticals that require a copayment in some cases. As expansive as the system is today, it has not always been this accessible. During the 1940’s and 1950’s, the public healthcare system remained largely marginal in terms of population coverage and extent of benefits. For instance, in 1942 the public insurance system covered about

20% of Spain, in 1950 it covered 30%, and in 1960 it covered roughly 45% of the population.12 Then, the Basic Social Security act of 1967 initiated the expansion of coverage to self employed professionals and qualified civil servants which resulted in a huge expansion of coverage from 53% in 1966 to 82% in 1978.12 Finally, Law 4/1986 (Ley General de la Sanidad) expanded coverage to all Spaniards. Since this law, the public healthcare system has had a tremendous reputation in terms of access. In particular, Spain has the sixth highest rate of doctors per capita in the world according to the World Health Organization.13 Cuts to Spanish Healthcare Access The global recession that started in 2008 was the worst economic crisis since the Great Depression in the 1930’s form most OECD countries.14 While unemployment has been the most visible consequence of this global crisis, an additional concern has been the effect on government spending on healthcare. While Europe as a whole (through the European Union) has identified health inequality reduction as a major area of interest and warned of “the negative consequences for health, social cohesion and economic development if health inequalities are not effectively tackled”15 the fiancial crisis interfered significantly with these priorities, especially in Spain.

Prior to the crisis, Spain experienced extended economic expansion with real GDP growing at approximately 3% per year and unemployment falling below 8% in 2007.16 The effects of the global financial crisis become obvious in Spain beginning in 2008 when GDP growth fell from 3% to below -3% between the first quarter of 2008 and the first quarter of 2009, while unemployment roughly doubled during the same time.16 The figure above17 illustrates just how big of an impact this financial crisis had on the Spanish economy. This stress on the economy reverberated throughout all of Spanish society and led to many new highly charged political discussions about the financial practicality of the Spanish

Figure 3: Unemployment and GDP growth in Spain universal healthcare system. In order to cope with these financial pressures the health and social services budget was reduced by 13.65% in 2012, with disproportionately high cuts to professional training (75%) and public health and quality programs (45%).18 These cuts coincided with increased demands on the health system because of the well known link between unemployment and poor health, but also because of a €600m cut in a specific fund that supported the elderly and individuals with disabilities.18 The budget cuts were also accompanied by a major change that was introduced by a royal decree (whereas these sorts of changes normally happen after debate through parliament). Royal Decree-law 16/2012 came into force in September 2012, excluding undocumented migrants from all but basic emergency care, prenatal care, and pediatric care. This ended the principle of free services for all and has been the most significant change in access to care experienced in Spain since its inception of universal healthcare coverage.19 According to some estimates this royal decree prevents around 500, 000 undocumented people from accessing the full range of healthcare in Spain.20 Since its announcement, the Spanish government has said that primary care services will be available to those under 65 years who pay a monthly fee of €59.20 and up to €155.40 for

those over 65 years.21 Such payments have proved unaffordable and are more expensive than existing private policies in Spain. This has led many to be suspicions in that the policy may be designed to cozy up to the private healthcare sector.

Martin Niemoller, an outspoken advocate against Adolf Hitler once said, “First they came for the Socialist, and I did not speak out because I was not a Socialist. Then they came for the Trade Unionists, and I did not speak out because I was not a Trade Unionist.

Then they came for me and there was no one left to speak for me.”22 While it is clear that universal healthcare coverage as a right for all seems to be a cornerstone of Spanish culture that doesn’t seem to be going away anytime soon, many feel that the decree limiting access from migrants is an erosion of Spanish principles that could lead to more dramatic cuts in the future.

This hesitance to restrict healthcare access was exemplified in a few high profile cases in which hospitals/ providers disobeyed the decree.

In December 2012, the Spanish Constitutional Court upheld the right of the Basque Country region to provide free services to undocumented immigrants. This autonomous region of Spain prioritized health of the entire community over finances and argued that the central Spanish government had not shown how its policy would

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result in significant savings. Some other regions (Catalonia, Andalusia, Asturias, and Canary Islands) have also refused to exclude undocumented immigrants by arguing that it is unjust, dangerous, and potentially unconstitutional.

Professionals and organizations have also expressed concern about their ethical duty to provide care to undocumented migrants.21 Ultimately, these restrictions to healthcare access have been met with a lot of vitriol from Spaniards and have fueled members of the “White Wave.” Citizen waves are ongoing protests that have arisen in response to the cuts to social spending and austerity policies implemented since 2011. The “White Wave” specifically is a reference to the medical smocks that strikers wore. 23 Wait Times as a Healthcare Access Restrictor?

The wait times of patients can also serve as a significant barrier to receiving care. Wait times are often cited as one of the main pitfalls of any government universal healthcare system and in many cases, these complaints have been verified.24 In such systems, many argue that with a limited number of resources, public hospitals are unable to meet demand as efficiently as privately managed/financed systems and must thus create waitlist for primary care checkups as well as surgical procedures to manage said demand. During my interview with Mr. Burriel, I raised this very prevalent critique. In response he stated that, “You don’t have that much waiting in the states. But they are actually a good thing to have wait times. For non urgent procedures who’s effectiveness is ‘shadowy’ you get that at the end, 25% of the people that are on waiting list for back surgery, knee replacements, hip replacements etc. 25% drop out of the list, they just say whatever [I don’t really need it]. When you make comparative studies of the healthcare systems with the US it’s like how much do you invest vs. health outcomes. For most countries you have diminishing returns the more you spend but for the US it goes down. It proves that you guys are not only spending too much

on this issue but you’re spending a burden clearly because you’re harming.

In fact in the US because the third cost of mortality, which is not reported in many medical reports but is in some papers is medical errors (they have given wrong drug, wrong dose).”25 Mr. Burriel made it very clear that he believes that the issue of waiting times has been overemphasized by opponents. He asserted that is it really 100% necessary to be able to see a physician whenever you want for non emergencies. He also goes as far to suggest that wait times are actually beneficial in filtering out patients who do not really have serious medical concerns but would have otherwise used medical resources to address something “just to be safe.”

Furthermore, he offered evidence that the overutilization of healthcare services in the US is harmful for many patients who see physicians when it is not completely necessary, further exposing them to risks.

Dr. Benach also spoke to the accusation that wait times in Spain restrict access to healthcare. During my interview with him he said, “Spain does not provide care for every single thing.

But the most important problems are addressed and covered under the system paid for by social security.”26 He went on to explain that Spain differs from the US in that the Spanish healthcare system values breadth over depth. He described healthcare as a zero sum system in which you can either treat the entire population for most ailments or treat portions of the population with greater detail; you cannot do both. Thus, while it is perfectly feasible to get a new, innovative, extremely expensive surgical procedure with little waiting time in the United States this comes at a cost in that there are many individuals who don’t have access to the basic pharmaceuticals or routine medical treatments. He suggested that the critique of exuberant wait times was an overplayed criticism and attributed much of the critique in the United States to insurance companies that oppose universal government run healthcare by saying,

“What they do is they spend a lot of money not only on their own services but to defend their own point of view.

Lobbying and affecting the minds of the people, putting arguments, putting justifications and many things that show [negatives] like wait times, saying “socialized medicine” and things that scare people like socialism, communism. All of this is done on purpose, don’t be naïve. Why? Because there is a lot of money, you cannot imagine.26” Ultimately, Dr. Benach stressed that he believed that wait times were not a true barrier to accessing healthcare.

He suggests that even though wait times exist they do not truly degrade the prestige or integrity of the Spanish healthcare system as being open and accessible for all people. While these sentiments were ones that I heard several times in my small talk conversations with locals there are opposing viewpoints worth noting.

One study found that the majority of the Spanish population thinks the health system should be altered.27 The problems cited related mostly to long wait times; however, over the last 15 years, the proportion of people who have very negative views about the health system has also decreased by half. The majority believes that not enough money is spent on health care but very few would support an increase in taxes to provide additional funding.

Overall, the study found that the National Health System’s institutions and health professionals are more trusted than other institutions and groups in the country .This would suggest an apparent distrust in many public institutions and not necessarily the healthcare system specifically.

This contrasts greatly with the United States where there is public distrust but disdain for the healthcare system is extremely apparent. Either way, if there was one area where the Spanish system could improve addressing wait times would be this area.

QUALITY OF CARE COMPARISON

The quality of medical care is a secondary measure that I used to evaluate both healthcare systems. No

matter how accessible or inexpensive healthcare is quality remains an important metric to measure because it is truly what impacts the patient the most. So, even if the United States and Spain have several differences in terms of access to care, are there similarities in the quality of care that is provided for patients? Quality of medical care is dependent on a few factors like established clinical standards, the judgment of the healthcare professional and patient reviews. Metrics can include biomarkers and other tests of patient physiology. Patient satisfaction can be measured by data on travel time, waiting time, length of stay in the hospital, healthy communications with the physician or other healthcare providers involved in their care, and the technical quality they received. It is also important to consider more macro perspective metrics of evaluating the quality of care in a health system.

Quality of care is a relatively new metric that has gained popularity in recent years and is increasingly measured by doctors, insurance companies/payers, health policy makers, patient groups and researchers as relatively direct outcomes of healthcare delivery.

In order to assess healthcare quality between these two countries I examined a host of different metrics including: avoidable admissions, in hospital mortality, procedural or postoperative complications and screening and survival for cancer. Informed by an OECD publication, I included the most significant of quality findings above.28 There were a few major takeaways from the OECDâ&#x20AC;&#x2122;s quality data. The most significant point is that the Spanish system looked to be outperforming the US on most routine procedures (like addressing a patient with diabetes) and many other more serious illnesses (breast cancer for example). I was unable to find data to support the idea that the US preformed significantly better than most countries on treating patients with rare/more life-threatening diseases. However, anecdotally and through my interview of Dr. Benach, I would venture to guess that the United States is probably superior in this regard due to the

Figure 4: Higher breast cancer mortality in US

Figure 5: Spain outperforms US in lack of medical errors

Figure 6: Spain outperforms US on routine procedures/treatment presence of expensive and innovative technology as well as world renowned research facilities that may not be as present in Spain. Overall, I was quite surprised by the Untied Statesâ&#x20AC;&#x2122; quality metrics in comparison to Spain. While the US outperformed most OECD averages, I would at least expect the hospitals in the US to outperform other countries in areas like cancer care (due to the prevalence of hospitals like MD Anderson) however; it is likely that my proximity and familiarity with the US system biased my hypothesis.

Dr. Aloia (who focuses his research on quality and outcome reporting of cancer care) emphasized that the United States does not do a great job of measuring the quality of care. He stressed that outside of mortality rate, we really donâ&#x20AC;&#x2122;t have many patient centered outcome measurements that are used widely in the United States. By measuring our outcomes more widely, he believes that it would encourage hospitals to benchmark and compete against each other, not only for revenue but for quality of

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healthcare delivery. He also echoed Dr. Feeley’s comments about some of the flaws with the fee for service model in that in this profit driven environment hospitals focus more on patient volume than the quality of the service they are delivering.

In Spain I noticed a much different approach to healthcare. People seemed to be much more focused on health from a holistic standpoint (especially prevention techniques). This may heavily influence physicians in the way they practice medicine by making them much more patient focused and interested in making patients healthier and not just getting rid of symptoms/ailments. Also, in terms of differences between publicly run or privately run/finaced hospitals in Spain the public hospitals maintain relatively good quality. Dr. Benach said that the only reason one would go to a private hospital was to avoid waiting list, get more comfort rooms with a TV and more space, but not the quality of healthcare. Ultimately, the public system in Spain is robust enough for there to be pretty uniform quality of care throughout the country.

CONCLUSION

Cultural Differences One of the main things I tried to keep in mind as I spent a week in Barcelona was “What aspects of Spanish culture led to the formation of this healthcare system?” I firmly believe that any changes to policy must take into account the specific cultures of the country and region one is in.

On the topic of healthcare, societal values and expectations seemed to heavily drive healthcare policy. In the United States many things are profit driven. In my interview and subsequent correspondence with Mr. Burriel he even noted that he didn’t like living in the US in comparison to other countries he’d lived in (Mexico and Spain specifically) because every single aspect of life seemed to be work and money driven. This type of lifestyle, in his eyes and through my observations did not seem very prevalent in Spain. Additionally, within the United States, this profit

driven mindset often impacts politics in those lobbying groups, insurance companies and pharmaceutical companies within the healthcare industry, employ representatives who often put the interests of the industry they represent above the interests of the public. Lastly, within the Untied States there seems to be a strong desire to be self reliable; there is not a strong sense of common humanity. For better or for worse the “you vs me” sentiment seems pervasive. If someone lives in a city where homelessness is rampant this isn’t often seen as a threat to public wellbeing, it’s seen as an opportunity to help those less fortunate (if at all).

This mentality is also quite obvious in discussions about healthcare.

When there are large proportions of uninsured in a population, this raises healthcare costs for everyone, whether they want it to or not. In my interactions and readings it seems that the Spanish understand that a commitment to improving/supporting society at large isn’t merely an act of benevolence but in the end it helps everyone.

Another major cultural difference that became apparent was that in Spain there are different expectations for the role healthcare plays. In the US there does not seem to be as much focus on prevention. Additionally, in the US there seems to be a willingness and desire to prologue life (by any means necessary) even if a patient seems to be dying. However, this does not seem to be as much of a common expectation in Spain. For example, in Spain an ambulance/dispatcher will sometimes ask the age of the patient in order to help inform the ambulance how they should prioritize. This illustrates a clear cultural difference in that the young are expected to be given more resources than an elderly individual near death. While those judgments are made in every country, that fact stuck out to me in understanding cultural differences.

Policy Recommendations In evaluating both the United States and Spanish healthcare systems it is clear to me that the United States could

learn a lot from the Spanish system’s ability to provide more accessible, higher quality care at lower costs. Thus, my policy recommendations will be centered on areas of improvement for the United States.

The most significant recommendation that I would make is to reimagine Medicare and Medicaid by transforming it into a robust public payer system. With shifting age demographics and growing income inequality, the United States will have a significant number of individuals on Medicare and Medicaid in the coming decades. As a system, I do not believe that our robust private healthcare system has an incentive to keep costs down without a robust government healthcare system challenging and competing for patients. “Free market” competition only exists if entities are willing to offer lower costs than their competitors. By working to implement a robust public option/multi payer system (private and public beyond Medicare/Medicaid) this would create more honest competition for the benefit of patients because the government would have an incentive to keep costs manageable. Furthermore, this would encourage greater access to preventative care because it would be in the best interest of the public system to treat a disease at an earlier time, at lower costs than to deal with it at a later and more serious time.

My second main policy recommendation comes from my conversations with experts at the Institute for Cancer Care Innovation at MD Anderson. I would recommend mandating hospitals and physicians meet quality/outcome measure benchmarks in order to encourage healthcare providers to compete against each other for better services.

I would also recommend eliminating the fee for service payment model, as it only incentivizes overuse of medical services thereby driving up costs and knocking out those who are unable to afford expensive healthcare. Instead, I would recommend tying physician reimbursement to patient outcomes so that a physician is paid for the value they bring to the patient, not

the number of lab tests or imaging tests they order. This would transform healthcare in the United States by making it extremely patient centric.

There are many other aspects of the United States healthcare system that I recommend changing, but more than anything I truly believe we need to overhaul the entire system with an appreciation and understanding of other successful and global models. No matter who you are, no matter your socioeconomic status or race, everyone can relate to the importance of being healthy to needing a doctor to address their ailments. As Americans we need a healthcare system that is committed to caring for all Americans in sickness, and in health in as effective and efficient of a manner as possible.

ACKNOWLEDGEMENTS

I would like to thank all of the experts (Dr. Benach, Dr. Feeley, Dr. Aloia, Ms. Guzman, Mr. Calhoun, Mr. Burriel) who let me pick their brains on everything related to healthcare in the US, Spain, and other countries around the world . My life-long dream is to use the knowledge of healthcare systems around the world to help inform and radically change the United States healthcare system.

You all’s commitment to research and learning is infectious and I thank you.

Additionally, I’d like to thank Dr. Nia Georges, Victor Aliaga, and Dr. Ipek Martinez for their guidance through the Rice Global Urban Lab Program.

This paper would not have been possible without their dedication to making our time in Spain fruitful and eye opening.

REFERENCES

“Health expenditure, total (% of GDP).” Health expenditure, total (% of GDP) | Data. World Bank, n.d. Web. 10 May 2017. <http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS>.

2 “2014 Has Seen Largest Coverage Gains in Four Decades, Putting the Uninsured Rate at or Near Historic Lows.”

National Archives and Records Administration. National Archives and Records Administration, n.d. Web. 10 May 2017. <https://obamawhitehouse.archives.gov/ blog/2014/12/18/2014-has-seen-largest-coverage-gainsfour-decades-putting-uninsured-rate-or-near-his>.

3 Sommers, Benjamin D., et al. “Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act.” Jama 314.4 (2015): 366-374.

4 Angier, Heather, et al. “An early look at rates of uninsured 1

safety net clinic visits after the Affordable Care Act.” The Annals of Family Medicine 13.1 (2015): 10-16.

5 Feeley, Thomas. Personal interview and Department Meetings. 2016-2017 6 Agency for Healthcare Research and Quality, National Healthcare Disparities Report (2015), Pub. Num. 16-0015, April 2016.

7 Ward, Brian W., et al. “Early release of selected estimates based on data from the 2015 National Health Interview Survey.” National Center for Health Statistics. March (2015).

8 Dai, Dajun. “Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit.” Health & place 16.5 (2010): 1038-1052.

9 Avila, Rosa M., and Matthew D. Bramlett. “Language and immigrant status effects on disparities in Hispanic children’s health status and access to health care.” Maternal and child health journal 17.3 (2013): 415-423.

10 Regenstein M, Mead H, Muessig, K. E., et al. (2008).

Challenges in language services: Identifying and responding to patients’ needs. Journal of Immigrant and Minority Health/Center for Minority Public Health 11 Flores, G., Abreu, M., & Tomany-Korman, S. C. (2005).

Limited English proficiency, primary language at home, and disparities in children’s health care: How language barriers are measured matters. Public Health Reports, 120(4), 418–430 12 García-Armesto, Sandra, et al. “Spain Health System Review”. European Observatory on Health Systems and Policies. Vol 12. No. 4, 2010.

13 World Health Organization. “Density of physicians (total number per 1000 population, latest available year).” (2015).

14 Jenkins, Stephen P., et al., eds. The great recession and the distribution of household income. OUP Oxford, 2012.

15 European Commission, 2009. Solidarity in Health: Reducing Health Inequalities in the EU. Brussels.

16 Carrasco, Raquel, Juan F. Jimeno, and Ana Carolina Ortega Masague. “Accounting for changes in the Spanish wage distribution: the role of employment composition effects.”

(2011).

17 Coveney, Max, et al. “Health disparities by income in Spain before and after the economic crisis.” Health economics 25.S2 (2016): 141-158.

18 Spanish Government. Programa Nacional de Reformas (National Program of Reforms). La Moncloa, 2013.

19 Cimas, Marta, et al. “Healthcare coverage for undocumented migrants in Spain: regional differences after Royal Decree Law 16/2012.” Health Policy 120.4 (2016): 384-395.

20 Casino, Gonzalo. “Spanish health cuts could create “humanitarian problem”.” The Lancet 379.9828 (2012): 1777.

21 Legido-Quigley, Helena, et al. “Will austerity cuts dismantle the Spanish healthcare system?.” BMJ (Clinical research ed) 346 (2013): f2363.https://www.ushmm.org/wlc/en/article. php?ModuleId=10007392 22 “Spaniards Say No to Privatized Healthcare.” In These Times. N.p., n.d. Web. 11 May 2017.< http://inthesetimes. com/article/16423/spaniards_say_no_to_privatized_ healthcare> 23 Siciliani, Luigi, Valerie Moran, and Michael Borowitz.

“Measuring and comparing health care waiting times in OECD countries.” Health policy 118.3 (2014): 292-303.

24 Burriel, Miguel. Personal Interview. March 2017 25 Benach, Joan. Personal Interview. March 2017.

26 Jovell, Albert, et al. “Public trust in the Spanish health‐care system.” Health Expectations 10.4 (2007): 350-357.

27 OECD. Publishing. Health at a glance 2011: OECD indicators. OECD publishing, 2011.

MEET THE AUTHOR Justin Onwenu (’18) is a student studying International Health and Policy.

As a high school student interested in biology and politics, ready to “change the world,” he wrote in my college admissions application to Rice, “I will take my interests in microbiology, public policy, and international relations to tackle diseases globally. My destinations are: India, Cuba, Israel, Iran, Spain, UK, Nigeria, and China . I will also travel the world, from the World Health Organization in Geneva to Haiti, meeting, learning, and curing.” These goals have not changed and he is so grateful for GUL for this wonderful opportunity. On his research, he adds, “Access to quality healthcare is one aspect of public policy that everyone in the world can relate to. In the United States, for decades and in recent years, our healthcare system has endured a lot of contentious debate. I truly do believe that the United States can provide high quality care at low costs to all Americans with the right research and leadership.

Looking to models around the world is imperative to understanding the intricacies of this topic and in leading this change.”

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healthcare EXECUTIVE SUMMARY

III. RECONSTRUCTIVE SURGERY

FOR SURVIVORS OF FEMALE GENITAL CUTTING

Female genital cutting (FGC) is the removal of female genitalia. While mainly occurring in Africa and the Middle East, migratory patterns to areas around the globe have made the issue prevalent worldwide. Because FGC is a cultural practice steeped in tradition, many women from these communities consider it to be a necessary ritual, and subject their daughters to the practice. However, as African and Middle Eastern families settle abroad, women and young girls are exposed to vastly different social norms and begin to advocate against and find solutions to the performance of genital cutting in their communities.

One such solution is reconstructive surgery, a procedure that attempts to repair physical damage to external genitalia.

Albeit controversial, survivors in the developed world are undergoing the operation and influencing loved ones to do the same.

This paper investigates clinical versus preventive stances on FGC and reconstructive surgery in Barcelona and Houston. Through interviews and literature analysis, the research focuses on the response of survivors to reconstructive surgery, and highlights organizations and policies that increase or bar accessibility to the procedure. A comparison of reconstructive surgery for FGC to genital cosmetic surgery is presented, and factors that surround the perceptions of each are analyzed.

INTRODUCTION

Female genital cutting is a traditional ritual with symbolic meanings and nuances in many communities around the world. The practice has a plethora of social functions, and a dense history behind it. Oftentimes, the practice is considered a rite of initiation into society to demonstrate the worth of a woman, as well as exhibiting the femininity and purity of a young girl

to her peers (AAP, 1998). In certain Sudanese communities, the word “tahur” is used for genital cutting, and translates to “purification”, conveying that its ultimate purpose is to cleanse women (Gruenbam, 2001).

And in yet other communities, female genital cutting holds implications for a women’s role and honor in her current family, and future one through marriage and childbirth (Hayes, 1975). In addition to the social impact that FGC holds through its variance in function, it also has physical consequences.

The World Health Organization enumerates the consequences, including frequent urinary tract infections, bacterial vaginosis, painful menstruations, pain and decreased satisfaction during sexual intercourse, and an increased risk of childbirth complications. Additionally, young women experience depression, posttraumatic stress disorder, and other psychological problems (WHO, 1997).

Research has shown that female genital cutting is performed on women in their prepubescent stages, with some being cut at ages as young as 5 or 6 years. Because most survivors undergo the ritual during their developmental years, these effects are felt over the course of a lifetime, and have significant impact on body image and self-perception (Reuters, 2013).

The process of female genital cutting can be classified into 4 categories. Type 1, clitoridectomy, involves the removal of the clitoris. Type 2, excision, includes removal of the clitoris and the inner folds of the vulva (labia minor). Type 3, infibulation, narrows the opening of the vaginal canal through the construction of a seal; the vulva is partially cut, repositioned, and stitched over the opening. Type 4 covers any other procedure done to female genitalia for non medical purposes (AAP, 1998). Reconstructive surgery directly tackles the physical aspect of genital cutting by repairing wounds from these four categories (Gultekin, 2016).

Reconstructive surgery for survivors of FGC is a new and emerging solution for women who have been cut. Pioneered

by Frenchman Dr. Pierre Foldes, the doctor developed surgical techniques to repair the vast damages caused by FGC (Crossing Continents, 2014). The technique has the capability to remove scar tissue from the vulva and decrease pain during urination, childbirth, and intercourse. The procedure additionally preserves nerves and blood vessels to restore function to the clitoris (Reuters, 2013). Although developed in the late 20th century, genital reconstruction is just now beginning to take off, but research on the topic from a comprehensive array of perspectives is lacking. The procedure has different meanings to varying groups, all of which will be discussed.

To surgeons, it is an innovative tool in a medical arsenal for the purpose of restoring function. To advocacy organizations, it is a point of contention as activists struggle to label the surgery as friend or foe to their cause. But for the most important group, women who are cut, it is an opportunity to reclaim

what had once been stolen from them. This paper will look into each perspective, and combine them for a multi-faceted review of reconstructive surgery for survivors. It will serve as a resource for young women considering the practice, along with surgeons and organizations struggling to understand the issue fully. Lastly, ideas presented here will urge the Western world to ponder over their perceptions of cultural practices in Africa, and the similarities of the developed world to the underdeveloped.

ISSUE STATEMENT

Genital reconstruction is much more readily available in Barcelona than in Houston. However, in both cities, resources for FGC and reconstruction are not widely advertised or well known.

Factors that inhibit or conversely aid access to the life changing procedure such as price or attitude need to be analyzed, and solutions found to make the surgery more accessible and

acceptable for survivors.

Much could be added to current research on reconstructive surgery for survivors of female genital cutting. The topic lies at a vital intersection of public health, Womenâ&#x20AC;&#x2122;s and Childrenâ&#x20AC;&#x2122;s health, and treatment in lieu of prevention.

Notably, the topic also emphasizes the intersection of physical and mental health, and highlights the importance of holistic healthcare in all contexts.

RESEARCH & METHODS

Although female genital cutting is an issue in both cities of focus, there is a variance in intensity of the problem and accordingly, in constructed amenities for survivors. This is for a variety of reasons. To investigate this and delve deeper into factors behind this disparity, interviews were conducted in Barcelona and Houston, along with a literature review on the topic in both areas, and secondhand accounts from survivors of FGC themselves. Genital cutting is an extremely sensitive topic

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and it is difficult to find survivors willing to recap this vulnerable time in their life, and subsequently, how the experience influenced later decisions on reconstruction. This study communicates an array of indirect interactions with survivors, through podcasts, news articles, and the experiences of surgeons whom have administered to hundreds of survivors.

Female genital cutting originated and is mainly practiced in sub-Saharan African, along with areas of the Middle East, Asia, India, Malaysia, and Indonesia. With increased migratory movements of these families to Europe, Australia, and the United States for a better life, the culture preserved in the move includes FGC, subsequently making the practice a global issue (Gultekin, 2016).

In order to determine the risk of FGC occurring in either city, it was necessary to take a look at population sizes from high risk countries. Officially, 16,000 Senegalese immigrants alone reside in Catalonia, a third of the total Senegalese population in the entire country of Spain (Hammargren, 2013).

Unofficially, these numbers may be a lot higher. Spain and itâ&#x20AC;&#x2122;s cities hold a high number of African and Arab immigrants, with statistics that are only expected to grow. Because Spain is bordered by African countries such as Morocco, there is increased access to Europe, and rates of illegal immigration into Spain are high. Immigrants scale vast border fences, or in extreme cases, swim across the sea in order to make a way for themselves and their loved one. They come seeking refuge from conflict zones, war, poverty, and political instability, and oftentimes sacrifice their life savings to be smuggled across the border, arriving in Spain with nothing but the clothes on their backs. Economic instability in the home countries of immigrants is a large factor contributing to emigration, and a problem that transfers with migration. Traveling abroad has become a ritual in these communities, and young men are encouraged by their families to migrate in order to find jobs, and send money back to those left behind (Hammargren, 2013). The large influx of African immigrants to

Spain has increased the prevalence and risk of young women being cut in the country, and the practice infiltrating throughout major cities such as Barcelona. Although some countries that the immigrants reside from are slowly eradicating the process, others continue to use the tradition of physical initiation. Two such countries are Senegal and Somalia, both which have had heavy retention of female genital cutting over the centuries.

Studies show that multiple areas in southern Senegal have a prevalence of the ritual at rates of 92% in Kedougou, 85% in Tambacounda and Kolda, and 35% in Matam (28toomany, 2015). A large proportion of immigrants reside from these locations, and have forced Barcelona to prepare for this emerging health shift.

While Houston remains one of the most diverse cities in the nation, with a significant number of immigrants from all over, the levels of African immigrants are nowhere near those of Barcelona. In 2013, Houstonâ&#x20AC;&#x2122;s foreign born population was at 1.3 million persons, with the largest group of African immigrants being a cohort of 20,000 Nigerians (Capps, 2015).

Houstonâ&#x20AC;&#x2122;s immigrant population continues to grow rapidly, but most of this growth is due to other foreign born groups. The most prominent immigrant issues are from groups that do not practice FGC, namely Hispanic populations. Focusing on the Nigerian population, a recent study pamphlet

indicates that 27% of Nigerian women are subjected to female genital cutting.

In stark contrast, a striking 98% of Somalian women undergo FGC. This is in addition to the Senegalese population, with a 26% rate of genital cutting (Sanidad, 2015). The prevalence and risk of FGC in each city as a result of their largest African populations varies, and as a result, less resources are geared towards the eradication of FGC in Houston than in Barcelona.

The study next looked to what steps Barcelona and Houston have taken to deal with the issue of FGC. Additionally, the factors in each city that have contributed to reconstructive surgery being available and accessible were analyzed.

FINDINGS

Access & Policies Spain runs on a public healthcare system, one in which health care is provided for by the government through public funding (Basu, 2012).

Through the Spanish National Health System, legal immigrants have the right to access public health care. However, illegal aliens also utilize the public healthcare system, and in 2007, were hospitalized and in use of healthcare resources at higher rates than natural born Spaniards (Carrasco-Garrido, 2007). In addition to the accessibility of the health system, programs that may have additional costs are offered free of charge independently through

clinics and programs.

One such example is genital reconstruction in Barcelona.

Gynecologist Pedro Barri, one of the first apprentices of aforementioned Pierre Foldes, introduced the technique to Spain after studying the procedure with the French. Barri now heads a genital reconstruction program at Dexeus Hospital in Barcelona.

He, along with fellow surgeons at Dexeus, perform the treatment free of charge for survivors and work to find organizations and sponsors to fund it (Crossing Continents, 2014).

In the program’s initial stages, finding participants among Barcelona’s immigrant population was extremely difficult, especially when considering the sensitivity of the subject.

However, since the onset of Barri’s free reconstruction program in 2008, the numbers of women seeking surgery has steadily increased, and continues to climb (Wheatley, 2014). The clinic is being utilized more widely, as word spreads, is having a significant impact on survivors in Barcelona.

On the other hand, no such reconstructive program is found in Houston, only individualized cases. A study from doctors at Baylor College of Medicine described a reconstructive procedure performed on a woman from Morocco, whom had been undergone genital cutting in her home country at the age of 10. Since migrating to the States, she had pursued genital reconstruction at various places, only to be turned away twice before doctors at BCM agreed to the procedure. For her specifically, barriers to reconstruction were due to her lack of insurance, and her inability to pay out of pocket as due to socioeconomic status. Additionally, in prior instances, doctors had been uncomfortable offering treatment because of a lack of familiarity with cutting procedures (Craven, 2016).

Unlike in Spain, the United States private healthcare system prompts increased prices for the uninsured (Ku, 2001) . This combined with a decreased knowledge of FGC and reconstruction techniques were huge impediments.

Even without a distinct program, access to reconstructive surgery was finally found in Houston as a result

of motivated doctors with education about the procedures, techniques, and results of the surgery.

Barcelona also has a number of policies directed at female genital cutting and reconstructive surgery. Spain is a part of the European Union (EU), and subject to it’s laws. In 2012, the Council of the European Union adopted conclusions to “combat violence against women and provide support services to victims of domestic violence” (Ministry of Health, 2015). Specified among the conclusions was a note referring to FGC, that it was to be considered a form of violence against women, and that countries of the EU would receive support in any and all measures established to face the practice of FGC. On a smaller scale, upon identifying women who have been cut, healthcare professionals are required to inform and remind the women of the benefits of reconstructive surgery. Protocol notes that in many cases, even with local anesthesia, woman cannot handle the procedure because painful memories become unleashed (Ministry of Health, 2015).

Perspectives on Reconstruction There is some discontent toward the option of reconstructive surgery. Nora Salas, technical director of the Wassu Foundation in Barcelona speaks out against genital reconstruction for FGC survivors. The Wassu Foundation advocates for the eradication of FGC in Barcelona and in the Gambia, and

strives to incorporate and consider the cultural significance of the ritual in their efforts. One motto is “initiation without mutilation”, as a reminder to to help communities recognize that women can be considered worthy of their society, without going through a painful and inhumane process (Wassu, 2017). This goal is mainly achieved through frequent educational sessions with families that are at risk of cutting their girls, to influence family heads and community leaders to speak out against the practice. From a public health perspective, Wassu takes a very upstream approach to solving the problem of FGC. Their resources and personnel focus on the thought processes, culture, and nuances of the practice in order to end it. They engage communities through an emphasis on prevention based problem solving from the root of the issue, in this case, the social aspect. From this unique perspective, Wassu maintains that they do not recommend women to physicians or programs that perform the surgery (Salas, 2017).

Keeping the mission of Wassu in mind, and coming from background in psychology, Salas argues that reconstructive surgery offers a quick solution to a ritual with tales as old as time, and centuries of development.

Reconstructive surgery is temporary and has a individual, small impact, while prevention is long term, sustainable, and culturally impactful. Physicians need to ask if it is irresponsible to slap

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a suture on a gaping cultural wound, and rather than asking hard questions about the practice itself (Salas, 2017).

Salas brought up another excellent point, that although reconstructive surgery heals physical wounds, it also completely disregards the psychological ones. Many of the complications from FGC are physical, but a significant amount of it’s consequences affect mental health. Women report suffering from chronic depression, anxiety, low self-esteem, and post traumatic stress disorder as a direct result of childhood cuttings. Physicians should be made aware of this, and required to conduct an extensive psychological evaluation before performing a reconstruction.

Many of the personnel at prevention organizations agree that some of the psychological consequences of female genital cutting should be talked through with a licensed therapist, with the hope of being solved through acknowledgement and confrontation of the memories. FGC is a traumatic event, both for the woman and her peers, and the mental aspect of healing is just as significant as the physical. For example, a surgeon in Spain described instances in which young women seeking reconstructive surgery would seek out Dexeus clinic’s free program.

However, after an examination, the genitalia appeared to be intact and healthy. These women retained memories of seeing it performed on others, and yet experienced similar symptoms and feelings of inferiority (Wheatley, 2014). In this case, the defining factors of FGC that made them believe they had been cut were not physical pain or lack of sensation, but memories of terror, feelings of trauma, and experiences with depression and anxiety. Relatedly, not all reconstructive surgeries are successful, partly because of the psychological aspect. About 10% of women report no change in sensation to their clitoris or during intercourse.

In interviews, surgeons have reported that a lack of improvement in this group may result from “psychological reasons” that could not be corrected or overcome with the surgery (Wheatley, 2014). Several cohort studies of women undergoing genitalia

reconstruction around the world have shown smiler averages in percentages for psychological and physical strides made. Above are results of followups from one such cohort of women from a cohort study conducted in Egypt (Seifeldin, 2016).

This being said, in most instances, quality of life and wellbeing, due to psychological improvements, rise in the aftermath of reconstructive surgery, even without consulting a trained mental health professional (Seifeldin, 2016). Survivors of FGC opt for reconstruction to reclaim their sexual identity. As aforementioned, female genital cutting is a tool, not only of initiation but also of constraint. It is often welded by men to control the femininity, sexuality, and virginity of young girls. It is utilized to deem some pure or impure, and to form a standard of womanhood to be attained, even though by birth, it has already been reached. Upon migrating, woman recognize the power dynamics behind genital cutting, and in response, use reconstructive surgery to strip the dynamics of their power (Crossing Continents, 2014). Reconstructive surgery provides an opportunity for the bold empowerment of women who had previously been stripped of it.

Women additionally report increased sexual satisfaction, decreased pain during menstruation, decreased pain during intercourse and childbirth, and vast increases in confidence, self-

esteem, and body image (Wheatley, 2014). However, a study in Egypt reported that enhanced satisfaction during intercourse may be due to increased confidence and image more so than a functional and exposed clitoris (Seifeldin, 2016). This further emphasizes and supports the stance of Wassu’s technical director, that psychological evaluations may fix a problem that a surgery is tackling.

This would especially be pertinent for women that opt out of reconstructive surgery, because they don’t want additional cutting of their genitalia.

However, this is not to say that the decision for reconstruction is made lightly. Surgeons describe women coming to frequent consultations for reconstruction, with a desire to undergo the procedure (Wheatley, 2014). Time and time again, they hesitate because of a deep rooted respect for the culture of their communities, both in the home countries, and presently. Additionally, the surgery may garner threats and disapproval, resulting in isolation and ostracization from family members and the community at large (Crossing Continents, 2014).

Conversely, many times, the deciding factor for women seeking reconstruction was through familial and spousal prompting. In Baylor’s study, a woman that had been turned away by doctors numerous times renewed her search because complications of FGC began to cause stress in her marriage

(Craven, 2016). News articles have highlighted young women whose main reason for reconstruction is to increase sexual pleasure and satisfaction with boyfriends. And seen most often, first generation immigrants to Spain experience a shift in perceptions, and undergo reconstructive surgery.

Through their actions, mothers, aunts, and sisters have been prompted to do the same, and feel the confidence and support to seek reconstruction (Wheatley, 2014).

Comparison to Western Practices Literature has shown a rise of women in the United States seeking cosmetic vaginal surgery. The American Society for Aesthetic Plastic Surgery released information that since 2014, there has been an 80% increase in girls 18 years and younger that had cosmetic genital surgery done (Rabin, 2014). This is a result of increased social media and online accessibility to images of the vulva, along with frequent recommendations and descriptions of the “perfect body” or “ideal shape” (Maltby, 2011).

Other than a couple of hidden doctors, there were no resources in Houston specifically aimed at reconstructive surgery for survivors. Yet, a quick internet search will show that there are a plethora of plastic surgery clinics, with vast resources and options for the women to look her best.

Similarly, Barcelona contains extensive opportunities in which women can undergo cosmetic genital surgery.

In a radio show’s interview with Pedro Barri, he posited that in addition to gaining feelings of confidence, reasons for reconstructive surgery are that FGC survivors “just want to feel like European women” (Wheatley, 2014).

Earlier in this paper, it was implied that assimilation into European culture results in a shift of social norms, and instills a desire to seek solutions to genital cuttings. One could assume that in Barri’s statement, he meant that patients want to feel free to make their own sexual choices, and safe in these decisions. Delving deeper, however, the nuances of this statement imply that patients want to feel liberated,

and free from the social and cultural bondages of their home countries.

This in itself is problematic, and points to a gaping hole in the developed world’s treatment of women and social pressures towards women.

It can be argued that a women feeling social pressure to the point of undergoing surgery to change her face, breasts, genitalia, etc is a form of societal acceptance very similar to the ones practiced in African and Middle Eastern countries (Aguado, 2009). Stigma impacting a women to the level of voluntary physical change sends a message about our culture, and warrants a hard look into our culture’s ideal for femininity (McGrath, 2000).

A country with liberated women doesn’t mean that they are free. A culture with women making their own choices doesn’t mean that those choices are without influence. And a forced hand doesn’t necessarily have to be physical, but can also be social. The next logical question to ask is if vaginal cosmetic surgery is a form of FGC, but self-invoked. The World Health Organization defines FGC as any cutting of the genitalia for “non-medical reasons”, and this is for purely aesthetic change (WHO, 2017). If vaginal cosmetic surgery can be considered as a subset of FGC, the train of thought that follows that follows is why we don’t deem it to be so (Aguado, 2009)? This question is one to be investigated in future studies.

This is not to suggest that female genital cutting is in any way acceptable.

But this point serves to highlight the ways in which cosmetic vaginal surgery may be a modern form of genital cutting, with the same intents, ideals, and purpose, just in differing contexts (Aguado, 2009). For every survivor that goes through genital reconstruction, there are many that do not. Outside of family and community influences, the main barrier to reconstruction for these individuals is fear that it would be a second cutting (Crossing Continents, 2014). Similarly, any form of cutting of the genitalia has the potential to be labeled as such.

Interestingly enough, people don’t skate around plastic surgery or

vaginoplasty. Women that choose this may be lauded or ridiculed, but are accepted all the same. A study of teenager’s highlighted two main themes in perceptions of women opted for cosmetic surgery; these women were labeled as “motivated” or “vain” (Weston, 2003). Clearly, the internal battles and risk of isolation that African women face in pursuing reconstruction is not replicated for

“For every survivor that goes through genital reconstruction, there are many that do not. ” aesthetic procedures.

Doctors try to combat these perceptions by noting that these images are mostly airbrushed or Photoshopped, and an inaccurate portrayal of female genitalia (Rabin, 2014). In, the committee on Adolescent Health Care, through the American College of Obstetricians & Gynecologists has new recommendations on adolescent requests for genital cosmetic surgery. After offering education and nonsurgical alternatives, patient counseling and a physical maturity assessment is conducted. If deemed appropriate, patients will be screened for body dysmorphic disorder (ACOG, 2017). Unfortunately these recommendations did not come out until earlier this year, and even so, do not apply to individuals older than the age of 18.

CONCLUSIONS

Survivors of genital cutting face immense amounts of shame and

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trauma in discussing the events of their past, and the implications it has had on their future. Genital cutting has impacted their whole self, and is a sensitive topic both for survivors, and those that hear their stories.

One young woman described it as the stealing away of her life, while another likened the ritual to rape and abuse. Genital reconstructive surgery has granted hundreds of women the opportunity to work through their shame, and reclaim their identity and feminine sexuality. However, while the impact of reconstructive surgery is huge for survivors of female genital cutting, the psychological aspect is just as important. In the aftermath of this study, it is recommended that organizations such as Wassu send trained therapists and psychologists to clinics for evaluations, in conjunction and collaboration with physicians.

Alternatively, physicians that perform reconstructive surgeries can be required to take competency and evaluation courses.

Survivors of FGC that decided to go through reconstruction were the largest influence on their peers to do the same. Strong relationships of sisters, mothers, and dear friends pushed others to also be empowered to make their own sexual health choices. This speaks to the nature of African communities. On one hand, the strength of social networks promotes positive change, education, and empowerment for women that were previously marginalized. On the other hand, the cohesiveness of the same networks may contribute to a certain groupthink or fear of deviating thought, subsequently contributing to centuries of the practice of female genital cutting without a clear end in sight.

Additionally, it is important to consider that when reconstructive surgery is presented to survivors, the effects of the surgery are touted. It would be beneficial for an trial to be done on a control group and experimental group, in order to determine a potential placebo effect through One group will be told benefits of the surgery in purely pertaining to the physical, while the other group is told in a physical and

mental context. Both followups would then be evaluated.

BIBLIOGRAPHY

Committee on Bioethics. (1998). Female genital mutilation. Pediatrics, 102(1), 153-156.

UNICEF, & World Health Organization. (1997).

Female genital mutilation: a joint WH. Thomas Reuters Foundation. (2013, May 28). How female genital mutilation blights life - Interview with French urologist, Pierre Foldes. Retrieved May 10, 2017, from https://www.youtube.com/ watch?v=ob3wsi30ZlQ Paterson, L. Q., Davis, S. N., & Binik, Y. M. (2012).

Female genital mutilation/cutting and orgasm before and after surgical repair. Sexologies, 21(1), 3-8.

Hammargren, C. (2013, January 18). Senegalese migrants in Spain fight for survival. Retrieved May 11, 2017, from https://www.equaltimes.org/senegalesemigrants-in-spain-fight-for-survival?lang=en#.

WREaz2Tyv-Y Gültekin, İ. B., Altınboğa, O., Dur, R., Kara, O. F., & Küçüközkan, T. (2016). Surgical reconstruction in female genital mutilation. Turkish journal of urology, 42(2), 111.

Carrasco-Garrido, P., De Miguel, A. G., Barrera, V. H., & Jiménez-García, R. (2007). Health profiles, lifestyles and use of health resources by the immigrant population resident in Spain. The European Journal of Public Health, 17(5), 503-507.

Ku, L., & Matani, S. (2001). Left out: immigrants’ access to health care and insurance. Health Affairs, 20(1), 247-256.

Basu, S., Andrews, J., Kishore, S., Panjabi, R., & Stuckler, D. (2012). Comparative performance of private and public healthcare systems in low-and middle-income countries: a systematic review. PLoS med, 9(6), e1001244.

Craven, S., Kavanagh, A., & Khavari, R. (2016). Female genital mutilation management in the ambulatory clinic setting: a case study and review of the literature.

Journal of Surgical Case Reports, 2016(6).

Wheatley, Jane. (2014). Undoing the Damage. The Sydney Morning Herald. Retrieved May 11, 2017, from http://www.smh.com.au/world/undoing-thedamage-20140427-37csl.html Sanidad. (2015). Common Protocol for a healthcare response to Female Genital Mutilation. Ministry of Health.

Seifeldin, Amr. (2016) Genital Reconstructive Surgery after Female Genital Mutilation. Obstet Gynecol Int J 4(6): 00129.

Rabin, Roni Caryn. (2016). More Teenage Girls Seeking Genital Cosmetic Surgery. The New York Times. Retrieved May 10th, 2017 from https:// well.blogs.nytimes.com/2016/04/25/increase-inteenage-genital-surgery-prompts-guidelines-fordoctors/?_r=0.

Pearl, A., & Weston, J. (2003). Attitudes of adolescents about cosmetic surgery. Annals of plastic surgery, 50(6), 628-630.

McGrath, M. H., & Mukerji, S. (2000). Plastic surgery and the teenage patient. Journal of pediatric and adolescent gynecology, 13(3), 105-118.

Aguado, T., & Del Olmo, M. (2009). Intercultural education. Perspectives and proposals. Madrid: Proyecto ALFA. Retrieved from http://www. uned. es/grupointer/interalfa_book+ english. pdf.

ACOG Committee on Adolescent Health Care. (2017).

ACOG Committee Opinion Number 686, May 2016.

Breast and Labial Surgery in Adolescents. Obstet Gynecol 2017:129:e17–9.

Presley, Linda. “Spain: Operation FGM”. Crossing Continents Podcast. N.p., 2017. Web. 24 Feb. 2017.

Salas, Nora. Wassu Technical Director. 2017. in person. March 14th, 2017. The Universitat Autonoma de Barccelona.

Capps, R., Fix, M., & Nwosu, C. (2015). A Profile of Immigrants in Houston, the Nation’s Most Diverse Metropolitan Area. Migration Policy Institute, March.

28TooMany. June 2015. Country Profile of FGM in Senegal.

Wassu Foundation. (2017). Methodology. Retrieved May 10th, 2017 from http://www.mgf.uab.es/eng/ methodology.html.

Gruenbaum, E. (2001). The female circumcision controversy: an anthropological perspective.

University of Pennsylvania Press.

Chicago

MEET THE AUTHOR Aislyn Orji (’18) is a student studying Health Sciences with a minor in Sociology. As a first-generation Nigerian-American, her interest in public health was sparked through directly encountering health disparities in her native country. At Rice, she has been a part of several Alternative Spring Break trips through the Center for Civic Leadership, which have allowed her to investigate the impact of health on homeless populations.

Additionally, she particularly has an interest in global public health, with an emphasis on maternal & child health.

Aislyn is currently an undergraduate fellow with the Kinder Institute’s Urban Health Program. She aids principal investigators in looking into health effects from environmental pollution, as well as food insecurity for children.

BUSINESS IV. EXPLORING ENTREPRENEURSHIP Dylan Dickens V. MEGA-EVENTS, MEGA-PROBLEMS Noah Reich VI. THE HOUSING FINANCIAL CRISES Taylor Morin

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IV. EXPLORING ENTREPRENEURSHIP business ABSTRACT

A Comparative Policy Analysis of Barcelona and Houston

One of the biggest dilemmas for municipal policymakers when attempting to foster entrepreneurship in their city is determining the degree to which government intervention is beneficial for their city’s entrepreneurship ecosystem. While much of the literature tends to support the notion for minimal intervention, this study proposes both that a degree of government intervention during the initial phases of fostering an entrepreneurship ecosystem can prove to be beneficial for the ecosystem in the long run, and that an ecosystem too reliant on government support may find its opportunities for growth stunted.

These conclusions are based on a mixed-method comparative analysis of Barcelona, Catalonia, and Houston, Texas, two cities with approximately similar metropolitan statistical area

populations yet radically different approaches to entrepreneurship.

Quantitative analysis of venture capital investment into each city was conducted as was a series of in-depth qualitative interviews with primary entrepreneurship stakeholders in each city. Ultimately both sets of data suggest that government intervention has succeeded in starting a healthy entrepreneurship ecosystem in Barcelona, yet is currently stifling it, and that Houston’s lack of initial government intervention correlates to its lack of a healthy entrepreneurship ecosystem despite having many private resources.

INTRODUCTION

Entrepreneurship is far more than just a catchy buzzword or a college student’s pipe-dream, but rather an integral and important component of every economy. When discussing

entrepreneurship, it is critical to draw a distinction between entrepreneurship’s two sides. One type of entrepreneurship is small business, consisting of individuals who decide to employ themselves and occasionally a few others in a sector that is already established in ways that are usually align with the norm (Egan 2016), (Hochberg 2016).

These can be visualized as “typical mom and pop outfits.” While these businesses usually have no international renown and little ambition for growth, they have an immense value. Small businesses, in conglomerate, make up the vast majority of businesses in any nation and employ more individuals than any company. In effect, the millions of small businesses together form the powerhouse of the global economy, but lack the growth and expansion required for sustainable economic development

at the national level (Egan 2016).

This is where the other kind of entrepreneurship, start-ups, comes in. Start-ups, in contrast with small businesses are generally high-tech, high growth businesses that either invent their own sectors or disrupt previously established ones. Start-ups have huge ambitions, with massive potential for growth, and develop into the landmark businesses of any nation (Hochberg 2016). These can be visualized as companies like Facebook, Skype, Uber and AirBnB. Startups, due to their high growth and disruptive presence, shake up nation’s economies, create new jobs and force the economy as a whole to adapt for the better.

While both type of entrepreneurship are critical, this comparative analysis focuses on the latter, high-growth, high-tech start-ups. In order for startups to “start-up,” a complex and healthy entrepreneurship ecosystem must be maintained (Egan 2017).

These ecosystems can consist of some combination of the following; research universities, corporate giants, private support institutions like accelerators and incubators, angel investors, governmental support, private equity capital, and of course, ambitious entrepreneurs (Hochberg 2016). This study examines the ecosystems of two coastal cities, Barcelona, Catalonia, Spain, and Houston, Texas, U.S.A., with broadly-defined metropolitan statistical areas of between five and seven million people (U.N. 2009) each in order to develop further research on the question of whether or not government intervention is beneficial for an entrepreneurship ecosystem.

ISSUE STATEMENT

Municipal policy makers must understand and nurture the entrepreneurship ecosystem should they strive to turn their cities into hubs of innovation and entrepreneurship.

One of the largest disagreements in the literature on entrepreneurship ecosystems concerns the amount of government intervention required for a healthy ecosystem. Two bodies of thought exist, one that claims government intervention, especially

before the arrival of private resources, tends to foster entrepreneurship, and one that claims government intervention generally crowds-out and over-regulates the already fragile entrepreneurship ecosystem. A brief review of the literature on government intervention in entrepreneurship ecosystems quickly shows both schools of thought.

A study of the ecosystem partnership between research universities, startups and the municipal government of Hong Kong, (Mok 2005), found that heavy government intervention into the ecosystem of Hong Kong helped to establish the island as the entrepreneurship hub it is today.

Another major study in this school of thought concerns the biotechnology focused ecosystem of Washington D.C. (Feldman & Francis 2010). Throughout Feldman & Francis’ report an argument is made that government intervention early on into the development of the Capitol ecosystem allowed for the ecosystem to better capitalize upon its first major start-ups.

Significant findings have been generated on the other side of this debate as well. A study of South Pacific entrepreneurs, (Yusuf 1995), found that government intervention only succeeds in very specific cultural and economic circumstances, and suggested that government intervention as a whole is not necessarily a good thing for all ecosystems. A second major study focused on Canadian entrepreneurship ecosystems and found that government intervention generally led to a crowding-out of non-governmental entrepreneurship support, weakening the ecosystem as a whole (Brander, Egan & Hellmann 2010).

In order to bring further dialogue to this debate, a comparative study of government intervention into entrepreneurship ecosystems was conducted. This report choses to focus on the coastal cities of Houston, Texas, U.S.A., and Barcelona, Catalonia, Spain, both of which have similar metropolitan statistical area populations of between five and seven million people and comparative

venture capital investment rates of within $20 million USD of each other. Through quantitative analysis of venture capital data and qualitative analysis of stakeholder interviews in both cities this report aims to answer whether or not government intervention is beneficial to entrepreneurship ecosystems. This question takes an added element of interest when comparing these two cities due to their cultural contexts.

Europe, and Spain in particular comes from a more interventionist economic background whereas America, and Texas in particular comes from a less interventionist economic background.

“Entrepreneurship is far more than just a catchy buzzword or a college student’s pipe-dream.”

RESEARCH AND METHODS

This study takes a two-pronged approach to comparison, utilizing both quantitative and qualitative research methods. The quantitative data is pulled from the SDC Platinum database, powered by Reuters. The SDC Platinum database is an excellent repository for venture capital data, recording the date, amount, type, provider and recipient of every properly documented venture capital investment with reliability since the early 1990’s. Plenty of other data is provided as well, allowing researchers to filter by city, date of start-up founding, start-up industry and many other criteria. For this report, the date of start-up founding, the date of investment, the start-up name, the type of investment, the city of the

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start-up, the amount of investment and the start-up industry were pulled.

In order to tailor the analysis for this report, each data pull was restricted only to start-ups that were based in either Barcelona or Houston and that received venture capital investment sometime between 2000 and 2016.

Two summary numbers for each city were then generated, one for traditional venture capital investment and one for total venture capital investment. This breakdown is rather common in the academic study of entrepreneurship, as both numbers reflect important information. Traditional venture capital consists of investments that can be guaranteed as venture capital without further investigation and is restricted only to investments of the following types: Seed, Early, Late or VC Partnership. Due to the nature of these types of investments, it can be nearly guaranteed that all investments of these types are functioning as venture capital.

Unfortunately, other types of investments such as Acquisition for Expansion, Bridge Loan or Expansion type investments can sometimes function as venture capital but do not always do so. Without a more extensive examination of the data than this report allows for, some of these other types of investments that are acting like venture capital do not get counted as traditional venture capital. This means that the traditional venture capital number likely consists entirely of venture capital investments, but represents a lower total overall investment than there actually is. On the flipside, the total venture capital number almost certainly includes some other types of investments that are not acting as venture capital.

Due to the constraints of the data, a perfectly accurate number can not be reached. A happy medium between the two is likely the closest to reality, and thus both numbers are provided for the best possible quantitative analysis.

The qualitative data is generated through anthropological fieldwork interviews with relevant entrepreneurship stakeholders

in both Houston and Barcelona.

Interviewees were identified according to their expertise in the world of entrepreneurship. All stakeholders interviewed were either researchers at a university or policy institute, partners at a venture capital firm, or members of the executive team of an entrepreneurship support institution.

The interviews were in person and flexible, with each interviewee being asked the same initial set of structured questions before breaking off into more unstructured questioning dependent upon both the expertise of the interviewee and the topic of discussion. These interviews were then codified and analyzed to produce the quantitative data for this report.

A methodology of framework comparison was used for this report.

For each city, first the quantitative venture capital investment data was analyzed, potential conclusions were drawn, and then qualitative interviews were utilized to either confirm or deny these conclusions. Should new conclusions be developed during the interview process, the quantitative data was then utilized to confirm or deny these latter conclusions. After each city had been analyzed, the two analyses were then compared to draw upon similarities and differences. This comparison, and the lessons learned throughout form the basis for the policy recommendations presented in the conclusion.

FINDINGS

Starting with the quantitative examination of venture capital, a variety of interesting findings are generated. The first major finding comes from the initial comparison of venture capital investment in each city for the typical year of 2016. The city of Barcelona received $110.73 million USD in traditional venture capital investment and $122.37 million USD in total venture capital investment in 2016 (Fig. 1).

While this number for traditional venture capital lies within a few million of Houston, which received $89.22 million USD in 2016, the story quickly changes when examining total

venture capital in which Houston received $803.19 million USD (Fig. 1).

The reason for this discrepancy of over 600% is likely due to the robustness of the Houston private equity market. This consists largely of big companies within Houston acquiring smaller companies before the smaller companies have a chance to take off.

Since this is recorded in the data as a large amount of money early on in a company’s life, it can sometimes be confused as venture capital like.

In interviews with Houstonian stakeholders, the Houston market was described as having a high amount of these deals that look “a little like something like venture capital” but are not truly investments into fledgling start-ups. More often these investments are non-venture buy-outs or acquisitions of smaller companies with little ambition for growth and shouldn’t be considered as entirely venture capital. While this “false” kind of venture capital can be found in any ecosystem, including Barcelona, the sheer amount of it in Houston makes studying entrepreneurship with a generous definition difficult.

Thus one of the first major findings of this report is that only the traditional venture capital can really be compared in this situation, yet both kinds may be analyzed separately.

When analyzing these numbers separately however, it is important to draw attention to the relatively small size of both ecosystems when measured in terms of venture capital.

Both cities appear to be floating around $100 million USD in traditional venture capital invested in a year.

While this number sounds quite large $100 million USD is comparable to the amount of investment a mature entrepreneurship ecosystem such as Silicon Valley or Boston’s Route 128 generates in a month or two (Egan 2016). A caveat to this comparison, pointed out by multiple interviewees on both sides of the Atlantic, is that European entrepreneurship markets will always be smaller than American ones. In addition, Barcelona is the smaller of the two cities in comparison and furthermore, by examining the

FIGURE 1. BARCELONA AND HOUSTON COMPARISON OF VC INVESTMENT 2000 - 2016 Barcelona Traditional YEAR

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Barcelona Total

AMOUNT (MIL)

$16.55 $6.76 $12.06 $0.96 $55.86 $4.01 $4.02 $2.84 $19.70 $152.24 $47.29 $73.09 $31.06 $46.97 $105.02 $45.68 $110.73

YEAR

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Houston Traditional

AMOUNT (MIL)

$44.55 $26.56 $28.07 $175.98 $81.15 $42.35 $181.40 $78.48 $82.58 $174.68 $160.58 $208.62 $67.34 $106.91 $141.18 $68.60 $122.37

YEAR

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Houston Total

AMOUNT (MIL)

YEAR

$589.51 $138.15 $130.57 $67.63 $74.28 $84.62 $87.65 $93.70 $236.43 $77.11 $72.60 $204.36 $72.08 $125.48 $138.90 $97.50 $89.22

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

AMOUNT (MIL)

$1,294.23 $460.73 $214.36 $141.88 $106.06 $253.61 $250.80 $191.91 $351.00 $137.14 $297.25 $455.86 $612.57 $170.94 $414.86 $239.53 $803.19

All data from SDC Platinum™ 2017

discrepancy in total venture capital investment rates, Houston clearly has more capital under management within the city. Thus a secondary finding from examining these comparative investment rates is that Barcelona appears to be over-performing and Houston underperforming in the entrepreneurship sector when considering size, economic style, and capital under management.

This is a very important finding within this comparative framework.

When seeking to answer a question in regards to the degree of government intervention in an entrepreneurship ecosystem, the finding that the ecosystem without a history of intervention appears to be disproportionately weak is very interesting. While this first quantitative finding can not support this conclusion alone, further quantitative data and qualitative testimony suggests that there is a causative effect between intervention

FIGURE 2. TRADITIONAL VENTURE CAPITAL INVESTMENT BY SECTOR 2000 - 2016

Sector

Barcelona Amount (Mil)

Houston Amount (Mil)

$107.49 $2.68 $2.03 $188.52 $3.43 $11.01 $170.48 $156.19 $91.56 $1.44

$338.95 $76.67 $97.36 $325.24 $13.50 $633.45 $468.93 $139.52 $138.16 $148.01

Biotechnology Communications and Media Computer Hardware Computer Software and Services Consumer Related Industrial/Energy Internet Specific Medical/Health Other Products Semiconductors/Other Elect.

All data from SDC Platinum™ 2017

and ecosystem performance.

The next major finding can be found by looking at the two cities traditional venture capital investment by sector (Fig. 2). Venture capital investments in Barcelona appear to be focused on the computer software, internet

and medical sectors, whereas in Houston the investments tend to be focused towards energy, internet and biotechnology. These numbers correspond with stakeholder interviews. Multiple contacts in Barcelona spoke to the city’s reputation

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FIGURE 3. TRADITIONAL VENTURE CAPITAL INVESTMENT BY TYPE 2000 - 2016

Type

Barcelona Amount (Mil)

Houston Amount (Mil)

$369.17 $258.30 $65.98 $41.38

$812.79 $1,269.16 $296.05 $1.77

Early Stage Later Stage Seed VC Partnership

All data from SDC Platinum™ 2017

FIGURE 4. TRADITIONAL VC INVESTMENT IN BARCELONA 2000-2016

amount invested in millions of dollars

200

150

100

50

0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 year since 2000

FIGURE 5. TRADITIONAL VC INVESTMENT IN HOUSTON 2000-2016 600 amount invested in millions of dollars

for online mobile game start-ups and its strong medical sector. Interviewees in Houston confirmed the city’s strong energy and biotechnology sectors.

Yet again however, Houston appears to be underperforming when compared with its Spanish partner. $633 million USD invested over 16 years in the energy sector is rather disappointing for the “Energy Capital of the World” points out one stakeholder interviewed in Houston. For the city to have the U.S. headquarters of Shell, Chevron, Schlumberger and Conocophillips but this little investment into energy start-ups seems to be a bit of a nonsequitur. It is well established in the literature that the presence of flagship corporations tend to promote entrepreneurship in similar sectors (Egan 2017). Houston is home to the world’s largest medical center, yet also does not possess the amount of biotechnology or medical investment as expected. Barcelona, in comparison, has a start-up reputation for its largest sector, and investment amounts over the past 16 years that appear to line up with the rest of Europe.

Each investment into a start-up is classified dependent upon the goals of the investment. Seed and early stage investments are for more nascent companies, whereas later stage investments and VC partnerships are for more developed companies and special cases respectively (Egan 2017).

When examining traditional venture capital by type of investment (Fig 3.) an interesting trend may be noted. For Barcelona the largest type of venture capital investment over the past 16 years is early stage. Since early stage investments are for companies that have a strong business model but are not yet operational, this data implies that Barcelona has lots of promising companies that leave the city to look for larger investments later on. In Houston the opposite story is true, Houston’s largest investment type is later stage.

This is another important finding. The distribution of type of investment implies that promising businesses do not turn to Houston as a place to start a business, but rather a mature

500 400 300 200 100 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 year since 2000

economy to settle down in. These assumptions are further confirmed by interviewers, who acknowledge

both the lack of later stage, or series B, funding available in Barcelona, and the puzzlingly disproportionate lack of

early stage investment in Houston.

Entrepreneurship is a difficult industry that can have boom and bust years, therefore it is critical to examine entrepreneurial investments over time (Fig. 4), (Fig. 5) in order to assemble the complete picture. When examining traditional venture capital in Barcelona (Fig. 4) an overall trend of growth can clearly be seen. With the exception of a minor bump in 2004, Barcelona experienced little growth in the early 2000’s. In 2009, there was a large and unsustainable jump in investment, which quickly dropped (Fig. 4). After the drop, Barcelona experienced more sustainable growth was measured from 2009 onwards. The timeline of growth within the city appears to align well with the city’s emphasis on early stage investment and attempts to spur on entrepreneurship.

When looking at Houston the picture is a little different (Fig. 5). The city clearly experienced its year of unsustainable growth in 2000, likely a reflection of the larger American “.com bubble.” Following 2000, there has been relatively little growth, and save for exceptional years in 2008 and 2011 (Fig. 5), Houston has largely seen around the same amount of traditional venture capital invested each year.

While Barcelona is following a path towards growth and received more investment in the past year than any of the 5 years preceding, Houston is on a path of stagnation, and is currently receiving around the same amount of investment as it did 10 years ago, without adjusting for inflation. While Barcelona may be receiving more in terms of raw investment in USD, when factoring for the European market, the population discrepancy and Houston’s lack of growth, it is clear that Barcelona is the superior city when comparing entrepreneurship ecosystems.

In conglomerate the quantitative data tells a compelling story when concerning the cities of Barcelona and Houston. Barcelona, the smaller city in a smaller market with less capital under management and a smaller number of flagship companies appears to be maximizing the resources it has and outperforming the city of

Houston. With a larger population, larger market, more capital under management and a plethora of flagship companies, Houston should be doing far better. While the quantitative data can help suggest what some of the cause of this difference may be, this report turns to the qualitative data to further understand what differences may be behind this discrepancy.

When interviewing major stakeholders in Houston, the rhetoric is always the same, namely that Houston had all of the right resources but that something didn’t kick off quite right. Within the southern part of the United States both Denver and Austin became known as the hubs for entrepreneurship, while Houston focused on developing its medical and energy sectors. As time progressed, entrepreneurship never really became a priority for the city, and overtime the city fell behind many other American cities of fewer resources that spent those resources on starting up an entrepreneurship ecosystem. The only start-up of truly global name recognition to develop in the Houston ecosystem was the now infamous Enron. Today, startup institutions, venture capital funding and eager entrepreneurs would rather get started in Denver or Austin and the city of Houston misses out on entrepreneurship as a whole. The vast majority of capital under management in Houston is invested in start-ups elsewhere in the United States (Egan 2017).

This narrative, assembled through interviews with multiple stakeholders within the Houston ecosystem helps to explain what the quantitative data shows. When stakeholders were asked about government intervention in Houston’s entrepreneurship ecosystem, the notion was almost laughed at. The only government backed entrepreneurship institution in the city of Houston is the Houston Technology Center. When compared with other entrepreneurship institutions in the Houston ecosystem, of which none are particularly stellar, the Houston Technology Center tends to still underperform. Thus it can be reported with some confidence that

Houston has not had a successful government intervention. The major companies to have worked with the Houston Technology Center were mostly successful before their engagement with the Center, and over 18 years of operation the Center has only worked with 144 companies, a meager average of 8 companies a year. It was suggested by multiple stakeholders that this lack of effective government intervention within Houston’s ecosystem could account for the overall weakness of the system when compared with Barcelona’s more interventionist model.

In the city of Barcelona a different narrative was presented. Stakeholders there generally described the city as having been a desolate place for entrepreneurs until the city government chose to make entrepreneurship a priority. Then, through a variety of government sponsored endeavors, namely the Mobile World Congress, @22 Barcelona and Barcelona Activa, the city began to build a name for itself in entrepreneurship. Overtime, this fostered ecosystem began to grow and as more and more promising companies were developed within the city, private support institutions moved in as well.

Now however, with the comparatively small Spanish market, and the lack of capital under management within the city of Barcelona, the ecosystem has begun sputtering and has yet to produce a start-up with truly global name recognition. These narratives consist of codified interviews from two sets of interviewees, one in Barcelona and one in Houston, that have been analyzed and integrated. These narratives support and help explain the quantitative data analyzed above and provide a possible explanation for the differences in the two.

Only one explanation accurately fits the data provided by both the quantitative and qualitative data sets.

Barcelona possesses a solid ecosystem, started through government intervention, that has reached its cap in growth due to a small market and lack of capital under management.

Houston, on the other hand, has an enormous market and plenty of

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capital under management but lacks a healthy ecosystem. The finding here is that the only major factor in difference between the two cities that all stakeholder interviews touch upon and that explains the discrepancies in the data is government intervention.

The role of Barcelona Activa and other government interventions into the Barcelona ecosystem could not be overstated by the stakeholders interviewed. For only 5 million a year in operational budget, the vast majority of which goes to employment rather than entrepreneurship programs, Barcelona Activa has helped spur on the growth and development of entrepreneurship within its city.

Barcelona Activa helps attract venture capitalists to the city to invest in startups, provides fledgling businesses with office space and overhead resources, and acts as an accrediting agency for educational programs to give investors more confidence in Catalonian entrepreneurs. These are critical services that Houston misses out on. Other American cities have successfully experimented with similar interventions. The two cities to beat out Houston for entrepreneurship hub of the South, Denver and Austin, are both well-known for higher amounts of government intervention. Houston’s only attempt in this public space is the Houston Technology Center, which provides none of the above services, but rather focuses on networking and event planning. Barcelona Activa is also free for participating companies whereas the Houston Technology Center requires fees or equity.

Barcelona Activa, in comparison to the underperforming Houston Technology Center, is overperforming in its ecosystem, helping to generate an immense amount of support for entrepreneurs. On a comparable budget, Barcelona Activa works with almost ten times as many companies than the Houston Technology Center does in a similar time period.

These companies are given a free head start in the competitive world of entrepreneurship, a head start that appears to be key in taking the

ecosystem as a whole off the ground.

Perhaps the largest finding of the entire report then, and the only one supported by both the quantitative venture capital data and the qualitative interview data is that government intervention was critical to the start of Barcelona’s ecosystem and that Houston’s ecosystem never received a comparable kick. While Barcelona’s ecosystem appears to need many more resources to advance further, Houston’s ecosystem may just need its initial dose of government intervention.

CONCLUSIONS

This comparative study of entrepreneurship ecosystems in Barcelona and Houston suggests that effective government intervention in the initial stages of setting up an entrepreneurship ecosystem is beneficial for the ecosystem in the long run. Barcelona Activa, with its low budget and excellent impact schema, appears to be the shining model for how this intervention should operate.

The Houston Technology Center, with its limited impact and focus on networking rather than development is an example of how intervention should not operate. Furthermore, unlike Barcelona Activa, there appeared to be little focus on the part of the Houston Technology Center on the ecosystem of Houston as a whole.

Barcelona Activa worked to improve not just startups, but to act as an ambassador for foreign venture capital, interested entrepreneurs, and as a network for potentially rival institutions. It appears as if Barcelona has hit a rut that Barcelona Activa cannot work to get it out of however.

Later stage investments are rare with so little capital under management, and while the warm sun and cool seas attract the more laidback entrepreneur, the more growth-focused individual will seek out the larger markets of the United States.

While neither the situation of Barcelona nor the situation of Houston appears to be ideal, this report suggests a policy of mutually beneficial exchange.

Barcelona, through Barcelona Activa and other institutions, has a successful

and scalable model of government intervention that has helped to take the city’s ecosystem off the ground.

Due to a lack of past success with government intervention, this report proposes that Houston, with heavy consultation from Barcelona Activa and members from the Barcelona city hall, forms a new government intervention, Houston Activa. Following similar branding, funding and operational plans Houston Activa will aim to kickstart the Houston entrepreneurship ecosystem in a similar manner to how Barcelona kicked off the Barcelona ecosystem.

In return for this service, the City of Houston could use its influence to push for a policy of investment into Barcelona start-ups that have been certified by Barcelona Activa.

Tax cuts and other municipal policy incentives could be considered as well.

This will open a channel for the vast amount of capital Houston has under management to flow towards the healthy but cash-starved ecosystem of Barcelona. Through this quid pro quo situation, Houston could receive the effective government intervention it seems to need for a kickstart to its ecosystem and Barcelona will receive the capital that its ecosystem needs to sustainably grow further.

As added benefits, Barcelona can use this partnership to develop a global “Activa” system that can be potentially utilized all across the globe in a variety of cultural contexts, and managers of Houston capital can find start-up ecosystems to invest in that are not direct competitors with their own city.

Truly a policy win-win.

This report has served as a key continuation of entrepreneurship literature. Due to the relatively small nature of the field, further research in regards to the degree of healthy government intervention in entrepreneurship ecosystems is critical. Through a comparison of two somewhat similar cities, Barcelona, Catalonia and Houston, Texas, a variety of findings are found. Through a quantitative analysis of venture capital data it becomes very clear that Barcelona seems to overperform and

Houston seems to underperform when examined through the lense of venture capital. When accounting for the responses of qualitative stakeholder interviews, these performance metrics make sense in a broader narrative concerned with government intervention.

The early government intervention of Barcelona Activa in Barcelona was a key step in establishing the ecosystem, and was critical in kickstarting its growth.

Government intervention has always been weak or nonexistent in Houston.

While Houston has all the resources to grow it never really got off the ground, and Barcelona, which has taken flight, seems to be tethered to the ground, unable to go any higher due to small markets and a lack of capital. This report then identifies the opportunity for a policy of mutual benefit; Barcelona exchanges its successful model of governmental intervention for access to Houston’s massive amount of capital under management and many flagship companies. This policy recommendation holds much potential for both cities and could work to generate economic growth, entrepreneurial robustness and camaraderie between the two cities.

BIBLIOGRAPHY

Brander, James A., Edward Egan & Thomas F. Hellmann. 2010.

“Government Sponsored versus Private Venture Capital: Canadian Evidence” from Lerner, Josh & Antoinette Schoar.

2010.

“International Differences in Entrepreneurship” University of Chicago Press (275 - 320) Egan, Edward J. 2016. “Discussions with the McNair Center on Entrepreneurship” The McNair Center for Entrepreneurship and Innovation at Rice University’s James A. Baker III Institute for Public Policy Feldman, M. & J. Francis. 2010.

“Fortune Favours the Prepared Region: The Case of Entrepreneurship and the Capitol Region Biotechnology Cluster” European Planning Studies 11.7 Hochberg, Yael. 2016. “Accelerating

Entrepreneurs and Ecosystems: The Seed Accelerator Model” Innovation Policy and the Economy 16.1 Mok, Ka Ho. 2005. “Fostering entrepreneurship: Changing role of government and higher education governance in Hong Kong” Research Policy 34.4 SDC Platinum™.

2017.

“SDC PLATINUM INVESTMENT BANKING DEAL ACTIVITY” Thomson Reuters United Nations Department of Economic and Social Affairs. 2009.

“World Urbanization Prospects (2009 revision)” Archived October 31, 2013, at the Wayback Machine, United Nations Yusuf, Attahir. 1995. “Critical success factors for small business: Perceptions of South Pacific entrepreneurs” Journal of Small Business Management 33.2

ACKNOWLEDGEMENTS

This research was conducted during the Global Urban Lab Barcelona and would not be possible if it were not for the generosity of the Gateway Program of the School of Social Sciences at Rice University. The research would never developed to this point without the incredible teaching guidance of the instructors of the course, Dr. Nia Georges, Victor Gimenez and Ipek Martinez. The many contributors to interviews, whose names were intentionally kept out of this publication, are also greatly thanked.

Special thanks to Barcelona Activa, the McNair Center for Entrepreneurship and Innovation at Rice University’s James A. Baker III Institute for Public Policy and SDC Platinum. The researcher would also like to thank their parents for funding the fieldwork trip to Barcelona.

MEET THE AUTHOR Dylan Dickens (’18) is a student studying Comparative Political Science and Archaeology, with a minor in Energy, Water, and Environmental Sustainability. Dickens has worked in various leadership roles across campus, such as his role as the Executive Vice President of the Baker Institute Student Forum and his current role as President of Martel College. On his research project, Dickens says, “Entrepreneurship is far more than just a catchy buzzword, but a critical part of the economic system. Not nearly enough attention is paid to small business and innovation, together which are responsible for producing all of the jobs for the future.

Through comparative studies on entrepreneurship like this, better policies may be crafted to ensure economic prosperity for the future business and innovation, together which are responsible for producing all of the jobs for the future.”

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V. MEGA-EVENTS, MEGA-PROBLEMS business EXECUTIVE SUMMARY

Analyzing Recent Developments of “Mega-events” in Houston and Barcelona

Despite their apparent lack of similarities, the tourism industries of Houston and Barcelona have at least one commonality – the rise in so-called mega-events. This paper addresses a key question regarding the recent rise in mega-events of Houston and Barcelona: do the economic and social benefits of hosting these events outweigh their respective costs?

Whereas Barcelona’s main megaevent of interest is the Mobile World Congress (MWC), Houston has hosted a series of mega-sporting-events, such as Super Bowl LI and the 2016 NCAA Men’s Final Four. The findings of this report demonstrate that the net economic and social impacts of these mega-events are intrinsically tied to each city’s cultural shaping.

It concludes that while the MWC exacerbates the preexisting tourism problem in Barcelona and effectively

has a net negative impact on the city, mega-sporting-events in Houston, a city without a historically relevant tourism industry, have a net neutral impact. However, the effect of these mega-events in “putting Houston the map” poises the city for future economic development. Additionally, this paper judges the credibility of estimated figures regarding the economic impact of these mega-events in order to properly evaluate the net impacts.

INTRODUCTION

When it comes to tourism, Houston and Barcelona appear to be polar opposites. Houston, the oil and gas capital of America, is rarely thought of as a tourist destination. Barcelona, on the other hand, has a storied reputation as an ideal vacation spot and a cultural center of Europe. Despite their vast differences, each city’s government

has chosen to attract huge crowds of visitors by hosting large “mega-events.”

In literature, there is debate over what exactly constitutes a mega-event. For this paper, mega-events can be defined as “ambulatory occasions of a fixed duration that attract a large number of visitors, have a large mediated reach, come with large costs and have large impacts on the built environment and the population” (Müller 2015).

For Houston, mega-sporting-events such as the 2016 Men’s NCAA Final Four and 2017 Super Bowl exemplify this initiative. Since 2008, Barcelona has hosted and increased the size of the Mobile World Congress (MWC), the world’s largest conference for the mobile technology industry, as a means for attracting outsiders.

A comparison of Houston and Barcelona reveals a distinct cultural shaping of each city. Tourism has been an integral component of Barcelona’s

economy for decades and currently accounts for 14% of the city’s GDP (Mount 2015). Reactions among locals regarding the MWC are fundamentally shaped by Barcelona’s rich history as a tourist destination. Houston does not have a comparably rich history.

This paper focuses on and analyzes the economic impacts specifically associated with these mega-events as they relate to a city’s cultural shaping.

ISSUE STATEMENT

The recent rise of mega-events raises a few key questions. How does a city’s cultural shaping relate to the hosting of mega-events? Can we accurately measure the overall economic and social impact of these events? Do the perceived benefits outweigh the economic and social costs?

This report answers the last question – how can we assess the economic costs and benefits associated with these mega-events in light of their social implications? The other questions provide necessary context for its discussion. In general, Houstonian and Barcelonan residents weigh the costs and benefits of these events quite differently. Therefore, it is necessary to consider the sentiments of local residents when evaluating the impact of these mega-events.

The findings of this report demonstrate that the impacts of mega-events are necessarily dependent upon each city’s historical background in tourism. For Barcelona, although the MWC has brought some benefits to the city, the event exacerbates the existing tourism problem in Barcelona, which in effect far outweighs the positive economic impact. In Houston, megasporting-events have had a net zero economic impact on the city, but serve to “put Houston on the map” and poise the city for sustainable economic development.

The ultimate goal of this paper is to open a dialogue about the effects of tourism policies predicated upon mega-events; there currently is a wide gap in the amount of discussion in each city. While the MWC is already a hot topic in Barcelona, there is limited discussion of mega-events in Houston.

As it is noted in this report, academics and residents alike ought to think about Houston’s efforts to host megaevents more critically.

RESEARCH METHODS

For Barcelona, interviews were the primary sources of information.

Discussions were held with two anthropologists from Barcelonan universities. The first was with Dr. Gemma Cànoves, a professor in the Department of Geography at Universitat Autònoma de Barcelona (UAB), and the second was with Fabiola Mancinelli, a researcher in urban tourism at Universitat de Barcelona (UB). Each offered valuable insight as academics who personally experience the effects of tourism on Barcelona everyday. The interviews followed a similar structure – a combination of preset questions mixed with freeflowing conversation. Although megaevents were a central theme in the discussion, these interviews were geared towards analyzing tourism in Barcelona in general. For this reason, they primarily serve to provide context and an understanding of personal sentiments regarding tourism among Barcelonans. Dr. Cànoves discussed tourism with a focus on taxes and GDP growth, while Professor Mancinelli focused on regulation (or lack thereof) in new modern services that make up the so-called shared economy. In tandem, the interviews offered very useful background information.

Two group presentations provided an understanding for related trends in Barcelonan society. The first was given at the Institut de Ciència i Tecnologia Ambientals (ICTA) at UAB on “degrowth,” and the second at UB from Dr. Irene Sabaté. Dr. Sabaté discussed housing in Barcelona, detailing its cultural and economic significance. The presentations demonstrated that there exists a crucial relationship between tourism and mega-events, with housing at the center of discussion in the municipal government and among activist groups.

As I walked down the iconic tourist destination of Las Ramblas, stood atop the city at Park Guëll, and wove

through the streets of Barceloneta, the anecdotes related by the two academics became realities; my observations corroborated the points made by my interlocutors. Articles from Spanish media outlets and other pertinent reports provided additional information regarding the MWC. Understanding the impact of megaevents in Houston requires a different research focus. Unlike Barcelona, a city whose outlook on tourism has been influenced heavily by the sentiments of local residents, business interests tell the story in Houston.

Accordingly, business journals and news articles provide the most relevant information to evaluate mega-events. I also interviewed Tom Stallings, a professor in the Sports Management Department at Rice University. With direct experience working on Houston’s large sporting events (Super Bowl LI, the 2016 Men’s Final Four, Copa America Centenario, etc.), Stallings had much to say about the development of housing, effects on small businesses, and government policies as they relate to mega-events.

Stallings discussed not only megasporting-events, but also other megaevents such as Houston’s Offshore Technology Conference (OTC) and the Houston Livestock Show and Rodeo.

FINDINGS: BARCELONA

Barcelona is no stranger to tourism.

From having its world expositions in 1888 and 1929, to hosting the Summer Olympics in 1992, Barcelona has made a concerted effort to present itself as the cultural hub of the Mediterranean.

Civil war and Francoist Spain had inhibited tourism in Barcelona after the expositions, but the 1992 Olympics put Barcelona back into popularity and initiated a reboot and rise in tourism. Tourism in Barcelona takes many different forms. The most common is what Dr. Cànoves labeled as “materialistic tourism,” which involves Spaniards and foreigners alike using their time in Barcelona for the purpose of consuming goods. The other main form is cultural tourism. Whereas materialistic tourism is focused on the consumption of items and services,

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what Dr. Cànoves describes as “cultural tourism” is focused on the consumption of a city’s “culture.” At first glance, each definition is ambiguous, and between the two there is significant overlap. The key difference is that while materialistic tourism is incompatible with the quotidian affairs of local residents, cultural tourism does not interfere with and can serve to enhance the culture of a community. This contrast between materialistic and cultural tourism raises an important question: how can one define culture, and is this so-called culture even relevant?

According to Dr. Canoves, the question of whether or not there is a culture to protect in Barcelona is a pervasive one, especially under the scope of tourism and mega-events. At a given moment, a city can have a specific cultural shaping that locals and visitors alike denote as a city’s identity. However, as Mancinelli notes, the cultural shaping of the city evolves over time; because it is constantly changing, she believes there is effectively nothing to preserve. This approach dismisses the importance of maintaining a cultural shaping altogether, so some nuance is necessary to determine what does matter. The subtlety is rooted in the difference between materialistic and cultural tourism. For Barcelonans, the primary negative impact of tourism is the interference with their day-today affairs. This manifests itself in numerous ways. One can easily identify this phenomenon on Las Ramblas.

On average, 79% of the people there are not from Barcelona, with 58% being foreign tourists (Mount 2015).

During the day, tourists spend the day shopping at everywhere from large brand-name stores such as Adidas and Lululemon to street vendors attempting to pass off tchotchkes made in China as “authentically Barcelonan” goods. As materialistic tourism rises in Barcelona, markets adapt to cater to these interests. This compels shops to sell goods that are targeted for tourist consumption, driving local residents out of their own communities to buy basic goods and services.

Additionally, the tourists who visit these communities raise the prices of restaurants and shops. As Mancinelli

describes, local cafés, markets, dive bars and cheap bocadillo shops represent the true cultural shaping of a community, because these are places where local residents converse and exchange ideas. The correlation between materialistic tourism and the increase in prices is somewhat confusing – if tourist-oriented goods are cheaper, how would prices increase? The reason materialistic tourism is incompatible with the lifestyles of local residents is because these tourists, unlike cultural tourists, prefer to have cafés, markets, bars, and restaurants that closely resemble what they have back home. Since those who take vacations are able and willing to spend more in general, they also prefer more expensive restaurants and bars.

Small businesses and shop owners respond by adapting to fit the needs of the majority, which raises prices. One might argue that materialistic tourism is typical of certain areas of any major city. Perhaps if this phenomenon were contained to a few pockets of a city, a few local residents could simply bear the burden of moving to a different, more livable community. But such is not the case in Barcelona.

As a result, housing has become a major issue for those effectively displaced by the price inflation in and gentrification of these neighborhoods. In January 2017, a group of over 2,000 local residents marched with banners saying “Barcelona is not for sale” and “We will not be driven out.” Although the march was on Las Ramblas, it was composed of inhabitants from all over the city in a protest against mass tourism (Burgen 2017). The march coincided with the passage of a law in the city council that started a moratorium on the building of new hotels, and established that no new licenses will be issued for tourist apartments. There are 75,000 hotel beds and 100,000 beds in tourist flats in the city, and half of these are unlicensed and illegal (Burgen 2017).

This has led to the city fining Airbnb and HomeAway €600,000 each for violating licensing laws (Burgen 2017).

Increasing the number of tourists in hotels poses easily observable problems – when apartments become hotels, families are driven out of

their communities and must bear the burden of relocating. The new and likely more dangerous problem is the rise in tourists renting out flats via shared economy services like Airbnb and HomeAway. This can be attributed to the rise of cultural tourism. Although the cultural tourists consume in a manner that benefits local businesses, these are often significantly wealthier and are willing to pay a high price for a vacation rental. Demand for rooms in Barcelona is increasing, but the supply of apartments remains the same. When foreigners turn to apartment flats and compete with local residents to find an apartment, this raises the price of a bed in Barcelona for foreigners and locals alike.

Landlords face a steep tradeoff. Dr. Cànoves gives the hypothetical yet common situation. A landlord of a flat in Barcelona has the opportunity to rent an apartment to two individuals.

Person A is the breadwinner for a family of four, and would be willing to pay €600 per month for the flat. Person B, a tourist looking to spend time in Barcelona for a weekend, is willing to pay €300 per week for the flat. If there were not a sustainable flow of tourists, the landlord would rent out to Person A. However, because there is a constantly large influx of tourists, landlords are able to constantly rent out to Person B to maximize profits. With the landlord incentivized in this way, Person A loses out on the apartment.

This phenomenon, which defines the effect of tourism on the economy of Barcelona, can be described as a “plateau-of-peaks.”

The plateau-of-peaks became a primary motivator behind anti-tourism protests, including ones against the current nature of Las Ramblas and the rise of rideshare services. A popular buzzword in Barcelona is “degrowth,” which describes curbing growth that may be economically profitable for some industries but brings with it too many externalities, as in the case of tourism. Degrowth is the motivating idea behind what many Barcelonans, as noted by Dr. Cànoves, see as the ideal path for the tourism industry going forward.

Analyzing the significance of overall

tourism initiatives is beyond the scope of this paper. For the sake of remaining concise, the focus of this paper is on mega-events as they relate to the history and current circumstances of tourism in Barcelona. The megaevent that defines the city is the GSMA Mobile World Congress. Held annually at the Mobile World Capital of Barcelona since 2008, it is both the world’s largest exhibition for the mobile industry and a conference where executives from telecommunications operators to device manufacturing and technology services meet in Barcelona.

This is despite the fact that on a global scale, Barcelona lacks the recognition as a technology investment hub like Silicon Valley, Tel Aviv or Singapore.

However, this is exactly what the city government has aspired to. Yet this is only the beginning of the intended reach. While the direct focus of the MWC is to elevate the tech industry, MWC organizers and the city government hope to use the event to accomplish a variety of goals. In the short term, the primary objectives are to increase revenues and publicity for Barcelona. In the long term, the goal is to attract investment opportunities for Barcelona’s technology sector and other industries, which would ultimately bring benefits to the middle and working classes.

The reported economic benefits of the MWC are massive, and have been steadily growing. In 2012, the estimated economic impact of the MWC was €1.2M and led to 6,000 part time jobs (Carvalho 2017). In 2015, the MWC is said to have had a €400M economic impact on Barcelona, and additionally created 12,000 temporary jobs (Gómez 2017). Restaurants, hotels, and other service providers in particular enjoy many of these benefits.

In addition, because many attendees of the MWC have founded and actively invest in tech-disrupt apps such as Airbnb and Cabify, these companies are promoted and receive an economic boost. Furthermore, some say that the MWC serves as a strong model for how to prepare for the economy of the future. As noted by John Hoffman, principal of the MWC, the world is “moving from an economy based on

Figure 1. A screenshot depicting the (color) burst in credit card transactions Source: mwcimpact.com construction and manufacturing, to a digital economy, and this starts with the Mobile World Capital [Barcelona]” (Gómez 2017). Supporters of the MWC talk about Barcelona becoming a hub for information and communication technology (ICT) companies, who already bring in invoices of around €6B per year (“Why Is The Mobile World Congress so Important for Barcelona?”

2017). Banks have come into the scene as big investors in the event and attendee companies; Caixa, Santander, Barclays and BBVA are among some of the major players. BBVA has been the most visibly supportive bank.

For the 2013 conference, BBVA and intelligence software platform CartoDB partnered to create a dynamic visualization timeline tool that depicts the burst in credit card transactions during the week of the MWC. This was part of a large campaign to show the power of mobile technology and the economic benefits the MWC brings to the city.

Although the conference organizers and the city government are quick to say that these economic benefits will trickle down into communities and working-class families themselves, protesting groups take issue with the allegedly great benefits. For the event itself, the MWC pays only a small percentage of its revenue in wages to workers. Although the mega-event does generate jobs, they are often low paying and thus do not offer much benefit to workers

(Vazquez 2017). The tourism situation in Barcelona has had the impact of turning what have been community hangout spots into pricey bars and clubs. For better or worse, those who have followed this trend benefit greatly during the MWC. Meanwhile, owners of traditional and cheaper establishments gain a much smaller benefit, since they do not attract big spenders who attend these conferences. The housing situation is also made worse. Ada Colau’s moratorium on hotel stopped the growth of hotel building, but Barcelona is “an unstoppable beast at creating hotel room demand” in light of the MWC (Tadeo 2016). Because their wallets are as large as their demand for rooms, congress-goers have turned to Airbnb and HomeAway, who charge high prices for flats. This has led to landlords reaping tremendous profits, but has worsened the problem for those who face the same situation as “Person A” does. Lastly, the added congestion in certain neighborhoods dissuades residents from going out and supporting the local economy. In this way, the MWC puts a temporary halt on the “regular” economy.

Barcelona, from its politically active citizens to the ruling party Barcelona en Comú, has made efforts to bring the benefits of tourism back to the people. Although Colau and Barcelona en Comú have presented themselves as a fairly community-minded party, their continued support for hosting and spending money on the MWC

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is somewhat perplexing. The city government contributes around €5M each year for the event, and private donors such as the telecommunications company Telefonica and La Caixa put in about €15M (Carvalho 2017).

The justification for this government spending is that much of this money goes towards making the city more digital friendly for all residents through the development of mobile infrastructures and diffusion of technology from the conference (Carvalho 2017). This effort is made with the hope of retaining current tech labor and attracting new workers to the fast growing mobile tech industry (Carvalho 2017). APARTUR, the association of tourist apartments in Barcelona, led a campaign to strengthen WiFi in all its apartments towards this end (“Free WiFi during Mobile World Congress” 2017).

The MWC also boasts that beyond the direct economic benefits to the tech industry and small businesses, there are other positive outcomes. In 2015, the MWC was awarded a Guinness World Record as the largest carbon neutral world trade show in the world (GSMA 2016). In this way, Barcelona hopes to join the likes of other European cities as being environmentally sustainable.

Nevertheless, economically and socially motivated protests continue to highlight perceived ills connected to the MWC. Signs from angered protesters suggest that Barcelona “kneels before the showcase of capital controlled by the multinational cellphone giant” (Price 2017). They remain upset with the “precarity [sic] of jobs, unemployment benefits of youths and crappy jobs…invasive tourism, [and Barcelona’s] identity usurped with increasingly high rents that could only be paid by tourists with money to burn” (Price 2017). Others draw concern over the rise of prostitution associated with the event (Vazquez 2017). Apricots, an escort service, not only purchased a billboard to advertise its agency along the highway going to the MWC – it even used the official MWC logo on its website in advance of the event, causing protestors outside the event to hold signs saying, “Real men don’t buy girls” (O’Reilly 2015).

Among other concerns with the MWC, many believe that the event drains valuable police resources, and that some conference attendees come from immoral manufacturing backgrounds, from countries where labor is often exploited in the production of mobile technology materials and products.

The disagreement between the promoters of the MWC and local communities remains problematic.

Almost all will agree the MWC is a revenue driver, but the city is split over whether the overall economic boost outweighs the economic and social costs faced by local residents. Furthermore, disenchanted and angered Barcelonans are starting to demand that some of the profits be shared with them.

While some have gone to the streets via protests, community centers such as Can Batllo have held educational events to provide residents with tools to fight against the growth of the MWC. Can Batllo has even held an annual event known as the anti-MWC, which looks at the development of mobile technologies through a more critical lens. Nevertheless, the schism in Barcelona remains, and the debate continues.

FINDINGS: HOUSTON

Relative to Barcelona, Houston is new to the world of tourism.

Unlike Barcelona, Houston lacks the distinguishable cultural shaping that defines nearby cities like Austin and New Orleans. The one event that perhaps gives Houston a sense of identity is the annual Houston Livestock and Rodeo Show. This month-long event draws families from all across Texas, nearby states, and even other countries for concerts, bull riding and carnival activities. Another mega-event that attracts many to Houston is the Offshore Technology Conference (OTC), which has been held in Houston annually since 1969.

The conference is the largest oil and gas industry event in the world, with attendees representing a hundred countries from around the world. The OTC fits with Houston’s image as an oil and gas capital, but is professionally oriented and does not attract outside spectators like the MWC. Additionally,

both of these events are already well integrated into Houston’s economy.

Instead, this paper focuses on the new wave of mega-sporting-events hosted in Houston, which aim to “cast a grown-up, not-just-big-oil Houston as an international city that’s the ‘culinary cultural capital of the South’” (Jansen 2017).

An important distinction between Houston and Barcelona is whom the citizens hope to protect under public policy initiatives. In Barcelona, social activists talk about how the government ought to serve their neighbors and communities. Stallings notes that this is different for Houston; in Texas, small business owners and entrepreneurs are the stakeholders of interest. Going one step further, Barcelonans are much more politically active citizens. While protests against the government occur fairly often in Barcelona, such activity in Houston is rare. An important takeaway is that Barcelonans, because they are more active, are in turn more aware of public policy. When it comes to mega-sporting-events, Houstonians are politically uninvolved – not only in the dark, but also unconcerned. As long as both large corporations and small businesses benefit from events, the public is complacent and the hosting endeavor is supported with little resistance.

Texas makes it easy for its cities to host mega-sporting-events. Unlike other states, whose cities use tax hikes to fund mega-sporting-events, Texas pools public trust funds into its Major Events Trust Fund. Texas cities can then apply to the state to tap into this trust fund to host events such as the NCAA Final Four tournament, without raising city taxes (Rosenblat 2016). Houstonians, unaffected by any sort of direct tax, assume that they can only benefit from the citywide initiative, even though they are simply taxed through the state instead of the city. This is a fairly deceptive yet effective way for cities to raise money for funding these events, without arousing public concern.

The estimated figures for the economic impact of these events are astronomical.

For Super Bowl LI, direct revenue from sales and hotel occupancy taxes is

estimated at $11M – a sharp increase from $3.2M for Houston’s Super Bowl XXXVIII – and a net economic impact of $500 M reported by Accenture, the consulting firm largely in charge of calculating the profits of the event (Jansen 2017). However, economists argue that these Super Bowl figures are “based upon bogus assumptions and shamefully overblown numbers” (Jansen 2017). Since consulting firms seek to promote themselves as a useful business partner, they are incentivized to inflate projections for Super Bowl profits. Dr. Phil Porter of the University of Southern Florida reports the net economic impact of a megasporting-event such as a Super Bowl, after accounting for measurement error bias and other data collection concerns, is statistically insignificant, as the estimated impact of these events are reported larger than they truly are (Matheson 2006). The Final Four was projected to have had a $300M overall economic impact (Rosenblat 2016).

Dr. Craig Depken of the University of North Carolina in Charlotte reported in 2012 that forecasts for Final Fours promised ten times the actual net economic benefit that actually

Source: Rosenblat 2016 occurred (Rosenblat 2016). Another economic study at the University of Northern Kentucky found that there are no substantial gains to host cities’ economic development (Matheson 2004).

A foundational component of these projected economic gains are sales and occupancy tax revenues. Regarding sales revenues, Houston reported $115M in mixed beverage sales for the month of Super Bowl LI, around $15 M more than the annual average (Witthaus 2017). One bar “Underdogs” reported $745,000 in sales around the time of the game, triple the bar’s average annual revenue (Witthaus 2017). However, these figures fundamentally neglect important substitution effects: “it is conceivable that some residents may dramatically change their spending during the competition given their desire to avoid the congestion at least in the venue(s) environs” (Matheson 2004). Reports for mega-sporting-events in Texas show that there is no consistently statistically significant positive relationship between mega-sportingevents and retail/sales tax revenue (Matheson 2006).

The other main economic contributor is occupancy revenue. Traditional hotel chains certainly receive significant revenue during these events. However, many economists are skeptical that Houston benefits because the money generated from the Super Bowl leaves Houston and goes back to the parent organization (Matheson 2004).

As was the case in Barcelona, new shared-economy services benefit from these events. HomeAway rentals for homes around NRG Stadium around Super Bowl LI went for as much as $15,000 per night (Jansen 2017). One Airbnb user rented her one bedroom apartment, which usually rents for around $90 per night, went for $280 a night (Rumbaugh 2016). Dr. Cànoves notes that in Barcelona, residents feel contempt for those who rent out flats to the aforementioned Person B. Houstonians appear to take a somewhat different perspective, since “average families” are able to benefit from the influx of high spending individuals, without profits leaving the city. Houstonians, because the city does not suffer from congestion the way Barcelona does, consider the availability of these services to be a healthy entrepreneurial venture that poses little or no negative externalities to local residents.

However, drawing a direct comparison to the impact of HomeAway and Airbnb in Barcelona would be naïve.

While Barcelona mainly suffers from gentrification due to the large number of foreign tourists, Houston’s primary housing problem is urban homelessness. Before the Super Bowl, homeless-service organizations were told by city government officials that they would receive leftover carpet and chairs from the Super Bowl, but anticipated that homeless individuals would be bused out of certain areas to make the city more pleasing to tourists (Jansen 2017). Whereas the tourism problem in Barcelona has a direct effect on coercing families into moving out of their homes due to gentrification, the homeless population in Houston suffers from temporary relocation.

Houston’s continued push to host these mega-events is viewed in the public eye with little skepticism. Beyond being

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the fourth- (and soon to be third-) largest American city and incredibly significant as a capital for the energy and healthcare industries, Houston struggles to draw in tourists, foreign and international, for anything other than professional services. One can argue that the Rodeo is an exception to the rule. Although the Rodeo certainly attracts many visitors from within and outside of Texas and adds some semblance of a cultural shaping to he city, it has been insufficient in making Houston a yearlong tourist destination like the nearby Austin or the distant Barcelona. Accordingly, Houston hopes to use mega-sportingevents to create an identity for itself as a destination city. While hosting the Super Bowl and Final Four annually is infeasible, Houston has been able to host other smaller but still important mega-sporting events, such as the Copa America Centenario and the Bassmaster Classic. Becoming a “sports city” could very well be the identity Houston seeks to take on, or perhaps it could highlight its status as the “international culinary capital of the South” as noted before. Either way, it is important to note that hosting these mega-sporting-events is done not only for immediate profits.

Rather, these events are strategically designed to further Houston’s ongoing efforts to become a tourist destination.

Luckily for the city, Super Bowl LI involved what could be considered the greatest comeback in American sports history. Many fans look at sports championships as events influenced by higher-order fate, and Houston will certainly continue to leverage itself as a magical place and an ideal host city.

CONCLUSIONS

These findings show that the economic impacts of mega-events are necessarily dependent on their cities’ respective histories in tourism. For Barcelona, the Mobile World Congress strikes such a painful chord with its local residents because it activates and energizes the very problems stemming from Barcelona’s history in tourism – the unsustainable rise in the prices of goods, the gentrifications of communities, the lack of regulation

surrounding shared economy services, and believed negative social implications of an overly capitalistic society. The paradox in the MWC is that in an effort to develop a sector in its economy (telecommunications and digital technology), which should ideally decrease Barcelona’s reliance on tourism as a major component of its economy, hosting the event highlights the very problems caused by tourism.

Indeed, the prominence of the MWC and the elevation of tourism in the city violates core tenets of degrowth, which has in turn aggravated a group of local residents. As noted earlier, hosting this event does benefit Barcelona with an economic boost for hotels, flat owners, the tech industry, and some small businesses. However, the MWC exacerbates that already severe plateau-of-peaks problem. The only strong way for the MWC to justify itself as a net economic gain would be if the technological advances of the conference diffused rapidly into communities. The strongly negative views among local residents, between protests and events such as the antiMWC, suggests that these benefits do not sufficiently cover the costs of redirected government resources, price hikes, the gentrification of communities, and other concerns of livability.

A major concern in Houston is the lack of accurate information on the economic impact of mega-events.

Inflated estimates for the economic benefits are biased, but perhaps just as troubling, face little skepticism from local residents. Economic reports indicate that hosting a mega-sportingevent has a statistically insignificant effect on the economy of a city, which can be explained by the inverse relationship between the spending of tourists and locals: as tourists dominate downtown areas through both physical crowding and spending, locals are discouraged from these areas and their own consumption decreases.

For specific small businesses such as bars and restaurants, as well as landlords and miscellaneous providers of services for mega-events, there is potential to reap great profits.

However, when Houstonians avoid

the congestion of these events, the other remaining businesses do not experience an economic boost or may be negatively affected. For this reason, mega-events may be considered to have a net zero effect on the Houston economy. The intangible benefit of hosting these events, putting Houston on the map and associating the city with a sense of sports magic, does not have demonstrable present monetary value. The city government believes that creating buzz for Houston will lead to the creation of a more diverse tourism industry. While it is naïve to think that Houston can gain a reputation as a destination city like Austin or Barcelona in the immediate future, progress in that direction should help develop a new sector within and improve the overall wellbeing of the economy.

The comparison of tourism in Barcelona and Houston reveals a few important conclusions. Each city’s respective history in tourism intrinsically shapes its outlook on the recent developments of mega-events. Barcelona’s doubleedged dependence on tourism makes the MWC more of a public concern.

Houston’s mega-events receive far less scrutiny because of its lack of history and identity as a tourist destination.

Similarly, evaluating the economic impact of each city’s mega-events is rooted in context. The core problem that has persisted in Barcelona is the plateau-of-peaks, which has led to the rise of prices and the gentrification of neighborhoods. In the greater context of the tourism situation in Barcelona, the MWC is not a problem per se, but rather exacerbates the already tense relationship between local residents and the city government. Even in the best case scenario – the technological advances and economic stimulus from the MWC are as great as event organizers say they are – the benefits of the event are offset by the costs associated with the growth of tourism in Barcelona. For Houston, tourism’s historical clean slate eliminates the worry of deepening existing wounds.

Nevertheless, a major concern remains, the unreliable statistics provided by consulting firms and the city government, both of which overinflate

the economic benefits of hosting these events and effectively deceive the public from the funding stage to the forecast of long-term economic effects.

BIBLIOGRAPHY

Burgen, Stephen. The Guardian. N.p., 28 Jan. 2017. Web. 28 Apr. 2017. <https:// www.theguardian.com/world/2017/ jan/29/barcelona-residents-protest-high-rents-fuelled-by-tourism>.

Carvalho, Luis, Leo Van Den Berg, Hazem Galal, and Peter Teunisse. Delivering Sustainable Competitiveness: Revisiting the Organising Capacity of Cities. Rotterdam, The Netherlands: European Institute for Comparative Urban Research, 2017. 2017.

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“Free WIFI during the Mobile World Congress.” Apartur. N.p., n.d. Web. 27 Apr. 2017. <http://apartur.com/en/wifi-world-mobile-congress-p73.htm>.

Gómez, Carla, Aina Jiménez, and Patricia Romero. “The Big Impact of the Mobile World Congress.” El País De Los Estudiantes. N.p., n.d. Web. 27 Apr. 2017. <http://estudiantes.elpais.com/EPE2015/ periodico-digital/ver/equipo/2875/articulo/the-big-impact-of-the-mobile-worldcongress->.

GSMA. 2016 GSMA MOBILE WORLD CONGRESS SURPASSES RECORD 100,000 VISITORS. GSMA. N.p., 25 Feb. 2016. Web. 27 Apr. 2017. <http:// www.gsma.com/newsroom/press-release/2016-gsma-mobile- world- congress-surpasses-record-100000-visitors/>.

Jansen, Steve. “The Super Bowl May Bring a $500 Million Boost to Houston, or None at All.” Houston Press. N.p., 02 Feb. 2017.

Web. 27 Apr. 2017. <http://www.houstonpress.com/news/the-super-bowl-maybring-a-500-million-boost-to-houston-ornone-at-all-9156999>.

Matheson, Victor A., and Robert A. Baade.

“An Economic Slam Dunk or March Madness? Assessing the Economic Impact of the NCAA Basketball Tournament.” The Economics of College Sports (2003): 11133. 2004. Web. 27 Apr. 2017. <http:// www.nku.edu/~lipping/PHE385/ncaa. pdf>.

Matheson, Victor A. “Mega-Events: The Effect of the World’s Biggest Sporting Events on Local, Regional, and National Economies.” (n.d.): n. pag. 15 Oct. 2006. Web. 27 Apr. 2017. <https://pdfs.semanticscholar.

org/563d/87b3ffeb5a27cec38704a1cfd50f98a17ca6.pdf>.

Müller, Martin. “What Makes an Event a Mega-event? Definitions and Sizes.” Leisure Studies 34.6 (2015): 627-42. Taylor and Francis Online. 13 Jan. 2015. Web. 2 May 2017. <http://www.tandfonline.com/ doi/full/10.1080/02614367.2014.99333 3>.

Mount, Ian. “Barcelona: A Victim of Its Own Tourism Success?” Fortune. N.p., 30 Mar. 2015. Web. 28 Apr. 2017. <http:// fortune.com/2015/03/30/barcelona-tourism/>.

O’Reilly, Lara. “An Escort Agency Bought a Billboard on the Main Road into Mobile World Congress.” Business Insider. N.p., 05 Mar. 2015. Web. 27 Apr. 2017. <http:// www.businessinsider.com/escort-agencyapricots-buys-mobile-world-congress-billboard-ad-next-to-samsung-2015-3>.

Price, Rob. “Angry Anti-Mobile World Congress Protesters Marched through the Streets of Barcelona.” Business Insider. N.p., 02 Mar. 2017. Web. 27 Apr. 2017. <http://www.businessinsider. com/anti-mobile-world-congress-protesters-march-barcelona-gentrification-mwc-2017-3>.

Rosenblat, Josh. “How a Public Trust Fund Helps Texas Cities Host the NCAA Final Four.” Vox. Vox, 02 Apr. 2016.

Web. 27 Apr. 2017. <http://www.vox. com/2016/4/2/11347208/ncaa-finalfour-houston-2016-march-madness>.

Rumbaugh, Andrea. “For Local Economy, Final Four Was a Slam Dunk.” Houston Chronicle. N.p., 05 Apr. 2016. Web. 27 Apr. 2017. <http://www.houstonchronicle. com/business/article/For-local-economyFinal-Four-was-a-slam-dunk-7228038. php>.

Tadeo, Maria, and Sharon R. Smyth.

“Mobile Elite Hitting Barcelona Means Bonanza for Hotels.” Bloomberg. N.p., 22 Feb. 2016. Web. 27 Apr. 2017. <https://www.bloomberg.com/news/articles/2016-02-22/mobile-elite-hitting-barcelona-means-bonanza-for-city-s-hotels>.

Vázquez, Nuria. “Los Argumentos De Los Anti-Mobile World Congress.” CronicaGlobal. N.p., 24 Feb. 2017. Web. 27 Apr. 2017. <http://cronicaglobal.elespanol.com/vida/argumentos-anti-mobile-world-congress_68629_102.html>.

“Why Is the Mobile World Congress so Important for Barcelona?” U•TRANS. N.p., 22 Feb. 2017. Web. 27 Apr. 2017. <http://www.utrans.global/2017/02/22/ mobile-world-congress-important-barcelona-2/>.

Witthaus, Jack. “Washington Ave. Sports Bar Muscles past Big-name Houston Joints in Super Bowl Liquor Sales.” Houston Business Journal. N.p., 27 Mar. 2017. Web. 27 Apr. 2017. <http://www.bizjournals.com/ houston/news/2017/03/27/washingtonave-sports-bar-muscles-past-big-name. html>.

ACKNOWLEDGEMENTS

I would like to acknowledge Dr. Nia Georges, Victor Giménez, Ipek Martinez, and the rest of the GUL team for making this research project such a memorable experience. I also extend my gratitude to Dr. Gemma Cànoves, Fabiola Mancinelli, and Tom Stallings for taking the time to meet in person and helping out along the way in my research process.

MEET THE AUTHOR Noah Reich (’19) is a student studying Mathematical Economic Analysis and Computational and Applied Mathematics. On his research project, Reich says, “At Rice, we often talk about going “beyond the hedges” and truly understanding the ways of Houston. As Houstonians, we take for granted the process by which megaevents are funded and organized - they don’t just magically happen. After going to Barcelona, it became obvious to me how impactful these megaevents are in terms of soaking up public resources and having an effect on the city economy. Although there is much discussion of this topic in Barcelona, the conversation is limited in Houston.”

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VI. THE HOUSING FINANCIAL CRISES business

The Financial Crisis and Cultures of Housing in Houston and Barcelona

EXECUTIVE SUMMARY

Citizens of both Houston and Barcelona have historically felt the pressure to buy and own a home because of familial and societal expectations. However, the financial and housing crisis that devastated both the United States and Spain drastically changed the rates of homeownership and renting in both cities. This paper analyzes whether this short term change in housing tenure choice is indicative of a longer-term trend away from ownership, and how that trend differs between Barcelona and Houston.

INTRODUCTION AND BACKGROUND

The decision to buy a home is one of the most important decisions an individual makes in their lifetime.

Where and how you live influences so many aspects of everyday life, from tangible concerns such as the ability to raise a family to more immaterial

effects such as the sense of identity and responsibility that comes with owning a home. Homeownership is also one of the biggest commitments we make in our lives, in the U.S. people stay in the same home 5 years longer than they can stay in a marriage (Emrath, 2013)(The Economist, 2014). Thus it is worth it to analyze the decisionmaking process by which individuals choose between buying and renting a home or alternatively doing neither.

The housing tenure decision, however, and the reasons behind it are not static. In this paper, I will analyze two important external factors that affect such a momentous decision.

The first is location. Thanks in part to heavy migration, cities are on their way to becoming the new centers of society and are often becoming culturally independent from the nation-states they are a part of. Culture and tradition now passes through cities, and as a

result, expectations about housing often derive from the city where one lives. Further, each city faces a particular set of social and economic conditions that affects both the supply and demand of housing.

The second is time. Local and global macroeconomic conditions are always changing, and they change with such complexity that predicting their future is a foolâ&#x20AC;&#x2122;s errand. These conditions correlate strongly with changes in the housing market The relationship between changing economic conditions and housing tenure choice is far more complex than simply looking at charts of GDP. The changing dynamic between housing as a necessity of life and as financial instrument requires discussion of how the global financial crisis reignited a long-studied field of research: â&#x20AC;&#x153;Moral Economiesâ&#x20AC;?.

These two changing dynamics set up the condition for comparing

housing tenure choice in Barcelona and Houston. As cities, the two are very different in so many aspects: economically, culturally, and spatially.

These differences allow for a potent comparison of what about a given city influences tenure choice. Both cities were also hard hit by a housing crisis, allowing this paper to analyze how a somewhat similar change in economic conditions over the same period of time affected two distinct cities in different ways.

To understand how the financial crisis affected housing in both Barcelona and Houston, it is important to understand the history of cultures of home ownership in the two cities before the crisis. In America, single-family home ownership was often classified as one of the main tenants of the ‘American Dream.’ As Ted Ownby notes in his study of the 20th century American Dream in Mississippi, homeownership has historically been seen as a status symbol for the middle class, a barrier that separates the well-off from the poor (Ownby, 1999). As quoted in the New York Times in 1988, Susan Saegert, a professor of environmental psychology at the Graduate Center of the City University of New York noted “[Home ownership] has been pushed, ideologically, almost as a basic American fantasy, it has fed right into the ethos of the United States from the beginning, it has become an aspect of being an American” (DePalma, 1988).

How does Houston play into this American ideal? The strong suburban culture of Houston truly defined the American Dream. Starting in the 1890s, suburbs such as a Bellaire and River Oaks allowed for single-family home ownership in a growing city.

Suburban growth reached its peak by 1983, as The Woodlands, funded by oil money, finished development (McComb, 2017). This growth helped defined the sprawl that characterizes Houston. While many today now look down upon that sprawl, the ability for developers to create large neighborhoods full of cookie-cutter homes unrestricted by geographic constraints meant that Houston’s growth was a real microcosm of the

Figure 1. [Texas State Historical Association - http://bit.ly/2q0V9TI] American Dream.

Barcelona has a significantly different housing history. In the periods before and after the Spanish Civil War, Spain experienced a large migration of urban citizens into the cities due to its industrial focus. Barcelona was not prepared to handle this influx of people and a housing shortage was imminent (Phillips, 2014). The problem was exacerbated by the Franco Regime’s Urban Tenancy Law of 1946. The law gave tenants unpresented rights, including allowing close relatives to succeed one as a tenant in the same dwelling and establishing fixed rent increases (Mora-Sanguinetti, 2011).

This discouraged building, and thus the housing shortage was made worse.

In the 1950s, the Franco Regime’s stance changed. They created policies allowing landlords to sell their properties to tenants at low prices. The policies were popular and effective, sales took off and home ownership skyrocketed.

The Franco regime continued their housing friendly policies in the 1960s with legislation that established propiedad horizontal, an ownership structure similar to what is called a condominium in America. Anna Cabre

and Juan Antonio,economists at the UniversitatAutònoma de Barcelona, wrote in 2004: “The law created a legal basis for massive investment in new buildings that would be sold by individual flats and apartments. Movement to the cities, high employment, the virtual absence of urban land use regulations and norms, and skyrocketing inflation did the rest. Rural migrants brought their savings and invested them in stone (or should we say concrete?).

Young couples bought cheap and comparatively small apartments in new areas of the expanding cities.

Middle-aged families left the historical centers and improved their standard of living by acquiring new and betterquality flats. And steady employment at inflated wages helped all of them pay their mortgage. In a matter of years, homeownership had become the goal of most Spaniards”(Cabre & Antonio Modenes, 2004).

Thus between the ‘American Dream’ and the homeownership desires of Spaniards (‘Cultura de la Propiedad’) established by the Franco regime’s policies, the stage was set for an explosion in both Barcelona and Houston’s housing market that lasted

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Figure 2. [private homeownership rates – Institute of National Statistics, Ministry of Infrastructure, and UK National Statistics - http://bit.ly/2q0YNNz]

Figure 3. [Data adopted from St. Louis Federal Reserve] until 2007. In 1990s Barcelona, home purchase subsides covered between 20% to 50% of the price of a home and almost 9 out of every 10 Spaniards owned a house, making

Spain first in Western Europe in homeownership(Aramburu, 2016).

Meanwhile, in the U.S., not only did homeownership rates rise, but home prices skyrocketed as household debt

reached 127% of annual personal disposable income by the end of 2007 (UNC Statistics Department).

Barcelona and Houston, as extreme versions of the national housing market, mirrored these trends on a local level.

As is well known, starting in 2007, the rosy housing bubble violently popped.

Starting in the U.S., house prices began to fall, mortgage defaults spiked and banks began to fail.

As can be seen in the graph above, it was at this point that homeownership reversed course and people turned to rentals.

The U.S. housing crisis quickly spread across the globe and hit Spain, who had the highest percent change in housing prices in Europe prior to the crisis, particularly hard. As one commentator overheard, for-sale signs became “Spain’s national tree” (Hill, 2013).

However, Spain deals with mortgages defaults differentlythan the U.S. and most European countries–Spanish law does not enforce mortgage debt forgiveness after eviction. Thus those who have already lost their homes still are liable for whatever debt remains plus heavy default and legal fees (Hogan, 2011). This non-forgiveness model combined with a high rate of evictions (184 per day in 2013) have led to the growth of Plataforma de Afectados por la Hipoteca (PAH - Platform for People Affected by Mortgages), a grassroots organization arguing that eviction not only removes you from your home and your finances, but from society itself (Bhandar, 2015).

We now have a clear picture of the history of housing in both Barcelona and Houston. In Houston, the ideal of the ‘American Dream’ combined with unrestrictive geography lead to massive suburban growth that prioritized single-family homeownership. On the other hand, Barcelona has a shorter history of home ownership influenced by authoritarian state policies. The financial crisis hit both cities hard, as homeownership rates in the U.S. have plummeted and a social movement against evictions has taken hold in Spain. The rest of this paper will evaluate how the crisis is affecting these expectations of homeownership in both cities.

Figure 4. (Mercedes Pincay, 50, empties her apartment through the back door during her eviction in Madrid. Andres Kudacki - AP -http://time.com/4007349/ spain-evictions-housing-crisis/)

ISSUE STATEMENT

This paper aims to examine if the housing and financial crisis in Barcelona and Houston created longterm changes in each city’s culture of homeownership. If so, I also want to examine why. Particularly, I will examine the factors unique to each city and country that make it more or less likely for a culture of homeownership to be changed.

The issue of housing tenure choice is of clear importance to both cities. While, previous local policies have tended to shape citizen behavior regarding housing, cities should instead focus their housing policies to meet the needs of its inhabitants. If citizens desire long-term homeownership, local governments and businesses have clear reason to action that supports homeownership. On the other hand, if homeownership is no longer a priority of citizens, both cities can look at policies that fit a preference towards renting. In Houston this might take the look of desuburbanization, while in Barcelona, policies to reduce tourist pressure on rentals would fit the needs of a population looking at renting.

Beyond the policy needs of each city, preferences for housing tenure choice

also matter on a cultural level. As already noted, the choice of where and how you live is one of the most important decisions and individual can make in their life. If the financial crisis created a shift in housing culture in either city, that would signify a significant change in both economics and culture that is not worth overlooking.

RESEARCH METHODS

This research started with a search for data to support anecdotal evidence gained in conversations with a friend from Madrid. I quickly confirmed that homeownership rates in Spain were very high, and that they had been hard hit by the housing crisis. I then began a more comprehensive data search, using data from Eurostat to compare homeownership in Spain over time and to other countries. I also reviewed similar data for the United States.

Local homeownership data was hard to find, but I was able to confirm with my interviewees that the national trends apply to each city.

Next I conducted a literature review, the results of the review can be found in the next section, but I will outline my process now. I initially started with articles from The Atlantic and Quartz. com that linked to helpful research paper and data sources. I then searched

on Google Scholar and found many of the papers that served as the backbone for my research. I received many great papers from Irene Sabaté and Melissa Garcia Lamarca, the two researchers I interviewed. These helped me discover new aspects of my research.

When in Barcelona, I interviewed Ms. Sabaté and Ms. Garcia Lamarca about their research on housing cultures in Barcelona. I structured many of my questions around their research, but I also allowed the conversation to flow, and got many anecdotal examples that helped me solidify my opinion.

Finally, I traveled to Can Cuyàs, a suburban working class neighborhood of Barcelona. Can Cuyàs is an example of one of the condominium neighborhoods built as the Franco Regime implemented policies to boost homeownership. Thus this neighborhood felt important to my research as one of the places where Spain’s ‘Cultura de la Propiedad’ began.

LITERATURE REVIEW

A Quartz article enticingly called “How Spain’s bloody history gave it the world’s highest concentration of elevator,” points out the fact that despite the fact that Spaniards have some of the highest rate of homeownership in Europe, they also have the highest share of the population living in apartments, two statistics that usually have a negative correlation (Phillips, 2014). It then goes on to explain the historical story of Franco Regime housing policies that was explained in the introduction.

Aramburu 2016 was one of the most influential pieces of research on my topic. Aramburu conducted focus groups on the topic of housing tenure choice amongst working class youth in Spain. Particularly, he aimed to use an empirical study to determine whether a series of values associated with homeownership (security, stability, investment, freedom) are less important to younger citizens after the financial crisis.

He begins by arguing that “access to homeownership through financialization has often been viewed as the ultimate expression of neoliberalism.” While neoliberalism is typically thought of as a political

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value and belief, neoliberalism also influences our everyday thoughts and actions. He cites Hilgers who argues that “liberal policies have forced the individual to become an “enterprising self” in order to adapt to a market ordered by competition” (Hilgers, 2013). The increased financilization of the housing market in the late 20th and early 21st century was one of the main mediums for the spread of neoliberal values and helped create the ‘financialized self,’ and individual who viewed life as a series of investment decisions that must be made correctly.

How did these neoliberal ideas come into place? Spanish government policies that emphasized neo-liberal beliefs helped shape the “enterprising self.” In a turn away from the policies of the Franco Regime, the Spanish government of the 80s and 90s implemented a variety of free market policies, helping establish individual neoliberal values.

“The financial crisis potentially eliminated a lot of perceptions and expectations of homeownership in Houston, while such expectations still exist in Barcelona.”

Turning to his focus groups, Aramburu found that historically, “the canonical path for working-class young people moving out from their parents’ household has been to buy.”Yet the financial crisis created a tension between this desire and financial circumstances. In short, Aramburu found that homeownership was desirable but impossible to these working class young adults. Instead renting is their only option, and homeownership is seen as some far off ideal potentially achieved between the ages of 40-60.

Aramburu’s key finding comes after he analyzes the language used by the participants in the focus groups.

He notes that these individuals do present their choices as a ‘neoliberal’ choice, a maximization of the self.

Even though the reason they cannot buy is financial constraints, they tend to present these constraints as a naturalized, inevitable fate. Thus they ‘reformulate’ their financial situation into believing that they are “middleclass young individuals who essentially act according to what they choose to do at any given moment.” The main takeaway from this finding is that the neoliberal desire to maximization a given choice is still strong in Catalonian youth. Thus, when financial situations change, these individuals may still very well perceive that ownership is still the best way to maximize their housing choice (Aramburu, 2016).

The Aramburu paper contrasts well with Reid 2013, who conducted similar focus groups on low-income families.

The study has some limitations, the focus groups took place in Oakland, CA and Albuquerque, NM, not Houston, and the interviews focused on why those who had already decided to buy had made that choice, instead of looking at those on both sides of the buy/rent decision. Despite these challenges, I was still able to draw from one of the main findings of the paper, that lowincome Americans often choose not to rent because of a perceived lack of quality options, not because of a major underlying preference for ownership over renting (Reid, 2013).

The next major paper that influence my work was Mortgaged Lives: The biopolitics of debt and housing financialization (Garcia-Lamarca, 2016). Garcia-Lamarca reframed the securitization of mortgages in the years before the housing crisis as a form of biotechnology. When an individual signs a mortgage contract, they sign away so much more than money: reduced future labor mobility and decision making flexibility combined the mental stress that comes with continuous mortgage payments make mortgages a significant part of an individual’s life. Yet despite the large role that a mortgage plays in

a homeowner’s life, those operating in the financial sector took those mortgages and created complex financial instruments that could be bought, sold, hedged and traded.

Thus, as Garcia-Lamarca put it, “home security and future wealth became directly dependent on the fluctuations of financial products, interest rates and capital accumulation strategies rooted in the built environment.”

Of course, this was no worry during the housing boom, individuals actually stood to gain from the securitization of mortgages as housing prices kept rising. Yet when the financial crisis hit Spain, homeowners faced the ‘violence of financial capitalism.’ Not only do individuals who face eviction lose their home, they also lose any sense of selfworth, replaced with feelings of guilt, fear, shame, and even suicide and depression(Garcia-Lamarca, 2016).

How do negative effects to mortgage financialization apply to my discussion of the preference of ownership over renting? I initially hypothesized that Spaniards would internalize the negative mental, ‘biopolitical’ effects of the housing market and begin to view banks and mortgages in an intensely negative light. As a result, they would push back against the assumption that they must pursue homeownership because they do not want to subject their lives to global financial markets.

I explored the hypothesis in my interviews, and summarized those discussions in the results section below.

FINDINGS

In Barcelona, I have concluded that while the financial crisis has created a short term barrier against homeownership, the culture and expectation of homeownership is still strong. Much of this has to do with expectations of family in regards to owning a home. For one, there is a lot of parental pressure for children to buy and own a home. Parents save money so that they can help pay their children’s mortgage the same way that American parents save to help pay for college. Garcia-Lamarca (2016) recounted the experience of an evicted female who was despaired after her

Figure 5. [Kinder Institute 2017 Houston Area Survey - http://bit.ly/2q08QR1 ] father-in-law told her and her husband “it is shameful that you find youself in this position.”

Beyond the parental pressure, there is also the societal expectation that a couple must own a home before starting a family. Irene Sabaté said while that she has children and rents an apartment, she is an extreme outlier and knows no one else that considers renting with children (Sabaté, 2017).

Thus to undergo the common life event of having a family, ownership is almost a prerequisite.

Further, as Aramburu 2016 found, neoliberal influences are still a strong part of how Spaniards and Catalonians make important life decisions. While those making the housing tenure choice may say they prefer renting because it provides ‘freedom’ or ‘flexibility,’ this is simply a positive, self-maximizing perception of their financial circumstances; many still prefer to own a home in the longrun. Finally, if the rental market in Barcelona was easy to access, there could be a longer term shift towards renting as people recognize the benefits of renting. However, the rise of Air B&B and exploding tourism has made renting today just as difficult as securing a mortgage.

Addressing the issue raised by Garcia-Lamarca’sMortgaged Lives: The biopolitics of debt and housing financialization, Irene Sabaté noted

that while distrust of banks and mortgages exists, there is equal distrust in landlords, the system created by Air B&B, and general Spanish institutions (Sabaté, 2017). Thus, the distrust of the banking system is not a major detractor from the culture of homeownership.

Houston, on the other hand, has had a significant change in its culture of homeownership. Most of this is due to changes at the national level.

A study by the National Institute for CPAs found that only 11% of Americans define financial success as homeownership. Ernie Almonte, chair of the AICPA’s National CPA Financial Literacy Commission notes “We’re seeing that today’s American dream is greatly shifted from the one defined by previous generations. No longer are home ownership and upward financial mobility the hallmarks of financial achievement” (AICPA, 2015). Thus the drop in homeownership seen in Figure 3 is not simply due to circumstance, Americans are looking elsewhere for financial success.

Beyond the national trends, Houston in particular is seeing an increasing number of residents who would prefer to live in smaller, more urbanized areas instead of a large single family home. In the U.S, the preference for more urbanized areas also implies a desire more apartment and townhome rentals instead of home ownership; Carl Frinzi, senior vice president of

multifamily housing for Balfour Beatty Construction notes ““Demographics is destiny I’ve often heard. And the preferences of young people for renting and this type of living defined that destiny and is a big reason for the trend, Millennials — or the 34 and under age group — are choosing to rent instead of buy and more are choosing city life over suburbia” (Sexton, 2014).

CONCLUSIONS

In summary, the financial crisis potentially eliminated a lot of perceptions and expectations of homeownership in Houston, while such expectations still exist in Barcelona.

There is of course uncertainty in these findings, housing preferences are always subject to change and it may not be possible to completely asses long-term cultural change soon so after the financial crisis. Yet it is still worth asking why the crisis Barcelona and Houston in different manners.

Primarily, the reason why housing culture changed in Houston but not in Barcelona is because of the strength of the existing culture. While the ideal of the ‘American Dream’ is strong, there is little established expectations that come along with that ideal. As the AICPA study showed, homeownership used to be simply a measure of financial success, yet now that measure has changed. While similar survey

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data is hard to find for Barcelona, my research has identified two cultural aspects that make homeownership culture harder to change. First, the presumption that parents will save to help their children pay a mortgage inherently puts pressure on those children to actually get a mortgage in the first place. Thus parental pressure and expectations strength then culture of homeownership against a crisis.

Second, unlike the United States, there is a Spanish belief that to start a family you must own a home. This has persisted through the financial crisis.

The decision to buy or rent a place of residence is one of the most important decisions an individual can make in their lifetime. This paper analyzed how the financial crisis changed cultures of homeownership in Houston, but failed to affect them in Barcelona. Yet the most important finding is how each city affected the changing of these cultures.

While Houston was susceptible to national economic trends, in Barcelona culture and societal expectation were still far more important than the worst economic crisis since the Great Depression.

BIBLIOGRAPHY AICPA. (2015, 4 9). New AICPA Survey Finds Comfortable Retirement Best Defines Financial Success for Americans. Retrieved 5 8, 2017, from AICPA: http://www.aicpa.org/press/ pressreleases/2015/pages/survey-finds-comfortableretirement-defines-success.aspx Aramburu, M. (2016). RENTAL AS A TASTE OF FREEDOM: The Decline of Home Ownership amongst Working-class Youth in Spain during Times of Crisis. INTERNATIONAL JOURNAL OF URBAN AND REGIONAL RESEARCH, 1172-1190.

Bhandar, B. (2015, 1 30). From Proletarians to Proprietors. Retrieved 5 6, 2017, from Jacboin Magazine: https://www.jacobinmag.com/2015/01/ spain-evictions-pah/ Cabre, A., & Antonio Modenes, J. (2004). Home Ownership and Social Inequality in Spain. In K. Kurz, Home Ownership and Social Inequality In a Comparative Perspective. Pao Alto: Stanford University Press.

DePalma, A. (1988, 9 11). IN THE NATION: Why Owning a Home Is the American Dream. Retrieved 5 5, 2017, from New York Times Real Estate: http:// www.nytimes.com/1988/09/11/realestate/in-thenation-why-owning-a-home-is-the-american-dream.

html?pagewanted=all Emrath, P. (2013, 1 3). Latest Study Shows Average Buyer Expected to Stay in a Home 13 Years. Retrieved 5 5, 2017, from Eye on Housing: http://eyeonhousing. org/2013/01/latest-study-shows-average-buyerexpected-to-stay-in-a-home-13-years/ Garcia-Lamarca, M. (2016). ‘Mortgaged lives’: the biopolitics of debt and housing financialisation.

Transactions of the Institute of British Geographers, 313-327.

Hilgers, M. (2013). Embodying neoliberalism: thoughts and responses to critics. Social Anthropology, 75-89.

Hill, S. (2013, 10 18). To Hell and Back: Spain’s Grotesque Recession and Its Surprising New Economy.

Retrieved 5 6, 2017, from The Atlantic: https:// www.theatlantic.com/business/archive/2013/10/ to-hell-and-back-spains-grotesque-recession-and-itssurprising-new-economy/280678/ Hogan, C. (2011, 11 14). Spanish property bubble fallout continues with evictions, debt and fear of homelessness. Retrieved 5 6, 2017, from Irish Times: https://web.archive.org/web/20111114231718/ h t t p : / / w w w. i r i s h t i m e s . c o m / n e w s p a p e r / world/2011/1114/1224307526614.html McComb, D. (2017, 2 15). Houston, TX. Retrieved 5 5, 2017, from Texas State Historical Society: https:// tshaonline.org/handbook/online/articles/hdh03 Mora-Sanguinetti, J. (2011). The Regulation of Residential Tenancy Markets in Post-War Western Europe: An Economic Analysis. The European Journal of Comparative Economics, 47-75.

Ownby, T. (1999). American Dreams in Mississippi: Consumers, Poverty, and Culture, 1830-1998. Chapel Hill: The University of North Carolina Press.

Phillips, M. (2014, 10 9). How Spain’s bloody history gave it the world’s highest concentration of elevators. Retrieved 5 6, 2017, from Quartz: https:// qz.com/273214/how-spains-bloody-history-gave-itthe-worlds-highest-concentration-of-elevators/ Sabate, I. (2017, 3). (T. Morin, Interviewer) The Economist. (2014, 2 14). When the embers grow cold . Retrieved 5 5, 2017, from The Economist: http:// www.economist.com/blogs/graphicdetail/2014/02/ daily-chart-10 UNC Statistics Department. (n.d.). Subprime mortgage crisis. Retrieved 5 6, 2017, from http://www. stat.unc.edu/faculty/cji/fys/2012/Subprime%20 mortgage%20crisis.pdf

MEET THE AUTHOR Taylor Morin (’18) is a student majoring in Mathematical Economic Analysis and Policy Studies. He is passionate about environmental issues and clean energy, and hopes to pursue a career focused on the business side of the clean tech industry. However, after conducting research at the Kinder Institute for Urban Research, he has also become passionate about urban housing issues. The combination of this research background and his economic studies led Taylor to pursue a project on housing tenure choice in Barcelona and Houston.

SUSTAINABILITY VII. LAND USE AND INFRASTRUCTURE Claire Casey VIII. DEVELOPING PUBLIC SPACE Amy Kuritzky

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VII. LAND USE AND INFRASTRUCTURE sustainability

ABSTRACT

Houston and Barcelona: Land Use and Transportation Infrastructure Through the Lens of Sustainability

Houston and Barcelona are both international cities housing millions of individuals. These cities are also diverse and thus residents in both hold a variety of views on sustainability and the necessity to act in a way that conforms to the ideals of sustainable development.

However, despite varying viewpoints, the way the cities are designed ultimately condition the sustainable actions of residents there.

This paper compares two aspects of the city design, land use and transportation infrastructure, and how they relate to the sustainability actions of residents. Differences in the creation and building of the cities, land use, and transportation are all discussed in detail in this report.

Ultimately, it is seen that Barcelona tends to push residents towards more sustainable actions through transportation and land use. However,

Houston has already begun developing different plans for moving toward land use and transportation infrastructure that guide residents toward behaving more sustainably, but there is more it can learn from Barcelona as well.

By acknowledging the importance the built environment has on residentâ&#x20AC;&#x2122;s everyday actions within the realm of sustainability, cities can move forward toward shaping an environment conducive to sustainable development and thus help humankind plan for the long-term.

the natural environment. Within cities, while residentâ&#x20AC;&#x2122;s mindsets about sustainability may differ drastically, ultimately their actions with regards to sustainability are largely predetermined and conditioned by their built environment. Two concepts in particular, land use and transportation, are of extreme relevance to this topic. The similarities and differences of these two aspects of the city will be compared with regards to Houston, Barcelona, and the broader issue of sustainability in this paper.

INTRODUCTION

ISSUE STATEMENT

Whether we want to or not, our actions as humans around the world must be altered for humanity to continue as it has been. With the world becoming more and more urbanized, ironically, it is the environment that we have built that ultimately pushes us towards protecting or harming

Most people have all heard the buzzwords that threaten our perception of a world that can continue to grow as it has been. Climate change, deforestation, air pollution, ozone depletion, loss of biodiversity, and overpopulation are just a few. In 1992 at the Worldâ&#x20AC;&#x2122;s first Earth

Summit, the word “sustainability” was coined, and the definition of sustainable development was said to be “development that meets the needs of the present without compromising the ability of future generations to meet their own needs.” Since then, most people have been aware of the distant need to think about sustainability in the present, but oftentimes this worldwide issue is put on the backburner for smaller, tangible individual issues. This is where I propose cities can make a change.

By the year 2050, it is expected that over seventy percent of the human population will live in urban areas. While those of us among that seventy percent may think we all have the freedom in our daily lives to choose how sustainably we wish to live, ultimately a huge portion of this possibility of sustainable actions is taken away by the way our city is designed. Two components of urban design, transportation and land use, are perhaps the most important aspects of a city design that restrict the choices the city gives its residents from a sustainability lens. Cities hold the key to helping the world be more sustainable, not only because they have connected populations, divisive leadership, innovation and experimentation at every level, but also because help shape individual’s actions as well. Even if every person decided they wanted to practice more sustainable development in their lives today, a city’s infrastructure must be there to support that. And even if that thought does not cross their minds, the infrastructure can also be there to push them in the right direction.

Two subsets of anthropology are specifically used in this research, which are the anthropology of infrastructure and urban anthropology. In Larkin’s paper, “The Politics and Poetics of Infrastructure,” he explains how “infrastructures are built networks that facilitate the flow of goods, people, or ideas and allow for their exchange over space… They comprise the architecture for circulation, literally providing the undergirding of modern societies, and they generate the ambient environment

of everyday life.” The infrastructure networks thus promise “modernity, development, progress, and freedom to people and governments around the world...The anthropology of infrastructure is the study of how these networks play a role, both technological and human, in cultural life and how people experience space.”

Infrastructure networks are vital to our functioning cities and world as a whole, and do allow us great freedom and ability to overcome our human limitations and travel, communicate, and see across the world. However, when it comes to the freedom of choice for transportation infrastructure, we have come so far that this infrastructure component is actually inhibiting our ability and freedom to be sustainable, as will be discussed later. Analysis of the anthropology of infrastructure is necessary to understand how humans interact with the built environment, and how we can better this interaction for a more sustainable future.

The second subset of anthropology in this paper is urban anthropology. This is a subset of anthropology concerned with issues of urbanization, poverty, public space, and social relations. One approach to this study is how the city is planned. There are four central approaches to the anthropological study of cities. The second is based on power and knowledge, specifically of how the city is planned. This is what I will focus on with regards to how the city is designed as far as land use and transportation goes, and how this impacts the sustainability choices and freedom in the city’s residents’ lives.

The way humans interact with the built environment has clear impacts on their daily actions and the way they choose to live our lives, even though this is often overlooked by most people. Combining the anthropology of infrastructure and urban anthropology, I will discuss the difference in transportation and land use in Houston and Barcelona and how they work to enable or restrict how sustainable an individual lives, whether sustainability is on the individual’s mind or not. We, as humans, should instinctively feel the need to protect future generations and practice

sustainable development. However, this is only one piece of the puzzle of how to live sustainably; the second is to understand how your environment almost invisibly conditions your actions, and how cities are the key to changing this for the better.

RESEARCH METHODS

For my research, I did a combination of site visits, scheduled interviews, and readings found online or on Rice’s database. For site visits in Barcelona, I walked around an abandoned factory that was reclaimed by the neighborhood called Can Batlló. I also walked around a neighborhood garden and gathering

“Our actions as humans around the world must be altered for humanity to continue as it has been.” space called Espai Germanetes. Both of these allowed me to get a sense of innovative land use projects taking place in Barcelona. I also walked around Barcelona a great deal and took public transportation various times in order to get a broader feel for the city layout and transportation habits of locals. For Houston, I have already driven around the city a great deal, as well as walked, used the Metro and Bus system, and ridden my bike around the city. Thus, I felt like I already had a good sense of the city design, layout, and transportation and I did not conduct any specific site visits apart from my daily life of getting around Houston.

I did conduct interviews in both locations, and had a skype call interview with someone who used to work in Barcelona. For my two interviews

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regarding Barcelona, both contacts were given to me by Lisa Lin, who used to work in the sustainability department at the City of Houston. Thus, both contacts had to deal with international relations for sustainability. The first person I met for coffee in Barcelona.

Her name is Marta Galceran, and she works at a sustainability consulting firm, Anteverti, in Barcelona. Before meeting with Ms. Galceran, I was still unsure about what my topic would be specifically. I was playing around with the idea of the different ways we approach environmental care and sustainability in cities, including notions and vocabulary. However, Ms. Galceran drew me into the idea that the environment of the city greatly influences the behavior of residents, whether they are more environmentally-conscious or not. Ms. Galceran somewhat summarized her main points by stating that “the way the city is built determines how you experience and the way you consume in the city.” She discussed land use and transportation as well, specifically the benefits of dense, neighborhoodcentric populations in the realm of sustainability.

After meeting with Ms. Galceran I also had a skype interview with Julia López Ventura. Ms. López Ventura is the Regional Director for Europe for C40, which is an organization for global leadership on climate change.

C40 creates networks for dialogue for sustainable solutions in cities. It allows for the facilitation of ideas, solutions, and questions to flow through different city governments and organizations.

Ms. López Ventura has over a decade of experience working for the city of Barcelona, and lead the Barcelona Smart City Office as well. She was able to go into further information about transportation and land use patterns in Barcelona, as well as provide context for the role of cities in fostering sustainability in an international context.

For the Houston component of my research, I interviewed three different people. The first was Steve Stelzer, who is the director of the Green Building Resource Center in Houston. He provided me with interesting insight

Figure 1. Image of part of Barcelona’s Eixample district designed by Cerda. www.amusingplanet.com/2013/07/the-peculiar-architecture-and-design-of. html into our interaction with the built environment, context to the barriers we face in Houston with regards to sustainability, and ideas for moving forward toward a sustainable future in Houston.

I also met with Lisa Lin, who was my connection with the two people I interviewed regarding Barcelona. She is now the Transportation Demand Management Program Director at Rice University. Lastly, I also interviewed Christof Spieler, who is the Director of Planning for the Houston office and also teaches Urban Transportation Systems here at Rice. He has worked for many years with the Houston Metro and the City on trying to encourage more citizens to use more sustainable transportation methods. Both Ms. Lin and Mr. Spieler helped me understand the challenges Houston currently faces when trying to move toward more sustainable transportation infrastructure, and how to encourage residents to make the behavior change towards those sustainable transportation options. They discussed how land use and city design tie into transportation decisions, and how interwoven different factors are to the city planning and transportation process in Houston today.

In addition to site visits and interviews,

I also read various articles and papers regarding my topic in a global sense.

Some of these were provided to me by one of my professors, Víctor Giménez Aliaga, and were both required in-class readings, like Marta Bausells’ article in The Guardian regarding Barcelona’s city design, as well as other articles and papers like Larkin’s paper, “The Politics and Poetics of Infrastructure” and an online series of essays called “The Infrastructure Toolbox.” I also found articles regarding the urban design and layout of Houston, and other articles on Urban Anthropology. These readings provided me with a background of the different types of anthropology that pertain to my research, as mentioned earlier. They also provided me with some of the context and history for why the cities were designed as they were, which allowed me to gain a deeper understanding into the different components at play regarding my topic.

These three different research methods: site visits, interviews, and readings, helped provide me with a deeper knowledge and understanding of transportation and land use in these two cities and how they relate to sustainability actions.

FINDINGS

Figure 2: The Texas Medical Center and main Downtown areas. https://www.pinterest.com/texasheartinst/texas-medical-center/

Differences in History of Urban Design Before I discuss specific anthropological findings, it is important to discuss the differences in the creation, urban design and layout of Houston and Barcelona, as this greatly ties into current land use patterns and transportation infrastructure.

The population of Barcelona increased rapidly in the early 19th century due to the Industrial Revolution. However, the city became suffocated by its third set of medieval walls, forcing factories to be located amongst farm and residential areas leading a terrible quality of life. As there was no room inside the city walls, inventive ways to increase the density of the city started taking place, including building arches and expanding house fronts into the streets. This high density building eventually created an air circulation problem. This, coupled with residents already having a Mediterranean way of life, walking and being or working on the streets whenever it was light out, in addition to problematic traffic by horse-drawn carts, all helped to create a hygiene issue and further worsen the health of the city.

In 1859, the walls were demolished and the small towns that were built outside of the city were now absorbed into the

city. This allowed neighborhoods now have their own city centers as they used to be their own functioning suburb. At this time, the engineer Cerdà stepped into the scene and created “urbanism.”

He used a grid pattern to impose order in the new areas of the city, called Eixample, shown in Figure 1. He made sure to also account for open space and ease of transportation. He calculated required atmospheric air per person to live a healthy life, and included in his design appropriate access to services needed like markets and hospitals.

He also attempted to put gardens in the center of each city block, and determined how wide streets had to be in order for ease of transportation.

Although his ideas were not praised highly and not all concepts he proposed were finally implemented, he did forever make the Eixample region of Barcelona a model for the rest of the city with open and green spaces, services in walking distance, and ease of transportation. These components of urban design have gone on to be incredibly important when it comes to sustainability in the city, and thus Cerdà was instrumental in helping Barcelona be the city that it is today within the lens of sustainability.

There was also a lot of change to the city design between then and now,

including a period of decay following the Civil War and a rejuvenation in 1992 as a result of the Olympics.

However, I do want to mention that today Barcelona is a trapped city and has geographical constraints on all sides, being surrounded by mountains and the sea. Therefore, it literally cannot grow, creating an interesting problem for Barcelonans which will be discussed later.

On the opposite side of the spectrum is Houston. Houston is a city characterized by growth. Since being founded in 1837 the city has continuously expanded, both in land area and population. When Houston was established, the city’s founders divided it into political geographic districts called “wards.” The ward designation is the progenitor of the nine current-day Houston City Council districts. The wards are no longer political divisions, but their names are still used and they create larger neighborhoods today rather than the compact neighborhoods of Barcelona.

Today, Houston is the most populated city in the United States without zoning laws. City voters rejected the creation of separate commercial and residential land-use districts in 1948, 1962 and 1993. As a result, Houston has grown in an unusual manner.

Rather than a single “downtown” as the center of the city’s employment, five additional business districts have grown throughout the inner-city, including one for Houston’s medical center complex. An image of two of Houston’s downtown areas is shown in Figure 2. If these business districts were combined, they would form the third largest downtown in the United States.

Houston is also one of the premier suburban organized cities in America.

Even today, new developments are being created as developers still see the desire for newer buildings rather than retrofitting older ones. And, conversely to Barcelona, Houston is often known as the city with no limits.

Another large contributing factor in the differences of the pattern of growth of these two cities is the time when they were built as related to the automobile industry. Barcelona grew

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before the car era began in the late 19th century. When cars entered the city, the city was already structured as a “walkable city,” as the main mode of transportation within the city was mostly walking during development.

Thus most services were already close by and the city was already developed with high density, as it had to lend itself toward walking during its main development period. Conversely, Houston can be defined as an “automobile city” and developed when cars were easily available. In his article titled “The Automobile Shapes the City,” Martin Melosi states “In some places such as…Houston…the automobile played a central role in creating low density, expansive, and some would say muddled and fragmented urban development…In cities like Houston, pedestrians have become endangered species.” The main enabler for the suburban sprawl and low density development in Houston has been the automobile industry. A main portion of Houston’s development happened when cars allowed for spread out neighborhoods and business areas.

This, along with the lack of zoning laws in Houston, also allowed for services to be spread out as people could just drive from one place to the next rather than walking. Houston developed with cars, whereas Barcelona has had to adapt to the automobile city and thus is more structured toward walking and accessibility today.

Clearly there are apparent differences in the city design and development process for these two cities. This has ultimately led to vastly different land use patterns and transportation infrastructures in the cities.

Differences in Land Use Both Houston and Barcelona have very different land use, as a result of both geography and culture. As you can see from the graph in Figure 3, 31% of total land use in Houston is devoted toward single-family residential land, and only 5.8% is multi-family residential land. While I could not find the specifics for Barcelona, just walking around Barcelona you can tell that the vast majority of residential land use is

Figure 3. Land usage in Barcelona www.houstontx.gov/planning/Demographics/Loop%20610%20Website/ landuse.html

Figure 4. Image of one section of Espai Germanetes Image: Taken by Claire Casey multi-family, and the residential areas are much more dense than in Houston.

The densities of both cities both differ drastically. The density of Barcelona is about 16,000 per square km, whereas Houston is only about

1,300. This density in Barcelona also encourages a culture of sharing public space, and having facilities like pharmacies and grocery stores that are in walking distance, as they were during the developing period

Figure 5 and 6. Automobile shop (left) and gymnastics area (right) of Can Batllรณ.

Images: Taken by Claire Casey as well. The neighborhood set-up of Barcelona due to its history of urban planning also facilitates festivals and activities that are oriented around neighborhood participation and gathering. Ms. Galceran explained to me that this density brings about communities, and by talking with their community, Barcelonans are more likely to talk about how to improve their neighborhoods, often which promotes sustainable behaviors like creating community gardens and self-organizing to reclaim abandoned space.

Two examples of this that I visited are Espai Germanetes and Can Batllรณ. Espai Germanetes is a space that had been wasted for many years before being reclaimed by the neighborhood. It is a gathering space for the neighborhood and houses a community garden, climbing wall, and other activities for the neighbors. Part of it is shown in Figure 4. Can Batllรณ is another example of neighbors organizing to reclaim abandoned space. It was once the site of a factory, and now is an open space for neighbors and others to come walk around, get drinks, work in the community garden, and many more

activities. It also houses a gymnastics gym of sorts and automobile shop, shown in Figures 5 and 6.

These spaces have come to be for a variety of reasons. The strong activist culture most likely played a role in the citizens organizing to reclaim the space. However, the dense population of Barcelona and strong neighborhood communities and nodes could have also played a role, in addition to the fact that Barcelona is a trapped city and thus there may be a feeling of taking care of the space that you have.

Ultimately these factors create land use patterns of community spaces that then condition residents to be more sustainable through their interactions with these spaces. Not only are the spaces themselves more sustainable in their creation using reclaimed space and buildings instead of creating new ones, but they also enable residents to live more sustainably as well.

Neighbors now can have community gardens to change the way they consume and buy produce, gathering an understanding of where their food comes from and also greatly reducing the carbon footprint of their food as well. The spaces also offer nearby

activities for residents to partake in.

Residents only need to walk a few blocks at most to have social gatherings and a meeting space, or rock walls and gyms. This greatly reduces the need for transportation.

These spaces in part were created by density and current land use pushing residents together to reclaim space.

Then, by creating these spaces there is also a positive feedback cycle in which the spaces then push and allow neighbors, more than just the ones who created the space, to behave more sustainable through community gardens and close location of activities.

Additionally, especially in the case of Can Batllรณ, these spaces may also change the way residents view consumption and the business world, beyond just having community gardens. Can Batllรณ has a brewery on site and has a bar led entirely by volunteers. The space also has an automobile shop and aerobics gym mentioned earlier. These, all together, create a culture within the community of collaboration, consuming less, and enjoying time and working for the community instead of for a paycheck.

These concepts ultimately tie into a

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Figure 7. Image of road and park for the Arc de Triumf in Barcelona.

Image: Taken by Claire Casey larger concept emerging in Barcelona called “degrowth”. Degrowth is essentially the dissolution of the concept of the requirement of growth for a successful economy.

As stated in the book: “Degrowth: A Vocabulary for a New Era,” degrowth suggests “a desired direction, one in which societies will use fewer natural resources and will organize and live differently than today. ‘Sharing’, ‘simplicity’, ‘conviviality’, ‘care’ and ‘commons’ are primary significations of what this society might look like.”

Can Batlló is not a perfect replica of what degrowth may look like, but it does pass on some of these ideas to the neighbors and visitors of the space.

There is no way of knowing the extent of change in people’s minds who visit this location. However, it can be assumed that at least some change is made through the way in which people view consumption.

While ultimately to achieve a truly sustainable city, many more minds must be changed through more than just one location, this location is still changing the sustainability actions and choices of the neighbors around it. Neighbors are using local foods

and brewing their own beer, as well as fixing their own cars and not travelling far for social events. These actions do play a role in sustainability, and thus through the innovative land use in Barcelona like Can Batlló and Espai Germanetes, residents are choosing more sustainable actions. Whether those actions manifest into cultural or political changes with regards to growth in the city is not discussed further in this paper, but is still something to consider when discussing the importance of land use in a city.

Nevertheless, more sustainable actions still are an improvement, and clearly reclaiming abandoned space does lead to an improvement in sustainable actions in Barcelona.

Additionally, because the city literally cannot grow, residents in Barcelona must learn to coexist closely with one another, and this also creates a culture of keeping what you already have as Ms. López Ventura pointed out to me. There is a culture of retrofitting, and energy efficiency in old buildings is something that is quite huge in Barcelona due to this geographical situation. Both of these concepts are important in the realm of sustainability, as re-doing a

nearby building is much more efficient than creating a whole new building far away and throwing away the valuable resources of the older one.

In Barcelona, 37.8% of flats were built before 1960, and 46.2% were built between 1960 and 1980. This adds to a total of 84% of flats being built before 1980. While the statistics on building age for Houston are not easily accessible, one can assume that this is vastly different in Houston, with much more of the built environment being newer buildings.

Furthermore, Houston is a city known for suburbia and urban sprawl. As Mr. Stelzer discusses, “In a city still focused on the capitalist shareholder model with a constant desire for a short-term return on your investment...it’s very hard to think long-term when you’re constantly fearful of not even being in existence.” Developers still feel the desire and push, and have the option and space, to create new and shiny developments rather than design for the long-term. The linear scale in Houston is vast, and by spreading out the city and creating a less-dense living area it also decreases the vibrancy and amount of people on the streets.

Figure 8 and 9. The CityCentre in Houston.

Image (top): http://brandpower.chron.com/martha-turner/wp-content/ uploads/sites Image (bottom): http://gotravelaz.com/wp-content/uploads/images/City_ Centre_Houston_144.jp Additionally, while more people in Houston are beginning to partake in neighborhood activities, Houston still has a culture vastly different from the activist and neighborhoodcentric culture of Barcelona, which is largely due to land use patterns. This makes community gardens and local gathering spaces in walking distance much less prominent in Houston.

Suburbs were created to generate safe neighborhoods for residents who felt unsafe in the city. As Mr. Stelzer says, “Suburbia is not a fiasco, we just ramped it up so much.” By continuing to expand constantly throughout the history of Houston, we have lessened the ability for neighborhood areas, and instead created un-walkable areas

where it is difficult to gather with others or reclaim land simply due to the fact that you are not in close contact or proximity to your neighbors.

Differences in Transportation While land use itself is a component to the sustainability choices a person makes, it also plays into the transportation infrastructure that the majority of the people I talked to thought was the most important component in a city for sustainability choices. According to Mr. Spieler, “sustainable transportation is having alternative modes of transportation easily available and not having to drive to everything you do, but also having driving trips be a short as possible.”

He explained that there are two main barriers to sustainable transportation in Houston: private and public.

On the private side, in Houston we are building places that are inaccessible except for driving. We are also building at low densities which makes walking, biking, and transit very difficult and forces trips to be longer. By having no geographical barriers to limit us in our land use, we can continue to expand, thus placing more emphasis on driving being the most feasible mode of transportation and limiting all others, while also making those driving trips much longer. The choices for the buildings are also not conducive to sustainable transportation.

Developers, architects, and engineers are constantly preoccupied with parking lots when developing new buildings. However, often times the building will lack a pedestrian path from the sidewalk to the building or a bike rack. While cars are the main mode of transportation in Houston, we are still developing with the mindset that this is best, instead of planning for a future where sustainable transportation is more apparent and used in Houston.

On the public side, we have designed the streets and highways to be incredibly car-centric for a very long time in Houston. This results in an environment where in many cases you don’t have a viable option except to drive. For example, if you were to take the bus on Westheimer through the Galleria you will still need to sit through traffic, and this creates a bus system by Westheimer that will not be reliable or fast until it has its own lane. This in turn drives people away from using it. We are attempting to adapt public transportation to a carcentric city, and the result is that those modes of transportation will not be as effective as possible because the way our public infrastructure favors cars.

In Barcelona, however, there is a larger culture of sustainable transportation.

Barcelona is your typical Mediterranean City which is compact and walkable.

As mentioned previously, the density and size of the city make walking and biking much more feasible, and the city has a strong public transportation system when compared to Houston.

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Figure 10 and 11. Comparison of public transportation and driving option from Rice University to CityCentre.

Images: www.maps.google.com As shown in Figure 7, Barcelona even has some large streets that are devoted solely to pedestrians and bikers.

However, the city still does have a car issue and is attempting to reduce the amount of cars on the street. One way of going about this is a plan to create more superblocks, or â&#x20AC;&#x153;mini neighborhoods around which traffic will flow, and in which spaces will be repurposed to â&#x20AC;&#x153;fill our city with life.â&#x20AC;?

These superblocks are one example of

how Barcelona, despite already having a strong sustainable transportation system, hopes to continue to redesign the city for an increase in these types of transportation and decrease in car use. Barcelona was not designed around cars, and is still working hard to mitigate car use in the city today.

While Houston is trying as well, it has a further way to go due to its design being centered around feasible car usage.

The design of Barcelona also allows for many services like grocery stores to be in walking distance, again allowing for more walking and biking and less dependency on cars and long commutes. Lastly, the city history, activist culture and reclaiming space also create neighborhood gathering spaces where residents can spend much of their leisure time, instead of having to drive to parks or centers like Houston. All in all, the Mediterranean

City atmosphere, design of the city rooted on density, and culture all make Barcelona much more bike, walk, and transit/bus friendly than Houston.

Knowing this, Houston can learn from Barcelona and other cities to move toward more urban planning and transportation that cause sustainable behaviors.

MOVING FORWARD

In Houston, there is a lot we can learn from Barcelona in going toward a more sustainable city from a land use and transportation standpoint, and there is a lot we are already doing. We do have transportation systems that have developed in a way that do figure out how to move people without cars. For example, according to Ms. Lin, most people commuting to Rice University can get there easily with a maximum of one transfer, whether they choose to or not.

Houston has also created a new way of approaching the metro system. More emphasis is being put on connected major nodes instead of commuter nodes, which in turn drives up housing quality within the city and encourages more densification and less commuting. This is clearly something we see in Barcelona. All walkable and bikeable cities work on the unit of the neighborhood, and increasing the presence of neighborhoods and nodes in Houston while also connecting them to the rest of the city by transit may be an important way to go.

There is, however, still a cultural barrier.

Mr. Spieler states that “we’ve built a lot of barriers and there has been a shift in the attitude, but even now there are a lot of members of the public who don’t think bikes belong on streets and who don’t think we need sidewalks and who don’t think there should be a bus stop in their neighborhood. Given everything that has been built and given that there is still resistance, it takes a lot to change those things.” Public perception of sustainable transportation will be a slow process, but Mr. Spieler does think that improving the infrastructure first is the way to go, and a cultural shift will come after that.

One important mindset barrier to consider in Houston is public perception

of safety on public transportation.

Safety is a concern for many riding the metro and bus system, as there is a perception that more questionable characters will also be using the system. Ms. Lin says, “The feeling of safety is one of those things that people are just manifesting. There may be questionable people on there but most times they keep to themselves, and I would feel much safer riding in a bus if there’s a collision. I actually feel safer in a bus than anything else.”

Clearly, according to her, safety from others on public transportation is not an incredibly reasonable concern, but still one to acknowledge that plays a role when people choose what mode of transportation to take.

Perhaps by increasing presence of ticketing personnel and making it clear the statistics on safety in public transportation, Houston can move toward alleviating this cultural barrier.

Additionally, by increasing bike lanes and sidewalk safety, Houston can also make those sustainable transportation choices safer as well.

With regards to walking and density, parts of Houston have also begun to take after European cities, like the CityCentre shown in Figures 8 and 9.

The CityCentrewas developed after studying European cities, butis still a pedestrian neighborhood that most people ironically do need to drive to. For example, if you were a Rice University student hoping to go for a late-night movie or food, driving would take eighteen minutes while public transportation would take about two hours as shown in Figures 10 and 11.

Clearly, driving in this case is the only viable option, despite the fact that this area is still pedestrian friendly-- once you get there.

Lastly, another infrastructure component that can be improved is using the cost of parking as an infrastructure component. When companies do not provide free metro passes but do provide free parking, suddenly the appeal of transit rapidly decreases. Parking was a kind of afterthought in most major cities like Barcelona, whereas here when Houston was developing we had so much space that parking lots were not a huge cost

to developers. Of total developed area in Houston, roads and parking areas account for 25% of the land. The parking industry is one that lends itself toward the unsustainable car-centric behavior of residents in Houston.

Americans go take trips to Barcelona partly because it is so walkable and has such vibrant streets. People inherently want to be connected to people and have communities in their lives.

Ultimately, people in Houston are not averse to walking and biking places, but instead the infrastructure doesn’t lend itself to them. Cities are not going to succeed by pushing people toward means of transportation that do not make sense to them, but instead need to make those means of transportation make sense to them.

CONCLUSION

I came into this class with a belief that people in Barcelona inherently care more about the environment and want to live more sustainably than people in Houston. However, I learned that a lot of it comes from the fact that Barcelona is built in a way that pushes you to be more sustainable. The way the city is predetermines how you experience sustainability in that city.

Surprisingly, though this research I became aware of the fact that none of us truly have freedom when it comes to transportation. All of our choices are circumscribed by decisions made by other people both public and private, and a large portion is how land is used in the city. There’s a very complex set of organizations and mechanisms and financial incentives behind all of this.

To change it we have to understand this and realize what a huge part of the overall picture of sustainability that is.

Hopefully by realizing just how large a role urban design has in conditioning and pushing people towards certain actions, residents will want to have a larger say in policy for land use and infrastructure in their cities.

Ultimately all cities can become more sustainable by creating and changing land use patterns and transportation infrastructure that push residents toward sustainable actions. Cities are powerful entities constantly shaping the behavior of people, and it is time

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we become aware of this and use it for future generations’ advantage.

BIBLIOGRAPHY

“Barcelona.” Wikipedia. Wikimedia Foundation, 03 May 2017. Web. 06 May 2017.

Bausells, Marta. “Story of Cities #13: Barcelona’s Unloved Planner Invents Science of ‘urbanisation’.” The Guardian. Guardian News and Media, 01 Apr. 2016. Web. 06 May 2017.

Bausells, Marta. “Superblocks to the Rescue: Barcelona’s Plan to Give Streets Back to Residents.” The Guardian.

Guardian News and Media, 17 May 2016. Web. 06 May 2017.

D’Alisa, Giacomo, Federico Demaria, and Giorgos Kallis. Degrowth: A Vocabulary for a New Era. London: Routledge, 2015. Print.

“Geographic Areas of Houston.”

Wikipedia. Wikimedia Foundation, 03 May 2017. Web. 06 May 2017.

Hannah Appel, Nikhil Anand and Akhil Gupta. “Introduction: The Infrastructure Toolbox — Cultural Anthropology.” Cultural Anthropology.

N.p., n.d. Web. 20 Apr. 2017.

History of Barcelona - Lonely Planet Travel Information. N.p., n.d. Web. 06 May 2017.

Hitchcock, David. “Cool Houston! A Plan for Cooling the Region.” (2004): n. pag. Houston Endowment. Web. “Houston.” Wikipedia. Wikimedia Foundation, 05 May 2017. Web. 06 May 2017.

Human Population: Urbanization.

N.p., n.d. Web. 06 May 2017.

Larkin, Brian. “The Politics and Poetics of Infrastructure.” Annual Review of Anthropology 42.1 (2013): 327-43.

Web. Lockrem, Jessica, and Adonia Lugo. “Infrastructure — Cultural Anthropology.” Cultural Anthropology.

N.p., n.d. Web. 06 May 2017.

Melosi, Martin L. “The Automobile Shapes The City.” Automobile in American Life and Society. N.p., n.d.

Web. 10 May 2017.

“Statistics.” Ajuntament De Barcelona.

N.p., n.d. Web. 10 May 2017.

“Urban Anthropology.” Wikipedia.

Wikimedia Foundation, 04 Apr. 2017.

Web. 06 May 2017.

“What Is Sustainability?” What Is Sustainability. N.p., n.d. Web. 06 May 2017.

ACKNOWLEDGEMENTS

I would like to thank the School of Social Sciences Gateway Program at Rice University for providing me with this incredible opportunity to research, interview in, and experience two different cities. I do not think I would have had another opportunity to conduct anthropology research in a topic of my choosing had it not been for this class, and I believe I have grown greatly because of it. Specifically, I would like to thank Ipek Martinez for helping organize the program and taking the time to travel with us to Barcelona.

I would also like to thank my two professors, Dr. Georges and Professor Giménez Aliaga for their continued support and help in this process.

They were always so welcoming and responsive, and I would have felt lost without them.

Lastly, I would like to thank ISGlobal and the Institut of Environmental Science and Technology for welcoming our class, as well as the five people I interviewed for donating their time to talk with me.

MEET THE AUTHOR Claire Casey (’19) is a student majoring in Civil and Environmental Engineering, with a minor in Water and Energy Sustainability. She is passionate about structural engineering and environmental engineering because she hopes to pursue a future career in Green Infrastructure. She is interested in the social implications of sustainable design.

VIII. DEVELOPING PUBLIC SPACE sustainability

EXECUTIVE SUMMARY

Top-down and Bottom-up Approaches to Developing Public Space: A Comparative Study between Houston and Barcelona

This study investigates top-down and bottom-up approaches to developing public space across Houston and Barcelona. While there are wellsubstantiated benefits to green and open-air spaces, city-led greening efforts, such as urban parks, risk raising property values and displacing local residents. I compared how different approaches accounted for and addressed local values and needs.

Houston and Barcelona are similar in that a wide-spread initiative to beautify the cityâ&#x20AC;&#x2122;s outward image drives many greening projects which, accordingly, do not always take into account the welfare of local residents.

Barcelona has many instances in which neighborhood groups occupy a vacated area, developing it into a selforganized space with a cooperative form of governance. The prevalence of these initiatives stems from a long history of social movements around

citizensâ&#x20AC;&#x2122; rights in Barcelona and from a strong sense of neighborhood identity.

While Houston does exhibit some neighborhood mobilization, most bottom-up development of public space is the work of non-profits and primarily tied to a specific issue, such as organic gardening or conservation.

Given that many bottom-up approaches more directly account for local needs, studying such efforts may prove valuable for promoting the socially-just installation and maintenance of urban public space.

Introduction When in a public space, it is easy to overlook the significance, values, contention, and possibly injustice underlying its existence. However, critically examining the conception and use of different spaces suggests there is a wide variation in how they serve, or oppose, the needs of local communities. I looked at top-down and bottom-up approaches to developing

public space. In doing so, I analyzed the complications associated with different approaches and how well they addressed community needs. There is a significant range in what constitutes a public space. To make my investigation feasible, I have limited its scope to include urban parks, community gardens, and self-organized spaces with an open air component. Drawing upon sites from Barcelona and Houston, I was able to examine how the political, economic, and cultural conditions of a city influence how public spaces are developed and valued.

ISSUE STATEMENT

The public spaces I am interested in all have a green, open air component, and there are well-studied benefits to these types of spaces, including improved well-being, aesthetic value, and facilitated social interaction.

In particular, previous studies have found a positive relationship between

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human health and exposure to green space (Triguero-Mas 2017). However, different ethnic and socioeconomic groups do not always derive the same health benefits from surrounding greenness (Dadvand et al. 2014). This finding suggests the benefits of green space may be influenced by how people perceive, value, and use such spaces, rather than just their physical attributes (Triguero Mas 2017). Accordingly, the relationship between greenspace and health has important social justice implications. While research suggests that populations exposed to green environments tend to have lower levels of income-related health disparities, urban greening efforts must consider how different communities perceive and value greenspace to ensure that the types of spaces implemented are best attuned to community needs (Mitchell and Popham 2008).

Greenspaces are often my favorite parts of the city, and I always assumed everyone appreciated them, even if not to the same extent I did. Many of the question driving this paper stem from realizing that this ubiquitous appreciation may not always be the case. To begin, urban greenspace is far from equitably distributed. Many socioeconomic and racial groups have disproportionately lower access due to physical distance away and/or perceived social exclusion in certain spaces (Wen et al. 2013, Byrne and Wolch 2009). Furthermore, efforts aimed at increasing greenspace in underserved areas can actually have adverse consequences by raising housing costs and property values, thereby catalyzing gentrification and displacing the original community (Wolch et al. 2014). “Green gentrification” describes the process by which new or restored environmental amenities, such as parks and preserved wilderness areas, raise property values, attract wealthier people, exacerbate socioeconomic gaps, and disrupt preexisting residents. Policymakers and city officials often implement such greening projects in accordance with a sustainability agenda, an agenda which does not always consider the livelihood and needs of local communities (Anguelovski 2017).

With my idealized view of urban parks destabilized, I wanted to investigate how urban greening could be implemented in ways which more assuredly account for local community values and needs. Accordingly, I became interested in exploring both top-down and bottom-up approaches to developing urban spaces. There are many instances in which community members, tied together by neighborhood identity or a common interest such as environmental conservation, mobilize and develop a space for public use. In beginning my research, I quickly found that not all such spaces are particularly green, as in the actual color green. Grassroots coalitions might claim a vacant lot or occupy an empty building. Therefore, I broadened my investigation to include public spaces more generally. However, for the feasibility of my study, I have limited the scope of my investigation to include public spaces with at least a semi-green, open air component.

Specifically, this includes urban parks, community gardens, and more general self-organized spaces but which have an outside, often garden-related component.

In examining different approaches to the development of public spaces, I am interested in how such spaces take into account or overlook the needs of existing communities. I believe that in considering how we develop and maintain public space, it is important to consider the values of local residents and look for potential adverse effects, rather than imposing a top-down assumption of what constitutes a beneficial public space.

While attentive city hall initiatives are capable of implementing socially just spaces, I maintain that examining grassroots initiatives could deepen our understanding of how to best address community needs and avoid unjust consequences.

RESEARCH AND METHODS

I began my research with a literature review to situate my topic within wider discourse about the benefits and complications of urban public/ green spaces. While in Barcelona, I was fortunate enough to meet

with Margarita Triguero-Mas, a researcher at ISGlobal, who both gave a presentation and spoke with me individually about the relationship between urban greening and human health. I also interviewed Stephanie Loveless, a doctoral candidate at Institut de Ciència I Tecnologia Ambientals, part of the Universitat Autònoma de Barcelona, who gave insight about green gentrification and how urban greenspace relates to issues of social justice. Together, they provided much of the expertise which informed my background research above, both through what they said and their suggestions for further reading. At the Universitat de Barcelona, I attended a talk Dr. Irene Sabaté Muriel, a professor of anthropology. She discussed Barcelona trends in housing and tourism which proved important for contextualizing my research on recent top-down development of public space.

While in Barcelona, I was also able to visit public spaces developed from both top-down and bottom-up approaches.

Parc Central del Poblenou and Plaça de Catalunya provided examples of an urban park and city center respectively, both created and maintained by city hall. From visits to Espai Germanetes, Can Batlló, and El Forat de la Vergonya, I also witnessed how community members mobilize to occupy and selforganize spaces for common use.

I gathered much of my information on top-down greening initiatives in Houston through news articles and park websites. I also visited Discovery Green and Herman Park to augment my online research with participant observation. To try and better understand how Houston differs from Barcelona in terms of grassroots self-organizing of public space, I interviewed Dr. Kyle Shelton, a researcher at the Kinder Institute for Urban Research. I looked into Last Organic Outpost as an example of a community gardening initiative in Houston. I spoke with a student intern there who provided more information about the non-profit’s organizational model, mission, and participants.

FINDINGS

Top-down Approaches Barcelona Since the time of the 1992 Olympic Games, when Barcelona made a grand entrance onto the global stage, the city has undertaken an effort to brand itself as a prime tourist destination and great place to live. The idea of the “Barcelona Model” began with plans to revitalize the city in preparation for the Olympic Games. However, some residents feel that municipal officials and planners, with their focus on showcasing Barcelona in the eyes of foreign visitors, overlooked local needs and ways of life in making plans for development (Sabaté Muriel 2017). With the Games over, city-wide change did not stop there. In fact, the Games seemed to have catalyzed an accelerating trend in urban planning initiatives aimed at attracting tourists and wealthy immigrants, but which disadvantaged current residents through rising house prices and an economy driven by the “Barcelona brand.” Today, Barcelona has 7,243 acres of greenspace, comprising around 29% of the city’s 25244 total acres (Barcelona Department D’Estadistíca). Dr. Sabaté Muriel, from the Universitat de Barcelona, uses the term “beautification” to describe how gentrification and tourism have affected public spaces. City hall has made an effort to increase greenspace across Barcelona, but as a means to improve the city’s global aesthetic image. Given this purpose, it seems likely that new urban parks would cater to the desires of tourists and wealthy immigrants, rather than local residents.

To get a better sense of how newlyestablished urban parks might reflect this top-down vision for Barcelona, I visited the Parc Central del Poblenou.

The park, situated within the Poble Nou neighborhood, was designed by a French architect, Jean Nouvel, and inaugurated in 2008. Looking around the park, I was struck by its immaculately-planned layout and architectural features. The park was not overwhelmingly green, but more of a brown open space decorated with structures made of metal and selected plant life. These structures served more

as modern art pieces than usable park equipment. There were metal chairs positioned throughout, prearranged and unmovable. While there, I spoke with a man who was sitting and watching his young daughter play nearby. He said he had managed to walk past the park for years on his way to work, and never recognize it for what it is – an urban park – until just recently, perhaps suggesting that the park was not well promoted among preexisting neighbors. Now, he takes his daughter there after preschool to let her run around and burn off energy. He values the park for its utilitarian purpose, as a playground for his daughter, rather than for its aesthetic value. And yet, certain features of the park suggest its design was more invested in aesthetics than practically. For example, it is hard for the father and daughter to stay late because the metal structures and trees block the lamps such that light can hardly reach where the children play.

When prompted, he also said that the park has little sense of community. His daughter may play with some other girls if they are around, but he has yet to build relationships with neighborhood families through visiting the park.

In a Barcelona case study on green gentrification, the Parc Central del Poblenou had among the highest levels of gentrification in its surrounding residential area. While historically, the neighborhood consisted of mostly working class families, its occupants have shifted towards a professional elite in recent years. The number of residents with at least one university degree has increased by 689%.

The income of nearby families has jumped by 20.5% and the presence of foreigners from Northern countries by 3791% (Universitat Autònoma De Barcelona 2016).

After visiting a space seemingly designed for the palate of wealthy residents, I visited a space which now seems to exist purely for tourists: Plaça de Catalunya. This public space – a large open circle decorated with manicured patches of grass and wellmaintained flower beds – is primarily occupied by tourists. The only nontourists, from what I could tell, were those selling items on blankets. I spoke

with a woman later that day who said she used to go to the Plaça with her grandmother and feed the pigeons. At one point, city hall closed off the Plaça to renovate it and now she does not visit anymore, knowing she will only find it swarming with tourists. The streets surrounding Plaça de Catalunya are lined with high-end clothing stores and expensive restaurants.

Even top-down initiatives meant to serve the existing communities may not be well-attuned to what local residents want and need. For example, the city-wide plan to restructure Barcelona into a “superblocks” model intends to increase open space, providing more room for community events and reducing traffic-related air pollution. However, locals contested the pilot example which, though beneficial in theory, ended up raising property values. City hall is trying to improve for the future by working more with local residents (TrigueroMas 2017, Loveless 2017). This situation exemplifies how top-down development of open public space, though intended to benefit everyone,

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may prove unsuccessful without bottom-up involvement.

Another aspect of this top-down beautification process is the increasing regulation of public space (Sabaté Muriel 2017). Such regulation is exemplified in the small green signs posted around nearly every public space in the city. These signs dictate, using the same few graphics, what can and cannot be done in each space.

At Plaça de Catalunya, for example, a sign placed in front of a patch of grass indicates that neither humans nor dogs may step on this grass, but people should clean up after their pets and dispose of trash. The regulation of public space is an especially pronounced subject in Barcelona, a city in which the right to spaces which are truly public has become a prominent issue for many social movements.

For the clarity of my study, public space is an important term to define.

The United Nations, specifically the UNESCO website, defines it as “an area or place that is open and accessible to all peoples.” However, given that social movements in Barcelona comment on increased regulation in discussions of public space, I will use a broadened definition in which public spaces are open and accessible areas where people feel their personal freedom is unthreatened. Between new spaces created to attract tourists and wealthy immigrants, parks which drive gentrification and displace locals, and increasing regulation incongruent with how citizens value public areas, it seems as if, at least in these ways, topdown approaches to developing public space may not always account for local needs and values.

Houston In Houston, similar to in Barcelona, a widespread initiative to beautify the city seems to, at least partially, drive the top-down development of public spaces. Historically and generally speaking, Houston was self-aware, yet indifferent, about its lack of greenspace. The city grew prosperous on oil and gas, maintaining that its appeal lay in the promising energy industry rather than in aesthetic appearance. However, there is a

growing concern among municipal officials for what will happen when oil prices drop too low or, in the long-term, the economy no longer runs on fossil fuel. Consequently, there has been an impetus to transform Houston into an attractive city people will move to independent of the energy sector. Tom Bacon, chairman of the Houston Parks Board, explains how the United States, at large, is undergoing a greening movement in urban centers. Like other cities have done already, Houston has come to recognize that green space is necessary for attracting the intellectual capital which will sustain cities in the future. Therefore, the development and restoration of urban parks across Houston is, at least partly, an effort to reach the aesthetic caliber of other cities. Greening projects often reflect a mission to attract young professionals with the ultimate goal of sustaining Houston’s economy even in a post-fossil fuel era (Swartz 2015).

Today, Houston has 52,912 acres of greenspace, comprising around 14% of the city’s 384,000 total acres (Visit Houston website, US Census Bureau).

This is compared to Barcelona’s 7,243 acres, 29% surface cover, of greenspace.

If there is a top-down desire in Houston to attract wealthy outsiders and boost the economy, green gentrification seems like it would be inevitable. One specific initiative, Bayou Greenways 2020, aims to expand the park system such that there will be 150

miles of continuous parks and trails along the bayous. In an interview published online, Roksan Okan-Vick, the executive director the Houston Parks board, discusses many benefits of the project: increased recreational opportunities, better water and air quality, habitat preservation, and an economic benefit. She explains that any kind of park project, especially those along waterways, enhances property values by creating more desirable places to live (Okan-Vick 2015). Such a trend is characteristic of green gentrification. Her interview response has an internal contradiction, citing both equitable access to greenspace and higher property values as benefits.

It seems unlikely that greenspace could be equally accessible to all Houstonians if increased property values risk displacing local residents.

Discovery Green, a park located in Downtown Houston, suggests a relationship with gentrification through its website. In particular, the website boasts about the impact of the park on the surrounding area, saying it “has served as a catalyst for $625 million in downtown development.”

The text goes on to list significant projects which chose their location based on proximity to Discovery Green: a high-end residential tower, the highest priced commercial space in Houston at the time, and multiple expensive hotels. I visited Discovery Green to observe its function as a park

and impact on the surrounding area firsthand. It was a weekend day and the park was filled with families and children playing. However, because there are only office buildings and hotels nearby, not any residential space, there is no single community for which the park is readily accessible. The adjacent newly-constructed and highend buildings allude to gentrification in the surrounding area.

The revitalization of Emancipation Park, another top-down greening project, is unique because its 10-acre plot has such a deep-rooted significance for the surrounding neighborhood.

Former slaves purchased the land in 1870 as a site for their Juneteeth celebrations. Just recently, 33.6 million dollars went into the park’s

redevelopment, a plan designed by a distinguished architect (Rudick 2013). Nearby residents feel a strong identification to the neighborhood, the Third Ward, and are wary that the revitalized park might lead to gentrification (Binkovitz 2016). Robert E. McGee, Pastor of a notable church in the Third Ward, expresses intent to fight back against gentrification and wants to involve community members in the development and planning of parks, such as Emancipation Park (Rodgers 2015). This situation parallels the superblocks in Barcelona: an initiative meant to serve existing residents but must account for and communicate with local communities in order protect against inadvertent gentrification.

While some regard the increased regulation in Barcelona as encroaching on the concept of “public,” Houston more explicitly blurs the line between public and private. Across the city, public-private partnerships have played a critical role in urban greening.

Discovery Green, Buffalo Bayou Park, and plans for Bayou Greenways 2020 all involved significant funding from private donors (Meredith 2016).

For one particular model, a private developer purchases land for largescale development and then sets aside a portion to serve as public park space (Gattis 2006). Levy Park is an example of this public-private partnership: Midway, a Houston-based real estate firm, partnered with the Parks and Recreation Department to establish a park amid its commercial and residential development (Smith 2017).

These public-private partnerships guarantee that the area surrounding a park will have high property values, enhanced by the presence of greenspace, and be aimed at a wealthy, likely young and professional, demographic. Dr. Kyle Shelton, an urban planning researcher, deems these parks “quasi-public” spaces because having private firms involved means more stringent regulation of the parks. He posits that parks created from public-private partnerships raise the question of what it even means to be a public space in the city today.

However, in light of these examples, it is still important to not oversimplify the situation and generalize all topdown-developed parks as causes of gentrification, exclusive, and unappreciated by community members.

My visit to Discovery Green revealed a lively and well-used park occupied by a diverse set of families. In Barcelona, the Parc de l’Espanya Industrial is the result of community mobilization against housing development on the site of a vacated mill. I passed through the park and despite its top-down creation and high-brow artistic design, the surrounding area appears to have remained mostly working class. Yet, as discussed above, both Barcelona and Houston exhibit clear instances when the top-down development of public space overlooks community

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needs and leads to gentrification. In both cities, urban greening is at least partly driven by an initiative to attract wealthy outsiders, whether they be tourists or young professionals. And accompanying new development is the increasing destabilization of what constitutes public space, through more stringent regulation in both cities and the prevalence of public-private partnerships in Houston.

Bottom-up Approaches Barcelona Local residents in Barcelona often feel a strong, deep-rooted attachment to their neighborhoods. Neighbors identify with their physical surroundings and each other through a sense of “collective memory” (Sabaté Muriel 2017). The city also has a long history of social movements and community organization, resurging with the 15M movement in 2011. At the intersection of strong neighborhood identification and a deep-rooted culture of social movements is the practice of selforganizing spaces, or developing vacant areas into community-managed commons for public use. While this concept of self-organization has a long history in Barcelona, the recent political and financial crisis has led to the devaluation of public space and abandonment of many public and private partnerships. Thus, there have been an increasing opportunities for community movements to claim vacated spaces and reorganize them for public use (Parés et al. 2014).

These self-organized spaces, also called urban commons by the research group El Observatorio Metropolitano Barcelona, can include outdoor meeting areas, community gardens, occupied buildings, and any other type of space. For the purpose of my study, I focus on the types of spaces which most parallel the top-down-developed urban parks I examined earlier. Accordingly, I investigate urban commons which are either entirely outdoors or have a significant outdoor portion, such as a community garden.

One such space is El Forat de la Vergonya, or “Hole of Shame,” located in the Casc Antic neighborhood. Casc Antic, a traditionally low-income

and immigrant neighborhood, has been the site of communityorganized revitalization for over 15 years. Between 2000 and 2006, residents constructed and managed parks, playgrounds, and community gardens in the face of municipal opposition. In 1999, a company tore down several buildings in Casc Antic with the intention of building a car park and high-end apartments. The lot remained vacant for two years until community members decided to occupy the space, now called El Forat de la Vergonya, and installed greenspace, a community garden, playground, and sports equipment.

Following the bottom-up project came a long fight between residents, local officials, and the police, which lasted until the city agreed to cancel plans for the car park and, instead, rebuild the area to mostly align with community desires. The grassroots mobilization around developing El Forat de la Vergonya exemplifies how movements for environmental quality can serve as a tool for addressing large-scope issues faced by marginalized communities.

In Casc Antic, the fight for access to public greenspace represents an environmental justice initiative situated within larger political and socioeconomic movements concerning the right to the city, urban inequality, and the struggle for control over land in the face of gentrification (Anguelovski 2013).

I visited El Forat de la Vergonya midday on a weekday. Despite the unconventional time for a park visit, the space was well-occupied and animated. A large group of kids were playing basketball and a good number of older people, and a few youngeraged, lounged on benches around the area. Beside the park, there was a community garden which was fenced off but had signs welcoming people to come use the plot. One sign read, “Benvinguts, Welcome.” Another began with “Queridos Amigos,” and asked that people leave the space better than they found it. The garden was lush and well-maintained, the clear result of a cooperative effort.

I interviewed a middle-aged, African woman who was watching her son play basketball with the large group of kids. Despite her limited English, she appeared eager to convey her satisfaction with the neighborhood space. She said she liked it because it was lively and had everything: a play area, garden with food, and community events. She went on to describe the park’s importance to the surrounding community because they fought for it.

When asked how this space compares to other parks constructed by city hall, she explained that it is better because all people mixed – rich, poor, Africans, Dominicans, and Italians. I found this interview to be especially interesting for how it paralleled the interview at Parc Central del Poblenou; both were

with a parent watching their child play.

While the father at Poblenou seemed ambivalent about the quality of the park and did not cite a strong sense of community, the mother at El Forat de la Vergonya was enthusiastic in communicating her preference for that particular space and the importance of community there. Both visited their respective park with a similar desire, to give their children a place to play, but the community-organized El Forat de la Vergonya better provided for such a desire, or so it seems from the enthusiasm of my particular interviewee.

In addition, I visited Espai Germanetes – another urban common which provided a clear look into the process of self-organization. The public space consisted of an outdoor meeting area with scattered building, cooking, and recreational supplies, a well-kept community garden, and an open park. Propped up in the meeting area was a sign explaining the purpose of the space and how the community assembly functions, emphasizing that everyone collaborates to make it work. I spoke with an older man who has been coming to Espai Germanetes every day for years to look after the garden. His enthusiasm as he spoke about the flowers suggested he felt a strong connection to the space and its purpose in the community.

The third public space I chose to explore was Can Batlló, located at

the site of a vacated textile factory.

When the factory first shut down, the city made plans to redevelop the area. But after years of inaction, the neighborhood mobilized and fought against municipal officials to gain control of the space. In 2011, the city ceded Building 11 to the community.

The total area has expanded some since and through cooperative efforts it now includes meeting spaces, a library, brewery and bar, community garden, mechanic workspace, and climbing wall. (Martí-Costa and Dalmau Torvà 2013). Unlike my other sites, much of Can Batlló is located inside buildings. However, I still chose to include it because it has an outdoor component and, more importantly, is a well-studied example of grassroots trends in self-management and social cooperation. Like other urban commons throughout Barcelona, the bottom-up development of Can Batlló constitutes part of a larger movement which authors Marc Martí-Costa and Marc Dalmau Torvà call “insurgent urbanism.” To that end, again like other urban commons, Can Batlló is overt in asserting its publicness and devotion to community needs. In developing the space, residents tore down a wall separating the old industrial site from the rest of the neighborhood – a literal and symbolic transition from privatization to being truly public. The agreement governing the Can Batlló for the Neighborhood Platform states that “it is of the people, by the people, for the people” (Martí-Costa and Dalmau Torvà 2013).

From a visit to Can Batlló, I could tell the vacated area was not just organized as a public space for community members to come and socialize.

Rather, it seems to be a prototype for an alternative economic and social model. An alternative to capitalism, consumerism, and, endemicallyspeaking, the Barcelona brand. From the practice of shared labor to the frequent community assemblies, underlying values of cooperation and sharing are impossible to miss. In addition to the shared economy within the perimeter of Can Batlló, there are workshops for reviving traditional crafts which will be well-suited to their

vision for the future: a cooperative city of trades (Martí-Costa and Dalmau Torvà 2013). Can Batlló represents a sort of experimental arena for anticapitalist theories such as cooperative economics and degrowth, but in ways aimed at meeting the specific needs of community participants.

The sites I chose to study in Barcelona suggest that bottom-up development of public space seems to stem from strong neighborhood identification and a history of community organization.

The widespread practice of occupying vacant lots and revitalizing them for public use takes part in a larger culture of social movements and the fight for citizens’ rights. Accordingly, these grassroots-developed spaces represent much more than just a place to spend time outside, deeming them fundamentally different than, say, an urban park. These urban commons are a nexus of environmental revitalization, rights of use over land, community organization, cooperative modes of governance, and in cases such as Can Batlló, alternative economic models.

Despite the varying histories and physical appearances of these different spaces, they appear to share one key commonality: a dedication to the needs and values of local residents.

Houston While Houston does exhibit bottomup approaches to developing public space, such as a myriad of community gardens, I was unable to find instances of neighborhood mobilization and self-organization analogous to those in Barcelona. I interviewed Dr. Kyle Shelton, a researcher for the Kinder Institute of Urban Research, about what might explain this discrepancy between the two cities. A historian by training, Dr. Shelton offered historical context as a possible explanation.

Older cities, such as Barcelona, tend to have tighter-knit communities and more of a shared understanding about what a neighborhood is. This suggests that Barcelona residents feel a stronger identification with their physical surroundings and have more of an impetus to fight for discrete, tangible spaces. Additionally, Dr. Shelton posited that the impulse to

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mobilize and the collective idea of a city exists more in Europe than in the United States. He elaborated that European cities have older communal histories while American, and especially southern, cities were developed around the idea of private property. Aligning with typical American values of privatization and individualism, people in Houston might be more likely to fight for their right to the city as individuals, rather than part of a collective effort. As an important qualification, Houston does have neighborhood associations and instances of such associations working with city hall to serve community needs. However, while these efforts in both Houston and Barcelona address economic development and affordable housing, efforts in Houston appear less concerned with the right to public space. Furthermore, this process of bottom-up urban planning is more formalized than some of the grassroots occupying efforts seen in Barcelona (Shelton interview). Barcelona’s longer history of social movements might explain this difference in mechanism.

This is not to say Houston does not have bottom-up efforts for urban greening or developing public spaces.

However, from the limited cases I’ve studied, it appears that efforts are less driven by neighborhood identification.

Houston has many community gardens distributed throughout the city. But unlike the gardens in Barcelona, mostly located in neighborhood self-organized spaces, many Houston gardens are associated with schools, churches, and nonprofit organizations. One nonprofit in particular, Last Organic Outpost (LOO), describes itself as “an urban pioneer collective.” The website goes on to say: “We are a project-based, non-profit organization created to develop community resources through urban agriculture” (LOO website). I interviewed a student intern working with LOO to get a better sense of the mission and activities of the organization. The community gardens are organized to be communal for the most part, not plot-based. There is a sense of community building around the land, though it is a community

of participants who come to use the garden from elsewhere, rather than the surrounding neighborhood. However, LOO just recently switched locations and at their old location, there was a successful effort to get neighbors involved. The surrounding area had a high number of immigrants who used the community gardens as a staple food source. The organization brought in some non-native crops which is a contentious issue among gardeners but much appreciated by the immigrant community. Yet for the most part, and especially now that the location has moved, the nonprofit caters more towards people coming in from other parts of the city, drawn by an interest in urban gardening and sustainable living.

Relatedly, many instances of developing or preserving public space seem to be nonprofit-driven initiatives and thus oriented towards a specific cause. Dr. Shelton spoke to this trend, saying that mobilization over widespread issues is more common than mobilization over a physical space. He hypothesized there is an impulse in Houston to have movements be more than just place-specific. Accordingly, LOO is not just about developing gardens for community use but also about promoting ecological consciousness and sustainable practices. Along with listing “accessing community needs” as a focus, the website lists “resourcing soil development” and “aggressive water conservation strategies.” The purpose of the gardens is not to serve the specific community where they are located, but rather to provide a model for a natural and sustainable relationship with urban land.

According to their student intern, the organization’s vision is to create and promote community gardens across Houston, deeming it clearly not placespecific.

However, describing bottom-up development in Houston as often issuespecific rather than place-specific is not meant to imply Barcelona initiatives do not engage larger issues. On the contrary, and as I describe earlier, selforganized spaces in Barcelona often embody city-wide social movements

concerning citizens’ rights and autonomy over land use. Both cities also have bottom-up-developed spaces which were envisioned to serve as models. For example: similarly to how LOO serves as a model for urban organic farming and sustainable practices, Can Batlló serves as a model for cooperative governance and shared economics. However, in my investigation of different initiatives between cities, I found that many self-organized spaces in Barcelona identified with their surrounding neighborhood and interacted directly, first and foremost, with the neighbors.

In Houston, I noticed that many grassroots initiatives identify with a specific issue, such as organic farming, more so than their physical location within a neighborhood.

CONCLUSIONS

From my four-way comparison, looking at top-down versus bottomup approaches and Barcelona versus Houston, there are both telling commonalities and intriguing differences. Between Barcelona and Houston, there are many similarities in the motivations and outcomes of top-down initiatives to develop public space. In both cities, these initiatives seem at least partly driven by an impulse to beautify the city’s outward image and attract others. For Barcelona, this impulse is entangled with a dependence on tourism and desire to attract wealthy immigrants.

In Houston, the motivation is similarly economic but focused on attracting young intellectuals and professionals to sustain a post-fossil fuel economy. Consequently, many new greening projects do not always account for, or emphasize, the needs of local communities. That is not to say residents never benefit from nor appreciate the beautification of their surroundings, but that top-down projects may not consider marginalized communities in particular. New urban parks frequently lead to gentrification of the surrounding area, disrupting and often displacing lower-income residents. Another trend seen in both cities is increasingly stringent

regulation of public spaces and, predominantly in Houston, the development of parks through privatepublic partnerships. Such trends destabilize a pure definition of “public,” at least as I define the term earlier, and prompt the question of whether truly public spaces are becoming a relic of the past.

When comparing bottom-up approaches between the two cities, many more differences arise. In Barcelona, contrary to how cityinstalled parks may overlook local needs, grassroots development of public spaces is overtly devoted to the surrounding neighborhood. Across the city, there are many instances in which neighborhood coalitions occupy a vacant space and self-organize it for public benefit. This process seems rooted in a culture of strong neighborhood identification and a long history of social movements. The occupation and organization of public space often stands as an expression of citizens’ rights and functions using cooperative modes of governance. In Houston, the bottom-up development of public spaces seems to be primarily nonprofit driven and issue-specific, rather than overtly tied to a particular neighborhood. Such efforts appear less focused on addressing the needs of a nearby community and more so on promoting a larger-scope agenda, such as organic gardening. However, some qualification here is necessary. Parts of Houston do have a strong sense of neighborhood identity and there are certainly instances of neighborhood mobilization for rights. Grassroots organization of neighborhood spaces just seems to be less characteristic of the city than it is in Barcelona. It is also important to acknowledge that the line between top-down and bottomup action is far from defined. Many bottom-up initiatives are aimed at, or result in, the top-down development of public green space in an underserved community. However, this process often holds a critical paradox: greening projects meant to benefit a marginalized community raise property values, lead to gentrification, and might ultimately place the original

residents (Anguelovski 2017).

I believe the findings of this study have important implications. As Dr. Isabelle Anguelovski, a researcher at Universitat Autònoma de Barcelona, states in an online interview: “Sustainability has been de-politicized.” That is, people assume city-led greening projects will benefit everyone when, in reality, they often exacerbate socioeconomic inequalities. Because public spaces, such as urban parks, are not readily recognized as sources of distress, there is a lack of attention to the question of who benefits and who suffers from these beautification initiatives (Anguelovski 2017).

However, it would be similarly unjust to abandon revitalization efforts in low-income areas because there are well-studied benefits to having open/ green space for social contact. Such benefits are substantiated both by peer-reviewed research and by the enthusiasm of people I interviewed throughout my research. Therefore, I believe it is productive to examine other approaches to developing public spaces, specifically those with grassroots organization by residents and for residents. Studying how bottom-up efforts successfully identify and address local needs may prove valuable for promoting the sociallyjust installation and maintenance of urban public space in the future.

ACKNOWLEDGEMENTS

I want to thank all researchers who gave presentations and/or spoke directly with me throughout my time in Barcelona: Margarita TrigueroMas, Stephanie Loveless, Dr. Irene Sabaté Muriel, and Dr. Giorgos Kallis.

Additionally, I want to thank Dr. Kyle Shelton and the student intern at LOO for providing invaluable perspectives on Houston. Last but not least, I want to thank Dr. Nia Georges and Victor Gimenez Aliaga for the incredible guidance and mentorship, and Victor for sharing parts of Barcelona which I would never see as just another tourist. And, of course, the rest of the Global Urban Lab class for such an amazing array of perspectives, great conversations, and making the trip to

Barcelona unforgettable.

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N.p., n.d. Web. “About the LOO.” The Last Organic Outpost. N.p., n.d. Web. Anguelovski, Isabelle. “Beyond a Livable and Green Neighborhood: Asserting Control, Sovereignty and Transgression in the Casc Antic of Barcelona.” International Journal of Urban and Regional Research 37.3 (2013): 1012-034. Web. Anguelovski, Isabelle.

“Isabelle Anguelovski: “Powerful Investors Have Taken over the Ecological Agenda”.”

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Barcelona Metròpolis. N.p., 2017. Web. Okan-Vick, Roksan. “Bayou Greenways 2020: Transforming Parks in Houston”.” Interview by Sachin Shah.

January Advisors. 27 May 2015. Web. Binkovitz, Leah. “Third Ward Looks to Shift the Gentrification Conversation.”

Urban Edge Blog. Kinder Institute for Urban Research, 25 May 2016. Web. Byrne, Jason, and Jennifer Wolch.

“Nature, Race, and Parks: Past Research and Future Directions for Geographic Research.” Progress in Human Geography 33.6 (2009): 743-65. Web. Dadvand, Payam, John Wright, David Martinez, Xavier Basagaña, Rosemary R.C. McEachan, Marta Cirach, Christopher J. Gidlow, Kees De Hoogh, Regina Gražulevičienė, and Mark J. Nieuwenhuijsen. “Inequality, Green Spaces, and Pregnant Women: Roles of Ethnicity and Individual and Neighbourhood Socioeconomic Status.” Environment International 71 (2014): 101-08. Web. Gattis, Tory.

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Discovery Green. Discovery Green Conservancy, n.d. Web. “Houston Parks and Outdoors.” Visit Houston. N.p., n.d. Web. “Inclusion Through Access to Public Space.” UNESCO. N.p., n.d. Web. Loveless, Stephanie. interview. 13 Mar. 2017.

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Martí-Costa, Marc, and Marc Dalmau Torvà. “Can Batlló: Sustaining an Insurgent Urbanism.” Planning Theory and Practice 14.4 (2013): 534-38. Web. Meredith, Catherine. “Public-Private Partnerships Help Houston Go Green.”

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Smith, Michelle Leigh. “Reimagining the Urban Oasis: The New Heights of Public/Private Partnership Blossoms at Levy Park.” Realty News Report. N.p., 24 Feb. 2017. Web. “Superficie (m2) Según Calificaciones Urbanísticas Del PGM Y De Sus Instrumentos Derivados 2015.”

Department D’Estadistíca. Ajuntament De Barcelona, n.d. Web. Swartz, Mimi. “Green Acres.” Texas Monthly. N.p., Oct. 2015. Web. Triguero-Mas, Margarita. interview. 13 Mar. 2017.

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Wen, Ming, Xingyou Zhang, Carmen D. Harris, James B. Holt, and Janet B. Croft. “Spatial Disparities in the Distribution of Parks and Green Spaces in the USA.” Annals of Behavioral Medicine 45 (2013): 18-27. Web.

Parés, Marc, Rubén Martínez, and Ismael Blanco. “Collaborative Governance Under Austerity in Barcelona: A Comparison Between Evictions and Empty Urban Space.”

City Futures International Conference (2014): n. pag. Web.

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CultureMap. N.p., 17 Mar. 2013. Web. Sabaté Muriel, Irene. 16 Mar. 2017.

MEET THE AUTHOR Amy Kuritzky (’18) is a student studying Comparative Political Science and Archaeology, with a minor in Energy, Water, and Environmental Sustainability. On her research project, Kuritzky says, “For my study, I looked at top-down and bottom-up approaches to developing public spaces between Houston and Barcelona. Greenspaces, such as urban parks, are often my favorite parts of the city. Many of the questions driving my project stem from realizing that this ubiquitous appreciation is not always the case...

I wanted to investigate how urban greening efforts could be implemented in ways which more assuredly account for the values and needs of local communities... In comparing different top-down and bottom-up efforts, I was interested in how the resulting spaces take into account or overlook the desires of local residents. I am hopeful that examining grassroots initiatives will prove valuable for promoting the socially-just installation and maintenance of urban public space.

CULTURE IX. CITIES OF REFUGE Colton Cox X. CHALLENGES OF A GRAYING POPULATION Tim Wang

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IX.CITIES OF REFUGE culture EXECUTIVE SUMMARY

A Comparison and Contrast of NGO-Municipal Relations and Broader Political Contexts

Barcelona and Houston are two prime laboratories through which to study the complexities of issues relating to the contemporary migrant crisis, as well as immigration in general. This paper interrogates the differential contexts of these two urban spaces, with an eye to how non-governmental organizations execute their activities and cooperate with the municipal government.

Specifically, I find that Barcelona conceptualizes a “refuge city” as being an environment which contains a thorough reception infrastructure of dedicated NGOs and generous public services to accommodate incoming refugees. Conversely, while Houston also boasts a number of well-staffed refugee resettlement services organizations, activism from City Hall in the present day tends to be more focused on “sanctuary city” policies specifically protecting illegal

immigrants. Barcelona, a municipality led by former members of activist institutions, can ultimately be said to have more tangible networks of cooperation between City Hall and grassroots activists, while Houston is currently more engaged in exerting sheer political capital to protect select immigrant populations. In sum, I utilize the question of refugee and migrant crises management in order to elucidate the larger question of changing governance structures in both the United States and Europe, the latter of which is witnessing increasing challenges to the three-tiered federal model of the European Union, the state, and the city.

INTRODUCTION

Houston and Barcelona occupy relatively opposite ends of the spectrum when considering sanctuaryrelated activism and policymaking.

As the nation’s fourth largest city, Houston also accepts the highest number of refugees out of all cities in the nation, admitting nearly 30 out of every 1,000 refugees resettled by the United Nations High Commissioner for Refugees (Kragie 2015). Houston resettled nearly 2,000 refugees in 2015 alone (Blaney & Stengle 2015).

Barcelona, however, has found itself frustrated with European Union policies which have made it a lower priority destination for refugees. In 2016, the city settled only 600 out of the 160,000 refugees designated for resettlement by EU leaders, provoking the ire of Barcelona’s activist mayor Ada Colau (The Local España 2017).

Notwithstanding, Houston’s level of what I denote “municipal activism,” or the introduction of charitable initiatives for refugees specifically at the command of city politicians, pales in comparison to the fervor

displayed by Barcelona’s City Hall.

Led by Colau and her leftist Barcelona en Comú party, Barcelona has indeed compensated for its lack of refugees through the diligence with which it has sought to enact measures to transform the city into a space hospitable for refugees (Barcelona Ciutat Refugi 2017). An entire “Barcelona Refuge City” campaign has been implemented by city leaders, and Mayor Colau has personally solicited dialogue and cooperation with non-governmental organizations who are poised to implement the city’s desired plans (Ajuntament de Barcelona 2017). Essentially, on an abstract scale, Barcelona ranks highly in terms of municipal activism, yet hosts a minuscule number of refugees compared with Houston.

Houston, though it can claim to be the refugee capital of the United States, nonetheless ranks much lower on the scale of municipal activism because fewer of its local policymakers derive directly from grassroots movements than is the case in Barcelona.

ISSUE STATEMENT

Based on the aforementioned contrasts, the question of how the two cities are tackling migrant crises through both policy and community organizing is particularly salient. Thus, I intend to analyze this topic by examining a number of crucial factors, the first of which questions exactly how nongovernmental organizations in both cities are structured. More crucially, how do NGOs receive aid or funding from public institutions, and what is the motivation of public institutions to supply such assistance? Additionally, how do conflicts of a federal and legal nature arise for both municipalities?

To elaborate, how might the policies of the American Federal Government and the State of Texas or the European Union and the Kingdom of Spain conflict with or inhibit the stated policy intentions of Houston and Barcelona’s leaders? Finally, I examine how these questions of local-level governance reflect macro-scale sociopolitical trends such as resistance to the policies of President Donald J. Trump

or criticism of the European Union as a non-democratic institution. Through these investigations, I deduce that Barcelona and Houston conceive of the “refuge city” model in varying ways; while Houston places most of its effort into conserving sound legal policies protecting the rights of immigrants, Barcelona endeavors to maintain the grassroots activism which has found such a welcome niche within its local government.

RESEARCH METHODS

Investigating the central questions of my research involved a mixed methods approach of utilizing secondary journalistic sources and firsthand fieldwork research. It must be stated that given the very recent nature of the current migrant crisis exacerbated by military tensions in Syria, there unfortunately exists a paucity of scholarly research specifically dedicated to Houston and Barcelona’s management of the effects of this crisis. Lamentably, this paper thus does not employ a great amount of academic literature.

Nonetheless, journalistic sources pertaining to these issues abound, and local, national and international media outlets form a prime component of my textual research. Moreover, in line with Barcelona’s push to direct activist efforts from the mayoral office and to proliferate public information on the refugee crisis (Asil.Cat Network 2017), Barcelona City Hall has published an entire interactive webpage dedicated to its pro-refugee initiatives. This source proves indispensable in supplying information on both the present activities and future goals of Barcelona’s city government for accommodating refugees into the city.

In addition, fieldwork within Barcelona and Houston proved vital for supplying greater contextual richness to this paper’s assertions. During mid-March of 2017, I traveled with fellow students in the Global Urban Lab program to conduct interviews with two researchers at the Grassroots Economics Institute of the Universitat de Barcelona. These researchers were Giacomo Loperfido and Theodora

Vetta, experts in migration and NGO-state relations, respectively. In Houston, two interviews took place in late April and the beginning of May. The first of these interviews was with Andrea Guttin, Legal Director at the Houston Immigration Legal Services Collaborative. I subsequently spoke with Basel Mousslly, Resettlement Program Supervisor for the Houston region at Refugee Services of Texas.

These interviews all took place in person, and they were recorded and partially transcribed at a later date in order to cull specific quotations from them.

“Houston and Barcelona occupy relatively opposite ends of the spectrum when considering sanctuary-related activism and policymaking.”

FINDINGS

In her interview, researcher Theodora Vetta noted that Barcelona’s activist style of governance is unlike any other case she had previously seen. “I think [Barcelona] is a very special case. It’s a very particular case because you have a municipality that is run by people that come from social movements. I haven’t seen it [in] any other case” (Vetta 2017), she claimed. Indeed, Vetta’s observations are borne out by Mayor Colau and fellow policy leaders within the Barcelona en Comú party, a party whose members have consistently drawn on their activist roots in the anti-foreclosure movement and other social causes to galvanize thousands of Barcelona’s residents. In February of 2017, the city witnessed a protest of over 160,000 individuals who called

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for the city to receive more refugees, pressuring Spain’s conservative government under Prime Minister Mariano Rajoy to abide by its promise of accepting 17,000 of them (Wilson 2017). The push for this enormous grassroots participation was publicly displayed by Colau, who “called on Barcelona residents to ‘fill the streets’ and march under the slogan ‘vollem acollir’ (‘we want to welcome them’ in Catalán)” (Agence France-Presse 2017).

Colau’s vocal leadership of the party has not been the only impetus for social organizing, however. Yusef Quadura, the coordinator for Barcelona en Comú in the city’s Gracia district, remarks that Barcelona en Comú formed as a collective of seasoned leftist political leaders and younger activists new to politics. In maintaining a number of “district assemblies” which formulate policies for specific regions within the city, Quadura believes that Barcelona en Comú has “carr[ied] forward its spirit of activism into institutionalized politics” (Quadura & Rozworski 2016).

In encouraging urban demonstrations and prioritizing district-level communication between policymakers and community members, leaders of Barcelona en Comú have exercised their belief that cities bear the most crucial responsibility for caring for refugees and must therefore be prioritized as welcome centers by the state (Morgan 2016).

February’s protest was not the first display of pro-refugee activism from City Hall, Barcelona en Comú leaders have been unabashedly vocal in supporting refugee causes since 2015.

However, another integral component of this “support” beyond facilitating mass demonstrations has involved communicating with NGOs in the city that remain on the front-lines of supplying services to said refugees.

In September of 2015, Colau invited various representatives of the Asil.

Cat [Asylum in Catalonia] network of NGOs to devise a strategic plan for refugee reception, simultaneously anticipating potential outcomes of such plans (meeting pictured). NGOs present at this meeting included the Red Cross, the Commissions Obreres [Workers’ Commission] union and the

Figure 1. Ada Colau meeting with NGO Insitut de Drets Humans de Catalunya [Catalonia Institute of Human Rights], and these leaders reported being satisfied that the municipal administration displayed such openness to their causes (Ajuntament de Barcelona 2015). What is more, a majority of factions within Barcelona’s City Council have voiced their approval for “the city’s becoming a haven for refugees” (Sánchez Montijano & Soler i Lecha 2015), and this very City Council has provided services through the Care Service for Immigrants, Emigrants and Refugees (SAIER) since 1999 (Barcelona Ciutat Refugi 2017).

This meeting is an ideal display of the way in which the municipal government has relied on NGOs for the implementation of its goal to accommodate refugees. Asil.Cat, the aforementioned network of NGOs hosted by Colau, states in its official description that it desires to “have an active presence in the decision making spaces of local and regional governments within the Catalan territory” (Asil.cat 2016). Barcelona en Comú’s responsiveness to the desire of NGOs to effect politically consequential policies has resulted in the creation of City Hall’s own “Barcelona Refuge City” initiative.

Ramón Sanahuja, Barcelona’s director

of welcome policies, has asserted that the city depends on a network of 160 NGOs who provide legal services and instruction on how to utilize the Spanish healthcare system (Calbó & Sanahuja 2017). Similarly, Ignasi Calbó, coordinator of this Barcelona Refuge City initiative, has lauded NGOs for “know[ing] the best way [to] integrate” refugees and possessing the tools to do so. Calbó further asserted: “Without civil society, if we only had official policy, we wouldn’t achieve anything” (Calbó & Sanahuja 2017). Municipal officials have tangibly displayed their dedication toward using NGOs as their arm of policy implementation through funding certain NGOs. As an example, CEAR, or the Spanish Commission for Helping Refugees, received donations from the Mayor’s Office in 2015 (Herman 2015), and Sanahuja confirms that the city is ready and willing to fund other NGOs who so desire (Calbó & Sanahuja 2017). Ultimately, these data exemplify the dynamic, symbiotic relationship found between NGOs and the municipal headquarters in Barcelona. While NGOs solicit funding and moral support for their activist cause from the institutionalized Barcelona en Comú-led administration, the Barcelona Refuge City initiative can only survive by virtue of having over

Figure 2. A map (in Catalán) of the many refugee resettlement authorities in Catalonia.

100 dedicated non-state organizations willing to integrate refugees into Barcelona’s society.

In reality, this model of NGOgovernment cooperation challenges certain conventional assumptions surrounding NGOs. While Julia Elyachar, a scholar focused on NGOs and neoliberal models of society, writes that “NGOs are [often] defined in opposition to the state,” Barcelona Deputy Mayor Gerardo Pisarello affirms that Barcelona’s local government has “relied on” activist NGOs for “support [and] expertise” (Faber & Seguín 2016). In other words, Barcelona’s city government, as a subsidiary of the larger Spanish state, has in effect sustained its political capital through collaboration with NGOs. Moreover, Vetta claimed that NGOs in Barcelona lack the “technocratic” structure of transnational, neoliberal-influenced NGOs, adding that the types of movements cooperating in Barcelona’s “Ciutat Refugi” plan are in fact “closer to social movements” (2017). Ultimately, this apparatus of local governmentNGO cooperation set up to address the refugee crisis can be described as a unique and new phenomenon arising from a transition away from neoliberal governance within Barcelona. Echoing

this idea, the European Website on Integration claims that “such coordination by local authorities of receptions activities [for refugees] can be considered unprecedented” (EWSI 2016). As a stark departure from former neoliberal leaders in Barcelona who sought to privatize services and retract the role of the state in municipal affairs, the rise of Barcelona en Comú over the past several years has seen the formation of a new municipalismo ethos that sees public sector activism as crucial to building a democratic society—in this particular case, a society hospitable to refugees (Faber & Seguín 2016). It is at this point that I turn to an examination of how Houston’s “reception infrastructure” for migrants differs from that of Barcelona.

While the City of Houston also possesses an infrastructure of organizations poised to facilitate the refugee resettlement process, the structure and dispersion of such NGOs, along with their cooperation with the Houston Mayor’s Office, differ in certain notable manners. On one hand, instead of hosting a wide variety of charitable organizations similar to Barcelona, Houston relies on five central organizations for the

implementation of resettlement work, namely YMCA International, Catholic Charities, Alliance for Multicultural Community Services, Interfaith Ministries and Refugee Services of Texas (Mousslly 2017). Basel Mousslly, the aforementioned supervisor of Refugee Services of Texas’ Houston branch pointed appreciatively to the internal cooperation and coordination exercised by these five organizations, stating that there are “a lot of things that we share together.” He asserts that the organizations jointly organize Houston’s annual “World Refugee Day” community event and reported that “resettlement agencies share their numbers [e.g. statistics]” regarding the families they have served in a yearly meeting (2017).

On face value, this synergy between refugee-focused NGOs in Houston resembles the context of Barcelona.

However, the way in which this interorganization cooperation translates into joint efforts with Houston’s municipal government is a more complex picture. Indeed, Mousslly expressed appreciation that Houston Mayor Sylvester Turner attended the World Refugee Day celebration and “has been very supportive to our cause.” “This is what’s great about being in Houston, that our mayor is very supportive,” he asserted (2017).

By the same token, the Welcoming Houston Task Force, in which Andrea Guttin’s Houston Immigration Legal Services Collaborative plays a role, explicitly seeks to communicate with City Hall through “recommend[ing] and implement[ing] policies and programs that foster the integration of immigrants and refugees into the civic, social and economic fabric of Houston” (Welcoming Houston Task Force 2017). Nonetheless, Mousslly also stated that he has “not reached out to the Mayor’s Office for a direct service or direct request,” adding that Refugee Services of Texas has not received any funds from Houston’s municipal government. While these facts do not signify any less intense activism on the part of Houston’s NGOs, they do reveal a notable departure from the close model of cooperation between NGOs and the municipality in Barcelona,

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Figure 3. A graph displaying Houston’s place as the top resettlement city in the United States. where the incumbent Barcelona en Comú party specifically coordinates in-person meetings with nonprofit organizations. Moreover, Guttin echoed Mousslly’s claim in stating that the Immigration Collaborative also does not receive funding from municipal public institutions, and remarked that the Welcoming Houston Task Force Plan submitted to the Mayor’s Office in January has not currently been implemented. These observations by both interviewees are in no way meant as an indictment of Houston’s political leaders or of the City Council’s intention to implement pro-refugee policies. Rather, they serve to indicate that there exists in Houston a wider gap between the municipality and nonprofit activists than in Barcelona.

The notable differences between the two cities’ organizing in support of migration issues in reality derive from broader discrepancies in the larger political contexts in which their leaders must govern. Specifically, one of the reasons that Houston’s municipal government has not devoted as significant an amount of time and resources toward refugee-focused nonprofits as Barcelona can be due in large part to the preoccupation of Mayor Turner with resisting national legislation aiming to threaten illegal immigrants dwelling in the city. This preoccupation reflects the different ways in which Houston and Barcelona’s localities conceptualize the “refuge city” model. For Barcelona, a refuge city is a municipality comprised of a “permanent, comprehensive reception model” supported by a network of NGOs and their resources (Barcelona Ciutat Refugi 2017). Houston, on the

Figure 4. Barcelona’s Pro-Refugee Protest in Feb. 2017. other hand, as a city home to over 400,000 undocumented immigrants (CPPP 2015), has recently seen calls for “sanctuary city” policies that center more on legally protecting this undocumented population than on assisting legally-settled refugees. Most notably, Mayor Turner himself has urged that Houston “continue to be a welcoming city” (Tallet 2017).

Turner’s pronouncement aside, Houston’s status as a “sanctuary city” is difficult to analyze primarily because this very term lacks clearly-defined legal parameters. Guttin states that “there is no definition of a sanctuary city,” and stresses that any federal legislation passed to prevent such cities from arising would need to aptly define this term (2017). Others claim that because law enforcement in Houston cooperates to a generous extent with federal immigration officials, it would be erroneous to

denote Houston as a “sanctuary city” in the first place (Barajas 2015). On this note, supplying coherent reasons for why Houston is or is not a “sanctuary city” is not of particular importance for this analysis. Rather, it is more crucial to focus on how this public debate about Houston’s status as a sanctuary city highlights the “federal vs. local” conflicts inherent in Houston’s mission to become a city of refuge for undocumented immigrants, asylum seekers and refugees alike. Specifically, Texas legislation in the form of Senate Bill Four would permit police officers to inquire about individuals’ immigration status or to detain them for a wide array of reasons, and would effectively ban any designation by a city of itself as a “sanctuary” municipality. This bill has been vocally opposed by both Mayor Turner and Houston Chief of Police Art Acevedo (Tallet 2017; Flynn 2017).

Figure 5. Promotional signs for the “Casa Nostra, Casa Vostra” [Our Home,Your Home] NGO which organized February 2017’s historic pro-refugee protest. Photo taken by the author himself when in Barri Gòtic, Barcelona.

Moreover, with respect to refugees, national-level legislation has also threatened Houston’s vision for being a prime refugee-friendly locality.

Mousslly elaborated that President Trump’s recent “Executive Order Protecting The Nation From Foreign Terrorist Entry Into The United States” has capped the number of refugees allowed to enter the United States at 50,000 for all of 2017. This occurs at a time when 48,000 refugees have already entered the country this year (Mousslly 2017). In addition, Mousslly said that because the State of Texas itself no longer acts as a jurisdictional authority for refugee-related services, nonprofit organizations have had to subsume this responsibility. As an example, he stated that YMCA International is now charged with administering services previously provided by the State of Texas to refugees in Houston (2017). In sum, a large determinant behind Houston’s municipal government not working as intensively with refugee-focused NGOs does not have to do with apathy from Houston’s political leaders. Rather, this lack of municipal activism stems

from the fact that Houston has at the moment prioritized legal advocacy for undocumented immigrants as being a crucial component of its “sanctuary” policies. The efforts by Democratic Mayor Turner to denounce Republican-fueled bills and executive orders reflects the deeper conflicts of federalism at play within this issue.

Although Barcelona and Houston’s political leaders conceive of “refuge and/or sanctuary cities” in fundamentally different fashions, these same conflicts at the federal level affect Barcelona as well. In this case, however, the Spanish state and the European Union are the two entities most challenged by Barcelona’s leaders. Here, Barcelona once again represents a unique case study for urban governance in that its leaders envision an activist role for the city in an international context. Barcelona en Comú’s activists-turned-politicians have positioned Barcelona “to work towards a network of refugee cities to tackle the crisis together” (Ajuntament de Barcelona 2017), and participated in a “Rebel Cities To Change Europe” event in July 2016. On the surface, this international campaign might seem to be a natural extension of the party’s activist approach. However, on a deeper level, the call for a crossEuropean network of cities following Barcelona’s model is an expression of burgeoning distrust in multilevel governance across Europe.

Yusef Quadura, the aforementioned coordinator for Barcelona en Comú’s Gracia district affairs, states: “We’ve created a huge network of such cities all over Europe…We don’t really have the power to bring in refugees because that’s essentially within EU jurisdiction, but we can put pressure on them.” (Quadura & Rozworski 2016). Similarly, Àgata Sol, the director of the Barcelona NGO Amb Drets [With Rights], argues that “[the network of refugee cities] is a way for the citizenry, the cities, and the regional governments to apply pressure to the national government to change its asylum policies” (Mount 2015). Even more crucially, Ada Colau recently proclaimed: “The current EU policies don’t represent us; we want

to welcome refugees. […] EU policies should change to prevent people from dying on the sea and on our borders” (Prim 2017). In his opinion, Grassroots Economics researcher Giacomo Loperfido proposed that “there clearly is a problem of lack of democracy, of transparency, of the power mechanisms of the European Union, that people feel increasingly uncomfortable with” (2017).

Additionally, Loperfido asserted that he has witnessed a growing distrust of political institutions across other arenas in Southern Europe, particularly in regions of Italy that he has researched.

The perspectives outlined in the paragraph above all serve to demonstrate that the concept of a sanctuary or refuge city cannot be separated from the larger national or even international context exerting authority over a particular city.

Estrella Galán, secretary general of the aforementioned CEAR, or Spanish Commission for Helping Refugees, has denounced the “lack of political will” on the part of Spanish and European leaders to increase the number of refugees entering Spain.

Other “underfunded” aid agencies in Barcelona have clamored for the State to provide more financial resources to bolster their initiatives (Herman 2015).

Whether the true impediment be a lack of finances or a lack of motivation on the part of Prime Minister Rajoy’s government and EU leaders, one can clearly observe that Barcelona’s goal of becoming a bona fide “Refuge City” is heavily conditioned by international legal and political structures. In other words, intra-city cooperation with NGOs can only come to fruition if EU and national policies actually allocate enough refugees to the city.

CONCLUSION

Overall, Barcelona and Houston represent optimal environments in which to compare the dynamics of municipal-NGO cooperation surrounding refugee and migrant issues. The two cities exhibit important differences. In the first place, one city leads the United States in numbers of refugees resettled, while the other

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city lags well behind other major European urban centers. One city contains dozens of agencies that execute various facets of resettlement aid, while the other relies on five key organizational stakeholders to manage this resettlement process. As a further matter, Barcelona’s ethos of marketing itself as a “Refuge City” rests upon its variegated network of NGOs that readily gain the ear of the municipal headquarters. Whether Houston can properly brand itself as a “sanctuary city,” however, depends primarily on how insulated the city’s undocumented migrants are in the face of more aggressively anti-illegal immigration policies. Despite such differences, leaders of both cities over the past several years have encountered the challenges of multilayered federal governance, finding that there is no simple solution to ensure that municipal policies can remain durable in the face of shifting political climates in the United States and in Europe. Ultimately, it would behoove international observers of all political and ideological persuasions to examine the rhetoric of Houston and Barcelona leaders toward refugee and migrant issues over the next several years, for these two local contexts embody some of the most salient global political controversies of the present day.

Press. March 18, 2015. http://www. houstonpress.com/news/stop-callinghouston-a-sanctuary-city-6729418.

REFERENCES

Elyachar, Julia. “Mappings of Power: The State, NGOs, and International Organizations in the Informal Economy of Cairo.” Comparative Studies in Society and History 45.3 (2003): 571-605. Web.

Agence France-Presse. “Protesters in Barcelona urge Spain to take in more refugees.” The Guardian. 18 February 2017. Accessed 12 April 2017.

Barcelona Ciutat Refugi. “Role of the European Union.” 2017. http:// ciutatrefugi.barcelona/en/cataloniaresponse.

Barcelona Ciutat Refugi. “The Plan.”

2017. http://ciutatrefugi.barcelona/ en/plan.

Calbó, Ignasi, Ramón Sanahuja and Cameron Thibos. “Barcelona: city of refuge.” OpenDemocracy.com. 26 September 2016. Accessed 1 May 2016.

Casa Nostra, Casa Vostra. “Press Kit. Campaign Presentation.”

November 29th, 2016. http://www. c a s a no s t rac a s avo s t ra . c at / s i te s / default/files/premsa/press_kit_-_ campaign_cncv_information_0.pdf Casa Nostra, Casa Vostra. “Who We Are.” http://www.casanostracasavostra.cat/ en/who-are-we/organization Center for Public Policy Priorities (CPPP). “Fact Sheet: Immigrants in Houston.” 2015. ForABetterTexas.org. http://forabettertexas.org/images/ EO_2016_Factsheet_Immigrants_ HOU.pdf.

Rails Against SB4.” Houston Press. 28 April 2017.

Guttin, Andrea. Interview by Colton Cox. 25 March 2016.

Herman, Marc. “Now What?” Take Part. 2 October 2015. Accessed 29 April 2017.

Kragie, Andrew. “Greater Houston resettles more refugees than any other American city.” The Houston Chronicle.

13 September 2015. Accessed 29 April 2017.

Loperfido, Giacomo. Interview by Colton Cox. 16 March 2016.

Morgan, Sam. “Barcelona Mayor: ‘Rebel’ cities must tackle Brussels on refugee crisis.” Euractiv. 18 July 2016.

Accessed 29 April 2017.

Mount, Ian. “In Spain, and All of Europe, Cities Open Door to Refugees.”

Fortune. 8 September 2015.

Moussly, Basel. Interview by Colton Cox. 1 May 2016.

Quadura, Yusef and Rozworski, Michal.

“Barcelona’s Wide Front.” August 24, 2016. https://www.jacobinmag. com/2016/08/barcelona-en-comuada-colau-podemos-cataloniahousing/ Prim, Sara. “Thousands march in Barcelona urging Spain to take in more refugees.” Catalan News Agency.

19 February 2017. Accessed 12 April 2017.

European Website on Integration.

“EWSI Analysis on Voluntary and Citizens’ Initiative: Spain.” European Website on Integration. 2016.

Sánchez Montijano, Elena, and Soler i Lecha, Eduard. “Cities and Refugees: Barcelona’s Message.” Barcelona Center for International Affairs. September 2015.

Asil.cat Network. 2017. “Who Are We?” http://asil.cat/en/qui-som/.

Faber, Sebastia and Bécquer Seguín.

“Barcelona, Where the Government Is Embracing Coops, Citizen Activism, and Solar Energy.” The Nation. 11 August 2016.

Barajas, Michael. “Stop Calling Houston a ‘Sanctuary City.’” Houston

Flynn, Meagan. “Houston’s Chief Acevedo, Defiant and Introspective,

Tallet, Olivia. “‘Mi casa es su casa’: Houston’s mayor on ‘sanctuary cities.’” Houston Chronicle. February 8, 2017. Accessed 12 April 2017. http://www.houstonchronicle.com/ l i fe s t y l e / c a l l e - h o u s to n / a r t i c l e / S y l v e s t e r -T u r n e r - o n - H o u s t o n and- the-attack-on-10918281.

Ajuntament de Barcelona. “Barcelona looks to strengthen its network for taking in refugees.” September 1, 2015. http://ajuntament.barcelona. cat/alcaldessa/en/noticia/barcelonalooks-to-strengthen-its-network-fortaking-in-refugees

php?t=b679052047438d9cbb The Local España News Staff. “Spain welcomed more refugees than ever before in 2016.” The Local España. 13 March 2017.

Vetta, Theodora. Interview by Colton Cox. 16 March 2017.

Welcoming Houston Task Force.

“Welcoming Houston: Task Force Recommendations.” 20 January 2017.

Wilson, Joseph “More than 160,000 march in Barcelona to demand Spain takes in more refugees.” The Independent 19 February 2017.

Accessed 12 April 2017.

ACKNOWLEDGEMENTS The author would like to thank Dr. Eugenia Georges and Víctor Giménez Aliaga for their dedicated teaching of the course and for guiding us throughout Barcelona. He would also like to thank Ipek Martinez for diligently coordinating the travel to Barcelona. Lastly, he is greatly appreciative of Theodora Vetta, Giacomo Loperfido, Andrea Guttin and Basel Mousslly for their willingness to speak and for all of their insights into his topic.

MEET THE AUTHOR Colton Cox (’18) is a student studying Sociology and Policy Studies. On his research project, Cox says, “My research examines the different ways in which Barcelona and Houston leaders conceptualize what it means to be a ‘refuge city.’ Among other findings, I determine that Barcelona’s municipal government is focused on cooperating with NGOs to facilitate the reception of refugees, while Houston’s governmental efforts are largely being placed in protecting undocumented immigrants.

Ultimately, I was drawn to this topic because of my own volunteer work with refugees in Houston through the Partnership for the Advancement and Immersion of Refugees (PAIR). Being aware of Houston’s large number of refugees and undocumented immigrants, I was curious to see how and why Barcelona’s policymakers and NGO leaders are tackling this highly politicized issue in a city with a notably lower number of said migrants.”

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X.CHALLENGES OF A GRAYING POPULATION culture EXECUTIVE SUMMARY

A Comparative Analysis of Spain and the United States

The populations in both Spain and the United States are aging rapidly.

By 2050, 34% of Spaniards and 21% of Americans will be over the age of 65. The graying of the population will cause a plethora of societal shifts and challenges for both countries. In fact, elderly care issues have already begun to manifest in recent decades. The infrastructure for older adult care in both countries suffers from critical inadequacies, particularly in the realms of health care, long-term care, and financial support. Furthermore, the elderly challenge in both countries are complicated by cultural, economic, and political factors. As such, this investigation quantifies the magnitudes of the elderly challenge, details the current elderly care infrastructures in each country, and discusses the aforementioned factors on elderly care in Spain and the United States. In turn, this paper offers

future outlooks and recommendations for sustainable solutions in the realm of elderly care. Ultimately, while some changes are inevitable with an aging demographic, the Spanish and American governments must synthesize sustainable solutions to provide adequate care and resources for the older adult population, now and in the years to come.

INTRODUCTION

Graying of the Population Spain and the United States have rapidly aging populations, which have created a plethora of challenges in the realm of elderly care. As of 2017, older adults (defined as individuals over the age of 65) comprised 19% of the population in Spain. The Spanish median age has increased readily over the last few decades, rising from 29.8 years in 1970 to 43.2 years in 2015. In the United States, the older adult population made up 15% of the population in

2017. The median age also increased significantly from 28 years in 1970 to 38.1 years in 2017. Moreover, the baby boomer generation in the United States, which consists of over 78 million people, is on the cusp of passing the 65 year mark. To compare these two countries to the rest of the world, the median age of the world population was 23 years in 1950 and 28 years in 2010. Both countries are therefore considered relatively old and quickly getting even older.

The graying the of populations is exacerbated by the low fertility rates and longer life expectancies. The Spanish total fertility rate is 1.33 and is predicted to remain at a similar rate in the next few decades. This rate is one of the lowest in the EU and the world.

While the United States has a higher total fertility rate of 1.74, it is still below the 2.1 necessary to maintain a stable population size. As such, the population of both countries are not

Figure 1. Older adults (65+) as a percentage of total population, 2010 and 2050. â&#x20AC;&#x192;

Figure 2. Old Dependency Ratio in Spain and the United States from 2010 to 2015.â&#x20AC;&#x192; only graying but also shrinking. This means that the elderly will make up an increasingly larger portion of the overall population. While the decreasing fertility and graying of the population is common to a lot of developed countries, it does not make the potential challenges in Spain and the United States any less daunting.

Looking forward, the two countries will continue to gray in the coming few decades. Figure 1 shows that the elderly population is expected to almost double in proportion in both countries from 2010 to 2050. Thus, it is evident that the trend of an increasing elderly population will continue for the foreseeable future.

The Elderly Challenge The level of support needed by the older adult population is standardized by the old dependency ratio (ODR), which is defined as the proportion of seniors (age over 65) per 100 working age people (age 15-64). In 2015, the ODR was 22% in the United States and 28% in Spain. By 2050, the UN predicts an increase in the ODR to 36% and an alarming 67% in Spain (Figure 2). Consequently, both countries will face a significantly higher burden in the working population to support the older adult population, both directly through familial economic support and indirectly through taxes and social security. Moreover, caring for seniors

will require increasingly more resources; they will expect to maintain their standards of living, which increases with each generation.

A rising older adult population will bring about a host of shifts in society. For instance, public investment may need to shift from allocation of resources for the needs of children to that of seniors. As individuals get older, they will require more health care.

In addition, family structures and living patterns may change to include more generations living under a single roof. There may also be potential for economic stagnation due to a shrinking work force and more social dependents.

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In the past few decades, elderly care issues have manifested in both Spain and the United States. The infrastructure of care suffers from critical inadequacies, particularly in the realms of health care and financial support. The aforementioned shortcomings in infrastructure will continue to increase in magnitude and urgency as the populations continue to age. While some shifts are inevitable with an aging demographic, the Spanish and American governments must identify sustainable solutions to provide adequate care and resources for the elderly populations, now and in the years to come.

ISSUE STATEMENT

Both Spain and the United States face significant current and upcoming challenges in later-life care. In particular, the United States has an infrastructural shortage that will be increasingly exposed as the population continues to rapidly age. Meanwhile, Spain already experiences many of the issues associated with a shortage in elderly care resources. Furthermore, the elderly challenge in both countries are complicated by cultural, economic, and political factors.

This study quantifies the magnitudes of the elderly challenge, details the current elderly care infrastructures, and compares the aforementioned factors on elderly care in Spain and the United States. In turn, this paper offers future outlooks and recommendations for sustainable solutions in the realm of elderly care management.

METHODS

To quantify the magnitude of the elderly challenge in Spain and the United States, an extensive literature search was conducted. Academic studies from various aging journals, news articles, and national census databases provided the quantitative basis for this study.

The majority of the original research done in this investigation came from qualitative interviews with experts in various aspects of elderly care management in both countries. These individuals included geriatricians, academic scholars on aging, and life planning financial experts. The interview data provided the basis for analysis of the

current elderly care infrastructure and the associated social, economic, and political factors in Spain and the United States.

The following experts were interviewed: • Carmel Dyer, MD, AGSF, FACP – Professor of Geriatric and Palliative Medicine at UT Health. She is ranked in the top 1% of geriatricians by US News and World Report and has been a field leader in aging and elderly care policy.

• Carlos Reyes Ortiz, MD, PhD – Assistant Professor of Geriatric and Palliative Medicine at UT Health.

• Jessica Lee, MD, MS – Assistant Professor of Geriatric and Palliative Medicine at UT Health.

• Patricia Morton, PhD – Postdoctoral Fellow in Sociology at Rice University.

• Silvia Bofill, PhD – Associate Professor in Social Anthropology at the University of Barcelona.

• Irene Sabate Muriel, PhD – Lecturer and Researcher in Social Anthropology at the University of Barcelona.

• Victor Gimenez Aliga – Doctoral Candidate and Lecturer in Anthropology at Rice University.

FINDINGS

Spain: Care Infrastructure The current state of care for the older adult population in Spain is inadequate. While not the entire cause of the care gap, the Spanish financial crisis of the last decade has severely exacerbated issues in the realms of nursing homes, home care services, and geriatric health care. Dr. Silvia Bofill states that “the elderly issue has been important since the 1980’s or 1990’s, but the economic crisis has made the issue even more prominent.”

Because the demand for private nursing homes rose significantly in the recent decades, the supply in both the private and public sectors have yet to catch up to the demand. As such, there are very few beds and long ques in nursing homes. Moreover, these homes often have prohibitive costs.

Many state-funded care homes require monthly fees of up to 80% of a Spanish pension (about 700 euros), while private care home costs are even higher, ranging between 1,700 to 3,500 euros.

Therefore, many older individuals sim-

ply cannot afford to live in a nursing home.

In addition, the economic recession caused the Spanish national health care system to cut back spending cargiving personnel. There is a sizeable number of former Spanish geriatric nurses who have been displaced because of cutbacks in the health system.

Since the government cannot fund enough geriatric nurses, many Spanish citizens have turned to hiring migrant workers. Female workers, mainly from Latin America and the Philippines, are often hired by individual families via unofficial means to care for seniors. In discussion about the increasing “commodification and externalization of care,” Dr. Bofill analyzed that “it creates a big inequality of care between families. Lower income families simply cannot afford it.”

Finally, while the national health care system is underfunded, there is actually a sufficient proportion of geriatricians. Moreover, the Spanish National Health System only comprises 40% of the hospitals in the country, as the remaining are private institutions. Private geriatricians are therefore also available. However, due to the economic crisis and aging population, the lines for low-cost nonemergency care can become very long. Moreover, there is an overall shortage of trained physicians. Consequently, lower income seniors primarily suffer the consequences of a geriatric care gap.

Spain: Factors Influencing to Care Gap The current shortage of care in Spain is a complex issue that can be separated into economic, social, and political factors.

Economically, the Spanish financial crisis is one of the most significant contributors to the elderly care gap. The significant decline in financial resources has crippled the government’s ability to provide services for its citizens.

The crisis exacerbated the pension system in Spain, which was already unsustainable. The millions of job losses directly correlated with a decreased contribution to the social security network. In 2016, the pension deficit was 19 billion euros. Experts warn that even the recent sweeping reforms in

policy. Dr. Bofill comments that “the dependency laws are very good, but it has not been implemented. Many older citizens have not received the support they need from the state, as the law promised. There simply is not enough money to fund the policies.”

While the economic, social, and political factors all play major roles in generating and perpetuating the care gap, it is apparent that the economic recession is one of the most damaging. The lack of funding adds to social tensions and blocks policy implementation, and is therefore at the very root of a complex and troublesome care gap for the elderly.

Figure 3. Youth Unemployment in Spain from 2010 to 2016 pension structure and taxation maynot be enough to save the system.

In addition, the youth unemployment rate (age 15 to 24) rose to a historic 56% in 2013, and has since hovered between 40 to 50% (Figure 3). The incredibly high number of unemployed young people means that many college graduates are unable to find employment opportunities, so they return to live with their parents. In fact, four out of five Spanish citizens between 16 and 29 years of age still live with their parents. This phenomenon further strains the resources of the parents, many of whom are in their late 50s and early 60s.

Socially, the Spanish family unit is strong, and there is solid integrational solidarity. Parents readily contribute financially to their children, even in adulthood. Likewise, adult children feel obligated to care for their parents in their old age. However, there is a distinction between providing emotional and economic support for elderly parents, and serving as a fulltime caregiver. The Spanish family unit can no longer fill the gap in the latter category like it could in the past.

Traditionally, one of the daughters of the family will serve a full-time duty of caring for the parents in their old age. However, in the past few decades, women are unable to fill the care needs of the older adult population because of increasing rates of female employment and shifting social norms. Dr.

Bofill indicates that “women have been entering the labor market in a big way since the 1990s… so the women who used to be responsible for [caring for the elderly] cannot and do not want to do it anymore.” As a result, the Spanish family structure and familial obligations norms will become increasingly strained as society continues to age during this economic downturn.

Finally, the Spanish elderly are not much of a political force. On one hand, Dr. Irene Muriel identifies that many local political leaders in Spain are older adults, many of whom entered public service during Spain’s transition to democracy in the 1960s and 1970s.

However, local political leaders are unable to dictate elderly policies, most of which are mandated at the national level. Moreover, Dr. Bofill suggests that “the elderly is not really a politically active segment of the population.

There is a lack of organization and a lack of solidarity.” As such, elderly care policy in Spain remained stagnant for several decades leading up to the early 2000s. Fortunately, the EU and Spain enacted a law at the beginning of 2007 to provide care for dependent people, most of whom were older adults. The Personal Autonomy and Dependent Care Law sought to consolidate public resources to ensure the baseline well-being of dependent individuals.

Unfortunately, the onset of the financial crisis the very next year greatly hindered the implementation of this

United States: Care Infrastructure The United States also faces significant challenges in the realm of providing care for the older adult population.

Currently, there are over 1.4 million American seniors living in 15,600 nursing homes, with an occupancy of about 90%. Most of these homes – 69.8% – are privately owned (Figure 4). However, the total number of nursing homes decreased 9% from 2000 to 2009, and new construction of nursing homes decreased by 33% from 2007 to 2011. Therefore, as the baby boomer generation rapidly approaching ages in which they will need consistent care, America faces an imminent undersupply of nursing home space.

In the realm of home caregivers, the old adult population depend heavily on family and friends. In fact, 65% of older adults with long-term care needs solely rely on friends and family, and another 30% employ family care with paid assistance. There is little to no assistance from the public health system, which has no well-established infrastructure to provide sustainable and affordable home care service for most of the old adult population. As such, the availability of family caregivers often determines whether an older individual with long-term care needs will enter a nursing home. Dr. Jessica Lee explains that “the majority of caregiving is at home by family members, but the public health system does not provide them any supplemental support at all.” This results in an uneven quality of life amongst the older adult

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the wider geriatric and gerontological community. Thus, many older adults do not have access to adequate care because the dearth of trained geriatricians and lack of governmental support for long-term elderly care at home.

Figure 4. Ownership type of American nursing homes population and can leave many individuals without accessible care options.

Finally, the United States has severe deficiencies in the realm of geriatric medicine. While the Medicare system provides medical insurance for older adults 65 years and older, the medical system itself is problematic. All of the American physicians interviewed identified that one of the biggest issues in geriatric care is the lack of professionals trained in geriatrics and gerontology. Dr. Carmel Dyer explains that “after age 75, the physiology of the body really changes; You are more vulnerable to disease, there is decline in kidney function, medications are metabolized differently, the way diseases present are totally different.” However, there is currently almost no required training in geriatric medicine in medical school. While American physicians can specialize in pediatrics for kids, there is no analogous training in geriatrics for older adults.

Dr. Jessica Lee specifies that “older patients tend to get lumped into adults, even though the needs of a 75 year old and a 21 year old are completely different.” Because geriatric care is underdeveloped, medical care for the elderly is very fragmented. Dr. Lee points out that “there are a lot specialists for adult medical care, but they do not communicate to provide the comprehensive care that the older adult population needs.”

The analyses of the geriatricians interviewed for this study is confirmed by

United States: Factors Influencing Care Gap The United States’ care gap for the older adult population can also be traced to economic, social, and political nuances.

Economically, the older adult population accounts for a significant portion of federal health care expenditures. In 2010, seniors made up 13% of the population but accounted for 34%of health care spending. Because all American citizens older than 65 years are eligible for Medicare and many older adults also qualify for Medicaid, the government pays for about 65 percent of all medical expenses for the older adult population. However, the money could be spent more efficiently. Because geriatric care is fractured and the government provides little to no home care service for older adults, many of them resort to the emergency department in hospitals for care. In fact, patients older than 75 years have the second highest rate of emergency room visits in the United States, only trailing infants under one year of age. This leads not only to unnecessarily high costs in hospital fees, but it also clogs up the emergency system for individuals who actually need urgent care. Moreover, treatment for many diseases in older adults are very expensive. Instead, many of these diseases could have been prevented t far lower costs through comprehensive geriatric care. As such, unlike Spain, the United States does not lack the absolute funds to serve the elderly; the money simply needs to be redistributed.

Socially, the elderly care situation is hopeful. Contrary to popular opinion, an overwhelming majority of American families take full responsibility of their elderly. Dr. Lee states that “the vast majority of older patients I see have family members taking care of them. Sometimes it’s not even their parents. A lot of people take care of their aunts and uncles.” Naturally, most seniors prefer to live in their own homes instead of a nursing home. Dr. Dyer adds that “for

most people, the obligation for family members to take care of the elderly is strong.” However, Dr. Ortiz indicates that the expectation of individuals taking care of their elderly parents does still “depend on the culture and family traditions.”

Like the Spanish government - though perhaps for different reasons – the United States government offers little to no supplement for the family caregivers. However, a major difference between the two countries is that most American seniors do not expect the government to take care of them. On the other hand, there is a general expectation in Spanish society that the government will take care of their needs in old age. Dr. Ortiz also states that “there is a mostly negative attitude towards aging and the elderly in the general public,” which negatively impacts the state of elderly care.

Politically, the United States elderly have a lot more political sway than their counterparts in Spain. The baby boomer generation is very politically active and have dominated American politics since the late 1970s. In fact, they eclipsed all other generational groups in the 2012 presidential election. Moreover, many of the baby boomer generations actually hold political office and positions of power in society. However, Dr. Stephen Barnes observes that there “have not yet [been] large voting blocks around age-related or life stage issues.” As such, elderly care is an unheralded public health priority, which leads to its neglect in the policy front. However, Dr. Lee speculates that the baby boomers “won’t just sit around and wait for people to do something for them. [The baby boomers] are in the position to make many policy changes themselves.” As such, the old adult population has lots of untapped potential in the arena of affecting policy changes for elderly care.

CONCLUSION & RECOMMENDATIONS

The elderly challenge is a multifaceted issue that both Spain and the United States must prioritize going forward.

Currently, both lack the proper infrastructure to support rapid aging demographics. In particular, both public health systems do not offer sufficient long-term care for the elderly. Conse-

quently, the responsibility for caregiving is predominantly held by family members. However, this system of familial care is unsustainable, as neither country provides adequate supplemental resources for the family caregivers.

Therefore, family tensions will continue to rise and more older adults will be left without options for care.

Older adult care issues do not receive enough funding in either country, albeit for different reasons. In Spain, the economic recession caused severe cuts to all federal spending due to a decrease in revenue. In fact, one of the biggest challenges in older adult care in Spain is the unsustainable level of pensions. On the other hand, the United States does not fund older adult care due to a lack of public health priority. The problem is particularly glaring in the medical field, as there is a critical lack of trained geriatric personnel. Finally, the older adult population in both countries currently do not have the solidarity to make a majority political impact to change policies on elderly care. However, there is political potential amongst this ever-growing population, especially with the baby boomers in the United States.

Looking forward, Spain needs to be ready to utilize its resources efficiently once it recovers from the economic recession. The country has well-intentioned policies on taking care of the older adult population, so it must stay true to that vision once the funds become available. Meanwhile, the United States needs major policy reform on elderly care so it can make its public health expenditures more efficient. In fact, many changes can be done without exorbitant amounts of funding. For instance, the medical school curriculum should be modified to reflect a greater priority on geriatrics. Promising students could be encouraged to specialize in geriatrics with programs such as loan forgiveness or other incentives.

Ultimately, investing in caring for the elderly population now can offer much bigger savings in public funds in the future. The two governments must not wait until the elderly care issue reaches a crisis point. As such, both Spain and the United States should engage stakeholders in the public and private sectors to identify and implement sustainable

solutions to take care of the older adult population.

BIBLIOGRAPHY

World Bank. Population ages 65 and above (% of total).

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Statista. Spain: Median Age of the Population from 1950 to 2020 (in years). 2017.

United States Census Bureau. U.S. and world population clock. 2017.

Worldometer. U.S. Population (live). 2017.

McGrath, Dan. “There Aren’t Enough Nursing-home Beds to Meet Demand.” CNBC, 07 Dec. 2015. http://www.pewforum.org/2015/04/02/main-factors-driving-population-growth/pf_15-04-02_ch1graphics_medianage310px/ htt p://www.pe wg lobal.org/2014/01/30/attitudes-about-aging-a-global-perspective/ http://www.pewresearch.org/fact-tank/2015/02/24/ is-u-s-fertility-at-an-all-time-low-it-depends/ http://www.pewresearch.org/fact-tank/2014/02/04/ the-countries-that-will-be-most-impacted-by-agingpopulation/ http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A44 Bofill interview http://www.expatfocus.com/expatriate-spain-elderly-care https://www.theguardian.com/society/2015/feb/24/ spanish-nurses-job-nhs-health Bofill interview http://www.europeangeriaticmedicine.com/article/ S1878-7649(11)00123-9/fulltext#sec0055 http://www.telegraph.co.uk/news/health/expat-health/11812696/Retiring-to-Spain-what-youshould-know-about-health-care.html https://human-resources-health.biomedcentral.com/ articles/10.1186/1478-4491-8-24 http://thecorner.eu/spain-economy/spains-most-urgent-problem-pension-system-bankrupt/59571/ htt ps://www.ipe.com/pensions/pensions -in/ s pain-and-p or tu gal/s pain-a-p essimist ic-outlook-for-pensions/10003246.fullarticle http://www.tradingeconomics.com/spain/youth-unemployment-rate https://www.ft.com/content/c12e01d2-dbc4-11e598fd-06d75973fe09 Victor Gimenez Muriel interview http://bookshop.europa.eu/en/care-for-the-elderly-in-spain-during-democracy-pbQMTA07013/?CatalogCategoryID=WpIKABst.SMAAAEjGJEY4e5L https://www.eurofound.europa.eu/observatories/ emcc/case-studies/tackling-undeclared-work-in-europe/law-to-support-care-of-dependent-people-spain https://www.cdc.gov/nchs/fastats/nursing-homecare.htm http://www.cnbc.com/2015/12/07/there-arentenough-nursing-home-beds-to-meet-demand.html https://www.cdc.gov/nchs/fastats/nursing-homecare.htm http://www.cnbc.com/2015/12/07/there-arentenough-nursing-home-beds-to-meet-demand.html https://www.ioaging.org/aging-in-america https://www.ioaging.org/aging-in-america, 50% of eldelry who have long-term care needs but no family to care for them enter nursing homes; only 7% of those who have family caregivers enter nursing homes

Lee interiew http://newsroom.ucla.edu/stories/q-a:-critical-issues-facing-aging-americans https://journalistsresource.org/studies/government/ health-care/elderly-medical-spending-medicare https://journalistsresource.org/studies/government/ health-care/elderly-medical-spending-medicare htt ps://www.ncbi.nlm.nih.gov/pmc/ar ticles/ PMC4244125/ http://www.gallup.com/poll/167012/baby-boomerspush-politics-years-ahead.aspx http://calbooming.sdsu.edu/documents/Baby BoomerPoliticalAgenda.pdf htt ps://www.ncbi.nlm.nih.gov/pmc/ar ticles/ PMC3487684/

MEET THE AUTHOR Tim Wang (’17) is a student studying Biochemistry & Cell Biology and History. On his research project he says, “Spain and the United States face significant current and upcoming challenges in caring for their respective older adult populations.

This study quantifies the magnitudes of the challenge, details the current older adult care infrastructures, and compares the social, economic, and political factors on older adult care in Spain and the United States.

Last summer, I worked for an international social sustainability consulting group, researching the elderly challenge in China. As such, my Global Urban Lab project allowed me to deepen my understand of issues in geriatric care and fueled my passion to contribute to an increasingly important issue in the coming decades.”

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GLOBAL URBAN LAB 2017: BARCELONA