Promoting breast cancer equity in rural communities

Jen Cruz
Jen Cruz

Jen Cruz, PhD ’25, finds deep personal meaning in her work conducting community-engaged research on breast cancer inequities in rural settings.

February 8, 2024—Jen Cruz is a self-identified snob when it comes to seafood—specifically, salmon. Living in Wapato, a working-class farming town of 5,000 people in central Washington, Cruz’s family would often trade construction services for fish their neighbors had just caught from the Yakima River.

“My family would, say, patch a hole in someone’s roof in exchange for this amazing salmon. It wasn’t money, but it was food for our family,” Cruz said. “And now I’m super snobby about what fish tastes like—which is so funny, because otherwise, we didn’t have access to fancy restaurants.”

Bartering is common in Wapato—as is providing help for help’s sake. The neighbor with the four-wheel drive car picks others up during a snowstorm without expecting anything in return. Childcare is a shared responsibility, offered freely. According to Cruz, the prevailing attitude in her town is one of true collectivism. “You show up for people,” Cruz said.

If idyllic, these informal systems were also there to compensate for a lack of social services in Wapato, a racially diverse, rural town where a large portion of residents live below the federal poverty line. This neglect has most obviously presented itself in people’s health. Cruz recalls that while she was growing up, “losing parents to cancer was the norm.” It happened to several of her friends, and then it happened to her. When Cruz was in middle school, her mother passed away from a rare metastatic brain cancer within a month of diagnosis.

Years later, as a first-generation student at Seattle University, Cruz began to uncover the roots of these tragedies. “I was introduced to the concept of inequities and learned to see things through a social justice lens, and that was really my way into understanding where I grew up. It wasn’t just random that all of my friends’ parents were getting sick and didn’t have access to resources, while someone’s aunt in a wealthier nearby town was able to go to Seattle and get the best care possible,” she said.

These realizations laid the groundwork for Cruz’s pursuit of a career in public health. After earning a master of public health degree in epidemiology from the University of Michigan, Cruz enrolled at Harvard’s Kenneth C. Griffin Graduate School of Arts and Sciences studying in the Population Health Sciences program based at Harvard T.H. Chan School of Public Health. With funding from the Harvey V. Fineberg Fellowship in Cancer Prevention and the Mike M. and Evelyn B. Donatelli Fellowship Fund, she’s currently working toward her PhD in what she has termed “applied social epidemiology.” Her dissertation marries social epidemiology, qualitative approaches, and community-engaged research to expose and recommend solutions for reducing inequities in breast cancer screening across rural settings.

Redefining rural

As an undergrad, Cruz majored in psychology, thinking she wanted to provide grief and bereavement care to cancer patients and their families. Her mind changed midway through her postgrad year as a Fulbright scholar, during which she worked in India with epidemiologists studying cancer inequities. “Why would I wait for someone to die?” Cruz remembers thinking. “What if I didn’t have to do the grief work? What if I focus on the public health side and help prevent cancer deaths from occurring in the first place?”

Cruz took this idea and ran with it, and has since developed her own unique, flexible approach to public health. “On one hand, I’m an epidemiologist who does statistics and who codes. But I also love deep listening and narratives. And on top of that, all of this research is totally insufficient to me without figuring out its applications,” Cruz said. “That’s ultimately why I chose this program: It allows me to be quantitative and qualitative and to work with scientists and researchers who are actually implementing solutions.”

Cruz’s dissertation, focused on showing the heterogeneity that exists across rural contexts and related inequities in breast cancer screening, embodies this interdisciplinary approach. First, she used quantitative methods to answer the question: Are there different types of rural, and if so, can we identify them? She’ll next conduct qualitative research in towns in the Lower Yakima Valley, including Wapato, which represent two of the four types of rural communities she identified that differ in their experience of social deprivation. She’ll record health care providers’ and residents’ experiences of the facilitators of and barriers to breast cancer screening. Lastly, Cruz will develop a simulation model that tests the effectiveness of solutions to reduce breast cancer screening inequities depending on the rural context.

“It’s all to demonstrate that there’s no one type of rural, and that different communities need different supports, and that even in one community, certain interventions may drive racial inequities,” Cruz said. The research—grounded in national health data, public health critical race practice, and the community capitals framework, a systems approach to analyzing community development—has implications for how public health funding is distributed across rural communities in the U.S.

It also has immediate benefits for her hometown. To conduct her research, Cruz has partners at local native serving organizations and the hospital systems in the Yakima Valley, all of whom have said her work directly aligns with their strategic plans around reducing breast cancer rates and improving health equity. Many of them also knew Cruz’s mother. Cruz is looking forward to repackaging her dissertation and handing it over to these agencies for their use.

“This work is so meaningful, not just to me, but also to these health leaders and their goals,” Cruz said. “My success is their success.”

Finding—and offering—mentorship

“On paper, it looks like I’ve always known exactly what I’ve been doing, right?” Cruz said. In reality, she continued, from high school on, she’s relied on the advice of mentors to forge her path. “In every place and at every institution, there have been people who have invested in me and with whom I’ve been able to build community and trust. That’s what has pushed me in the right direction,” she said.

At Harvard Chan School, Cruz has found these mentors and sense of community in the FXB Center for Health and Human Rights, where a group of “activist scholars” forms “the best academic home I could have found”; the Center for Population and Development Studies, where sociologists and demographers provide extra feedback on her dissertation; and Harvard Chan’s Department of Social and Behavioral Sciences, where faculty like associate professor Shoba Ramanadhan offer both professional and personal support. Ramanadhan was the faculty member who encouraged Cruz to apply to Harvard, and last year, while visiting the Pacific Northwest for a conference, she made sure to spend a few days in Wapato with Cruz.

“Jen brings her unique experiences, identities, and vision for the world into our community-engaged and qualitative work,” Ramanadhan said. “The ways and extent to which her action-oriented research is grounded in community show promise for the future of public health.”

Cruz herself has become a mentor to many in her current neighborhood in Boston, Allston-Brighton. A one-day volunteer gig monitoring attendance at a local COVID-19 vaccine clinic with the Allston-Brighton Health Collaborative (ABHC), and subsequent involvement as a resident member, eventually inspired Cruz to offer a community-based public health education program. Funded by the Harvard Presidential Public Service Fellowship and Rose Service Learning Fellowship, in the summer of 2022 she and the ABHC launched the Community Advocate Mobilization Program, which provided 12 Allston-Brighton residents with a crash course in public health concepts and methodologies, from health equity to data-driven decision-making. Today, the program is expanding to serve more cohorts and work with other local Boston organizations on community leadership development.

“Community health work can really meaningfully take root and affect people’s lives,” Cruz said. “It just takes someone investing in people and not deciding for them.”

Looking ahead, this is the spirit Cruz is committed to upholding in all of her future public health work—whether she continues to focus on cancer equity or branches out to explore other interests like gender as a social determinant of health. She’s also wide open to where she might work, be it a university, a public health department, or a community organization, in the U.S. or abroad.

No matter how her path continues to unfold, what keeps Cruz grounded is where—and who—she came from.

“It’s all because I lost my mom. My life could have gone in two directions. I could get lost to this not-great circumstance, or I could use it,” Cruz said. “I’ve gone farther than I ever expected, doing work that’s rooted not only in my training, but also in what I’ve experienced, and staying true to that—even when it’s hard.”

– Maya Brownstein

Photo: Kent Dayton