The Puerto Rico Department of Health (PRDOH) is the state agency responsible for all matters related to public health including the administration of programs funded through the Title V Block Grant. The PR Title V consists of the Maternal, Child and Adolescent Health Program (MCAHP) housed in the Maternal, Child and Adolescent Division and the Children with Special Heath Care Needs Program (CSHCNP) located in the Children with Special Medical Needs Division. PR Title V provides services and implements initiatives in the seven PRDOH Health Regions.

To place Title V efforts in context one must first understand the general conditions of Puerto Rican society that play a crucial role in the health and wellbeing of populations.

Puerto Rico (PR), a territory of the US, is divided in 78 jurisdictions known as municipalities, each headed by a mayor. Vieques and Culebras are offshore municipalities whose residents travel to the Great Island (PR) in small planes and/or ferry for secondary and tertiary health care and other services.

Every four years, a governor, 28 senators, and 51 House members are elected to serve in the PR government. A non-voting delegate to the US House of Representatives is also elected. Puerto Ricans are US citizens, serve in the US military, and contribute to Social Security and Medicare but are not eligible to receive the Earned Income Tax Credit that gives refunds to low-income workers. PR residents do qualify for the Child Tax Credit only if they have three or more children, whereas in the states it is applicable to working families with one or more children.

The governmental structure has three major branches: the executive (called Central government), the legislative and the judicial. Each major state agency is divided into a Central office and Regional offices distributed across PR.

Health Care System

In the 1990’s public healthcare was transferred from the government to contracted private insurers to provide health care services on a capitated payment plan. The PR Health Insurance Administration (PRHIA or ASES, Spanish acronym) oversees and negotiates contracts with private insurers.

The Government Health Plan (GHP) integrates physical and mental health in one facility, expands preventive medicine and screening, and provides direct access to specialists without need for referral within a Preferred Provider Network. The GHP is financed by a combination of state, municipal and federal funds (Medicaid and SCHIP). Medicaid funding to PR is limited to a fixed amount regardless of the eligible population medical needs, unlike the states that are set based on per capita income. ACA funds (non-recurrent) were added to the GHP for Medicaid assigned funds. Through ACA a number of benefits such as family planning and contraception methods services were added to the GHP’s coverage. In FY 2018-19, Medicaid assigned additional funds to cover GHP’s expenses on health services. HP  

In FY 2018-2019 there were 1,193,223 persons covered by the GHP through five   insurance companies. Vital Statistics 2019 data show that 67% of mothers’ health insurance at the time of birth was the GHP which means that it pays for a majority of births in PR.  The GHP has a Special Coverage Registry (SCR) for CSHCN. Enrollees have the option to choose the providers for services within the Preferred Provider Network of their PMG or their Health Plan’s General Network. Medications, laboratory tests, diagnostic tests and other related procedures specified are part of this coverage. In 2019, there were 44,043 children enrolled in this SCR. The GHP also has a SCR for ASD. When ASD is suspected, children are enrolled in a temporary coverage for up to 6 months for the diagnostic interventions. If the diagnosis of ASD is certified by one of the following GHP providers: neurologist, psychiatrist, developmental pediatrician, or clinical psychologist the child is included in the ASD Special Coverage Registry. In 2019, there were 2,067 children enrolled in the ASD-SCR.  

Since there has been a large migration of physicians to the US, Puerto Rico passed Act   No. 14- 2017 known as the “Incentives Act for the Retention and Return of Medical Professionals” aimed at retaining practicing physicians in PR as well as attracting those who already had left through tax incentives. This act establishes a 4% fixed rate of income contribution on all income generated by the medical provider by a term of fifteen years. 

To address the problem of the use of opioids in Puerto Rico, the Prescription Monitoring Program for Controlled Substances (under Law 70 of 2017 for Monitoring the Prescription of Controlled Substances) opened for physician’s registration in June 2018. This program aims at maintaining a system of electronic prescription monitoring of controlled substances dispensed in the island.

Population

Puerto Rico is an area of about 3,500 square miles and a population of 3.2 million (PRCS 2019 estimates) that tend to cluster in urban areas.

Puerto Rico is mainly a Spanish speaking country where the majority of its residents are Puerto Ricans (95.4% in the 2010 Census) followed by other foreign Hispanic ethnic groups like Dominicans and Cubans. Regarding racial composition, 75.8% of people in PR identified themselves as white, 12.4% as black, 7% as some other race, and 3.3% as two or more races in the 2010 Census.

It must be noted that race is a historically and culturally grounded concept that varies from one society to another. Race taxonomies in PR are constructed on the basis of phenotype traits such as texture of hair, skin tone, and lip and mouth shape and intermediate categories exist between white and black that are not represented in the US Census. Some examples are: “indio’’ (literally Indian, light brown and brown skinned with straight hair), “jabao’’ (fair skinned with kinky hair), and “trigueño’’ (light to dark brown skinned). According to PR cultural standards, a person is white if he/she has light skin color (fair and light brown) and straight and/or curly hair, regardless of ancestry. People in PR may opt to report their race as white (despite skin tone) due to an unstated contempt for everything associated with being dark or black skinned. For example, in PR people make a distinction between “bad hair’’ (kinky hair linked to being black) and “good hair’’ (straight hair linked to white and Indio). Although new generations are identifying themselves as black, the euphemism “de color’’ (literally of color) is commonly used as the word black is seldom used as a direct term of reference. There is also a generalized denial of racial prejudice and discrimination in the island. While it is not possible to explain in depth the manifestation of racism in PR, suffice is to say that it takes a covert form exemplified by sly comments and racial jokes (often seen as harmless) in day-to- day interactions. On an institutional level, dark/black skinned people are underrepresented in the main media outlets and high-status positions in both the corporate world and government, according to the PR Civil Rights Commission.

The population of Puerto Rico decreased by 532,095 (14.3%) from 3,725,789 000 in 2010 to 3,193, 694 in 2019, representing a 14.3% according to the State Data Center of PR. Two main factors are linked with population decline. First, the natural population growth continues to decrease due to declining natality and fecundity rates. Second, the migration of people to US mainland in search of better job opportunities and living conditions. From 2005 to 2016 about 525,769 people left PR, equivalent to 14% of its population. This trend continued and 69,343 people migrated between July 2016 and July 2017. The migration from PR to the US intensified after Hurricane María and approximately 130,000 people left the island between 2017 and 2018, according to Census estimates.

The MCA population constituted 41% of the total 3.2 million population in 2018. The MCA population composition was as follows: 0.7% infants; 8.4% children 1-9 years of age; 12.2% adolescents aged 10-19 (6.2% males and 6.0% females) and; 19.5 % reproductive age women between the ages 20-49.

Education

The 2018 PRCS (1YR estimate) reports that people 25 years and over with less than 9th grade was 14.7 % and those with a high school diploma was 28.2%. Of those 25 years and over with post-secondary education, 22.6% had some college or associate degree; 18.8% a bachelor’s degree and; 7.9% a graduate or professional degree.

Student enrollment (kindergarten to 12th garden) in the public system diminished greatly from 544,076 in 2006 to 306,652 in 2018. Between 2006 and 2018 about 508 public schools closed across the island. According to the report “Population Decline and School Closure in Puerto Rico”  (Center for PR Studies, May 2019), 65% of public schools in the rural areas closed down compared to 35% in the urban areas, meaning that rural areas were the most impacted by the closures.

Socioeconomic Conditions

In the last decade, PR has experienced a reduction in employment in the private and public sectors. Between 2006 and 2019 employment fell by 22% according to the Bureau of Labor Statistics (BLS). Concomitantly, the labor force participation rate declined from 49% in 2006 to 41.2% in 2018 to 41% in 2019.

Lack of employment is accompanied by income levels that in PR are still far behind from the states. The per capita income for PR in the 1YR 2018 PRCS was $12,805 compared with the US $33,706. The 1YR 2018 PRCS median household income was $20,296, less than half of West Virginia ($44,047) and Mississippi ($44,717), the states with the lowest US median household income in 2018.

Poverty is a significant problem in PR affecting women, children, and families. In 2018, the poverty rate in PR (43.1%) was higher than the US (13.1%) and higher than the poverty rate in Mississippi (21.5%). Children under 18 years of age living in poverty in PR were 56.9% in 2018. Family structure influences poverty rates as single female-headed families tend to be poorer than married-couple families. While the percent below poverty level in 2018 PRCS in married-couple families with children was 32.4%, the percent of families with children headed by a female with no husband present was 71.3%. Residents of rural areas in PR have higher poverty rates than those living in urban areas (52.8% compared to 42.5% in 2018). High poverty rates and low-income levels leads families to rely on public assistance programs for survival. The 1YR 2018 PRCS reports that 41.8% of households in PR received nutritional assistance (food stamps) benefits compared to 11.3% in the US.

In many municipalities, mass transportation is unavailable, and people rely on private transportation services (12 passenger vehicles) called “carros públicos’’ (public cars) that may not be available after 2 PM or even earlier. Those who have their own private cars, may have to drive a long distance from and to their homes to work, study and receive services. To cover gaps in transport, there are municipalities that provide transportation mainly to the Greater Metropolitan Area to people in need of specialized health services. While mass transportation in San Juan municipality, - capital of PR - is available, there are limitations as the waiting time in some routes can be anywhere between one to two hours. The Urban Train only covers San Juan and Bayamón municipalities and lacks sufficient connecting buses to and from its 16 stations.

Like families, the PR government has been experiencing severe economic difficulties for almost a decade: a public debt of more than $70 billion, revenue loss, high GHP expenditure, depletion of pension funds, and insufficient liquidity to operate and meets its obligations. To face the crisis, the PR government has taken measures to reduce costs and increase revenues over the past years. Some of the measures are budget cuts to state agencies, school closings, reduction in subsidies to municipalities and NGO’s, and tax increases. Measures related to government employees include lay-off of public workers (Law 7, 2009), increases in employees’ contributions and retirement age (Law 2013) and fringe benefit reductions and mobilization across agencies (Fiscal Compliance Act of 2017).

In 2016 the US Congress enacted the PR Oversight, Management and Economic Stability Act (PROMESA), installing the Financial Management and Oversight Board (FMOB) with decision-making power on all fiscal matters. In May 2017, the Oversight Board filed in the federal district court for debt relief under Title III of PROMESA, a form of bankruptcy to restructure PR fiscal liabilities. Presently, the court proceedings are underway.

Amid the fiscal crisis, Hurricane Maria, with 155 mph winds struck PR on September 20, 2017.  The hurricane caused billions of dollars in damages leaving behind widespread destruction to homes, businesses, roads, highways, and public and private institutional facilities.  The wind force destroyed Puerto Rico’s energy grid causing  the longest blackout in US history.  Research on the deaths related to the hurricane place the death toll at approximately 3,000 people. Nearly three years (2020) after the hurricane, there are still thousands of houses with blue tarps,  damaged roads in rural and urban areas, a significant number of damaged traffic lights in the Metro Area, and many closed small businesses all over the island.  Yet, it was not until recently (July 2020) that FEMA disbursed the funds for home repairs.  The hurricane’s devastation also pushed people out of Puerto Rico to the US mainland.

In Puerto Rico, a sociohistorical event known as “the Puerto Rican Summer of 2019” occurred during the month of July 2019. For almost 12 consecutive days, massive protests - including two marches - of people from all walks of life, ages, and different parts of the island took place clamoring the resignation of Governor Ricardo (Ricky) Roselló with the chant “Ricky, resign”. All massive and daily demonstrations included TV personalities, singers, actors/actresses, and sport personalities.  The massive protests arose in response to the leak of chat messages between governor Roselló and 11 all-male top aides and associates [allies] that provoked people’s anger and indignation.  The messages (published by the PR Center of Investigative Journalism) included profane insults, mockery, and contempt for victims of Hurricane María, LGBT community, people with obesity, women, political opponents, and celebrities.   These demonstrations led to Ricardo Roselló’s resignation, the first governor of PR to ever resign.  On August 2, 2019, thousands of people across the island celebrated the governor’s last day in office, chanting Ricky te botamos! (Ricky, we threw you out!)

.

Ricardo Roselló was succeeded by Wanda Vázquez Garced - back then the Secretary of Justice - according to the line of succession to the governorship in the absence of a Secretary of State.  

While still struggling to recover from the devastation caused by Hurricane María, in early January 2020 Puerto Rico was hit by two major earthquakes.  On January 6, the day of the three kings’ day celebration, an earthquake of 5.6 magnitude struck the southwestern region. Ironically, this is one of the most important celebrations in the island in which children receive gifts from the wise men but this time - for many children and families - it became a sad day hardly ever to be forgotten.

The day after, on January 7, an earthquake with a magnitude of 6.4, the most powerful earthquake in 102 years, hit Puerto Rico with its epicenter located once again in the south/southwestern regions. Hours later, it was followed by an after shake of 6.0 magnitude. Although the earthquakes were felt all over Puerto Rico, the south and southwestern part of the island was the most affected as it was near or in the epicenter.

The most affected areas are five municipalities located in the south/southwestern part of the Island.  These municipalities are: Guánica, Ponce, Peñuelas, Guayanilla and Yauco. This area had been experiencing a series of earthquakes since December 28, 2019, of what the experts call an unusual earthquake activity.  All these five municipalities are in the DOH Ponce Health Region.

The southwest is one of the poorest areas in Puerto Rico.  The poverty rates for the five municipalities hardest hit by the quakes are higher than that of PR (43.1%): Guánica (63.8%), Ponce (50.9%), Peñuelas (56.5%), Guayanilla (55.6%), and Yauco (48.4%).  Child poverty in some of these municipalities are higher than that of PR (57%).  For example, child poverty in Guánica stands at 83% while Ponce and Guayanilla have 69% rates.

Immediately after the quakes, families, and individuals across the south/southwest set up camps along roadsides, home front yards, private farms, town squares, parking lots, and basketball courts. People also moved to official shelters and/or government tent camps once opened. People camped out for two main reasons. On the one hand, their homes suffered extensive structural damage (collapsed, about to collapse or had severe fissures). On the other hand, many people, despite having no major structural damages or no damage at all to their homes, slept outside in community/family or government tent camps because of fear to sleep in their homes due to the constant tremors. Many families opted to remain in community/familiar camps to be closer to home or because they felt more secure.

The quakes damaged more than 8,000 houses of which about 2,500 became uninhabitable, according to the PR Department of Housing, thus leaving thousands of people homeless.  

Nearly half of businesses were forced to close - some temporarily while others permanently, according to the United Retailers Center (CUD, Spanish acronym). There were losses to the infrastructure such as roads, bridges, government buildings and dams.  Besides damages to homes and buildings, there were mud slides and an iconic tourist attraction in the Guayanilla municipality simply [just] disappeared.

Puerto Rico’s main power plant (Costa Sur) that supplies energy to the northern regions was severely damaged and could be out of operation for more than a year. Economists in Puerto Rico estimated that the economic losses could total more than one billion dollars.

Schools in the affected area suffered extensive damage, some of which were at risk of collapse or collapsed as was the case of the Agripina Middle School in the Guánica Municipality, a participating school of Title V school-based Youth Promoters Program.  The collapsed of this school had an impact on students and their families that woke up the morning of January 7, to see their school in crumbles.

Classes in the public school and the private system across PR were suspended so the buildings could be inspected. In Puerto Rico, many schools have what structural engineers call a “short-column design” which buckles instead of swaying in an earthquake. Over 90% of all public schools were built before the 1970’s and 1980s and do not comply with current seismic safety standards.  The re-opening of public schools was a slow process across Puerto Rico that took several weeks and even months. Parents and teachers alike did not trust the school inspections as these were walk-in to assess visible signs of damage from the earthquakes but did not certify that a school could withstand a future earthquake magnitude 6.5 or higher.

Beyond economic costs and home displacement, the earthquakes caused sadness, distress, anguish, and uncertainty as people’s lives in the municipalities hit hardest were completely disrupted. For many people in these municipalities, it was like setting the clock back right after hurricane María, but this time the event did not stop as the tremors continued.

Over the past months (January through August) the earthquake activity in the southwest has continued with more than 10,000 quakes, according to the PR Seismic Network [US Geological Survey – USGS).  On May 2, amid the Covid-19 pandemic, lockdown, and night-time curfew, the southwest was struck by an earthquake magnitude 5.4 intensifying fears and distress among residents. It was then that the mayors of the five municipalities most affected by the January earthquakes, told the press that they have not been able to remove the debris of collapsed houses and buildings because they have yet to receive all the approved emergency funds set aside for debris removal.  In mid-May, the central government announced that the FMOB approved $47 million to be used for home reconstruction in these municipalities.

On June 28, two earthquakes, 4.8 and a 4.3 and three minutes apart, hit the southwest. Once again, fear, distress, and anxiety burdened residents of the area’s municipalities. As the mayor of Guánica described to the press “…I saw the people in backyards and balconies…It is despairing to see so many people feeling impotent, scared, crying…it is very hard. I do not know what would happen.”  Since then, the earth has continued shaking with tremors ranging from 2.3 to 4.8 magnitude.

In the midst of earth tremors, the COVID-19 pandemic reached Puerto Rico in early March. The first known cases were of an Italian couple who arrived in Old San Juan on Sunday, March 8 on the Costa Luminosa cruise ship.  The woman got sick while at sea and the couple was taken to a hospital in the Capital City where they were tested for COVID-19.  The PRDOH officials maintained that it was just a case of pneumonia and not COVID-19, but the tests done on the couple came out positive, ensuing government concern over the pandemic. Meanwhile, the PR DOH chief epidemiologist asserted that the COVID-19 pandemic did not pose a risk as China is far away from PR.  The mishandling of the pandemic and constant downplaying the risk to the island’s residents led to the resignation of the PRDOH Secretary and the Chief Epidemiologist in mid-March.

PR was one of the first US jurisdictions to order (EO 2020-20) a strict lockdown to protect the health system and halt the spread of the virus. The lockdown- effective March 15 - involved shutting down non-essential services including public mass transportation, a night curfew from 9 pm to 5 am and school closings. Services considered essential included: grocery stores, pharmacies, gas stations, convenience stores, banks, health care, and restaurants/eateries (could only operate for take-out orders and deliveries). During the day, people could leave their homes only to work in essential services; buy food, hygiene products and medicines; get gasoline; or go to the bank or laboratory and/or physician’s office. Central government public workers would remain home with full pay and benefits until further notice.  Some employees, consultants and professional services could work remotely if necessary. 

The measures taken in March included the establishment of a Medical Task Force composed of faculty (public health and medicine) from the University of Puerto Rico Medical Sciences Campus to advise the governor on all health matters related to the management of the pandemic.  Parallel, an Economic Task Force, comprised of representatives from the business sector was established to provide recommendations related to the reactivation of economic activities.

The initial lockdown was extended until April 12, but this time the night curfew started two hours ahead, from 7 pm to 5am.  Some businesses that had been banned such as auto repair shops, tire centers and hardware stores were allowed to operate on a limited schedule and by appointment only.

Subsequently, the governor of Puerto Rico issued a pandemic-related executive order every 15 days modifying some of the restrictions and curfew hours while requiring the use of masks in businesses, offices, and all public places.

On May 1, 2020 began the implementation of phase one (EO-2020-038) of the reopening involving outdoor activities (5 am-3 pm), and certain economic sectors while maintaining the 7 pm- 5 am curfew.  New commercial permitted activities included: barbershops, beauty salons, automotive sales, and extended the operating hours of auto repair shops, tire centers, and hardware stores. Parks, athletic tracks, beaches, gyms remained closed.  All businesses were ordered to remain closed to the public on Sundays.

The second phase of the reopening (EO-2020-041 May 25) extended the operating hours of businesses already opened and the re-opening of the ones that were closed.  The permitted activities included: use of restaurant dining rooms (at 25% capacity), barbershops/beauty salons by appointment and malls and retail stores at 50% capacity with preference for curb pick up. Other activities allowed included the utilization of recreational boats, public use of beaches, natural reserves, and golf courts.

The third phase of reopening (EO-2020-044 June 16) re-activated most of the economic sectors. The new economic sectors allowed to open included gyms, movie theaters, bars, spas, museums, and casinos. The order allowed restaurant dining rooms to operate at 50% capacity. Public transportation also re-opened and people could once again ride in buses and the urban train. The curfew remained in place being in effect from 10 pm to 5 am. Elective surgeries that had been banned previously were permitted.

The crowding of the surroundings of bars and food places while consuming alcoholic beverages, and noncompliance with physical distancing and use of face masks, along with an increase in COVID-19 cases and hospitalizations led the governor of PR to reverse the fourth phase (EO-2020-048) of the economic reopening that allowed increasing restaurant capacity at 75%, among other measures. 

Therefore, an executive order (EO-2020-54)  - effective July 16-31 - was issued closing clubs, movie theaters, concert halls, casinos, gyms, bars, and all marinas (recreational vessels). Public transportation like buses and the urban train were also closed.  The sale of alcoholic beverages was prohibited after 7 pm and all day on Sundays. The 10 pm- 5 am curfew remained in place as well as the mandatory use of face masks and physical distancing in all commercial establishments, offices, and public places. No commercial activity, with the exception of pharmacies, grocery stores, restaurants (take out only) was allowed on Sundays. The most recent COVID-19 executive order (EO-2020-060) effective August 1 through August 15 maintains the same measures as the previous one with some changes like permitting hardware stores to operate on Sundays (due to hurricane season) and the closing of beaches on Sundays. 

The COVID-19 pandemic has impacted Puerto Rican society in various ways. The sharp reduction in the economic activity had adverse effects on small businesses that struggle to stay afloat, and many could be forced to close down permanently. Reduced economic activity also resulted in reduced hours and job loss. Since March, more than 467,000 people have filed unemployment claims including the self-employed. Problems with unemployment claims has caused distress among displaced workers as phones were not answered and the online site of the PR Labor Department was not working properly. Quite often, displaced workers in desperation to get help, contact media TV and radio programs denouncing these problems.

A challenge faced by many families with children is related to school closures and distance learning. Distance schooling poses a problem for many children, adolescents, and families as only 54% of households in PR have access to the internet and 62% have a computer at home, according to the PRCS 2013-2017.   Public school students from the poorest sectors may not be able to engage in distance learning, even if they are provided with computers, as has been planned by the Department of Education.

In addition, many working parents, especially those with low-income, are unable to work from home as they have jobs that require their presence in the workplace.  How working parents - regardless of their income level - are coping with childcare is yet to be known as there is no research in Puerto Rico that have assessed this issue during the pandemic.  Given that many grandparents in Puerto Rico provide childcare (all day or after school hours) how being at risk of becoming extremely ill if infected affects their role in childcare deserves attention.

Another effect is food insecurity among students in the public-school system that depend solely in the school breakfast and lunch program to consume a healthy meal.  Due to school closures this service has not been available in Puerto Rico.

A problem during the pandemic has been the temporary closing of police stations while placing police officers in quarantine. At any given time, there could be anywhere between 200 and 600 police in quarantined across Puerto Rico

Hospitals in Puerto Rico experienced reductions in room occupancy and emergency visits due to people’s fears of becoming infected and the ban on elective surgeries. For example, in early April the room occupancy was 38% according to the Association of Hospitals which led to the reduction of working hours and temporary layoffs of hospital workers including nurses and physicians. The PR government provided aid to hospitals to offset this situation. Lately, hospital use by non-COVID-19-patients have increased as more people seem to trust the prevention measures taken and the restart of elective surgeries and other procedures.  The pandemic also affected medical offices whose operational costs increased by 20% or more, according to the President of the College of Surgeons.

The interruption of health services endangers the lives of patients with chronic conditions such as cancer, diabetes, renal and other. A telephone survey conducted by the PR chapter of the American Cancer Association among 409 cancer patients reveals that 34% saw their treatments affected, 50% had economic difficulties and 14% had problems to acquire medications.

Since data from contact-tracing has revealed that recent COVID-19 surges in Puerto Rico come in part through people who arrive at the airport, the government issued an order requiring arriving airport travelers to show proof of a negative molecular test result or in its absence must self-quarantine for 14 days.  However, it has been admitted by government officials that only 20% of passengers comply with the rule while pointing to difficulties following travelers supposedly on isolation.

Although the measures taken have been quite effective in containing the virus there has been a spike in COVID-19 cases and hospitalizations that coincides with the third phase of the re-opening phase. This surge has created deep concern among members of the medical task force (who had reservations about widespread re-opening), physicians and epidemiologists.  A shortage of reagents for molecular tests hampers widespread testing of the virus.

Form March through August 7, the number of COVID-19 cases amounted to 20,686.  Of these, 8,230 are confirmed cases (molecular test) while 12,456 are probable cases (serological test).  Up until then, COVID-19 deaths totaled 265. However, this number could be higher as for every known COVID-19 case another 5 to 10 cases go undetected.

Amidst the pandemic and earthquakes, tropical storm Isaias hit Puerto Rico in an unexpected way on Thursday July 30, 2020. The storm produced strong wind gusts, heavy rain, mudslides, flooding, and fallen trees.  Over 400,000 homes were without electricity and about 230,000 people had no potable water.  While it is too early to get a complete picture of damages, many homes were flooded with water (over 4 feet high), agricultural crops were destroyed, and principal and secondary roads were severely damaged across the island.

PR society strengths

The people of PR despite economic hardships do have cultural strengths like a sense of humor (helps to cope with stressful conditions), reciprocity and generosity. Kinship ties provide emotional and financial support (may include housing) to women and children as resources are pooled, borrowed, and shared. Grandparents (as well as other kin) are very influential in parent’s and children’s lives. It is common for grandparents to provide unpaid childcare to working mothers and/or at times of need. They also enjoy taking their grandchildren out and having them stay in their homes overnight.

There is a wide variety of informal and formal organizations geared to improve life through cultural promotion (arts, music, dance), neighborhood revitalization, environmental protection, youth development, and community development (may include micro enterprises, health promotion and community/home vegetable gardens) and alternative education to school dropouts. Other important assets are a strong cooperative movement, ecological movement, and the resurgence of agricultural work among young generations (under 40 years of age). A skilled and semi-skilled labor force that has been and still is sought after in the US is also an asset.

The strengths and resiliency in PR become most evident during critical events. In the aftermath of Hurricane María in 2017, the non-governmental agencies (NGO’s) were highly instrumental in helping people as they distributed food, water, water filters, solar lights and other supplies in shelters and communities. Very importantly, people themselves displayed generosity and resourcefulness as neighbors shared food, water, ice and even power from generators through extension cords. In some communities, neighbors shared their own money to pay private electricians to restore energy. All over the island, people turned to cultural practices like music, songs, phrases (like “Puerto Rico se Levanta” - Puerto Rico Rises) and the Puerto Rican flag as symbols of strength and resolve to help overcome the pain and desolation caused by the storm.

When the earthquakes hit PR the NGOs, professional associations, foundations, faith organizations, public school teachers, and the academia played a leading role in the provision of assistance – medical, psychological, educational, temporary housing - to the families and individuals affected.  Very importantly, citizens and groups across PR collected supplies and foodstuffs which they delivered to families and individuals in the affected areas. The drive to help is best portrayed in the following social media art.

 

During the COVID-19 pandemic lockdown individual citizens, NGOs, health professional associations, and faith organizations once again became key players.  Some groups distributed prepared meals and/or bags of foodstuffs to people in need like the homeless, the elderly, and the extremely poor including children and families.  Technological groups developed and distributed face shields among health professionals. NGOs continued providing interventions and support to programs’ participants through emergency lines and social networks.  Health organizations held virtual conferences on COVID-19 signs and symptoms, how it is spread, and what to do to decrease risk of contagion, among other actions.

PR Title V Roles, Challenges and Strengths

PR Title V has played a lead role in several important health related initiatives and public policies propounded by the DOH.

An important asset of PR Title V is leadership through committees and coalitions including the Regional Boards - composed of representatives from government and non-government entities, and community - located in each of the 7 DOH Health Regions. It has also a well-established health promotion component that includes parenting courses, prenatal course, massive media campaigns, community education, and professional training.

Having a broad and strong network of partners within and outside the health field (NGOs, medical associations, health organizations, parents’ organizations, among others) is also an asset that is crucial for conducting needs assessments and health promotion. The PR Title V supports the efforts of partners through staff participation in task forces, committees, and alliances.

The greatest strength of PR Title V is a highly committed workforce and capacity to respond speedily to emergencies or critical events Puerto Rico has experienced in the last four years (epidemic, hurricane, earthquakes, pandemic) that have impinged on the health and wellbeing of populations and families.  

A brief summary of PR Title V efforts to grapple these crises is presented below.

Zika Epidemic: The PR Title V was highly active in the management of the ZIKA epidemic that affects pregnant women and their offspring (fetal stage).

The Title V implemented two CDC funded surveillance and population-based assessment projects: a) The Zika Active Pregnancy Surveillance System (ZAPSS) to monitor pregnant women with laboratory evidence of Zika infection and prenatally or perinatally exposed infants born to these women. ZAPSS collected information about Zika infection during pregnancy, delivery, and outcomes in children up to 3 years of age and; b) the Zika Postpartum Emergency Response Survey in Puerto Rico (PRZPER I and PRZPER II) to conduct a rapid population- based assessment of maternal behaviors, experiences and attitudes related to Zika virus exposure among recently pregnant women in PR including a partner survey and telephone follow-up. 

Staff from Title V and other programs received training on the Zika virus and disease, transmission, and prevention enabling them to provide accurate information to women, families, and communities on Zika topics. Zika topics included signs and symptoms, risks, effects on the fetus, birth control, condom use, prevention of mosquito bites, elimination of mosquito breeding sites, and prevention within the household. Materials distributed included brochures, posters, mosquito repellents and condoms. The staff promoted early prenatal care and testing for Zika in pregnancy as well as referrals to the CSHCN program for developmental surveillance and coordination of specialized services.

Hurricane Maria: The PR Title V experienced severe damage to Central Level facilities forcing staff to relocate temporarily in cramped spaces. The State Action Plan was also affected as strategies and timelines had to be adjusted across domains.

Title V staff- even those who suffered personal losses- worked tirelessly to help MCA/CSHN populations and families across Puerto Rico in the aftermath of the catastrophe. The staff played a key role in identifying the emergent storm-related needs of MCA/CSHCN populations in shelters, households, and communities. The Register for Technology-Dependent Children was developed and implemented (2017) to register and follow-up families with a technology-dependent child.  Due to their knowledge and community networks, the HVNs played a leading role in the municipalities they serve by becoming the main liaison for the mitigation and recovery efforts directed to families.

Educational materials were developed on emergent public health threats and their prevention (e.g. leptospirosis, safe food storage, personal hygiene, hand washing, and breastfeeding during emergencies). The Title V also collaborated with partners in developing protocols and offering trainings to community leaders, teachers, and health professionals on the identification and management of common health conditions and the prevention of unintentional injuries after a disaster.  The “HOPE After Hurricane” session of the Alliance for Climate’s Education was translated and adapted to allow youth in PR to better understand and respond to their own emotions during and after a hurricane.

Earthquakes: The PR Title V collaborated with the PRDOH Office of Public Health Preparedness and Response in the revision of guidelines. Tittle V staff tended to the needs MCA/CSCHN populations and families in shelters and communities, coordinated services and helped them face the disaster and its effects including constant fear, insecurity, and sense of loss.

Title V staff collaborated and shared resources with its partners to offer urgent medical care, basic hygiene materials, psychological aid, stress management, breastfeeding practices, safe infant feeding practices, children’s safety, and health education in general. They also used and disseminated educational materials on how to cope with stress and secondary trauma. The staff adapted the Hope After Hurricane to the seismic events for use with youth and provided education on emergency backpack and earthquakes.

The HVN’s (live in the same municipalities they serve) in the affected areas in spite of experiencing personal losses and difficulties, assessed the needs of program participants related to basic necessities and housing and continued providing education and support including psychological first aid techniques. They also assured that pregnant women participants kept up their prenatal care and are aware of any signs of complications, and that infants and children are receiving adequate care.

The Ponce Pediatric Center continued providing services to CSCHN children/youth and families once it assessed the damages to the physical facility.  To assure safety they developed an evacuation plan for staff and center’s services recipients.  It also held special meetings with staff to allow them to vent feelings, emotions, and concerns.

COVID-19 Pandemic: Upon the threat of the COVID-19 pandemic in early March and subsequent lockdown, the PR Title V adjusted strategies, activities, and timelines across all domains. Most importantly, immediate steps were taken to face a situation that poses a different challenge than previous critical events due to the high risk of infection.

The PR Title V developed recommendations for the staff protection including instructions to maintain physical distance in the community or if the staff presented any symptoms. To assure understanding and compliance, the PR DOH protocol for on-site office work was presented to all staff through virtual conference.  All staff teams are now holding virtual meetings to discuss plans, interventions, assessments, protocols, and concerns.  The Title V gathered stakeholders’ input for the State Action Plan through online communication.

Services and interventions are now being provided remotely. The PR Title V HVP initiated and continues working remote to provide home interventions (case management, education, needs identification, emotional help) through telephone calls and other virtual technologies. The clinical services provided by the Pediatric Centers and Autism Center to the CSCHN populations and families continues through telehealth activities.

Presently, efforts are underway to adapt face-to-face individual and community education to the digital (online) platform.  For instance, the prenatal course that targets pregnant women and companions (relatives or partners) has already been adapted to a 30 minutes video that includes pre-and post- tests. The health educational materials, posters, brochures, and videos across domains are available online at the PRDOH website, Google Drive, You Tube, and the websites of health partners. Online addresses are detailed in each domain’s reports and current actions.

The staff in collaboration with partners have developed virtual conferences and webinars on population health and wellbeing.  For example, an infant/child health webinar was offered to the staff of day care centers, head start, early head start and families.  The pediatric consultant collaborated in the production of social media short videos educating the population on protective measures to adopt to avoid contagion or spread of the virus. She also - in collaboration with health partners - organized and moderated a virtual conference on COVID-19 essential topics relevant to pediatric medical care that was attended by pediatricians from PR and abroad.

PR Title V will definitively continue drawing on its internal resources and partnering with collaborators to face societal challenges and emergencies as they arise.