Life and Death in Puerto Rico

Puerto Rico's health crisis was 100 years in the making.
By Rebecca Buckwalter-Poza ,

Banana trees are seen knocked over by the winds of Hurricane Maria, in Corozal, Puerto Rico, on October 2nd, 2017.

(Photo: Joe Raedle/Getty Images)

Soon after landing in Puerto Rico, two weeks after the storm, President Donald Trump bragged that Hurricane María's official death toll on the island was "16 versus in the thousands." His remark wasn't merely callous; it was also untrue. More than 60 deaths have been confirmed, albeit not officially. You'd think the American president would know that sort of thing.

The truth is, looking at the mortality rate in Puerto Rico, no one should be "proud," as Trump suggested, least of all the federal government. Federal neglect began inflicting fatalities in Puerto Rico long before María—perhaps even thousands of deaths. Consider these two figures: Over the last 10 years, hypertension deaths rose 50 percent in Puerto Rico; diabetes deaths, 22 percent.

Doctors and other medical professionals have been leaving the island in droves for years. Demand for nurses and medical professionals is higher than that for any other type of professional. Yet some of Puerto Rico's hospitals cannot afford to employ enough of those that remain on the island because of funding shortfalls, lacking reimbursement, or hiring freezes. Even patients willing to pay out of pocket find accessing health care difficult.

Despite Puerto Ricans' full tax contributions to federal health programs, the federal government shortchanges Puerto Rico when it comes to federal benefits. Almost half of Puerto Ricans count on Medicaid for their health care. If Puerto Rico were a state, the federal government would cover approximately 83 percent of its Medicaid costs. Instead, the island receives federal funding for, on average, between 15 percent and 20 percent of its Medicaid costs. Puerto Rico is presumed to be able to make up the rest, a fiction that has exacerbated the island's fiscal struggles.

Trump's not just discriminating against Puerto Rico relative to states; he's doing less than we did for Haiti.

There's more than a whiff of racism detectable in these disparities. In 1980, the Supreme Court decided that giving Puerto Rico less funding for federal benefits was acceptable because there were rational bases for the disparity. Among these reasons, the justices listed a concern that "greater benefits could disrupt the Puerto Rican economy." Nearly 40 years later, Trump offered the same reasoning to justify the shockingly inadequate federal response to Hurricane María in Puerto Rico: "They want everything to be done for them."

"This is an island surrounded by water," Trump protested in response to criticism of his slow response. "Big water. Ocean water." It's actually not that far away at all—far closer to Washington, D.C., than California is. And its distance was no barrier to investment. If anything, investment in Puerto Rico has proven how easily the island can be accessed for any purpose, even flagrant exploitation.

Start here: Puerto Rico was supposed to be a state. Instead, it's a territory, subject to Congress' control. Puerto Rico's citizens are United States citizens but had no say in the presidential election that installed the man who is now neglecting Puerto Rico. A non-voting Puerto Rican member of the House of Representatives voices the island's needs in that chamber but wields no power. The lack of political clout has left Puerto Rico particularly vulnerable to corporate predation.

Special interests have influenced Puerto Rico policy for more than a century. The policy Trump so recently suspended—the Jones Act, or the Merchant Maritime Act of 1920—is an artifact of the influence of just such interests. Its mandate that shipments from the mainland be restricted to U.S.-built, U.S.-crewed ships was a boon for the shipping industry that devastated, and continues to harm, Puerto Rico. When I lived in Old San Juan, six ounces of blueberries, even spoiled, sometimes cost more than $20 at my local Supermax supermarket.

An MH-60S Sea Hawk helicopter attached to the Sea Knights Sea Combat Squadron 22 delivers cargo to the hospital ship USNS Comfort in support of humanitarian relief operations in Puerto Rico.

(Photo: Danny Ray Nunez Jr./U.S. Navy/Getty Images)

The most proximate cause of the island's insurmountable debt was the elimination of a tax loophole critical to its economy, Section 936. Passed in 1976 to create jobs and attract industry to the island, the provision offered a tax exemption to companies operating primarily in U.S. territories. And it worked very, very well—too well. Companies, including pharmaceutical giants like Smith-Kline, Merck, and Bristol-Myers, were escaping as much as $3 billion in taxes per year in some years. So the federal government came knocking.

In 1996, Congress sacrificed Puerto Rico to give lip service to reducing the federal deficit. Puerto Rico warned of the consequences, but politicians persisted. Just as predicted, companies promptly decamped to other tax-free havens or now more-favorable Latin American countries where wages were lower. The federal government's tax influx was short-lived; its consequences for Puerto Rico are still mounting.

Far from a surprise, Puerto Rico's health-care crisis was the only possible outcome of U.S. policy.

As a result, Puerto Rico began relying more heavily on bonds to stay afloat. Without sufficient advantages to entice industry and no alternative economic engine forthcoming, its governments and utilities were unable to make good on the bonds. Tourism, by the way, a staple of Puerto Rico's economy, predominantly benefits stateside entities, just as the sugar industry had done before it. Money spent in San Juan merely flows back to Manhattan. Puerto Rico's tax base has steadily shrunk, the losses disproportionate, as they correspond with the outflow of its most skilled, best-paid citizens.

Predatory investors eagerly bought up debt, then began waging epic legal battles to ensure they can squeeze the island for pennies, even at the explicit expense of its senior citizens. Desperate for a means of addressing the now overwhelming debt, Puerto Rico's legislature passed legislation in 2014 that would allow public utilities to restructure debt, as Detroit did. The Supreme Court struck the law. Why? Chapter 9 of the Bankruptcy Code specifically excludes Puerto Rico.

Why would Congress target Puerto Rico for exclusion from bankruptcy? In 1984, having created a triple tax exemption for Puerto Rico's bonds to encourage their purchase, Congress was looking out for investors. Last year, Congress passed the inaptly titled PROMESA Act to create an oversight board for Puerto Rico—with minimal roles for Puerto Ricans. This structure, too, may do more to protect corporate interests than help Puerto Rico manage repayment.

Far from a surprise, Puerto Rico's health-care crisis was the only possible outcome of U.S. policy. When I was in Puerto Rico in 2015, health care was already a precious commodity. It took months to see a specialist for routine appointments. Even after admission to a hospital, patients might wait days to be seen by specialists. The wait for critical surgical procedures could be lengthy enough to send friends to the mainland.

Five people died in two months this summer in Rio Piedras while under the care of the only government-operated mental-health facility for patients with a variety of afflictions. Just six psychiatrists, some part-time, were overseeing the 200-patient clinic. Without adequate reimbursement, or funding, such facilities simply cannot function.

María has exacerbated existing insufficiencies. Electricity in Puerto Rico, like health care, was already unstable. Now the island is almost completely without power; lines for gas are hours long. Two patients on life support in San Juan died when fuel ran out. One man reported via Twitter that every patient in the nearest medical center's intensive care unit had died.

"With an already inadequate infrastructure," one emergency responder tells me, speaking of both Puerto Rico and the U.S. Virgin Islands, "the islands just couldn't handle two back-to-back hurricanes."

What’s remarkable is that Trump's not just discriminating against Puerto Rico relative to states; he's doing less than we did for Haiti. And these are the early days in a process of recovery that will take years. Floodwaters and sewage create the perfect environment for mosquitoes. In Puerto Rico, they carry dengue and chikungunya. Then there are the bacteria that gain footholds when people don't have clean water.

María has exposed one of the greatest ongoing injustices of U.S. government: its treatment of territories and their citizens. Its policies had already inflicted casualties and fatalities. Now these harms have grown by an order of magnitude—and will continue to grow.

There is no forgetting the pleas from Carmen Yulín Cruz, the mayor of a U.S. city, as she begged for help. "I am going to do what I never thought I would do. I am begging, begging anyone who can hear us to save us from dying." There will likewise be no forgetting Trump's response, attacking Cruz and Puerto Ricans.

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