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Puerto Rico’s Health Care Crisis: Where Empire and Climate Change Collide


On Wednesday, September 20, 2017, after an already uncharacteristically volatile hurricane season, Hurricane María made landfall on the island of Borikén (“Puerto Rico” in the indigenous Taíno language). Dr. Angélica Pérez-Andújar, a Puerto Rican professor of radiation physics, reflects, “Although our generation has gone through two catastrophic hurricanes, Hurricane Hugo and Hurricane George, we did not know what a category five hurricane would be like. We could not imagine the devastation that Hurricane María was going to cause.” According to the Milken Institute School of Public Health at The George Washington University, its wake of destruction resulted in 2,975 excess deaths between September 2017 and February 2018 — and “if it was bad for San Juan, it was much worse for the central rural part of the island,” such as Dr. Pérez-Andújar’s childhood home of Utuado where her family members remain.

The hurricane’s flattening of power lines, destruction of roadways and contamination of potable water sources left rural Puerto Ricans vulnerable to chronic illness complications and sometimes fatalities. The care of those with chronic conditions, such as kidney failure and diabetes, was left to whichever family members were not waiting in egregiously long lines for generator fuel or water — potable or not

Despite Hurricane María’s destruction of infrastructural access to health care, the roots of the current Puerto Rican health care crisis extend back to the colonial era. So, while Hurricane María certainly heightened the island’s health care crisis and served as an ominous example of how climate change will impact the most vulnerable populations on our planet, its winds and rain did not subjugate a people to economically forced labor for the sugarcane industry nor did they instigate the United States’ Medicaid cap on Puerto Rico. Rather, the United States’ consistent colonial subjugation of Puerto Rico and the island’s resultant slipshod public infrastructure has left the Puerto Rican people increasingly vulnerable to climate disaster, only compounding Hurricane María’s destructive potential.

The first health care crisis on record was brought to Borikén by the Spanish empire, in which the fatal combination of a smallpox epidemic, slavery in gold mines and starvation completely eliminated the island’s indigenous Taíno people. Ricardo Alegría, a Puerto Rican historian and anthropologist, states that Spain asked the Spanish governor of Puerto Rico, “How many Indians are there? Who are the chiefs?” three decades after first contact. The governor responded, “They are gone.” 

‘They’ — the nearly three million men, women and children across the Caribbean — are gone.

Over the next two centuries, Puerto Ricans fought for independence from Spanish colonial rule and finally gained a constitution and Spanish voting rights in February 1898, just months before the United States invaded the island during the Spanish-American War. By December, the Spanish ceded Puerto Rico to the United States as an ‘unincorporated territory’ in the Treaty of Paris. According to the U.S. Supreme Court’s Insular Cases (1901), Puerto Rico was inhabited by “alien races” that would not understand “Anglo-Saxon principles.” Labeling Puerto Rico as an ‘unincorporated territory’ meant it would not become a state nor would Puerto Rico’s inhabitants have voting rights. The Jones-Shafroth Act of 1917 gave Puerto Ricans statutory citizenship to the United States (and the right to serve in the U.S. Army with World War I beginning one month later).

However, as of February 2019, Puerto Ricans still cannot vote and do not have certain statutory protections such as Supplemental Security Income (not to be confused with Social Security, as SSI is funded by federal income taxes). While most Puerto Ricans do not pay federal income taxes, whatever benefit this presents to U.S. citizens on the island is negated by the Jones-Shafroth Act which also increases the price of goods on the island by 15 percent to 20 percent due to import, export and commodity taxes. This adds up to an additional cost of $1.7 billion dollars per year and is only the most superficial of the many de facto tax burdens placed on islanders.

But what of 20th century U.S. colonial rule? First, the United States encouraged sugar cane monocultures that benefited few Puerto Rican landowners, leaving field workers hungry and with sparse opportunities for vertical mobility. Yet again, the people were subjected to a health crisis due to regular starvation and unjust labor laws. When field workers unionized and the Puerto Rican government exercised its ability to keep field workers justly employed, the sugar cane industry declined through the 1960s — this was an industry that “accounted for 23 percent of total Puerto Rican wages.” Fighting for dignified working conditions only resulted in the U.S.-mediated industry’s collapse. 

Nevertheless, the U.S. government and private sugarcane oligopoly did not act alone in orchestrating 20th-century Puerto Rican health care crises. Medical practitioners also played a significant role in the catalysis of two documented attempts at Puerto Rican oppression. In 1931, Dr. Cornelius Rhoads wrote in a letter to a colleague, “Puerto Ricans are beyond doubt the dirtiest, laziest, most degenerate and thievish race of men ever inhabiting this sphere. What the island needs is not public health work but a tidal wave or something to totally exterminate the population. I have done my best to further the process of extermination by killing off 8 and transplanting cancer into several more.” A formal investigation yielded no evidence against Rhoads. However, Professor Susan Lederer of the Yale School of Medicine contends that the “medical imperial project” was not only meant to be a civilizing force of the “alien race”; physicians like Rhoads also “increasingly appropriated these colonial subjects for their investigations.”

Dr. Rhoads was never punished for his racist rhetoric. Instead, he was subsequently celebrated as a founding member of the Sloan-Kettering Institute for Cancer Research. The Rhoads murder mystery was followed in 1937 by the passage of Law 116, or the U.S. government-approved sterilization of Puerto Rican women without offering contraception, to ameliorate the alleged overpopulation and subsequent economic collapse of the island. As a result, even after the law was repealed in 1960, women of childbearing age in Puerto Rico in the 1960s were more than 10 times more likely to be sterilized than women from the United States.” Ultimately, the medical system — comprised of doctors on the front lines of racialized U.S. legislation — has historically bolstered the expansion of the U.S. colonial project in Puerto Rico by creating health care crises of its own.  

These health care crimes against Puerto Ricans widened the health care disparity between the island and the poorest U.S. states, and the federal government has yet to grant Puerto Ricans basic statutory rights as it does its mainland citizens. These rights include Supplemental Security Income, uncapped Medicaid and equitable Medicare funding (Puerto Ricans pay Medicare and Social Security taxes). In August 2015, two years prior to Hurricane María, The New York Times stated, “This disparity is partly responsible for $25 billion of Puerto Rico’s $73 billion debt, as its government was forced to borrow over time to keep the Medicaid program afloat, according to economists.” Furthermore, Puerto Rican doctors, faced with declining income due to these capped federal funds, are emigrating to the mainland at the rate of one doctor per day in search of better employment opportunities. Finally, 900,000 Puerto Ricans could lose their Medicaid coverage by the end of September 2019 — and this is after National Public Radio reported on July 3, 2019 that rural Puerto Ricans still do not feel safe or prepared for the coming hurricane season.

The United States has further contributed to Puerto Rico’s present-day health care crisis through its purposeful failure to address climate change. Historically, our nation’s delayed, easily corruptible and now regressive policy towards clean energy left the island superbly vulnerable to storms like Hurricane María and future climate change disasters. In the EPA’s “What Climate Change Means for Puerto Rico” report, the agency cites intensifying storms over the past 20 years as contributing to this health care vulnerability, especially when one considers that insurance will become either more expensive or increasingly difficult to secure as damages to infrastructure increase. Furthermore, the rise in daily temperatures since 1950 presents direct threats to human health in the forms of heat stroke, dehydration, increased cardiovascular risk and increased likelihood of exposure to tropical diseases in tandem with accelerated mosquito life cycles.

And, to add insult to injury? The U.S. military “is the world’s largest institutional user of petroleum and correspondingly, the single largest producer of greenhouse gases (GHG) in the world.” The United States, therefore, has the world’s ‘single largest’ hand in creating present-day climate disasters per Michael Mann et al.’s controversial but ultimately proven landmark paper, “Global-scale temperature patterns and climate forcing over the past six centuries.” To be perfectly clear: the U.S. colonial project has placed the burden of climate change on the Puerto Rican people and their health. Through both purposeful and insidious mechanisms of empire that include promoting the rapid progression of climate change and starving the Puerto Rican people of equitable health care access, the United States has only exacerbated public health crises in the wake of climate change, and more specifically, climate disaster. 

Yes, Hurricane María destroyed many means of accessing health care, but access to equitable health care has never been guaranteed; rather, Hurricane María amplified empire-promoted behaviors beginning with the genocide of 3 million Taíno souls and transforming into the starvation of sugarcane field workers, the experimentation on cancer patients, the sterilization of women, the de facto taxation without representation of the U.S. colony and an underfunded health care system that should care for our most vulnerable U.S. citizens. The Economist Intelligence Unit reports, “After GNP fell by an estimated 8% in the 2017/18 financial year owing to damage from Hurricane Maria, reconstruction is contributing to a partial recovery that will last into 2019/20, before the economy slips back into its secular decline.” In other words, disaster capitalism (or, the federal push through [of] radical pro-corporate measures”) will rebuild Puerto Rico before the United States maintains the subordination of its colony by cutting the cost of privatized rehabilitation from the budgeted government aid to Puerto Rico, thereby maintaining its economic decline. This arrangement of systemically corrupt disaster relief will lead to increasingly horrific humanitarian disasters and debilitating secular decline on the island, as the magnitude of future storms will grow. 

I am a rising second-year Hispanic medical student who aspires to work for frontline communities, or those communities likely to experience climate impacts first and worst in the wake of future climate disasters. Puerto Rico is a frontline community, but it did not become one in a vacuum. As future health care providers, it is our responsibility to learn how our patients arrive at our clinics before moving forward with a plan of care; it is up to us to learn the biological, sociological and psychological roots of our patients’ ailments. The above research on Puerto Rico is my attempt at better understanding a frontline community I hope to serve in the future. 

I am presently leading a delegation to San Juan, Puerto Rico with Fossil Free PCUSA, a grassroots organization calling on the Presbyterian Church USA to divest from the fossil fuel industry as the American Medical Association did in June 2018. One of our co-planners on the island, Michelle Muñiz-Vega of Presbyterian Disaster Assistance, shares, “It is our hope that delegation members better understand our cultural context, therefore harnessing the ability to identify methods of advocacy around topics like our island environment, societal colonialism, etc. while also developing a direct connection with the leadership in el Presbiterio de San Juan. In short, this delegation will give us the platform to amplify the struggles of the Puerto Rican people, within and apart from climate change natural disasters.” 

In a forthcoming piece, I will share about the delegation and its further impact on my worldview as a future physician. I will also elaborate on the coexisting roles of lament and hope in achieving health care justice for frontline communities like Puerto Rico. Until then, I encourage anyone reading this to do the work of understanding our underserved patient populations, local or global. After all, the chief concern we try to address, like Puerto Rico’s health care crisis in the wake of Hurricane María, is only the most apparent and immediate manifestation of a more complex history, like that of empire and climate change.

Aida Haddad, MDiv Aida Haddad, MDiv (2 Posts)

Medical Student Editor

Indiana University School of Medicine


Aida is a second-year medical student at Indiana University School of Medicine. Prior to medical school, Aida earned her Bachelor of Science in environmental science from Indiana University Bloomington and a Master of Divinity from Princeton Theological Seminary. In June 2018, she walked from Louisville, Kentucky to St. Louis, Missouri to witness to the forced migration of climate change refugees and to advocate for her church's divestment from fossil fuels. Aida feels called to work at the intersection of medicine, anti-racism, & environmental justice.