Each year, millions of tourists come to Puerto Rico on jets and cruise ships for the beautiful beaches, the warm breezes and sunshine, the songs of rare colorful birds, the beat of salsa music, the history preserved in the oldest city on American soil, and the tastes of tropical fruits, fresh seafood, and island-made rum.
However nice it may be to visit, Puerto Rico is not known as an ideal place to live. Images of poor Puerto Rican immigrants making their way to New York or other parts of the United States make the US territory seem a less than ideal home. Some residents, however, find their ties to "La Madre Patria" are stronger than the lure of prosperity - sometimes real, sometimes imagined - in the United States.
Eugenia Ayala, MD visited the United States last year to take her son to Disney World and to interview for a pediatric position in Charlotte, North Carolina. On their way back home to Puerto Rico, the divorced mother and her son agreed they weren’t ready for a move to the United States or all the changes it would entail.
"My son, Alexis, said, ’I want to stay at my school in Puerto Rico,’ and it was too quiet, too peaceful for my type of temperament. The houses are too far apart," Ayala said of the Charlotte neighborhoods she toured. "We live in a development where all the houses are connected."
While her son, now 13, sometimes asks her not to complain so loudly about his messy room, Ayala finds comfort in knowing the next-door neighbors are at home and that they’ll notice if she comes home later than usual. "Hearing your neighbors through the walls, to me, that’s a way of sharing," she says.
Located midway in the string of Antilles Islands, Puerto Rico is a major gateway to the Caribbean Sea. Between its western coast and the neighboring island of Hispaniola - home to Haiti and the Dominican Republic - is the deep water of the Mona Passage, a seaway to the Panama Canal and the Pacific Ocean. More than six million tons of dry cargo are handled in the Port of San Juan, making it second only to New York among ports on the eastern seaboard.
Puerto Rico also sits in the middle between being fully part of the United States and part of the Caribbean islands surrounding them. In 1898 Puerto Rico was ceded to the United States after the Spanish-American War, and its residents were extended American citizenship in 1917. Migration to the United States has been an important factor in the island’s population, now 3.8 million. Approximately 2 million more Puerto Ricans live in the United States.
Political camps are classified based on whether they advocate that Puerto Rico should maintain the status quo as a US commonwealth, become the 51st state, or seek complete independence. The argument is complicated since the commonwealth’s economy is closely tied to the United States, but much of its culture reflects a smaller, formerly colonial society similar to its island neighbors.
The currency is US dollars but residents pay no US taxes and cannot vote for the US president. Both Spanish and English are official languages, but Spanish is dominant among average citizens.
Their affiliation with the United States gives the commonwealth a mighty economic big brother, and a number of federal programs serve Puerto Rico. Manufacturing jobs are likely to be in American-owned pharmaceutical and electronics companies, which have been lured there by tax breaks from the US government. The tax incentives have their origins in the Operation Bootstrap economic development programs of the 1950s designed to bring non-agricultural jobs to Puerto Rico. Nevertheless, unemployment is higher than in the states at around 12 percent.
Puerto Rican life has a distinctly more American flavor than other Caribbean islands in other ways. The population is about 71 percent urbanized, for example, and traffic jams are part of life in the metropolis of San Juan, Puerto Rico’s largest city.
Had Ayala chosen to move to the United States, she would have had a boost to her income and an escape hatch from the massive health-care reform that is taking place in Puerto Rico. Instead, she finds her salary equivalent to about $25 an hour for her weekday office work and $35 an hour for weekend emergency room work. Since the health-system reforms reached Bayamon, the western suburb of San Juan where she works, two years ago, worries over the referrals she makes and the bottom line at her government-funded, primary-care clinic have complicated her work.
Yet Ayala, 47, has learned to work within the system. Every quarter, the staff in her clinic meets to review patient treatments, referrals, and emergency room activity.
"We have these meetings and most of what they talk about is how we are spending the money," Ayala said. "What I have done through all this, if my patients need a certain kind of care, I make sure they get it. I tell myself, ’This is a process, and we have to teach the patients how to take better care of themselves and to come to us earlier in their illness.’ I have learned that nothing is impossible, so I try to have a positive attitude and I try to give my best to help my patients."
Ten years ago, more than half the residents of the island were medically indigent and receiving care at government-run clinics and hospitals. Since then, managed care arrived in Puerto Rico and was phased in to cover all of the island in the past year. Physicians working in the public sector are getting a strong dose of bottom-line medicine and wondering how Americanized their system will become.
Reforming the system to provide more primary care and cut costs by turning it over to the private sector was one of the campaign promises of Pedro J. Rosselló, MD, when he ran for governor in 1992. He completed his second term in 2000, without seeking re-election. Rosselló is an American-educated Puerto Rican physician. A native of Santurce, another San Juan suburb, he graduated from Notre Dame University and received his medical degree from Yale University. In Puerto Rico, he was a faculty member at the University of Puerto Rico School of Medicine. In 1985 he was named director of the city’s Department of Health.
Rosselló’s health-care reform is called "La Tarjetita," a diminutive for "the card," referring to the ID card issued to participants. In the new health-care model, the Department of Health delegates responsibility for delivery of services to private management systems and pays for them with government funds. La Tarjetita provides virtually all forms of therapy and surgery through a network of facilities on the island including several supra-tertiary care hospitals in the San Juan area, according to a 1999 report from the governor’s office. Patients with private health insurance (typically employer-supplied) or who belong to the US Medicare system use privately funded facilities.
Ayala works for the Bayamon Health Center, which operates a main clinic with an emergency room and two satellite diagnostic acilities in the Bayamon area. The facility, previously owned by Bayamon County, is now privately held by the Corporation for the Development of Health of Bayamon County and serves La Tarjetita participants.
Payments to the clinic’s corporation from the management system are capitated, said Jose Abdiel Cruz, MD, a family practitioner and the clinic’s medical director. While he makes sure patients get the care they need from the doctors at his clinic, he’s aware of some physicians at other facilities "holding back" care of the chronically ill by not making themselves available. "Some aren’t working every day. It’s like rationing of services a bit."
La Tarjetita is bound to continue in Puerto Rico, Cruz said, because it’s very popular with patients, who get their medications, surgeries, and choice of primary care physicians. "There’s no turning back. It’s everywhere now. But there has to be a lot of changes because all the risk is falling on the primary-care physician."
Like Ayala, he is hopeful that the new system will be open to physicians’ concerns.
Cruz, 48, grew up in the United States, the son of a career Army officer. His family lived in Washington state, Kentucky, North Carolina, Massachusetts, and on Long Island in New York. When it came time for college, he came home to study at the University of Puerto Rico. He received his medical training in Spain at the prestigious University of Zaragoza.
Then he returned home to Puerto Rico to begin his profession. "I had the opportunity to go back to the United States or to practice in Spain, but I chose Puerto Rico because I knew the language, there was instant prestige, it was more affordable, and all my family was here."
He also claims an inborn affinity for the sea. "As an islander, you take for granted the sea and the beaches, " he said. "When I was a student in Zaragoza," Cruz said of the capital city of the austere province in northeastern Spain, "I had such a yearning for the sea that I would go down to the banks of the Ebro River just to see some water. Of course, it wasn’t the same."
Now, just 15 minutes from the beach, Cruz goes to the sea at least once a weekend. "I’m a beach fanatic."
If that’s not escape enough, he’ll book a cruise out of San Juan Harbor for a few days. "There are three to four major cruise ships coming in there every day, and it’s very cheap because there’s no plane to catch. All the islands have different cultures to experience - the French, the Dutch, the Spanish, the English. It’s a wonderful way to get away from stress for a few days." In fact, San Juan is the largest home-base cruise port in the world. At least 28 vessels use San Juan as their home port, and each year new cruise ships originate or call at the port.
Back in the office, Cruz claims a patient base as far-reaching as his Caribbean getaways. "I receive patients from a whole bunch of places. Word gets around that I’m bilingual, which makes it much easier for some patients to communicate."
Bilingual is the operative word in Puerto Rico. Spanish is the first language, and English is spoken by about a quarter of the population, with limited capabilities. English is required in all federal matters and is spoken in all major tourist areas.
In the examining room, Spanish is likely to be the first language. Ayala believes Spanish fluency and cultural understanding are crucial to "getting to the right place to work because there are small groups that monopolize opportunities here," she says.
There are a few opportunities in Puerto Rico to work through the US National Health Service Corps to repay government loans or fulfill scholarship requirements, according to Guillermo Otero, MD, MPH, the director of the Puerto Rico team subfield office of the US Health Resource and Services Administration.
Otero says of the NHSC, programs: Right now, we have 19 grantees with about 39 clinics throughout the island. But in most of our centers, the turnover is not very high, the programs are stable, and the working conditions are good for physicians." Otero manages the more than $30 million appropriated annually through the US Public Health Services Act to Puerto Rico for community health care, health care in the schools, homeless health care, mental health care, and prison health care.
Several NHSC positions are becoming available in correctional facilities, and are more appealing than they sound, Otero says, because of federal oversight. "There were complaints regarding health care and not enough providers, so now the correctional health program is monitored by the federal court.
"For the student finishing medical school, it can be attractive, because in less than four years, you can get rid of most of your student loans," Additionally, corrections salaries are some of the highest in Puerto Rico for primary-care physicians. "The salaries are not very high in the private sector," says Otero. "In public health, they’re about $60,000, and in corrections they’re $80,000 to $85,000."
Despite loan repayment advantages and the appeal of island life, physicians from the United States are not often seen here. Jose S. Belaval, MD, the medical director of the Community Health Center in Santurce says, "Mostly, people practicing here are from Puerto Rico."
As in the United States, the physicians tend to congregate in the urbanized areas. The Pan American Health Organization of the World Health Organization reports a ratio of 17.5 physicians per 10,000 population in Puerto Rico, which is somewhat low by US standards but not critically so.
"There is an adequate number of physicians on the island but there is not adequate distribution throughout the island," Otero says. "Usually, it’s the areas in the mountains that are the most underserved because of lack of adequate facilities, backup hospitals, and the things people want for their families, like good schools and good housing. They are too distant from the cities, and, sometimes, the roads are not that good."
"For some people, though, they like the small communities because they’re a good place to raise a family," he says.
With good roads, some smaller communities can be served without being cut off from bigger cities. For example, Belaval, who had an NHSC scholarship when he attended medical school at the University of Puerto Rico, drove from his San Juan area home every day to fulfill his commitment to work in an underserved community.
"I had my internship and residency at Caguas Regional Hospital, only a half hour from San Juan on a very good highway."
Caguas now has a population of about 133,000 and is on the main highway that connects San Juan, on the island ’s northern coast, to the southern coastal city of Ponce. With a population of 188,000, Ponce is the island’s second largest city. That road then continues to the west-coast city of Mayaguez, with a population of 100,000 and just 98 miles from San Juan.
The less accessible areas are in the central interior, where long inactive volcanic mountains occupy large sections of the island. The highest peak, the Cerro de Punta in the Cordillera Central, reaches 1,338 meters.
For physicians who want to retreat inland occasionally, several forest reserves protect plants and wildlife. El Yunque Tropical Rain Forest is the only rain forest in the US National Parks System. The 28,000-acre forest in the eastern part of the island is home to 240 types of trees, the rare Puerto Rican parrot, and the coqui frog, Puerto Rico’s mascot. The little frog, no more than an inch long, makes a "koe-kee" chirping sound and can survive nowhere else in the world.
"There is no camping in El Yunque, but there is hiking on marked routes, and there is an old, brick observation tower where you can see this incredible view," says Cruz. "You can see the different areas of fauna with their different colors and shapes, and there are these incredible, gigantic ferns."
Cruz also enjoys the city, where he strolls the cobblestone streets of Old San Juan and dines at open-air cafes. "Old San Juan is a jewel. You can spend the whole night there just walking. But all of San Juan is a very interesting contrast between the old colonial and the new, which is very modern with shopping malls and high rises."
Christopher Columbus landed in Puerto Rico in 1493, on his second voyage to the Caribbean. He explored it briefly, gave it the name San Juan Bautista (St. John the Baptist) then returned to Hispaniola.
In 1508, Juan Ponce de León, a former aide to Columbus, arrived to colonize Boriquen, as it was called by the natives. Boriquen (origin of the national anthem "La Borinqueña") meant "land of the great lord," referring to the Indians’ belief that the god Juracan, controlled the weather from his residence on the island’s highest peak. The word hurricane is derived from this god’s name.
Ponce de León’s first settlement was Caparra, a small village not far from the harbor of San Juan. In 1521, because of unhealthy conditions at Caparra, the settlement was moved to the present site of Old San Juan. In the same year, the Casa Blanca, the oldest building in the historic zone today, was constructed as a home for Ponce de León, the island’s governor. Unfortunately, the seeker of the Fountain of Youth never actually lived in the governor’s mansion since he was killed the same year during the Spanish conquest of Florida. Now home of the Juan Ponce de León Museum, the house did revert to his family, which occupied it for 250 years.
Morro Castle, the formidable fort at the entrance to San Juan Harbor, was completed in 1591 by the Spanish empire to protect the colony against attacks from French, English, and Dutch invaders who were colonizing other Antilles islands.
Unfortunately, the fort’s walls cannot protect the citizens and physicians from problems facing health care in modern Puerto Rico. Physicians here hope the reforms patterned after those in the United States will bring financial stability to a system challenged by a large indigent population while providing much-needed care.
At his community health center in Santurce, pediatrician and medical director Belaval says his clinic serves a working-class area that "has a very sick population. Right now, our demographics are just terrible. I’d say 80 percent are hypertensive, diabetic, and all of that. We work very hard to educate the patients so they will make the best use of the services we provide. We have several people looking at our utilization trends, and so far, we are in the reasonable bracket concerning referrals" he says. "But I don’t know how long we’re going to survive."
Belaval knows there’s no beating back reform of the island’s public health-care system. But balancing the need for an economically realistic health budget with the intense needs of the people will be no easy task. "All I can hope is that we are going to move slowly because we have to balance good medicine with cost effectiveness."
Pam Prescott, a freelance writer based in Roscoe, Illinois, regularly contributes community profiles to UO.