The US commonwealth of Puerto Rico will face a major crisis if it cannot contain a Covid-19 outbreak when it arrives. And it will arrive soon, if it hasn’t already. A cruise ship passenger diagnosed with pneumonia was admitted to a San Juan hospital and isolated while waiting the results of a coronavirus test. Meanwhile, her fellow passengers visited the city’s sights, restaurants, and bars. In addition, a doctor from Panama visited the island March 4 for a salsa festival in spite of showing symptoms, and has now been diagnosed with the disease.
In response to the first case, Governor Wanda Vázquez Garced decreed that all cruise ship passengers must be screened for clinical symptoms before coming ashore. This is not sufficient because people can spread the disease before they display symptoms, and these would not be caught by such a screening. Also the screening requirement applies only to people who arrive on cruise ships.
What Puerto Rico needs, urgently, is to test people for the presence of the virus itself. However, as of today, its testing ability for Covid-19 is still listed as “in progress” on the CDC website. The fact that the entire US mainland is still not testing people sufficiently, which means we are potentially missing thousands of cases, makes it even harder for Puerto Rico to assess its risk of importing infections from travelers. And without knowing if community transmission has taken hold on the island already, Puerto Rico will scramble to respond if and when it does.
As a population, Puerto Rico is at greater risk of sickness and death compared to the mainland United States. The severity of Covid-19 increases sharply in elderly people, with estimates from China suggesting mortality among people who have the infection around one in 12 for people ages 70 to 80, and one in seven for people over 80. According to the Census, Puerto Rico has a higher proportion of elderly people compared to most places in the United States — 21 percent over 65 Puerto Rico in 2017 compared to 16 percent in the rest of the United States. In addition, Puerto Rican elderly residents are seven times as likely to live in poverty compared to the rest of the country. If we look at hospital preparedness, and consider one metric of our readiness to care for patients with Covid-19 — intensive care unit beds — Puerto Rico has five times fewer ICU beds per capita compared to the rest of the country.
These numbers are sobering, but they underestimate the enormity of the challenges facing Puerto Rico. In 2017, Hurricane Maria devastated Puerto Rico, and much of the island is still recovering. Since then, many younger Puerto Ricans moved off the island, and by 2018 about 15 percent of the island’s medical specialists had left too. These departures left behind weakened infrastructure, fewer low-risk age groups, and medical staff to help keep things running during a crisis, and many elderly people who are particularly vulnerable to Covid-19. To be clear, this epidemic will not only impact people who get this virus — many of whom will end up spending a significant amount of time in the hospital. It will also critically stress the health system to the point where those with other health issues — diabetes, cardiovascular disease, cancer — may not be able to access essential care and medication. A widespread outbreak would raise mortality across the board for medically vulnerable groups.
Despite the grave risks facing its people, Puerto Rico has two strengths in this fight that set it apart from the rest of the United States. First, it is an island. Unless community transmission has already begun, which is possible, then immediate travel restrictions could be effective at keeping the virus out. The economic costs of doing so would be significant, but they pale in comparison to the devastation an outbreak would bring to Puerto Rico’s people and health system.
Second, Puerto Rico has a large pharmaceutical manufacturing capacity. The island was once a top drug-making center, but drug makers largely left after tax breaks ended in 2006. China currently accounts for the vast majority of precursor chemicals for US drugs, and there may be shortages of the chemical components of the Covid-19 test kits. Aside from the possibility of immediate ramping up of production of reagents and ICU drugs to control this outbreak and mitigate its impacts, there is a longer-term strategic rationale for bringing much of the historic pharmaceutical manufacturing back to the island.
Puerto Rico is vulnerable. It, with assistance from the federal government, must establish surveillance, determine whether there is community transmission, and prepare its health system immediately.
Caroline Buckee is associate professor of epidemiology at Harvard TH Chan School of Public Health TH Chan School of Public Health.
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