The island of 3.2 million people remains unable to shake its history, overcome its poverty, and secure adequate healthcare to all of its inhabitants.
It has been inspiring to witness medical education turn its attention to health disparities and the social determinants of health. In fact, curriculum in medical schools around the country have long included classes describing health disparities and how socioeconomic circumstances, environmental factors, community conditions, or on occasion blatant racism, prevent its citizens from accessing adequate healthcare. Such inequities not only increase mortality, but are costly accounting for an estimated $93 billion in excess medical care costs and $42 billion in productivity loss per year. The problem is such that medical students are no longer surprised when they learn to predict patient outcomes by simply searching the zip code of their patient’s home address. Many strategies are being deployed to reduce such inequities, yet it took decades to forge the socioeconomic and cultural structure that created and helps sustain the healthcare disparities observed today; it will take longer to dismantle that structure in order to secure equal access to affordable and top healthcare for all.
Health disparities in the US are not circumscribed to the mainland, as they stretch deep into the Caribbean Sea extending to the island of Puerto Rico, a US Territory since the Spanish American War. Soon after disembarking from General Mile’s ship in 1898, Dr. Bailey Ashford documented the rampant healthcare disparities that ravaged island natives and ensured the early death and the continuing poverty of an entire people. Since then, and despite its improved socioeconomic infrastructure, the establishment of not one but four medical schools, and the generation of physicians trained in specialties regulated by the US Graduate Medical Education Accrediting Council, the island of 3.2 million people remains unable to shake its history, overcome its poverty, and secure adequate healthcare to all of its inhabitants. The island’s inability to train and retain medical specialists ensures the further deterioration of healthcare delivery. As the latest example, in 2021, the only Neurosurgery Residency training program in Puerto Rico closed its doors for not having the appropriate infrastructure or sufficient funds to sustain adequate training.
The circumstances that led to the current economic and healthcare crisis of Puerto Rico have been described extensively. These writings describe how hurricanes and earthquakes, coupled with the inequitable taxation of goods entering the island, the deployment of a subclass Obamacare, corruption, and the actions of insurance companies led to a fragmented healthcare system currently on ventilatory support. More recently, we witnessed the latest impact of years of neglect: the emigration of well-trained physicians seeking a better quality of life elsewhere, while leaving behind an aging population unable to shake the shackles of history. This not only deprives island natives from accessing well-trained physicians capable of addressing their healthcare needs, but ensures the further deterioration of the island’s healthcare infrastructure by preventing medical schools from attracting top talent for the education of its students in the classroom and from the teaching of the diagnosis and management of patients during clinical rotations. Thus, the Puerto Rican Saga continues. Medical students in the island do not need to go far to learn about health and healthcare disparities; they only have to attend the clinic at the University Medical Center, assist a parent with an urgent need of a cardiologist, or try to reach an orthopedist in the emergency room on a weekend night.
To improve the situation, island legislators recently introduced Senate Bill 1134, which proposes to award specialty licenses to doctors who have had experiences in the emergency room for ten years, perhaps without appropriate supervision, thereby lowering the standards needed to obtain such specialty licenses. The bill continues to be discussed, but if ratified, the proposed legislation will forego the need for training in an ACGME accredited program. The intention is to reduce the number of physicians leaving the island, while expanding care to those in need of specialty care. Many, however, predict that while well intended, the new law would greatly deplete the island of talent and reduce medical expertise in a territory already devoid of sufficient well-trained and equipped medical providers. There is general agreement that the answer lays not in decreasing standards of medical education, but in improving investments in healthcare infrastructure and eliminating the many obstacles imposed on new doctors, which are considered root causes.
Watching from a distant shore how the Puerto Rican saga continues to evolve is painful. The only silver lining of such circumstances is to ensure that we learn from our mistakes. To learn how history, culture, politics, legislation, and racism came together, and continue to conspire to perpetuate disparities in this island paradise, while healthcare providers continue to navigate treacherous waters without a captain. This reminds me of one of the most important tenants of medical education – ‘First, do no harm’. To date, Puerto Rico has not been able to keep pace with the healthcare needs of its inhabitants. Yet, it keeps working at it, as Ashford dreamed of, with an understanding of what true excellence is and how citizens well trained in engineering, architecture, law, business, education, and yes, medicine, may help elevate its people out of poverty. The new proposed legislation will undermine more than a century of hard work by trying to retain doctors, not necessarily well trained doctors, through an intervention that will ensure the further deterioration of healthcare delivery. In the end, we might find that this intervention will finally unveil a cure for health disparities in Puerto Rico, by ensuring that islanders receive equal care – worse care. Clearly, the introduction of the bill denotes an understandable sense of despair, but despair is never a good basis for public policy. We forget… First, do no harm.
