COVID-19 in Puerto Rico: Preliminary Observations on Social Distancing and Societal Response Toward a Novel Health Stressor

Abstract

Countries worldwide are making wide-ranging attempts to stymie the outbreak of the 2019 novel coronavirus (COVID-19), and most of their efforts depend on the financial, structural, and social resources available. Given the increase in documented cases of COVID-19 in Puerto Rico, the extension of an aggressive and restrictive quarantine has been the correct step to slow down the potential contagion. Nevertheless, in this article, we discuss additional concrete actions that should be considered. This unprecedented scenario provides us the opportunity to rethink our limited resources based on a socioecological perspective, with the aim of creating efficiency and reducing the inequities that could accompany the pandemic.

Editor’s Note.

This commentary received rapid review due to the time-sensitive nature of the content. It was reviewed by the special section Guest Editors and the Journal Editor.—KKT

Puerto Rico (PR), like most of the other 212 countries and territories of the world that have been affected by the 2019 novel coronavirus (COVID-19), has suffered profound repercussions in multiple domains and at multiple levels of analysis. As we will document, family and social encounters, jobs, religious observance, sports, media events, and shopping, among others aspects of life, have been hugely altered by COVID-19 and the measures the government has taken to curtail the contagion.

How Is the Situation in Your Country Regarding the COVID-19 Pandemic?

Countries worldwide are making wide-ranging attempts to stymie the COVID-19 outbreak, and most of their efforts depend on the financial, structural, and social resources already available. PR, an archipelago and U.S. territory located in the Caribbean, with a population of 3,193,694 (U.S. Census Bureau, 2020), is not an exception. The local government has faced many challenges that undermine the response in dealing with COVID-19. One of them is that the government has an enormous financial debt that is in the process of being restructured. At the present time, we are in fiscal austerity, which cuts deeply into PR’s public service budget, including cuts to health care.

To date, almost 45% of the population for whom poverty status is determined in PR (1.54M out of 3.44M people) lives below the poverty line; that percentage is higher than the U.S. national average of 13% (U.S. Census Bureau, 2020). In addition to these financial and social challenges, the people living in PR are still recovering from 2020 earthquakes and the 2017 Hurricane Maria, in which hospitals were flooded or closed entirely and the death toll was estimated at 4,645 (Kishore et al., 2018). The people living in PR do not trust the government because of its perceived poor response during times of crisis (Kim, 2020; Robles & Rosa, 2019). In addition, this skepticism has increased since the government mentioned that the PR Department of Health does not have enough tests to effectively identify positive and asymptomatic COVID-19 cases, and personal protective equipment is scarce both in health-care and community settings (Kim, 2020).

As of the time of writing, there were 2,866 identified cases of COVID-19 and 125 (4.3%) deaths. The governor of PR, Wanda Vázquez, was one of the first governors in the United States to impose various restrictions on the inhabitants, including (a) a shutdown from 7:00 p.m. to 5:00 a.m., during which police officers are on patrol to ensure no one leaves their homes; (b) the closing of all stores, beaches, businesses, schools, universities, and churches; and (c) measures conducive to social distancing. The exceptions to the closures are pharmacies, gas stations, and food markets. Locals may leave their homes during the shutdown hours if they need medical attention; otherwise, no outdoor activity is allowed.

The shutdown was extended twice after the first one on issued on March 15, until May 3. According to the data that are presented daily to the public, the social-distancing politics are reducing contagion among the population because new cases tend to double in a 6- to 7-day period. Nevertheless, despite the absence of enough tests to monitor the population, the government announced expectations that the new cases would demonstrate a peak in the first weeks of May and that a subsequent flat curve would be demonstrated in the following weeks. In sum, compared with other countries, PR has been deeply affected at all levels of society by COVID-19, but according to the limited available data, the relatively rigorous social-distancing measures and lockdowns that were extended for 2 months were effective in restricting the proliferation of the virus.

How Do You Think the Pandemic Is Affecting the Population From a Mental Health Perspective?

Pandemics usually generate a decline in the well-being of an affected country’s inhabitants. The COVID-19 pandemic that we are currently experiencing worldwide has had a direct impact on the mental health of people living in PR. The fear of contagion, the alarming numbers of positive cases around the world, and the increasing numbers of deaths that continue to add up day by day since March have kept us in constant tension and anguish. Social isolation, as a preventive measure against contagion, and the different curfews that have been imposed by the government, as advised by the governor’s Medical Task Force, have been complied with by the vast majority of people in the hope of being able to control this epidemic. Because the government declared that all stores should be closed on Sundays, there have been occasions where, on Mondays, long lines of people waiting to enter supermarkets are seen on the streets, and this has provoked some uneasiness in government officials. Calls to mental health emergency lines have increased by 50%, and approximately 40% of total calls are related to COVID-19 (Laracuente & Quintero, 2020). Many of the inhabitants of PR have lost their jobs. For example, 76,623 self-employed workers claimed a monetary government incentive 1 day after the government offered the benefit. This represents 41% of self-employed workers who meet the requisites (Giusti, 2020). Also troublesome has been the heavy economic toll in PR, which, at the present time, is more than $10 billion, or 10% of the gross domestic product. Tourism has been a hard-hit area, and unemployment, at a relatively low 8% before the COVID-19 pandemic, has increased to an astonishing 23%, with a projected 380,000 people without jobs for the month of June 2020 (Sepulveda, 2020).

In addition, people report a lot of fear, the anguish of being alone, feelings of guilt for having infected their relatives, and despair for the uncertainty of when everything will end. An alarming rise in the number of domestic violence cases has also been documented in the press (Rivera Sánchez, 2020). Added to these are the economic stressors resulting from job losses and the fact that this pandemic followed two major events that PR recently experienced: Hurricanes Irma and María (September 2017) and the 2020 earthquakes. The most vulnerable populations—people who are incarcerated; immigrants; the elderly; the homeless; the lesbian, gay, bisexual, transsexual, transgender, and other gender-related minorities (LGBTT+) community; and the poor—are in an even more fragile position as they face this crisis and are the ones whose mental health may be affected the most.

How Do People Respond to the Situation in Your Country?

There have been informal surveys conducted through a TV show that is very popular in PR (Playing Hard Ball); these surveys have asked the members of the viewing audience if they approve of the governor’s orders and the shutdown of all stores, utilities, and government and private offices. More than 80% of the viewers said they approved of the shutdown. Moreover, because the police force has rigorously enforced the governor’s orders, nearly all stores are following the shutdown rules. We think that people living in PR are cognizant of the urgent need to protect themselves, their families, and their communities. Additionally, the PR state police have enforced the governor’s order in cases of citizen violations of the order; as of April 11, there were 621 arrests and 1,478 infractions. Nevertheless, anecdotally, some politicians have indicated that the incidence of intimate partner violence might increase during the lockdown, as has been demonstrated in other states. But the only quantitative data offered recently by Lieutenant Aymeé Alvarado, police coordinator of family violence, revealed that from March 15 to April 12, there had been 526 reports of gender violence. However, during that specific period in 2019, there were 583 documented reports. We have no specific data on suicide rates in the last 2 months. Suicide rates typically increase in periods where there are high rates of unemployment and national crises (Oyesanya, Lopez-Morinigo, & Dutta, 2015).

What Is Helpful and What Is Less Helpful in Dealing With the Situation?

Given the increase in documented cases of COVID-19 in PR, the extension of an aggressive and restrictive quarantine has been the correct step to slow down the potential contagion. At the individual level, people have strengthened their hygiene and personal protection. At the societal level, behavioral changes have occurred in the population, largely through the mobilization of resources and media support. However, these strategies alone will not suffice. In the face of a fragile health-care system and the absence of enough tests to monitor the entire population, it is up to all citizens of PR to join the efforts to slow the spread of COVID-19. At the public health level, it is essential to provide and exchange relevant information with the public, partners, and stakeholders to allow them to make well-informed decisions. Communications should be based on the five principles outlined in the World Health Organization (WHO) Outbreak Communications Planning Guide (WHO, 2008): to maintain and build public trust in public health authorities, to support coordination and the efficient use of limited resources, to provide relevant public health information in order to make well-informed decisions, to take appropriate actions to protect the population health and safety, and to minimize social and economic disruption.

How Is Health Care Currently Organized?

In response to the COVID-19 pandemic, the governor created two task forces, the Medical Task Force and the Economic Task Force, in March 2020. The Medical Task Force provides recommendations regarding how to effectively deal with the scientific information, including epidemiological data, currently available about COVID-19. Every day, members of the Medical Task Force provide up-to-date information regarding new confirmed cases and deaths caused by the disease, as well as recommendations to control the spread. The Economic Task Force was created to maintain and increase the production and distribution of essential supplies (e.g., medical equipment, medicines, food). More than 50 professional organizations have argued that in addition to these task forces, it is imperative to have a Social Task Force that considers the social implications of prolonged quarantine and isolation among vulnerable populations, such as children and youths, people who have mental disorders and their families, people with functional disabilities, women and men who live in violent relationships and environments, incarcerated individuals, immigrants, LGBTT+ communities, and homeless people, among others. Up to the moment of this publication, the government has not followed the advice to create a Social Task Force. However, professional organizations have been developing different approaches to provide support to those in need (e.g., psychoeducational materials).

Conclusion

The COVID-19 pandemic has negatively affected all the major parameters of our society, creating a major impact on the behavioral, emotional, economic, and social well-being of people living in PR. The fact that the local government has limited economic resources has complicated and narrowed a more effective approach to curtailing such behavioral impacts. Actions to be considered should be based on the parameters exposed by the WHO (2008) and by the following recommendations: (a) Supplement the work of the state in carrying out community tracing; (b) activate a Social Task Force with the aim of providing specialized recommendations about the implications of the pandemic and the state’s regulations for vulnerable populations; (c) determine the extent to which the existing health system can expand to manage the additional patient load; and (d) support the communities in terms of food-distribution services for those who are in need. This unprecedented scenario provides us an opportunity to rethink our limited resources based on a socioecological perspective, with the aim of creating efficiency and reducing the inequities that could accompany the pandemic.