They’d watched nervously as invasive Aedes mosquito species that can carry the virus appeared in Los Angeles about a decade ago and began to spread, likely introduced by international trade and enticed to stay by a warming climate that makes it easier for mosquitoes to thrive.

Then, in October 2023, an email came from the Pasadena Public Health Department: A person in the city had contracted California’s first-known case of dengue from a local mosquito.

“When it happens in real time, real life, you know, it is very different,” Farned said. “There’s no room for error here. We have to be quick and effective in identifying the most at-risk areas and responding.”

Across California, public health and pest control authorities are facing a new reality as the Aedes mosquitoes bring the threat of dengue and potentially other tropical diseases, such as chikungunya, Zika, and yellow fever, that were once of concern only to international travelers.

So far this year, authorities have identified at least 13 cases of locally acquired dengue, up from two in 2023, with 11 in Los Angeles County and two in the San Diego area. The Aedes mosquitoes spread the disease by biting an infected person and then biting a previously uninfected person.

Mosquito-borne viral illnesses, chiefly malaria, have long been a scourge in many tropical regions, and preventive measures focus mainly on controlling the mosquitoes. The Aedes mosquitoes, known for their aggressive, daytime biting, are now present in at least 24 California counties. They breed in water, in as little as a capful.

“When these locally acquired cases occur, … we want to act on them pretty quickly so that it does not become an endemic infection in our region,” said Aiman Halai, director of the Los Angeles County Department of Public Health’s Vector-Borne Disease Unit.

California officials are hoping to beat back dengue by expanding mosquito surveillance, developing detailed response plans for mosquito outbreaks and human infections, and improving data sharing across agencies. They’re also going door to door in neighborhoods to remove standing water sources and apply pesticides. Residents are advised to wear bug repellent and long-sleeved clothing and control mosquitoes around their homes to prevent biting and infection.

Some vector control districts — local agencies charged with managing disease-bearing insects and other animals — are even growing their own sterile mosquitoes to release into the wild to reduce local Aedes populations.

Outside of California, locally acquired dengue cases have occurred in Arizona, Florida, Hawaii, and Texas. In March, Puerto Rico declared a public health emergency after a spike in cases there, where dengue is endemic. Meanwhile, worldwide dengue cases are on track to , with 12.3 million documented through August, up from 6.5 million in 2023, according to the World Health Organization.

Most people who get dengue have no symptoms, but about 1 in 4 become ill. A mild case can feel like the flu and usually dissipates within a week, but about 5% of those infected with dengue , with symptoms that can include internal bleeding, shock, and organ failure, and the most severe cases can be fatal. People infected a second time are at especially high risk.

There is no specific medication to treat dengue. Japanese pharmaceutical company Takeda developed a vaccine that has won approval in Europe and elsewhere, though it withdrew an application to the FDA last year, saying it could not provide data requested by the agency. A vaccine developed in Brazil could soon be approved for use in that country. But the only FDA-approved vaccine is authorized only for children in narrow circumstances and will soon go out of production.

At the San Gabriel Valley Mosquito and Vector Control District, one of five agencies tasked with mosquito control across Los Angeles County, public health workers have put together an Aedes and dengue response plan based on from the state.

When they discover a case, they identify all the properties and public spaces within 150 meters — roughly the distance an Aedes mosquito can fly — and then go door to door, removing standing water, where mosquitoes can breed; applying pesticides from backpacks or trucks; and educating residents about the risk of dengue and how to protect themselves. District officials also set traps to catch mosquitoes so they can figure out their prevalence and test them for dengue.

Since local dengue cases began to appear, the district has gotten more efficient in implementing its response plan, district manager Farned said. All full-time and seasonal staff members — about 40 people — have been trained in a variety of tasks, such as door-to-door education and coming in during off-hours to answer phones, Farned said.

While vector control teams respond to cases, separate teams from the Los Angeles County Public Health Department go door to door in the affected neighborhood when they determine that a dengue case was locally acquired, surveying residents and offering free dengue testing to try to identify others who may be infected.

Additionally, the department has been sending alerts to local health providers, advising them to be on the lookout for possible dengue cases and test for it when suspected, even among patients who haven’t traveled to a place where dengue is endemic. This advice follows a put out by the Centers for Disease Control and Prevention in June. Health authorities are also emphasizing that people who travel to locations with dengue should continue to wear mosquito repellent when they get home, to reduce the risk of spreading the disease to local mosquitoes.

As happened during the covid-19 pandemic, mistrust of public health authorities can make outreach challenging for health and pest control teams in some neighborhoods, officials said.

Pest control officers can seek a warrant to enter and treat a property for mosquitoes if a homeowner refuses to give access, said Jeremy Wittie, a former president and the legislative committee chair for the Mosquito and Vector Control Association of California, which represents the more than 70 mosquito and vector control agencies in California. This is easier in districts such as his, the Coachella Valley Mosquito and Vector Control District, that have warrants giving officials standing permission to enter a property after 24 hours without needing to ask a judge.

In counties such as Santa Clara, where Aedes mosquitoes but have yet to establish themselves, officials hope to suppress the threat with stepped-up surveillance, speedy eradication efforts, and more public outreach. Santa Clara County Vector Control District Manager Nayer Zahiri said the aim was to eliminate Aedes but acknowledged the climate conditions that encourage the mosquitoes’ spread are “totally out of our control.”

In some counties with pervasive mosquito problems, including , San Joaquin, and , officials have sprayed pesticides from planes or helicopters to address spikes in local mosquito populations, Wittie said. These sprayings typically aim to control the larvae of a different type of mosquito, Culex, that can spread West Nile virus and which — unlike the Aedes species, which thrive in urban habitats — are found in harder-to-reach rural environments, Wittie said.

Aerial spraying hasn’t been deployed to address the recent dengue outbreaks, which are in more urban environments where spraying from trucks is a better option, Wittie said. Drones are another option that some vector control authorities are exploring.

Some districts are experimenting with the decades-old sterile insect technique, commonly used for other pests such as fruit and screwworm flies, in which males are sterilized with radiation and then released to mate, resulting in eggs that don’t hatch. (Female mosquitoes are separated from the males before sterilization and not released. Only the females bite).

Ultimately, the public will have to take the mosquito threat more seriously and contribute to prevention efforts, Wittie said. “This mosquito is going to be here to stay, unfortunately. I hope it kind of wakes people up and pushes them to be part of that solution.”

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Wildelma Gastón pidió que le pusieran su rosario en el pecho y señaló su “brazo bueno”, donde Matos-Pagán le inyectó la primera dosis de la vacuna de Moderna. La familia Gastón, compuesta por cinco miembros, respiró con alivio. Aunque la vacuna estaba disponible desde hacía meses, Wildelma no había podido ir a un centro de vacunación.

Según el rastreador de datos de covid de los Centros para el Control y la Prevención de Enfermedades (CDC), la tasa de vacunación de Puerto Rico en marzo fue una de las más bajas entre los estados y territorios de Estados Unidos, a pesar de haber recibido más de 1,3 millones de dosis de vacunas. El despliegue puso de manifiesto las disparidades en el acceso a los servicios médicos, y los retos que supone el seguimiento y la comunicación con ciudadanos que viven en lugares lejanos, como Wildelma.

Cada vez que regresaban de la escuela o del trabajo, a los familiares les preocupaba la posibilidad de llevar el virus a su hogar, y la amenaza que suponía para la vida de Wildelma. Durante su visita, Matos-Pagán también vacunó a dos de los hijos de Beatriz, que son estudiantes de la Universidad de Puerto Rico-Mayaqüez.

“Llevamos mucho tiempo esperando este momento”, dijo Beatriz Gastón mientras se despedía con un abrazo de Matos-Pagán, expresando su gratitud por la visita a domicilio. Para ella la vacuna es algo más que una protección contra el coronavirus: le permite a la familia estar junto a su madre.

Para Matos-Pagán, es una nueva misión. La enfermera, que ha liderado tareas de ayuda tras los huracanes y terremotos en Puerto Rico y otros lugares, se ha propuesto vacunar al mayor número posible de personas contra covid en este territorio estadounidense. Algunos residentes de Mayagüez, ciudad situada en la costa occidental de la isla principal, la llaman cariñosamente “La reina de la vacunación” y se presentan en su casa pidiendo ayuda para vacunarse.

Según el rastreador de casos de The New York Times, hasta el 5 de agosto, Puerto Rico suma cerca de 182,000 casos dSegún el rastreador de casos de The New York Times, hasta el 5 de agosto, . Algo más del 59% de la población está totalmente vacunada, pero muchos de los que no están vacunados son difíciles de localizar porque viven en comunidades montañosas alejadas, o tienen enfermedades crónicas que les obligan a quedarse en casa.

Hasta ahora, Matos-Pagán ha vacunado a unas 1,800 personas en Puerto Rico, incluidas 1,000 con enfermedades crónicas o postradas en cama.

En los primeros días de la pandemia, la salud de Carmen Blas empeoró y empezó a utilizar una silla de ruedas. Blas, de 78 años, estaba confinada en su casa, en el tercer piso de un edificio de apartamentos, lo que la mantenía a salvo de contraer covid, pero más tarde no pudo encontrar transporte para ir a vacunarse. En junio, sus dos hijos, Lisette y Raymond, vinieron desde Wisconsin para ayudar y llamaron inmediatamente a funcionarios de salud pública para que Blas se vacunara.

“Suelo volver todos los años y esta ha sido la vez que más tiempo he estado fuera. Fue especialmente duro porque la salud de mi madre empeoró y me preocupaba no volver a verla”, contó Raymond, que pensaba prolongar su visita todo el tiempo que fuera necesario.

Matos-Pagán fue a la casa de Blas, en Aguadilla, para administrarle la vacuna. La familia celebró con alegría la vacunación.

“Ha sido muy especial tener momentos personales en la casa de alguien durante la vacunación. Se nota lo mucho que significa para toda la familia”, comentó Matos-Pagán.

La movilización durante una crisis no es algo nuevo para Matos-Pagán. Tras el paso del huracán María, que cortó el agua y la electricidad en toda la isla y se cobró más de 3,000 vidas, Matos-Pagán llevó a cabo evaluaciones comunitarias iniciales en las ciudades más remotas y afectadas de Puerto Rico.

Muchas carreteras eran inaccesibles debido a las inundaciones y a los escombros, lo que impedía a estas comunidades satisfacer necesidades básicas como alimentos, agua, recetas médicas y transporte. Después, tras una serie de terremotos que sacudieron la isla en 2020, dejando a más personas sin vivienda o en estructuras deficientes, Matos-Pagán organizó a las enfermeras locales para que prestaran atención sanitaria a la comunidad. Suministraron a las poblaciones en riesgo sus medicamentos cuando las farmacias cerraron y los equipos instalaron tiendas médicas móviles junto a hospitales que estaban saturados.

“Soy hiperactiva y estoy siempre ocupada en mi vida diaria, pero cuando hay una crisis, estoy tranquila y calmada. Con los pies en la tierra. Siento que estoy donde debo estar”, expresó.

Matos-Pagán nació en Nueva York. Se interesó por la medicina después de ver cómo las enfermeras ayudaban a su madre, que murió por complicaciones de un aneurisma cuando Matos-Pagán tenía 9 años. La muerte de su madre le enseñó que “nada era permanente”, dijo, lo que la ha inspirado a actuar cuando ocurre un desastre y a apoyar a las personas ante la tragedia y la pérdida.

Matos-Pagán regresó a Puerto Rico para estudiar enfermería y posteriormente obtuvo un máster y un doctorado en la Universidad de Puerto Rico-Mayagüez. Gracias a su trabajo, ostenta varios títulos: primera comandante del Equipo de Respuesta a Desastres de Puerto Rico, y directora y fundadora de la Coalición de Enfermeras para Comunidades en Desastre.

Su experiencia en la gestión de profesionales y recursos médicos durante los huracanes la ha llevado a lugares de la costa atlántica estadounidense y del Caribe. Durante la pandemia de covid, fue contratada para ayudar a dirigir el triage (sistema para seleccionar a los pacientes prioritarios que llegan a urgencias) de una unidad de cuidados intensivos, escasa de recursos, en El Paso, Texas, y en una residencia de mayores muy afectada en Maryland.

“No todo el mundo está hecho para esto. Es un trabajo realmente triste y deprimente”, señaló Matos-Pagán. “Pero incluso cuando hay miles de víctimas, se pueden salvar vidas y satisfacer las necesidades básicas de las personas. He visto a las comunidades unirse de manera increíble. Es un reto, pero eso es lo que me hace seguir adelante”.

Y mientras trabaja para inyectar con rapidez más vacunas contra covid en los brazos de los residentes de Puerto Rico, Matos-Pagán se prepara para la próxima crisis. La temporada de huracanes comenzó oficialmente en junio, y estará en alerta para otro posible desafío sanitario hasta finales de noviembre.

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Wildelma Gastón asked for her rosary to be placed on her chest and motioned to her “good arm,” where Matos-Pagán injected a first dose of the Moderna vaccine. The Gastón household, made up of five family members, breathed a collective sigh of relief. Though the vaccine had been available for months, Wildelma had been unable to reach a vaccination site. According to the Centers for Disease Control and Prevention’s COVID Data Tracker, Puerto Rico’s vaccination rate in March was one of the lowest among U.S. states and territories despite receiving more than 1.3 million vaccine doses. The rollout highlighted disparities in access to medical services, and the challenges of tracking and reaching remote citizens, such as Wildelma.

With each trip to school or work, family members worried about bringing the virus into their home and the threat to Wildelma’s life. Matos-Pagán also vaccinated two of Beatriz’s children, who are students at the University of Puerto Rico-Mayaqüez, during her visit.

“We have been waiting a long time for this moment,” Beatriz Gastón said as she hugged Matos-Pagán goodbye, expressing gratitude for the home visit. To her, the vaccine is more than protection from the coronavirus — it clears the way for the family to be together with her mother.

To Matos-Pagán, it is her latest calling. The nurse practitioner, who has guided relief efforts after hurricanes and earthquakes in Puerto Rico and elsewhere, has made it her mission in the U.S. territory to vaccinate as many people as possible against covid. Some residents of Mayagüez, a city on the western shore of the main island, candidly call her “The Vaccination Queen” and show up at her home asking for help in getting a shot.

According to The New York Times’ case tracker, as of Friday, Puerto Rico has had more than 182,000 covid cases and at least 2,594 deaths. About 57% of the population is fully vaccinated, but many of the unvaccinated are hard to reach because they live in remote mountainous communities or have chronic illnesses that leave them homebound. Matos-Pagán has vaccinated around 1,800 people in Puerto Rico so far, including 1,000 who have chronic illnesses or are bedridden.

In the pandemic’s early days, Carmen Blas’ health declined, and she began using a wheelchair. Blas, 78, was confined to her home, on the third story of an apartment building, which kept her safe from contracting covid, but later she couldn’t find transportation to a vaccination site. In June, her two children, Lisette and Raymond, visited from Wisconsin to help and immediately called the public health officials to get Blas inoculated.

“I usually come back every year and this was the longest I’ve ever been away. It was especially hard as my mother’s health worsened, and I worried I might never see her again,” said Raymond, who planned to extend his visit for as long as he was needed.

Matos-Pagán came to Blas’ home in Aguadilla, Puerto Rico, to give her the vaccine. The family cheered the moment the vaccination was over.

“It’s been really special to have intimate moments in someone’s home during vaccinations. You can tell how much it means to their entire family,” Matos-Pagán said afterward.

Mobilizing during a crisis is nothing new for Matos-Pagán. In the aftermath of Hurricane Maria, which cut off water and electricity to the entire island and claimed more than 3,000 lives, Matos-Pagán conducted initial community assessments in Puerto Rico’s remotest and hardest-hit cities. Flooding and debris made many roads inaccessible, blocking these communities from basic needs such as food, water, prescription medications and transportation. Then, after a series of earthquakes in 2020 rocked the island, leaving even more people without housing or in substandard structures, Matos-Pagán organized local nurse practitioners to provide community health care. They supplied at-risk populations with their medicines when pharmacies closed, and teams set up mobile medical tents near overcrowded hospitals.

“I’m hyper and busy in my daily life, but when there is a crisis, I am calm and still. Grounded. I feel like I’m where I belong,” she said.

Matos-Pagán was born in New York City. She became interested in medicine after watching nurses support her mother, who died of complications from an aneurysm when Matos-Pagán was 9. Her mother’s death taught her “nothing was permanent,” she said, which has inspired her to act when disaster strikes and support people through personal tragedy and loss.

Matos-Pagán returned to Puerto Rico to study nursing and later earned a master’s degree and a doctorate at the University of Puerto Rico-Mayagüez. Through her work, she holds various titles: first commander of the Puerto Rican Disaster Response Team, and director and founder of the Coalition of Nurses for Communities in Disaster.

Her experiences managing medical professionals and resources during hurricanes have taken her to locations across the U.S. Atlantic coast and the Caribbean. During the covid pandemic, she was recruited to assist in triage leadership for an ICU floor short on resources in El Paso, Texas, and a hard-hit senior living facility in Maryland.

“Not everyone is built for this. It’s really sad, depressing work,” Matos-Pagán said. “But even when there are mass casualties, you can still save lives and get people’s basic needs met. I’ve seen communities come together in the most incredible ways. It’s a challenge, but that’s what keeps me going.”

And, even as she is rapidly trying to get more covid shots into the arms of Puerto Ricans, Matos-Pagán is preparing for the next crisis. Hurricane season officially began in June, and she will be on disaster-ready duty until the end of November.

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“¡Quedarse en casa!”, responde otro usuario.

El grupo de Facebook llamado se ha visto inundado de comentarios mordaces que instan a los viajeros a mantenerse alejados. Es un cambio fuerte. Antes de la pandemia, los intercambios entre turistas y residentes de la isla significaban promesas de diversión. Ahora, los operadores turísticos del continente que administran la página de Facebook intentan eliminar rápido cualquier expresión de enojo.

En la cercana Puerto Rico, la fricción se ha extendido a la vida real. han detallado varios episodios en los que los turistas, escapando de las restricciones pandémicas en sus países de origen, se volvieron violentos y destruyeron mercadería cuando se les pidió que usaran máscara dentro de tiendas.

La pandemia de COVID-19 ha enfrentado los intereses económicos con las guías de salud pública en todo Estados Unidos. Puerto Rico y las Islas Vírgenes de los Estados Unidos sienten esta tensión de manera aguda, ya que ambos territorios estadounidenses dependen del turismo para generar ingresos y proporcionar empleos.

Cada vez más, los lugareños han comenzado a preguntarse si vale la pena arriesgarse a dar la bienvenida a los turistas.

El turismo representa más de la mitad del producto interno bruto de las Islas Vírgenes. En Puerto Rico, la industria representa 80,000 empleos y aproximadamente el 6.5% de la economía total de la isla.

Pero los isleños no sólo son vulnerables a los trastornos económicos de COVID-19. A los residentes tanto de Puerto Rico como de las Islas Vírgenes se les diagnostica condiciones de salud crónicas como diabetes y enfermedades cardiovasculares en tasas más altas que en la mayoría de los estados continentales, lo que los pone en mayor riesgo de desarrollar complicaciones si contraen el virus.

En resumen, la misma industria que representa un salvavidas económico para los isleños amenaza su capacidad de proteger su salud.

Un paso adelante

Cuando COVID-19 impactó a fines del invierno, Puerto Rico y las Islas Vírgenes adoptaron sólidas estrategias de prevención, incluso antes que la mayoría de los estados continentales.

En Puerto Rico, la gobernadora Wanda Vázquez emitió , que literalmente cerró la isla al imponer un toque de queda, una orden de quedarse en casa y cierres de negocios. Los primeros casos de coronavirus se reportaron allí el 13 de marzo.

De igual manera, el gobernador de las Islas Vírgenes, Albert Bryan Jr., emitió que prohibieron que hoteles, villas y otros alojamientos aceptaran huéspedes por placer entre el 25 de marzo y el 1 de junio.

El área permaneció abierta a viajeros de negocios, tripulaciones de vuelos, funcionarios de salud, personal de emergencia, residentes e invitados del gobierno. Según una del Departamento de Salud, el territorio tenía, en ese momento, seis casos confirmados de COVID y 43 resultados de pruebas pendientes.

Sin embargo, ninguno de los territorios pudo cerrar sus aeropuertos. Los funcionarios locales no tienen la autoridad para hacerlo porque el gobierno federal regula la aviación.

“Parte del desafío de ser una colonia de los Estados Unidos es que, ya sabes, no tenemos control sobre nuestras fronteras”, dijo Hadiya Sewer, presidenta y cofundadora de St. JanCo: The St John Heritage Collective , una organización de preservación del patrimonio cultural y derechos territoriales en la pequeña isla de St. John, parte de las Islas Vírgenes.

Aún así, las medidas agresivas, aunque efectivas, se cobraron un precio para residentes como Melina Aguilar.

Antes del cierre, la emprendedora de 31 años trabajaba como guía turística para Isla Caribe, una empresa que fundó y que ofrece recorridos históricos a pie por Ponce, Puerto Rico. La orden de quedarse en casa en marzo cerró el negocio de Aguilar durante tres meses.

Aguilar dijo que el sacrificio habría valido la pena si la isla hubiera podido mantener el control de la propagación al cerrar la frontera y hacer cumplir la cuarentena de 14 días para los viajeros. Pero no funcionó de esa manera. Según , el promedio de casos al 1 de mayo, mientras Puerto Rico todavía estaba cerrado, fue de 42 por día. El 1 de julio, 102 casos. Para el 15 de julio, 233.

Reabriendo las puertas

Para el verano, ambos territorios estaban ansiosos por reabrir negocios. Con muchos destinos de vacaciones en el extranjero prohibiendo la entrada de los viajeros estadounidenses, parecía que el continente cercano estaría lleno de bañistas que, después de vivir bajo órdenes de quedarse en casa durante meses, estarían listos para viajar, sin necesidad de pasaporte, a disfrutar del sol y la arena.

Las Islas Vírgenes de los Estados Unidos recibieron formalmente a los turistas de regreso a sus costas el 1 de junio, con salvedades. Los viajeros de los “zonas rojas” del coronavirus debían enviar la información de la prueba COVID-19 a través de para recibir un “código de certificación” de resultado negativo.

Aquéllos que no lo hicieron tuvieron que ponerse en cuarentena durante 14 días o hasta que tuvieran documentación de un resultado negativo de la prueba.

Pero tanto los lugareños como los turistas dijeron que las medidas de aplicación de COVID no han sido consistentes. El capitán Matthias Bitterwolf, propietario de Antillean Yacht Charters en St. Thomas, dijo que entregó un bote a Puerto Rico y no se le permitió salir del barco hasta que la policía local pudiera verificar su documentación de COVID. Su estatus para COVID no fue verificado al regresar a St. Thomas.

Los recuentos de casos de las Islas Vírgenes pronto comenzaron a aumentar. Entre junio y mediados de julio, aumentó en más de 3,500%, según .

El gobernador Bryan respondió emitiendo para recuperar el control del brote, incluida la prohibición de las visitas a la playa después de las 4 pm y no permitir que los clientes se paren o coman en los bares de los restaurantes. Al 24 de agosto, las Islas Vírgenes tenían un total de .

Puerto Rico dio la bienvenida formalmente a los turistas el 15 de julio sin dejar de imponer algunas restricciones relacionadas con COVID. Al igual que en las Islas Vírgenes, los funcionarios exigieron a los viajeros que presentaran documentación de un resultado negativo de la prueba para COVID a su llegada.

El doctor Víctor Ramos, presidente de la asociación médica de la isla que está involucrado con el , dijo que estas decisiones expusieron de alguna manera las diferencias “entre el grupo de trabajo médico que favorece el cierre y el grupo de trabajo económico que quiere dejar todo abierto”.

En julio, la economía local estaba en ruinas. El Departamento de Trabajo informó que más del 21% de la fuerza laboral de la isla estaba recibiendo asistencia por desempleo relacionada con la pandemia .

Pero el creciente número de casos atribuidos a los viajeros llevó a los funcionarios locales a alentar que sólo se permitieran los viajes esenciales. Hasta el 24 de agosto, la isla había registrado más de 30,700 casos de COVID y al menos 395 muertes, según la base de datos de The New York Times.

Sin embargo, los datos del gobierno indicaron que el aumento de casos en Puerto Rico no había sido causado por turistas. Ellos no son los culpables, insistió Leah Chandler, directora de marketing de Discover Puerto Rico, el sitio oficial de turismo de la isla en internet. Más bien, la propagación se relacionó con los residentes de la isla que regresaban a casa después de visitar puntos calientes de COVID como Texas y Florida.

A pesar de la pandemia mundial y las restricciones, ambos territorios no han experimentado escasez de veraneantes. “Habríamos esperado que éste fuera un momento lento en términos de turismo”, dijo Sewer. “Pero estamos muy ocupado”.

Aún así, los recuentos de casos de COVID no se movían en la dirección correcta en ninguno de los territorios, por lo que no fue una sorpresa cuando Puerto Rico cerró días después de la reapertura y las Islas Vírgenes hicieron lo mismo el 19 de agosto.

Los problemas socioeconómicos y de salud subyacentes ponen a los residentes en ambos lugares en alto riesgo. No se trata solo de la prevalencia de enfermedades crónicas como la diabetes y las enfermedades cardiovasculares. El elevado número de hogares multigeneracionales en ambas áreas complica la capacidad de una familia para distanciarse socialmente de sus miembros más vulnerables.

Aproximadamente de Puerto Rico y las Islas Vírgenes tiene 65 años o más, y la pobreza es generalizada.

Además, ambos territorios tienen una infraestructura de atención médica limitada, lo que dificulta imaginar que puedan cuidar a sus propias poblaciones en una emergencia, y mucho menos a los visitantes que podrían enfermarse e ir a la isla si el virus aumentara.

Actualmente, las Islas Vírgenes de los Estados Unidos tiene dos hospitales principales, uno en St. Thomas y otro en St. Croix, y una clínica de salud en St. John. El territorio cuenta con 20 camas de unidades de cuidados intensivos y alrededor de 100 ventiladores individuales para sus , dijo Justa Encarnación, comisionada de salud de las Islas Vírgenes. Cada isla tiene alrededor de 30 ventiladores de capacidad total.

En Puerto Rico, alrededor del de la isla para adultos estaban disponibles el 24 de agosto. Sin embargo, las camas de terapias intensiva son más difíciles de conseguir, dijo Ramos. Están llenas de pacientes con COVID y de aquéllos cuyas condiciones empeoraron después de evitar la atención por temor a contraer el virus, dijo.

La serie de problemas que han asolado a estas islas magnifica los efectos de la pandemia. Eso incluye crisis de deuda y daños a la infraestructura por huracanes y terremotos. Los residentes también temen la posibilidad de luchar contra un huracán y un brote de coronavirus al mismo tiempo.

Los investigadores de huracanes de la Universidad Estatal de Colorado predicen una temporada de huracanes en el Atlántico 2020 .

“En este punto, literalmente tenemos desastres superpuestos”, expresó Sewer, de St. John’s Collective.

Aún así, Joseph Boschulte, comisionado de turismo de las Islas Vírgenes, es cautelosamente optimista sobre encontrar un equilibrio entre los intereses económicos y de salud.

“Apreciamos las preocupaciones de nuestros socios turísticos y partes interesadas”, dijo. Pero con el aumento en los casos, dijo, “debemos hacer un balance, salvaguardar la vida humana y prepararnos para reiniciar nuestra economía turística más adelante”.

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“Stay home!” another user replies.

The Facebook group called “” has been flooded with pointed, exasperated comments urging travelers to stay away. This is a marked change. Before the pandemic, the exchanges between vacationers and island residents resonated with promises of excitement and fun. Now, tour operators from the mainland who administer the Facebook page quickly try to delete any expressions of anger.

In nearby Puerto Rico, the friction has spilled into real life. have detailed multiple episodes in which tourists, having escaped pandemic restrictions back home, became violent and destroyed store merchandise after being asked to wear a mask.

The COVID-19 pandemic has pitted economic interests against public health guidance all across the United States. Puerto Rico and the Virgin Islands feel this tension acutely, as both U.S. territories rely on tourism to generate revenue and provide jobs. Increasingly, locals have begun to wonder now if welcoming visitors to these islands is worth the risk.

Tourism represents more than half of the Virgin Islands’ gross domestic product. In Puerto Rico, the industry accounts for 80,000 jobs and about 6.5% of the island’s total economy.

But islanders are not only vulnerable to COVID-19’s economic disruptions. Residents of both Puerto Rico and the Virgin Islands are diagnosed with chronic health conditions like diabetes and cardiovascular illness at higher rates than in most U.S. states, which puts them at higher risk for the virus’s complications.

In short, the very industry that represents an economic lifeline for islanders threatens their ability to protect their health.

One Step Forward

When COVID-19 triggered alarms in late winter, Puerto Rico and the USVI adopted strong COVID prevention strategies before most U.S. states did.

In Puerto Rico, Gov. Wanda Vázquez issued an executive order, effectively locking down the island by imposing a curfew, a stay-at-home order and business closures. The first coronavirus cases on the island were reported March 13.

Similarly, Virgin Islands Gov. Albert Bryan Jr. issued prohibiting hotels, villas and other accommodations from accepting leisure guests between March 25 and June 1. The area remained open to business travelers, flight crews, health officials, emergency personnel, government guests and residents. According to a March 20 Department of Health , the territory had — at that time — six confirmed COVID cases and 43 pending test results.

Neither territory, however, was able to close its airports. Local officials do not have the authority to do so because the federal government regulates aviation.

“Part of the challenge of being a U.S. colony, in particular, is that, you know, we don’t have control over our borders,” said Hadiya Sewer, president and co-founder of St. JanCo: the St John Heritage Collective, a cultural heritage preservation and land rights organization on the small island of St. John, U.S. Virgin Islands.

Still, the aggressive measures — while effective — came at a price for residents like Melina Aguilar.

Before the lockdown, the 31-year-old entrepreneur worked as a tour guide for Isla Caribe, a company she founded that offers historical walking tours of Ponce, Puerto Rico. The stay-at-home order in March shut down Aguilar’s business for three months and sequestered her in her house.

Aguilar said the sacrifice would have been worth it if the island could have maintained control of the spread by closing the border and enforcing the 14-day quarantine for travelers. It didn’t work out that way. According to from The New York Times, the seven-day average for cases on May 1 — while Puerto Rico was still in lockdown — was 42 cases per day. On July 1, the seven-day average was 102 cases. By July 15, the average was 233.

“We could’ve basically had the fruits of being locked up for three months,” Aguilar said. “But now we’re stuck.”

Reopening the Gateway

By summer, both territories were itching to get back to business. With many overseas vacation destinations banning U.S. travelers, it seemed like the nearby mainland would be full of beachgoers, who, after living under stay-at-home orders for months, would be ready to travel — no passport required — to the sun and sand.

The U.S. Virgin Islands formally welcomed tourists back to its shores on June 1 — with caveats. Travelers from coronavirus hot spots needed to submit COVID-19 test information through an to receive a negative result “certification code.” Those who didn’t were required to quarantine for 14 days or until they had documentation of a negative test result.

But locals and tourists alike said COVID enforcement measures haven’t been consistent. Capt. Matthias Bitterwolf, owner of Antillean Yacht Charters on St. Thomas, said he delivered a boat to Puerto Rico and was not allowed off the vessel until local police could verify his COVID paperwork. His COVID status was not checked upon returning to St. Thomas.

The Virgin Islands’ case counts soon began ticking up. Between June and mid-July, the case count increased by more than 3,500%, according to one.

Gov. Bryan responded by issuing other to regain control of the outbreak, including prohibiting beach visits after 4 p.m. and not allowing patrons to stand or eat at bars located in restaurants. As of Aug. 24, the USVI had a total of .

Puerto Rico formally welcomed tourists on July 15 while still imposing some COVID-related restrictions. As in the Virgin Islands, officials required travelers to present documentation of a negative COVID test result upon arrival.

Dr. Victor Ramos, president of the island’s medical association who is involved with the, said these decisions tended to expose the rift “between the medical task force that favors closing things and the economic task force that wants to leave everything open.”

By July, the local economy was in shambles. The Department of Labor reported over 21% of the island’s workforce was receiving unemployment assistance related to the pandemic in the .

But rising case counts attributed to travel prompted local officials to encourage that only essential travel be allowed. As of Aug. 24, had recorded over 30,700 COVID cases and at least 395 deaths, according to the New York Times database.

Government data, though, indicated Puerto Rico’s climbing case numbers were not being triggered by tourists. They are not the culprits, insisted Leah Chandler, chief marketing officer of Discover Puerto Rico, the island’s official tourism website. Rather, the spread was linked to island residents coming home after visiting COVID hot spots like Texas and Florida.

Life on the Ground

Despite the global pandemic and the restrictions, both territories have experienced no shortage of vacationers. “We would have expected this to be a slow moment for us in terms of tourism,” said Sewer. “It’s very busy.”

Still, the trend lines for COVID case counts weren’t moving in the right direction for either territory, so it was no surprise when Puerto Rico closed days after reopening and the USVI followed suit on Aug. 19.

The underlying socioeconomic and health issues put residents in both places at high risk. It’s not just the prevalence of chronic health conditions like diabetes and cardiovascular disease. The high number of multigenerational households in both areas complicates a family’s ability to socially distance from its most vulnerable members. Roughly of the population in Puerto Rico and the Virgin Islands is age 65 or older, and poverty is widespread.

At the same time, both territories have limited health care infrastructure — making it difficult to envision that they can care for their own populations in an emergency let alone visitors who could become ill and island-bound if the virus were to surge.

Currently, the USVI has two main hospitals — one in St. Thomas and one in St. Croix — and a health clinic in St. John. The territory has 20 intensive care unit beds and about 100 one-time-use ventilators for its residents, said Justa Encarnacion, the USVI’s health commissioner. Each island has about 30 full-capacity ventilators.

In Puerto Rico, about of the island’s ventilators for adults were available as of Aug. 24. However, ICU beds are harder to come by, said Ramos. They are filled with COVID patients and those whose conditions worsened after avoiding care out of fear of catching the virus, he said.

The string of problems that have besieged these islands magnifies the effects of the pandemic. That includes debt crises and infrastructure damage from hurricanes and earthquakes. Island residents also fear the possibility of battling a hurricane and a coronavirus outbreak at the same time — a reality that they’ve already confronted when COVID hampered the USVI’s emergency management agency’s ability to distribute sandbags ahead of a storm in .

Colorado State University hurricane researchers predict an 2020 Atlantic hurricane season.

“At this point, we literally have disasters layered on top of disasters,” said Sewer, of the St. John’s Collective.

Still, Joseph Boschulte, tourism commissioner for the Virgin Islands, is cautiously optimistic about finding a balance between health and economic interests.

“We appreciate the concerns of our tourism partners and stakeholders,” he said. But with the spike in cases, he said, “we must reset, take stock, safeguard human life and prepare for restarting our tourism economy at a later date.”

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El estudio en JAMA Network Open encontró que el 7.2% de los estudiantes informaron síntomas “clínicamente significativos” de trastorno de estrés postraumático. Más niñas tendieron a mostrar signos de TEPT que los niños.

Los investigadores encuestaron a 96,108 estudiantes de escuelas públicas, cinco a nueve meses después del huracán que azotó la isla en 2017. Incluyó a jóvenes de tercero a doceavo grado en diferentes regiones.

Según el estudio, realizado por el Departamento de Educación de Puerto Rico junto con la Universidad Médica de Carolina del Sur, se están utilizando los datos para llegar a las áreas con mayor necesidad de servicios de salud mental.

María, que golpeó la isla como un huracán de categoría 4 en septiembre de 2017, en el territorio estadounidense. Los residentes tuvieron mucha dificultad para acceder a agua potable y algunos se quedaron sin electricidad por casi un año después de la tormenta.

La tragedia tuvo efectos dramáticos en los estudiantes. Casi el 46% dijo que su casa estaba dañada. Más del 32% experimentó escasez de alimentos y agua. Y aproximadamente el 58% informó que un amigo o miembro de su familia se había ido de la isla. Los efectos no variaron según el lugar donde vivían los estudiantes o el ingreso de sus familias.

Rosaura Orengo-Aguayo, psicóloga clínica de la Universidad Médica de Carolina del Sur y autora principal del estudio, dijo que los hallazgos muestran la amplitud y la naturaleza indiscriminada de la devastación.

“Eso solo explica lo grande que fue María, lo destructivo que fue en toda la isla”, dijo. “Sin importar tu ingreso o en dónde vivías, fuiste afectado”.

Se han reportado que también sufrieron los efectos de los huracanes de 2017.

El Congreso se encuentra en un punto muerto sobre la aprobación de un proyecto de ley de ayuda que enviaría más recursos a Puerto Rico y a otras áreas afectadas por desastres naturales. El presidente Donald Trump ha expresado su renuencia a proporcionar más dinero a la isla.

El trauma que causa un desastre natural puede manifestarse de varias maneras, explicó Frank Zenere, coordinador de distrito del programa de manejo de crisis en las Escuelas Públicas del condado de Miami-Dade, quien no está relacionado con el estudio. Las unidades familiares pueden romperse a través del divorcio o la violencia doméstica, dijo. Los niños pequeños pueden volver a chuparse el dedo o mojar la cama. Los adolescentes a veces intentan ejercer el control y pueden comenzar a usar drogas.

Zenere dijo que, sin embargo, la mayoría de las personas que sobreviven a un desastre natural no desarrollan afecciones de salud mental a largo plazo.

“Están angustiados. Tiene un impacto en su vida, sí “, dijo Zenere, quien ayudó a coordinar los esfuerzos de salud mental en Puerto Rico luego de María. “Pero la gran mayoría no va a desarrollar una enfermedad psiquiátrica”.

Agregó que las diferencias por género encontradas entre los estudiantes que informan síntomas de trastorno de estrés postraumático se alinean con la literatura médica: los niños tienen más probabilidades de exteriorizar lo que sienten, mientras que las niñas son más propensas a mostrar depresión y ansiedad.

Los autores del estudio dijeron que la pérdida y la disfuncionalidad causadas por María contribuyeron aproximadamente en un 20% a los síntomas del trastorno de estrés postraumático de los jóvenes. Si bien los investigadores no midieron qué otras circunstancias desempeñaron un papel, otros “factores de protección”, como el hecho de asegurar las necesidades básicas y el apoyo de la comunidad, influyen en la capacidad de recuperación, aseguró Orengo-Aguayo,

En particular, dijo, el nivel de síntomas de trastorno de estrés postraumático informado en el estudio es inferior al esperado. Algunos estudios muestran que hasta un tercio de los niños desarrollarían síntomas crónicos después de sobrevivir a un desastre natural, escribieron los autores.

Los lazos familiares o el hecho de que el estudio se realizó varios meses después de la tormenta podría haber tenido un papel en la capacidad de recuperación de los niños, dijo.

“Lo que podríamos estar viendo es que los niños en esa etapa aún estaban enfocados en obtener acceso a las necesidades básicas”, dijo.

Regan Stewart, psicólogo clínico de la Universidad Médica de Carolina del Sur y coautor del estudio, dijo que el equipo ha obtenido dos subvenciones de la Administración Federal de Servicios de Salud Mental y Abuso de Sustancias para continuar trabajando en la isla durante al menos tres años más. Planean utilizar la telemedicina para ampliar el acceso a los servicios de salud mental y capacitar al personal escolar y profesionales de la salud mental en las intervenciones centradas en el trauma.

Sin embargo, las escuelas públicas en Puerto Rico están agobiadas por restricciones económicas. La isla, que ya enfrentaba una crisis presupuestaria, cerró 300 escuelas en los últimos dos años debido a .

Zenere dijo que el personal de las escuelas se encuentra entre aquellos que necesitan ser atendidos primero, “porque van a ser el lazo que los mantiene unidos para ese salón de clases de 20 niños o menos”.

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The study in JAMA Network Open found that 7.2% of the students reported “clinically significant” symptoms of PTSD. More girls tended to show signs of PTSD than boys.

Researchers surveyed 96,108 public school students five to nine months after the 2017 hurricane. The cohort included youth in third through 12th grades across different regions of the island.

The Puerto Rico Department of Education — which partnered with the Medical University of South Carolina for this study — is using the data to target areas with the greatest need for mental health services, the study said.

Maria, which struck the island as a Category 4 hurricane in September 2017, killed an within the American commonwealth. Residents struggled to access clean water and some remained without electricity nearly a year after the storm.

It had dramatic effects on the students. Nearly 46% said their home was damaged. More than 32% experienced shortages of food and water. And roughly 58% reported they had a friend or family member leave the island. The effects did not vary based on where the students lived or their families’ income.

Rosaura Orengo-Aguayo, a clinical psychologist at the Medical University of South Carolina and the study’s lead author, said the findings show the breadth and indiscriminate nature of the devastation.

“That just speaks to how big Maria was, how destructive Maria was island-wide,” she said. “And it didn’t matter what your income was or your location was on the island — you were affected.”

Similar problems have been of the Caribbean also affected by hurricanes in 2017.

Congress is at a stalemate in passing an aid bill that would send more resources to Puerto Rico and other areas affected by natural disasters. President Donald Trump has to provide more money to the island.

The trauma caused by a natural disaster can manifest itself in a variety of ways, said Frank Zenere, district coordinator of the crisis management program at Miami-Dade County Public Schools, who was not associated with the study. Family units can break down through divorce or domestic violence, he said. Young children can revert to thumb-sucking or wetting the bed. Teens sometimes try to exert control by acting out or turning to drugs to self-medicate.

To be sure, Zenere said, most people who survive a natural disaster do not develop long-term mental health conditions.

“They’re distressed by it. It has impact on their life — yes,” said Zenere, who helped coordinate mental health efforts in Puerto Rico in Maria’s aftermath. “But the great majority are not going to develop psychiatric illness.”

Zenere said the differences by gender found among students reporting symptoms of PTSD align with existing literature — boys are more likely to act out, while girls are most likely to show depression and anxiety.

The study’s authors said the loss and disruption caused by Maria contributed about 20% toward the youth’s symptoms of PTSD. While the researchers did not measure what other circumstances played a role, Orengo-Aguayo said, other “protective factors” — like eventually securing basic needs and community support — influence resiliency.

Notably, Orengo-Aguayo said, the level of PTSD symptoms reported in the study is lower than what was expected. Some studies show up to a third of children will develop chronic symptoms after surviving a natural disaster, the authors wrote.

Familial ties or the fact that the study was conducted several months after the storm could have played a role in the children’s resilience, she said. Or the children might still be attuned to trying to survive.

“What we might be seeing is that children at that stage were still focused on getting access to basic needs,” she said.

Regan Stewart, a clinical psychologist at the Medical University of South Carolina and a study co-author, said the team has secured two grants from the federal Substance Abuse and Mental Health Services Administration to continue work on the island for at least three more years. It plans to use telehealth to expand access to mental health services and train school staff and mental health professionals on trauma-focused interventions.

However, public schools in Puerto Rico are burdened by economic constraints. The island — already facing a budget crisis — closed 300 schools over the past two years exacerbated by Hurricane Maria.

Zenere said school staff members are among those who need to be cared for first, “because they’re going to be the glue that keeps it together for that classroom of 20 children or so.”

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Pero no en Puerto Rico. Los pacientes de Medicaid en el territorio estadounidense no obtienen cobertura para estos medicamentos.

El programa de salud para las personas de bajos ingresos en el territorio federal, que cubre aproximadamente a la mitad de la población de la isla, no paga los medicamentos contra la hepatitis C. Tampoco cubre los trasplantes de hígado, un procedimiento que los pacientes necesitan si el virus hace que el órgano falle.

En 2015, el Departamento de Salud de Puerto Rico creó un proyecto piloto por fuera de Medicaid, para dar medicamentos contra la hepatitis C a las personas con este virus que también fueran portadoras de VIH, y luego expandió el programa para aquellas solo con hepatitis C. Sin embargo, según la Oficina de Servicios Legales del Paciente, una agencia territorial oficial que aboga por los consumidores, la iniciativa se quedó sin fondos y ya no acepta pacientes con hepatitis C.

La Administración de Seguros de Salud de Puerto Rico (ASES), que supervisa Medicaid, dijo que está trabajando con una compañía farmacéutica para crear un sistema rentable para proporcionar estos medicamentos.

“Definitivamente, se les debe dar cobertura”, dijo Angela Ávila Marrero, directora de ASES. “Necesitan atención”.

La hepatitis C, una infección transmitida por la sangre, aumenta el riesgo de cirrosis, cáncer de hígado y muerte. La detección deficiente llevó a muchos a contraer la enfermedad a través de sangre contaminada y trasplantes de órganos a principios de los años 90. Hoy en día, el causa la mayoría de los nuevos casos en los Estados Unidos.

William Ramírez, director ejecutivo de la Unión Americana de Libertades Civiles de Puerto Rico, dijo que está considerando presentar una demanda contra Puerto Rico por no cubrir el costo de estos medicamentos para los beneficiarios de Medicaid.

“Estás reteniendo medicamentos y, por lo tanto, permites que ciertas personas mueran”, dijo Ramírez.

Esa realidad es clara para Héctor Marcano, de 62 años, quien dejó de trabajar hace unos seis años a causa de esta enfermedad. Después de recuperarse de la adicción a drogas, se desempeñó como administrador de casos, conectando a usuarios de drogas con recursos de salud.

Su enfermedad hepática le está causando un deterioro general. Lucha al caminar. Un ataque de neumonía por el que estuvo hospitalizado lo dejó con una tos persistente. Pasa sus días leyendo, escuchando la radio y rezando por mantener la fortaleza para seguir buscando la cura.

Marcano no entiende por qué el gobierno no entrega medicamentos contra la hepatitis C, especialmente porque hay mucha gente que los necesita. “Entonces, ¿qué estamos esperando?”, se preguntó. “¿Qué ocurra una pandemia?”.

Costos de Medicaid impulsan deuda astronómica

Unas 3.5 millones de personas en el país tienen hepatitis C. El virus puede corroer el hígado silenciosamente durante años sin causar síntomas.

Por la naturaleza sigilosa de la condición, y la ausencia de datos recientes, el número de personas en Puerto Rico que viven con el virus es incierto. En 2010, investigadores estimaron que de entre 21 y 64 años lo portaban.

Los documentos proporcionados por el Centro de Innovación de Leyes y Políticas de Salud de la Facultad de Leyes de la Universidad de Harvard muestran que los proveedores médicos informaron más de 11,000 casos de hepatitis C al Departamento de Salud de Puerto Rico desde 2010 hasta septiembre de 2016.

Cynthia Pérez Cardona, profesora de epidemiología en la Universidad de Puerto Rico y autora de múltiples estudios sobre la hepatitis C en la isla, dijo que no está segura de cuán extendido está el virus. Pero otras estadísticas muestran una señal preocupante: un informe del de la isla encontró que la cantidad de casos nuevos de cáncer de hígado aumentó en un promedio anual de 2.1% entre los hombres y de 0.7% entre las mujeres de 1987 a 2014. La hepatitis C puede causar este tipo de cáncer.

A pesar de estas advertencias, Puerto Rico tiene menos recursos que la mayoría de la nación para atender a sus pacientes más pobres.

A diferencia de los estados, la financiación federal para Medicaid en Puerto Rico es limitada. Históricamente, estos dólares federales han estado muy lejos de cubrir los costos del programa en la isla. Los astronómicos gastos de Medicaid contribuyeron con la deuda de la isla, que alcanza la crítica suma de $70 mil millones.

Matt Salo, director ejecutivo de la Asociación Nacional de Directores de Medicaid dijo que, bajo estas restricciones, los funcionarios de Puerto Rico enfrentan decisiones difíciles al considerar la cobertura de medicamentos contra la hepatitis C.

Llegarían al límite de lo que Medicaid puede gastar en un mes, en vez de en seis, dijo Salo.

Proyecto piloto se queda corto

En el del departamento de salud, se excluyó a los pacientes con ciertas afecciones como una diabetes no controlada o un trastorno de salud mental activo, o aquellos que no pudieran probar no haber consumido drogas durante seis meses.

Pacientes y defensores sienten irritación por estas restricciones. “No le negamos el tratamiento para el cáncer de pulmón a una persona que fuma o el tratamiento de la diabetes a una persona que no come sano”, dijo Robert Greenwald, profesor de la Facultad de Derecho de la Universidad de Harvard y director del Centro de Derecho de la Salud e Innovación política.

El doctor José Vargas Vidot, miembro del Senado de Puerto Rico y médico, presentó una petición en 2017 a varias agencias territoriales que cuestionan la cobertura de Medicaid de los medicamentos contra la hepatitis C.

La Oficina de Servicios Legales del Paciente respondió a Vargas Vidot en una carta este año confirmando que el programa de Medicaid de la isla no cubría estos medicamentos. También señaló que el proyecto piloto del departamento de salud cerró su lista de espera después de llegar a los 100 pacientes, por falta de fondos. En noviembre, Vargas Vidot presentó una legislación para exigir que los medicamentos y el tratamiento de la hepatitis C formen parte de la cobertura básica de los planes de seguro y de Medicaid.

Ávila Marrero dijo que ASES está en conversaciones con una farmacéutica para crear una red separada del programa de Medicaid para proporcionar medicamentos a los pacientes. Agregó que espera que el acuerdo le permita al gobierno obtener precios más bajos por estos medicamentos. Pero aún no se ha llegado a ningún acuerdo.

A pesar de su éxito en los estados, demandar para obtener cobertura puede no ser la mejor opción para Puerto Rico porque el paquete de rescate de la deuda aprobado por el Congreso en 2016 incluye una disposición que impide que los acreedores tomen acciones legales en Puerto Rico.

Eso podría aplicarse a una demanda presentada contra el territorio por no cubrir el tratamiento de la hepatitis C en su programa de Medicaid, dijo Phillip Escoriaza, abogado experto en salud y subsidios federales en Washington, DC, quien ejerció en Puerto Rico. E incluso si el caso sigue adelante, entraría en el expediente de un tribunal especial de quiebras que ya tiene que revisar. Puede que sea en interés del gobierno de Puerto Rico que las cosas lleven mucho tiempo, dijo Escoriaza. Una vez allí, podría estancarse durante años, un tiempo que pacientes con hepatitis C como Marcano pueden no tener.

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But not in Puerto Rico. Medicaid patients in the American territory get no coverage for these drugs.

The joint federal-territory health care program for the poor — which covers about half the island’s population — does not pay for hepatitis C medications.ÌýThey also do not cover liver transplants, a procedure patients need if the virus causes the organ to fail.

The Puerto Rico Department of Health created a separate pilot project in 2015 to provide hepatitis C medications to those sickened by the liver infection who also have HIV but expanded the program later to those with only hepatitis C. However, according to the Office of Patient Legal Services, an official territorial agency that advocates for consumers, the program ran out of funding and is no longer accepting patients only with hepatitis C.

The Puerto Rico Health Insurance Administration (ASES), which oversees Medicaid, said it is working with a pharmaceutical company to create a cost-effective system to provide these medications.

“Definitely, they need to be given coverage,” said ASES director Angela Ávila Marrero. “They need to be given care.”

Hepatitis C, a bloodborne infection, increases the risk of cirrhosis, liver cancer and death. Poor screening led many to contract the disease through tainted blood and organ transplants into the early 1990s. Today, intravenous drug use drives in the United States.

William Ramirez, executive director of the American Civil Liberties Union of Puerto Rico, said he is considering filing suit against Puerto Rico for failing to cover the cost of these medications for people enrolled in Medicaid.

“You’re holding back medication and thereby allowing certain people to die,” Ramirez said.

That reality is clear for Hector Marcano, 62, who stopped working roughly six years ago because of the illness. After recovering from a drug addiction, he was a case manager who worked to connect drug users to health resources.

His liver disease is leading to overall deterioration. He struggles with walking. A bout of pneumonia that left him hospitalized lingers in his racking coughs. He spends his days reading, listening to the radio and praying for the strength to keep searching for the cure.

He doesn’t understand why the government does not provide hepatitis C medications, he said, especially as there are so many people in need of them.

“So what are we waiting for?” asked Marcano. “For a pandemic to happen?”

Medicaid Costs Drive Island’s Debt Crisis

Hepatitis C afflicts approximately 3.5 million people in the United States. The virus can silently corrode the liver for years without causing symptoms.

Because of the condition’s stealthy nature and the absence of recent data, the number of people in Puerto Rico living with the virus is uncertain. Researchers on the island in 2010 2.3 percent of 21- to 64-year-old residents had the virus.

Documents provided by the Center for Health Law and Policy Innovation of Harvard Law School show medical providers reported more than 11,000 hepatitis C cases to the Puerto Rico Department of Health from 2010 to September 2016.

Cynthia Pérez Cardona, an epidemiology professor at the University of Puerto Rico and an author of multiple studies involving hepatitis C in Puerto Rico, said she is uncertain of how widespread the virus is on the island. But other statistics present a worrisome sign: A report from the island’s found the number of new liver cancer cases increased an average of 2.1 percent annually among men and 0.7 percent among women from 1987 to 2014. Hepatitis C can cause such cancers.

Despite these warnings, Puerto Rico has fewer resources than most of the nation to care for its impoverished.

Unlike states, Puerto Rico’s federal funding for Medicaid is capped. Historically, these federal dollars have fallen far short of covering the program’s costs on the island. The territory’s crushing Medicaid expenses helped drive the island into its $70 billion debt crisis.

Under these financial constraints, said Matt Salo, executive director of the National Association of Medicaid Directors, Puerto Rico’s officials are left with a difficult choice when considering covering hepatitis C drugs.

“Rather than blowing through their cap in six months,” Salo said, “they’d blow through their cap in one month.”

Pilot Project Falls Short

In the health department’s , patients with certain conditions like uncontrolled diabetes or an active mental health condition or those who could not prove they had been sober for six months were barred.

Such restrictions rankle patients and their advocates. “You know, we do not deny lung cancer treatment for a person who smokes or diabetes treatment to a person that doesn’t eat well,” said Robert Greenwald, a professor at Harvard Law School and faculty director of the Center for Health Law and Policy Innovation.

Dr. José Vargas Vidot, a member of Puerto Rico’s Senate and a physician, submitted a petition in 2017 to various territorial agencies questioning Medicaid’s coverage of hepatitis C medications.

The Office of Patient Legal Services responded to Vargas Vidot in a letter this year confirming that the island’s Medicaid program did not cover these drugs. It also noted the health department pilot project closed its wait list after reaching 100 patients because of a lack of funding. In November, Vargas Vidot submitted legislation to require that hepatitis C medication and treatment be part of basic coverage for insurance plans and Medicaid.

Ávila Marrero said ASES is in talks with a drugmaker to create a network separate from the Medicaid program to provide medications to the patients. She said she hopes the arrangement will allow the government to get lower prices for the drugs. But no agreements have yet been reached for such a program.

Despite its success in states, suing to get coverage may not be the best option for Puerto Rico because the debt rescue package passed by Congress in 2016 includes a provision that bars creditors from taking legal action to collect from the territory.

That could apply to a lawsuit filed against the territory for not covering hepatitis C treatment in its Medicaid program, said Phillip Escoriaza, a health and federal grants law attorney in Washington, D.C., who practiced in Puerto Rico. And even if the case can go forward, it would enter the docket for a special bankruptcy court with more than , as of Dec. 14. It may be in the Puerto Rican government’s interest for things to take a long time, said Escoriaza. Once there, it could stall for years — time hepatitis C patients such as Marcano might not have.

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“3000 people did not die” in Puerto Rico, the president tweeted.

The death toll from the Sept. 20 storm, a Category 4 hurricane, has been a point of contention between officials and residents who live there. George Washington University (GWU) researchers of an in-depth investigation commissioned by Puerto Rico’s government. They estimated 2,975 people died as a result of the storm.

3000 people did not die in the two hurricanes that hit Puerto Rico. When I left the Island, AFTER the storm had hit, they had anywhere from 6 to 18 deaths. As time went by it did not go up by much. Then, a long time later, they started to report really large numbers, like 3000…

— Donald J. Trump (@realDonaldTrump)

…..This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico. If a person died for any reason, like old age, just add them onto the list. Bad politics. I love Puerto Rico!

— Donald J. Trump (@realDonaldTrump)

The president questioned that report’s credibility, insinuating that the count was a ploy by his political opponents and that it included people who died from causes unrelated to the storm.

“This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico,” he tweeted. “If a person died for any reason, like old age, just add them onto the list.”

The tweets prompted a sharp rebuke from Puerto Rico Gov. Ricardo Rosselló, who called for recovery efforts to remain above the political fray.

“The victims and the people of Puerto Rico do not deserve to have their pain questioned,” the governor’s statement said.

Here is a brief look at the issue of casualties and Puerto Rico’s response to Hurricane Maria.

How many people died?

Calculating a death count is not an exact science. Estimates are influenced by a variety of factors including the period analyzed and the definition of a disaster-related death, according to Columbia University professor John Mutter.

The Puerto Rican government accepts GWU’s estimate of 2,975 deaths as the official count. Local officials had originally said 64 people died in Hurricane Maria, counting only fatalities directly attributable to the storm, such as drowning deaths or mortal injuries caused when buildings collapsed. During the summer they had risen to more than 1,400.

The GWU their estimated death toll, which is about double that tally, by comparing the number of people who died in the six months after Hurricane Maria to historical averages in previous years.

The university issued a statement Thursday, disputing Trump’s comments. The investigation was “carried out with complete independence and freedom from any kind of interference,” according to the .

Prior to the GWU study, other researchers and one newspaper released estimates that also garnered media attention.

One , published in the New England Journal of Medicine, put the number of excess deaths at 4,645 in the three months following the hurricane. A by The New York Times used vital records from the government to calculate an excess of 1,052 deaths in the first 42 days after the disaster.

Still, the numbers are important, said Mutter, who researches disaster management and worked on collecting the number of deaths in New Orleans after Hurricane Katrina. These death counts are a key way the public measures a disaster and perception drives donations for relief, he said.

Why was it so confusing getting a death toll?

When Hurricane Maria made landfall in Puerto Rico, it devastated the island’s infrastructure, which can limit access to health care and impact mortality, especially among residents who are frail or dealing with chronic health issues.

The storm knocked out electricity for the entire island, which took nearly a year to restore fully. At least 80 percent of communications towers were not operational, crippling phone services. Medical centers across the island relied on generators for power, which sometimes failed and jeopardized patients. Some medical facilities in Puerto Rico were irreparably damaged, like the only hospital on the island of Vieques, which housed its only dialysis center. Residents must now leave the island three times a week for treatment.

Many roads on the island were impassable because of debris or erosion. Roads near rivers, like those in the mountainous, rural province of Utuado, washed away. Bridges also fell, leaving some communities isolated and unable to access assistance.

Hurricane Maria also cut off drinking water to more than half of Puerto Rico. The lack of electricity meant water pumps could not work. Some people turned to other sources, like natural springs and rivers, for drinking water. At least 26 people died of leptospirosis, a bacterial infection caused by exposure to water or soil contaminated with the urine of infected animals, from CNN and the Centro de Periodismo Investigativo, a nonprofit group that promotes investigative journalism.

In addition to the physical disruption, the GWU researchers noted that officials in charge of certifying deaths did not have a process that automatically noted when a death was a consequence of the hurricane or its aftereffects.

How did the federal government do in its response to Hurricane Maria?

According to the federal government, not very well.

A released earlier this month by the U.S. Government Accountability Office (GAO) details how the Federal Emergency Management Agency (FEMA) struggled to meet the needs of Puerto Rico and the U.S. Virgin Islands after the storms.

The agency didn’t provide adequate staffing to the disasters on the islands, according to the GAO. It faced a 37 percent staffing shortage as of Sept. 1, 2017. Of the personnel deployed to the islands, some “were not physically able to handle the extreme or austere environment of the territories,” the report said. The lack of bilingual employees also led to delays since many Puerto Ricans speak Spanish.

Transporting materials to the island was also an issue for the agency, as both islands are located more than 1,000 nautical miles from the mainland, the report said.

FEMA Administrator Brock Long addressed some of those issues Tuesday in . “We threw as much as we could towards Puerto Rico,” he said.

He added that FEMA’s prime concern is preventing deaths from natural disasters, but also that “there’s a difference between direct deaths of, you know, the winds, water, collapsed buildings, things that kill people directly versus the indirect deaths. Indirect deaths are always higher than the direct deaths after many events. … But what I really believe is that we have to concentrate on the pre-disaster mitigation, fix the infrastructure that was crumbling before the storms in the commonwealth, so that we prevent this from ever happening again.”

He noted that FEMA is now the largest employer in Puerto Rico as repair efforts continue.

What has the Puerto Rican government done in response to the death counts in Hurricane Maria?

After the GWU findings were released, Gov. Rosselló changed the official death count and accepted responsibility for the territory government’s failure to adequately respond to residents’ needs. He also said he would form a commission to consider the recommendations suggested in the GWU study on how to improve the island’s response to disasters.

However, how many changes the territory’s government can make remains to be seen. Puerto Rico’s purse is under the control of a fiscal oversight board put in place by Congress to address the island’s debt crisis, which stands at more than $70 billion.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).