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Coordinated Care Is More Than a Buzzword for Hospice Providers

By admin | May 10, 2018

April 24, 2018


By Edo Banach, JD
President and CEO

National Hospice and Palliative Care Organization


As much as we talk about “coordinated care” in health care today, it is regrettable that most people still contend with an uncoordinated, inefficient and stressful system at the end of life.

Often, health care professionals are singularly focused on eliminating illness and find themselves ill-equipped to provide the comfort and guidance needed when a person’s illness requires care rather than, or in addition to, a cure. Families who don’t know that there’s an alternative stand helplessly by as the last months of life get swallowed up by costly, sometimes unnecessary treatments that can hurt more than they help.

Health care consumers and policymakers must be aware that it doesn’t have to be this way. In an increasingly broken and fragmented health care system, hospice care – the nation’s first coordinated care model – shows how health care should and can work at its best for patients at the end of life.

A grassroots movement that began over 50 years ago, the success of the hospice model led to its adaptation into Medicare in 1982 — a mere four years after it began as a demonstration program. Today, an estimated 1.7 million Americans receive hospice services each year, with 1.4 million Americans choosing to utilize hospice through their Medicare benefit.

Expert medical care, pain management, emotional and spiritual support services are all provided and tailored to the patient’s and family’s needs. Hospice caregivers represent a comprehensive, interdisciplinary team of physicians, nurses, social workers, chaplains, volunteers and other professionals that ensures the patient is cared for beyond just his or her medical needs. Hospice respects the dignity of the patient’s life, honors his or her choices and provides a care plan reflective of a patient’s values. This philosophy of care is illustrative of hospice’s legacy and commitment to the best care for every hospice patient.

It’s a system that thrives because hospice providers understand how to balance the patients’ wishes with their health care needs – and coordinate care accordingly. This investment in care actually saves Medicare money – by one estimate, as much as $2,300 per patient — not at the expense of the patients, but rather by allowing the patients and their caregivers to guide decisions that can reduce their use of hospital-based treatments, resulting in fewer complications and side effects.

Despite more than 35 years’ success in the Medicare program, inevitable changes in our health care system could threaten hospice’s effective, original system of coordinated care. A rash or untested policy shift could lead to care delays, limitations on patients’ ability to select their preferred provider or a loss of autonomy for the hospice medical directors.

Change is inevitable and can often be good, but it must be incremental change that does no harm and respects patient and caregiver choice for more, rather than less, options for addressing serious illness.

While the goal of hospice care is not to save lives, it is still often called “lifesaving” by patients’ families. After experiencing the confusion and frustration of fragmented care, many are overwhelmed by the quality, compassion and personalized service that hospice care delivers. The hospice model exemplifies these principles of quality, compassionate and personalized care that beneficiaries, payers, policymakers and their constituencies want.

No patient or family should suffer needlessly at the end of life – and that includes either physically or emotionally. America is getting older, but members of the hospice and palliative care community are prepared to meet the growing need for more hospice care. And we are ready to do so in a way that is driven by our patients and their families.

Doing so demands that any health care reform allows hospice to continue to build on our successful foundation – and expand our patient and family-centered model across the care continuum. Protecting that continuity is essential to care for all patients with serious, advanced and life-limiting illness.

Rather than just trying to make hospice more like the rest of the health care system, how about making the rest of the health care system more like the original coordinated care model? Coordinated care should be more than a popular health care buzzword. It should be the driving force for all health care everywhere – just as it currently is for hospice.

It’s the model and philosophy that have driven hospice’s success and changed lives for the better. It is a model that we will continue to fight for and for policies that support peace, comfort and quality at the end of life.




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Puerto Rico’s Oversight Board Certifies Fiscal Plan: What are the Implications for Medicaid?

By admin | April 27, 2018

April 24, 2018 Edwin Park

As I have previously written, a robust and resilient Medicaid program is essential to Puerto Rico’s long-run recovery from the devastation of Hurricanes Maria and Irma.  Its residents disproportionately rely on Medicaid for their health coverage due to their low incomes and relative lack of access to private insurance.  For example, 62 percent of children in Puerto Rico — and 48 percent of its residents overall — were enrolled in Medicaid in 2016.  Moreover, after the hurricanes, there is a significant risk that more residents of Puerto Rico will likely become eligible for Medicaid in coming months — offset to some degree by the effects of overall population decline due to outmigration — and the average medical needs of beneficiaries may also increase.  Congress recognized the important role Medicaid is playing in the post-hurricane recovery by enacting critically needed temporary financial assistance for the Medicaid programs of Puerto Rico and the U.S. Virgin Islands as part of the Bipartisan Budget Act of 2018 in February.

On April 19th, the Financial Oversight and Management Board of Puerto Rico certified the Commonwealth of Puerto Rico’s fiscal plan, which includes a major overhaul of the island’s Medicaid program Mi Salud.  While much of the fiscal plan’s Medicaid provisions focus on delivery system reforms to improve quality and lower costs as well as lower prescription drug costs, other provisions raise substantial concerns.  Among the key takeaways from the certified fiscal plan:

Clearly, the most troubling aspects of the fiscal plan’s Medicaid proposals are its proposals to potentially increase beneficiary cost-sharing and further cut benefits.  If eventually implemented, they would place many low-income beneficiaries in Puerto Rico at risk of foregoing needed services and treatments, even though their health needs are likely to be greater in the aftermath of the hurricanes.

The fiscal plan includes these damaging potential Medicaid cuts because of the federal funding shortfalls Puerto Rico will face after the temporary Medicaid funding increase expires on October 1, 2019.  That’s why Congress should consider permanent Medicaid financing changes to sustain and strengthen the Medicaid programs in Puerto Rico as well as the U.S. Virgin Islands and the other U.S. territories over the long run.  Such improvements would help ensure that Puerto Rico maintains and expands Medicaid coverage for its low-income residents, continues to improve access to and quality of care and strengthens its severely stressed and damaged health care system.  It would also make its Medicaid program far more resilient and responsive in the event of another hurricane or other natural disaster.


Edwin Park is a Research Professor at the Georgetown University McCourt School of Public Policy.



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How is health care in Puerto Rico after Hurricane Maria? No one knows.

By admin | April 20, 2018

 April 18

Mekela Panditharatne is an attorney at the Natural Resources Defense Council

In Puerto Rico, locals say the best way to know whether someone died because of Hurricane Maria is to turn up at a morgue or funeral parlor rather than consult official sources.

Six months after Maria hit, the hurricane’s death toll is still a subject of controversy. After seismic investigations by the island’s Center for Investigative Journalism and the New York Times late last year showing that the true death count was probably several times higher than the official toll — more than 1,000 hurricane-related deaths, compared with the 64 deaths reported at the time — the Puerto Rican government asked a team of experts at George Washington University to review the numbers. But insufficient details were collected about causes of death by the island’s Demographic Registry. And as months go by, it becomes harder to trace the families of the deceased and ask questions about how a death occurred.

These mistakes are symptomatic of a broader trend. Recently, the island’s Institute of Statistics has found itself at the unlikely epicenter of a public outcry, as the cash-strapped local government considers ending the independent agency’s tenure. Now sidelined from participating in Maria’s maligned death count, the institute has historically played a critical role in correcting tendencies by local agencies to underreport health risks.

Last month, I traveled to Puerto Rico to get a handle on what doctors are seeing on the island now, six months after the storm. Doctors there say that poor data collection and underreporting are hiding a health crisis whose true scale eclipses official accounts.

The problems are particularly acute for chronically ill patients. Wendy Matos, a physician who supervises nearly 470 doctors as the executive director of the University of Puerto Rico’s faculty practice plan, said that her clinics are seeing increases in cardiac arrest and intracranial hemorrhage (bleeding inside the skull), more waterborne and infectious disease and swelling numbers of suicides since Maria.

Matos, whose doctors comprise the largest network of specialists and subspecialists on the island, also said her medical clinics have lost track of what has happened to tens of thousands of patients since the hurricane. From Sept. 1 to Dec. 31, doctors at Matos’s clinics saw nearly 25 percent fewer patients than they had the previous year — just under 91,000, down from about 117,000 patients in a comparable period in 2016. Some of these high-risk patients have left the island. Others are struggling to access care, immobile or unable to travel the long distance to San Juan on deteriorating roads. Some have died.

These issues, doctors think, either aren’t fully reflected in data put out by Puerto Rico’s Department of Health, or fail to surface because data on disease and injury isn’t being published at all.

An example: Under federal Centers for Disease Control and Prevention guidelines, Puerto Rico, like other states and territories, must publish weekly reports on influenza outbreaks. In January, officials on the island claimed thatinfluenza cases had not reached epidemic proportions. But doctors told me that diagnoses were artificially low because influenza test kits weren’t readily available after the storm. In February, several deaths were investigated for their possible connection to the influenza virus.

How frequent and severe have other health conditions been after Maria? The answer isn’t fully known because the numbers simply aren’t yet published. That’s typical in Puerto Rico, which periodically publishes annual health data in a lagging fashion, but doctors I spoke with said that after an emergency like Maria, the government should make information more readily available. With parts of the island still without power, though, reporting remains difficult for remote hospitals and health centers.

The testimonial data I collected suggest that Maria did make a dent. Hector Villanueva,  a physician and medical director of HealthPro Med, a federally qualified community health center based in Barrio Obrero, one of the poorest neighborhoods in San Juan, said his staff took over maintaining the island’s vaccine inventory for nearly two weeks after Maria hit, receiving and distributing vaccines from satellite centers across the island. His clinics also saw increases in waterborne and infectious disease in the months after the hurricane hit. Higher rates of mental illness linger.

Federally qualified not-for-profit clinics like Villanueva’s are now faring better than other private health-care providers on the island. Puerto Rico’s health infrastructure is glued together by private health clinics and offices; several of these have shuttered since the hurricane. As these clinicians pack up shop, their patients, set adrift, strain the capacity of an overburdened health system.

Even before Maria, rural and isolated areas in Puerto Rico didn’t have enough doctors and nurses. Specialists were in short supply. The hurricane has left more patients without care, or waiting longer for care. The island’s Center for Investigative Journalism found that after the storm, hospitals’ operational capacity had been overstated by the governor.

In some cases, capacity has still not returned to pre-Maria levels. Villanueva, who oversees a satellite health clinic in the area, told me that there still is no functional dialysis center in Vieques, where residents suspect that poor health outcomes are linked to toxic substances deposited by the U.S. Navy in decades past. To get treatment, dialysis patients must undertake a day-long trip three times a week, typically by boat, to the nearby metropolises of Fajardo or Humacao.

To fix these problems, the Federal Emergency Management Agency and the local government should direct federal aid to outreach tools such as telemedicine and to rebuilding the island’s regional health and water infrastructure. Accurate data collection and analysis, too, is key. Underreporting, or nonreporting, of hurricane-related disease and deaths in Puerto Rico means that resources aren’t being directed where they’re needed.

Meanwhile, the picture of the island’s health crisis is still precariously opaque.

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Why America’s Black Mothers And Babies Are In A Life-Or-Death Crisis

By admin | April 16, 2018

NY Times Magazine Feature Article: ‘Black infants in America are now more than twice as likely to die as white infants’
Why America’s Black Mothers And Babies Are In A Life-Or-Death Crisis
The New York Times Magazine 
“‘The answer to the disparity in death rates has everything to do with the lived experience of being a black woman in America.’ When Simone Landrum felt tired and both nauseated and ravenous at the same time in the spring of 2016, she recognized the signs of pregnancy. Her beloved grandmother died earlier that year, and Landrum felt a sense of divine order when her doctor confirmed on Muma’s birthday that she was carrying a girl. She decided she would name her daughter Harmony. ‘I pictured myself teaching my daughter to sing,’ says Landrum, now 23, who lives in New Orleans. ‘It was something I thought we could do together.’ But Landrum, who was the mother of two young sons, noticed something different about this pregnancy as it progressed. The trouble began with constant headaches and sensitivity to light; Landrum described the pain as ‘shocking.’ It would have been reasonable to guess that the crippling headaches had something to do with stress: Her relationship with her boyfriend, the baby’s father, had become increasingly contentious and eventually physically violent.”

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About Half Of Americans Support Single-payer Health Care

By admin | April 16, 2018

New Washington Post-Kaiser Family Foundation poll finds a slight majority of Americans support singlepayer health care approach, with numbers showing glaring partisan divide 

About Half Of Americans Support Singlepayer Health Care
The Washington Post
“As President Trump’s administration tries to chip away at the Affordable Care Act by giving more authority to states to regulate private insurance, a new poll finds a slight majority of Americans support a move in the opposite direction, with everyone getting health insurance from a national government-run program. A Washington Post-Kaiser Family Foundation poll finds a 51 percent majority of Americans support a national health plan, also known as a singlepayer plan, while 43 percent oppose it. Nearly three-quarters of Democrats support a singlepayer health plan (74 percent), while a slightly larger share of Republicans oppose it (80 percent). Independents break the tie, supporting a government-run health-care plan by 54 percent to 40 percent. Support is relatively high among rallygoers, defined as those who have attended a rally or a protest within the past two years. A 61 percent majority of this Democratic-leaning group supports a singlenational health plan. Just under half of non-rallygoers, 49 percent, feel the same way. Those who attended a protest or rally to express their views on the Affordable Care Act in the past two years favor a national health plan by a more than 4-to-1 margin, 79 percent to 18 percent. This group is also overwhelmingly defensive of the ACA, with 85 percent saying they came out to express support for the law.”

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Dialysis Patients are Still Trekking 12 Hours for Care After Hurricane Maria

By admin | April 13, 2018

Left without a hospital, some Puerto Ricans must travel by plane for lifesaving treatment.

Two men sitting inside an airplane. One is looking out a window.
Joe Garcia and Radamés Cabral Trinidad fly back to Vieques after dialysis treatment.Carmen Heredia Rodriguez / Kaiser Health News

VIEQUES, P.R.—As the cry of a rooster heralded the dawn, Joe Garcia, 41, pulled a vial of insulin from the fridge. He filled a syringe and wrapped it in aluminum foil in preparation for the long day ahead.

“I tell him that from here to there, that’ll spoil,” said his mother, Martina Collazo de Jesus, 63, watching the preparations under the fluorescent bulb lighting the family kitchen.

It is a gamble Garcia, who has both diabetes and kidney failure, has taken since Hurricane Maria slammed this Puerto Rican island just east of the main island. More than six months after the storm, Garcia and 13 other Vieques residents must still board a plane three days a week for kidney dialysis on Puerto Rico’s main island.

Hurricane Maria totaled Vieques’s hospital, which housed the island’s only dialysis clinic.

That set off an ongoing crisis for patients with kidney failure like Garcia—who cannot survive without dialysis and for whom the thrice-weekly round trip to a dialysis center in Humacao on Puerto Rico’s main island, including treatment, takes at least 12 hours.

When seriously ill patients like Garcia will again be able to access their lifesaving treatments in Vieques remains uncertain, as federal and local officials and nonprofit groups debate strategy and finances. No one knows when the hospital will be rebuilt, either. And the government and nonprofit organizations continue to punt the responsibility of paying for the flights.

“This is really hard,” Garcia said, as he prepared for his long day of treatment. “I am crazy, crazy, crazy for them to build a clinic here in Vieques.”

Before Hurricane Maria, Vieques, a sleepy island with about 9,350 people and miles of popular beaches along the Caribbean, was once home to a thriving tourism industry.

Since that September storm, residents have relied on generators for electricity, and tarps still serve as roofs for many houses.

The hurricane ravaged Garcia’s home. It tossed the appliances and ripped the metal sheets off, leaving only the wood frame standing. He now lives next door with his mother. The tattoos on his left arm bear her nickname, Tati, alongside the names of his sister and daughter.

Before Garcia received his diagnosis of kidney failure two-and-a-half years ago, he worked odd jobs, including as a handyman at a hotel and a manager at a car-rental business.

Puerto Rican government officials have discussed various solutions for restoring dialysis services, including bringing in mobile clinics and finding another building.

Puerto Rico’s health secretary, Rafael Rodríguez-Mercado, said in an interview last month in Washington, D.C., that the department is moving to bring in mobile dialysis units that should arrive within four to six weeks.

“I think this issue is a question of waiting for things to arrive, ‘go with the flow,’ and begin doing them,” said Rodríguez-Mercado.

He also said the government is searching for buildings suitable to house temporary dialysis services in Vieques.

But three weeks later, patients are still taking flights. Luis Emanuelli, the regional vice president of the national dialysis provider Fresenius Kidney Care, said he is aware of the plans for mobile dialysis clinics but is unaware of any time line. Officials with Puerto Rico’s Department of Health and local officials in Vieques did not respond to phone calls seeking information on the status of the dialysis units.

A medical van transports patients from their dialysis appointments to the airport in Ceiba, Puerto Rico. (Carmen Heredia Rodriguez / Kaiser Health News)

The health secretary and Vieques officials have disagreed about who is responsible for coordinating repairs of the ravaged hospital and its infrastructure—each pointing to the other.

Héctor Ortiz Jiménez, the Vieques municipal secretary, says, “All decisions with respect to the hospital correspond to the Department of Health because that is already part of the agreement between the Department of Health and the Vieques municipality.”

Meanwhile, the Federal Emergency Management Agency is collaborating with the territory’s health department and the federal Department of Health and Human Services “to help identify costs for mobile or temporary units that are eligible reimbursement expenses,” the agency said in an email.

It said officials hope to reconstruct buildings that “meet the needs of the community with resiliency for future disasters.”

But the email added that “no long-term solution has been identified yet for any reimbursement costs for reconstruction.”

Multiple groups have stepped up to help transport dialysis patients to a working facility. In the months following the hurricane, the responsibility of paying for this transportation has switched regularly between government and nonprofit organizations. These exchanges have at times left patients and the dialysis provider wondering where funds for the next flight would come from.

First, helicopters coordinated by the federal Department of Health and Human Services carried the Vieques residents to the main island for treatment.

In late October, the nonprofit organization ViequesLove began coordinating the flights, ultimately spending $9,000 in airfare, according to its founder.

Then Americares, a nonprofit, international relief organization focused on health, began paying, ultimately spending $55,000 on flights. The Puerto Rican health department informed Americares that it would shoulder the travel costs for March.

“The most sustainable solution for patients in need of long-term care is to have the local health system coordinate,” says Donna Porstner, the director of media relations for the nonprofit.

But this month, a local nonprofit that specializes in kidney health, the Renal Council of Puerto Rico, has assumed that responsibility. It secured the funding from the foundation Unidos por Puerto Rico, according to Renal Council’s executive director, Ángela Díaz. She says she expects the money will cover transportation for the next five to six months.

The council also asked for funding to rent a building in Vieques that could be retrofitted into a dialysis clinic. The foundation has not made a final decision on that request because it is waiting for the various government agencies to come up with a plan to reestablish services, Díaz says.

Eight hours after getting up in Vieques, Garcia dozed in one of the pink reclining chairs lining the walls of the treatment room in Humacao, still only halfway through his four-hour dialysis treatment.

Tubes full of blood snaked from his left arm and funneled into the machine on his right side. The electronic screen showed an assortment of numbers reflecting blood pressure and the amount of dialysis fluid flowing through the filter. The tattoo of his mother’s name on the same arm peeked out beneath the tangle of plastic.

Some patients from Vieques don’t know how much longer they can take the journey for this treatment.

Beside Garcia sat Radamés Cabral Trinidad, 65, who has threatened to stop dialysis to protest the traveling and the lack of effort to provide local treatment. “I want to die,” he said. “I want to die in Vieques.”

José Lorenzo, the director of operations of the clinic run by Fresenius Kidney Care, says he sympathizes with the Vieques residents’ call to reestablish the clinic as soon as possible. “I’m worried about these patients,” he says, noting the toll the grueling travel takes on their health.

It would be another four hours before Garcia pulled up to his mother’s home, plopped his bag down, and fixed a plate of leftover rice, exhausted. He took off his shirt and checked his blood pressure to make sure it was stable post-travel, post-treatment.

“I’m glad we made it,” he said.

“Thank God,” his mother replied.

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By admin | March 21, 2018

Yesterday marked six months since Hurricane Maria made landfall in Puerto Rico. Although there has been progress in the island’s recovery, much work remains, including:
  • 11% of Puerto Rico and 8% of the U.S. Virgin Islands still suffer throughthe longest power outage in U.S. history.
  • No power means no cooling, which can present a serious health concernfor young children, older adults, and the nearly 400,000 people with disabilities in Puerto Rico.
  • After Hurricane Katrina, mold spread throughout New Orleans worsening asthma and long-term health. Now, the same is happening in Puerto Rico and the Virgin Islands.
A large crowd organized by the Power 4 Puerto Rico coalition demonstrated in front of the Federal Emergency Management Agency (FEMA) yesterday, “demanding equal treatment from the Trump administration and decrying the island’s ongoing woes.” Ramon Pergueo, president and CEO of the Committee for Hispanic Children and Families, attended the protest yesterday and told CAP Action, “It is outrageous that 6 months after this tragedy, 62 percent of all applications to rebuild have been denied…FEMA has to act.”
It’s clear the Trump administration needs to act to ensure residents of the island have the resources and support they need to recover from and rebuild after the most devastating hurricane seen in years. And to be clear: bungling contracts and faking Spanish accents don’t count.

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Congress: Don’t let 900,000 Americans become uninsured overnight! | TheHill

By admin | February 7, 2018


Congress: Don’t let 900,000 Americans become uninsured overnight!

By Jaime R. Torres, Opinion Contributor – 02/06/18

The islands of Puerto Rico and the US Virgin Islands are still recovering from the historic destruction caused by Hurricanes’ Irma and Maria. But it gets worst.  As The Hill’s Nathaniel Weixel warned us in October, “Puerto Rico is facing an imminent Medicaid funding crisis, putting nearly one million people at risk of losing their health-care coverage.”  Time is running out quickly: that crisis will happen as early as April 2018 when the onetime grant of $6.3 billion that Puerto Rico received, thanks to the Affordable Care Act, will run out.

How can this be? Puerto Rico and US Virgin Islands are US territories ruled by discriminatory, archaic and unacceptable Medicaid rules that, different from the states, limit the federal funding they receive to cover these US citizens — a fixed amount of funding that falls well below their actual Medicaid costs.

Puerto Rico, for example, covers 1.6 million residents through its Medicaid program at a cost of $2.8 billion a year. The US Virgin Islands covers 23,000 residents at a cost of $44 to $46 million per year.  If either territory were a State the federal Medicaid reimbursement would cover most of it, but because of unequal regulations we are facing this man-made, unavoidable crisis.

First, the reimbursement rate is unfair:  For all states the Medicaid federal matching rates are based on their per capita income and poverty rates, while the territories, like Puerto Rico and the Virgin Islands, receive a fixed matching rate of 55 percent.  As the Center on Budget and Policy Priorities has shown if Puerto Rico’s matching rate were set under the formula for states, it would be 83 percent.

Then, to add insult to injury, federal statute sets a cap limiting the annual Medicaid funding they receive. Puerto Rico can only receive $360 million and the Virgin Islands $18 million —that is it!

And due to Puerto Rico’s bankruptcy and the economic downturn after Hurricane Maria, it will be impossible for the local government to cover that immense shortfall.  In fact Governor Rosselló announced that his is new Fiscal Plan would a reduce $795 million for health care in the coming five years.

What can be done? Congress must act now and approve a temporary increase for two years to the federal Medicaid matching rate for Puerto Rico and the US Virgin Islands to 100 percent, similar to what was done after Hurricane Katrina. Then after the end of the 24-month 100 percent match, maintain current levels of funding for Puerto Rico’s Medicaid program, at current level of approximately $1.6 billion for a period of at least three years.

If Congress fails to act, 900,000 American citizens may lose Medicaid coverage in Puerto Rico, as determined by the US Department of Health and Human Services last year.

Eventually only full funding and equal participation for all federal health programs will solve this crisis. It would help reduce further migration to the States and save the federal and state governments money in the long run.  It costs 3-4 times more to treat a patient in a state like Florida than Puerto Rico.  In fact, at current migration rates, it would cost the federal and state governments $4.2 billion in Medicaid and $1.7 billion in Medicare annually.

Congress needs to protect US citizens still enduring the ravages of Hurricane Maria, and that is why these disparities should be addressed as part of the upcoming relief supplemental appropriations bill being considered now.

It is what they deserve. It is the right thing to do.


Dr. Jaime R. Torres is president of Latinos for Healthcare Equity, and the former regional director of the US Department of Health & Human Services, Region II—serving New York, New Jersey, Puerto Rico and the US Virgin Islands.


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Piden atención a la crisis de salud

By admin | January 29, 2018

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Puerto Rico’s mental health crisis

By admin | January 29, 2018

My earliest memory of childhood visits to Puerto Rico is the clapping when the airplane wheels touched down on the tarmac in San Juan. Between the applause were also blessings for the pilot and the island, “Ay bendito, que Dios bendiga el piloto y a Puerto Rico” — phrases usually uttered by somebody’s abuela.

The memory made my recent trip to the island more heartbreaking. This time, I was traveling to Puerto Rico as a doctor on deployment for New York City’s ongoing relief missions. When the plane touched down, the silence was deafening, and a chilling reminder that I was arriving at a place very different from the Puerto Rico I remembered.

During my 12-day visit, I heard countless harrowing personal stories of surviving the storm and what life is like in the aftermath. Stories of people dying for a variety of reasons attributable to the devastation, which seemed to confirm the news that the hurricane’s death toll is much higher than initially reported.

Among all the tragedy, what I found most disturbing was that every person I spoke to knew of someone personally, or within a degree of separation, who had attempted or completed suicide after the storm.

Studies have shown that suicides typically increase around eight months after a natural disaster. In Puerto Rico, the increase is starting much sooner, and appears to be affecting people of all age groups, including children.

Puerto Rico’s Health Department collects data on suicide completions, attempts and ideations from a number of sources including hotlines for suicide prevention and poison control.

While suicide rates have decreased in Puerto Rico since 2010, according to preliminary data, suicides in September and October of this year — in the aftermath of the hurricanes — were up roughly 30% compared to the same period for 2016. The data is likely to show only a piece of the full picture as non-functional telecommunications may have affected reports.

The early suicide spike may partly be the result of the complex nature of this natural disaster. Not only did Maria hit Puerto Rico two weeks after Irma, but it decimated an already fragile infrastructure at a time when Puerto Rico was essentially bankrupt.

Before the hurricane, Puerto Ricans were already struggling with the stressors of a severe economic crisis that broke basic support structures, such as stable jobs, savings accounts and family networks, as many left the island in search of better opportunities.

Since the hurricane, stories of acute mental trauma and PTSD are more common. Staff working at Veteran’s Affairs hospitals on the island said that Puerto Rican veterans who fought in Korea and Vietnam are reliving their trauma: The devastated landscape, in conjunction with helicopters surveying the destruction, is reminding them of war.

During my time on the island, I spoke with several mental health professionals who were also parents. They shared stories of their own young children becoming clingy or apprehensive when the sky grew cloudy, frightened in anticipation of another storm. The fear intensified with rain and wind.

One of them contacted me last week with alarming news that two school-age children she knows have recently died from suicide, and she is concerned her staff does not have the capacity to cope with the extreme trauma.

As a public health leader who is also a pediatrician, I am especially attuned to the lifelong impact of traumatic experiences in childhood, which can affect children’s physical, mental and emotional development.

In 2016, the United States census estimated that 56% of children in Puerto Rico under the age of 18 live below the poverty level — more than in any U.S. state. They are under immense pressure, whether from the loss of family members and friends who have left the island; prolonged exposure to darkness; or exposure to adults whose ability to model healthy coping skills has been exceeded by the complex nature of this disaster.

The mental health crisis on the island is an evident reality that grows every day and demands an urgent response. Congress must pass a relief package, now, because a stable energy grid, functional transportation system and relief from crushing debt will help protect the health of American citizens, the children and adults who live in Puerto Rico.

Barbot is New York City’s first deputy health commissioner.

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