How Puerto Rico became the most vaccinated place in America

Politics — or the lack thereof — was a key factor.

Florida shares deep connections with Puerto Rico as home to the territory’s largest diaspora community on the US mainland. But when it comes to Covid-19, the two places have little in common.

While Florida, like many states in the South, has seen high infection rates and troubling death counts, Puerto Rico has been something of a coronavirus success story. As of November 22, Puerto Rico had fully vaccinated 74 percent of its population — a higher proportion than any other US state or territory — and had among the lowest Covid-19 death rates since the start of the pandemic, with 102 in 100,000 people dying from the virus.

By comparison, Florida’s vaccination rate is far more typical for the US; it has administered two shots to 60.9 percent of its population, slightly above the national average of 59.2 percent. That’s after Florida led the country in total caseloads for months, and after significant loss of life: Florida residents have died of the virus at nearly triple the rate of Puerto Rico residents.

Throughout the US, politics has been a key factor in determining how states have fared during the Covid-19 pandemic. States that embraced the individualistic approach of the Trump administration, sometimes ignoring scientific guidelines and avoiding mandates, have seen worse outcomes than states that took more comprehensive actions to stop the spread of Covid-19.

Florida Republican Gov. Ron De Santis has been threatening government agencies with millions in fines if they mandate vaccines for employees and has boosted the voices of anti-vaxxers. At the same time, Puerto Rico Gov. Pedro R. Pierluisi, a member of the Partido Nuevo Progresista who caucused with Democrats while a commissioner in Congress, has quietly implemented some of the broadest vaccine mandates in the country across the private and public sectors.

And while Floridians have taken to the streets with signs reading “No jab, no job, no way,” Puerto Ricans have largely embraced the mandates without protest. Though coronavirus cases have risen across the mainland in recent weeks, Puerto Rico has avoided a spike, with cases and hospitalizations even trending downward.

Carlos Giusti/AP

So, how was Puerto Rico able to insulate itself from political polarization around the virus and outpace the rest of the country on vaccinations? Officials and NGOs had already built public trust and infrastructure in the aftermath of other recent crises, including Hurricane Maria in 2017. And importantly, scientists and physicians — not politicians — led Puerto Rico’s response to the pandemic.

Puerto Rico had already weathered several public health crises in recent years

A series of crises over the last few years made Puerto Rico’s public health system more resilient in the face of disaster than those in other states and territories, and its residents more receptive to the scientists leading the response.

This process began when Hurricane Maria made landfall in 2017. The category 4 storm left more than 5,000 dead and wreaked $90 billion in damage, destroying homes, roads, and bridges, and causing island-wide power outages.

The public health consequences were disastrous. Many Puerto Ricans had limited access to food and safe drinking water. Without adequate hygiene and sanitation, they faced increased risk from infectious diseases. Nearly every hospital was closed for days after the hurricane hit, and when they reopened, many had to rely on generators for power for months thereafter, causing disruptions to services. For many people with chronic diseases such as cancer and diabetes, that meant traveling far for lifesaving treatments.

Then, in late 2019, a 6.4 magnitude earthquake hit the island, followed by dozens of significant aftershocks and a second quake, this one at magnitude 5.9. That caused additional damage to critical infrastructure and hampered the island’s rebuilding efforts. Tens of thousands of people were relegated to emergency tent shelters with limited access to medical care.

The federal and Puerto Rican governments failed to adequately respond to the hurricane and the quakes, with the Trump administration deliberately delaying more than $20 billion in relief. The Puerto Rican government mismanaged the funds that were delivered.

NGOs and community leaders picked up the pieces, which built trust with the people they served. In the immediate aftermath, they helped assess the damage, mobilized volunteers, set up emergency support centers, helped clear routes to water sources and medical facilities, and distributed basic supplies including non-perishable food, medicine, water purifiers, hygiene kits, and tents.

“It was the NGOs that put together everything because the government, locally and federally, couldn’t deal with the aftermath of Hurricane Maria,” said José Rodríguez-Orengo, executive director of the Puerto Rico Public Health Trust (PRPHI), a public health institution that partners with the Puerto Rican government and community groups.

Data gathered after Hurricane Maria was crucial. PRPHI captured data on individuals whose homes had been damaged or destroyed and who were staying in camps in the southwest of the island. It provided that information to the local Department of Health to ensure that victims received the services they needed.

And Voces, a coalition of Puerto Rican community groups and health care providers focused on immunization, provided flu vaccines in the wake of both disasters to people who could not otherwise access a vaccination site. That was important because the lack of clean drinking water and overpopulation at emergency shelters was creating the ideal conditions for the flu to spread and become a serious public health issue.

By the time the coronavirus pandemic hit, such organizations had already established the infrastructure and community relationships necessary for effective Covid-19 prevention and vaccination campaigns under difficult circumstances — an advantage that Puerto Rico might have had over other states and territories. Voces alone, for example, has administered close to a quarter of a million vaccine shots.

Ricardo Arduengo/AFP via Getty Images

“The island has developed an expertise around addressing public health emergencies,” said María Fernanda Levis-Peralta, a consultant in Puerto Rico working on improving systems for public health delivery. “These organizations were already set up and deployed to do community outreach.”

From scientists to community leaders, the message was the same: Mask up and get vaccinated

Puerto Rico wasn’t untouched by the kind of vaccine misinformation that remains prevalent in the mainland US. Rodríguez-Orengo said his organization encountered Puerto Ricans who had heard conspiracy theories that they were being injected with a microchip that would allow the government to track them or that the first-of-its-kind mRNA vaccine could permanently alter their DNA.

But those conspiracy theories simply weren’t allowed to take hold in Puerto Rico, in part because the local political parties did not tolerate them.

“Our main sport in Puerto Rico is politics. We are a very political society,” Rodríguez-Orengo said. “What helped us out from the beginning was that the main political parties in Puerto Rico were saying the same message: ‘Let’s start with the scientists. They will lead us in public policymaking.’”

Initially, Puerto Ricans were somewhat skeptical of the vaccine. In November 2020, before the vaccines were available to the public, the Puerto Rico Public Health Trust conducted a study in partnership with the Centers for Disease Control and Prevention (CDC) and the Puerto Rico Department of Health that found that only 57 percent of Puerto Ricans wanted the jab, Rodríguez-Orengo said.

But government officials, scientists, physicians, pharmacists, the National Guard, and religious and community leaders rallied in a unified campaign around the vaccine and Covid-19 prevention.

The science always came first: Even when the CDC loosened its guidance on masking in May, the Puerto Rican government heeded the advice of local public health officials to maintain universal mask mandates in all indoor spaces regardless of vaccination status. That decision was later vindicated by the resurgence in cases due to the delta variant.

Public messaging also focused on how the vaccine could help protect families, a sentiment that resonated with the island’s “strong communitarian ethic that values helping and supporting one’s neighbors,” said Krista Perreira, a health economist at the University of North Carolina at Chapel Hill who has studied health care access in Puerto Rico. “When we get vaccines, we protect each other, protect our communities, and protect our futures.”

Unlike on the mainland, there wasn’t a singular figure like Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases and the White House’s chief medical adviser, who became the face of the vaccine campaign. This allowed for a multitude of trusted voices to advocate for vaccination, including the US’s first Hispanic surgeon general, Antonia Coello Novello.

“People trusted their physicians to provide them with health information,” Levis-Peralta said. “And one of the things that Puerto Rico has had is a very vocal physician community and consistent communication from folks on both sides of the aisle.”

As a result, the share of Puerto Ricans who wanted the vaccine had grown to 85 percent by February 2021, according to Rodríguez-Orengo. At that point, only 55 percent of US adults overall indicated that they wanted to get the vaccine or had already received it.

That public support laid the groundwork for a successful vaccine drive and compliance with later vaccine mandates.

Ricardo Arduengo/AFP via Getty Images

Puerto Rico made it easy — and for many, mandatory — to get the vaccine

Importantly, Puerto Rico made it simple to get the vaccine for free, even for people who face mobility challenges or are in medically underserved areas.

According to the federal government, 72 of the island’s 78 municipalities are medically underserved and have “unmet health care needs.” Nearly half of Puerto Ricans are on Medicaid and 350,000 people rely on Medicaid-funded community health centers to access primary care services, especially in rural areas.

The National Guard and Puerto Rico Department of Health operated at least a dozen mass vaccination sites across the island for months. The island’s high concentration of pharmacies and community health centers also helped in administering vaccines. And NGOs have led large-scale vaccination events and even gone door-to-door to vaccinate bedridden people in their homes and improve vaccination rates in communities with low uptake.

Voces, for example, has been able to give out nearly 250,000 shots by holding as many as 25 events daily across the island, meeting people where they live and work.

“Creating access directly in the community is very important because not everybody has a car to go to the pharmacy or the hospital or the clinic,” said Lilliam Rodríguez Capó, president of Voces’s board of directors. “There was no excuse not to get the vaccine.”

For many, there was also no choice but to get the vaccine. Puerto Rico adopted far-reaching vaccine mandates well before any of the 50 states or the federal government had implemented anything similar. And it did so with relatively little fanfare — a testament to the success of collective messaging efforts to build public support.

In July, Puerto Rico’s governor required all students to show proof of receiving at least one dose of the vaccine in order to return to school after the summer break. And in August, he extended the mandate to all employees in the public sector and at salons, spas, gyms, child care centers, grocery stores, casinos, gas stations, restaurants, and theaters, as well as on visitors to any establishment where food and drink is provided. In November, he expanded that mandate even further to all private businesses with at least 50 employees.

By comparison, it wasn’t until September — just as delta cases were at their peak on the mainland — that President Joe Biden issued an executive order requiring that all federal employees get vaccinated. Also that month, his administration pushed out a policy that would require employees of private companies with 100 or more workers to get vaccinated or undergo regular testing and wear masks. But the move immediately drew legal challenges that could prevent the policy from going into effect. Having used politics, culture, and public health infrastructure to get buy-in from Puerto Rico’s population, the island’s government has faced no such challenges.

Getting three-fourths of its population vaccinated took time and groundwork, meaning other states and territories may not be able to directly emulate its strategy. The previous presidential administration didn’t prioritize science over politics, and it is too late to go back and change that. Had the Trump administration made choices as those in Puerto Rico did, there might not have been such resistance to vaccination. It’s not too late to apply lessons to the future, however: States and the federal government can make greater investments in public health infrastructure and can continue to work to make it easy to access vaccines.

“Let the scientists lead public health policy. And once this is over, we can continue discussing politics,” Rodríguez-Orengo said.