In Fiona-ravaged Puerto Rico, hospitals were prioritized over health clinics for diesel, exacerbating rural health disparities

When Hurricane Fiona knocked out power across the entire island of Puerto Rico, hospitals turned to diesel-fueled generators to keep the lights on and critical machines running.

Community health centers — often the most accessible medical facilities in the poorest districts of the island, those hardest hit by hurricanes — couldn’t immediately do the same. Some had to wait 10 days or more to buy the fuel they needed. Others cut their hours way down. As the diesel supplies dwindled, they prayed.

Any emergency support they did get was from their own circles: Some community health centers kept vaccines or medications for others that were running out of fuel and had no solar panel-powered fridges; one center relied on a former colleague who owned a small gas station.

Now, community health center leaders and other advocates are waging an awareness campaign to ensure that if and when another natural disaster hits Puerto Rico, the island’s emergency response considers the needs of both hospitals and community health centers, not one over the other.

Advocates say the discrepancy hurts rural residents and those with mobility issues in particular. The community clinics faced the same inequities after 2017’s Hurricane Maria, and they’re sick of waiting for the government and agencies such as FEMA to learn lessons after another natural disaster.

“We’re talking about cutting off continuity of care, limiting patients’ access to care … which is dangerous,” said Tania Rodríguez Morales, executive director of Migrant Health Center, Western Region, in Spanish. “You shouldn’t play with people’s health, and what just happened — not prioritizing community health centers, not even giving us a call, obfuscating the current situation — it shows the country isn’t prepared to attend to patients’ health and to manage itself.”

A spokesperson for the Puerto Rico health department explained that in emergency responses, Puerto Rico’s government does prioritize hospitals over community health care clinics. She emphasized that the government considers all health care facilities “essential,” but didn’t respond to questions seeking clarification about how the department prioritizes different facilities in that category. The spokesperson said in Spanish that hospitals, which “deal with life and death situations” in their round-the-clock ERs, would “of course get all kinds of resources — be it water, diesel, electricity — first.”

A spokesperson for FEMA said via email that the agency works with state and local governments on decisions like this. She explained that “life-saving facilities,” including medical facilities, are first priority in an emergency response. But within that top tier, FEMA’s prioritization depends on multiple factors, such as how long the facility has been going without electricity, the populations it serves, and the operating status of its generators. The spokesperson also mentioned that the facility’s ownership is taken into account, but the criteria — public facilities and some private nonprofits that receive federal assistance are prioritized over private, for-profit facilities — doesn’t drop community healthcare centers lower on the priority scale.

Fiona made landfall in west and southwest Puerto Rico on Sept. 18, triggering floods and an islandwide blackout that persists for tens of thousands of residents amid the island’s weak electrical grid. Many residents and medical facilities, shored up with generators after María, needed diesel.

ERs need it to power ventilators and monitoring equipment. ORs, to maintain stringent temperature, ventilation, HVAC, lighting, and monitoring requirements. Community health clinics needed it to refrigerate vaccinations and medications, and to operate services ranging from urgent care to radiology to mental health and substance use counseling. It was also critical for all medical facilities to keep the lights on and electronic medical records accessible.

But when a national disaster like Fiona strikes, community health centers have to wait for hospitals to have their fill of fuel before they can get a drop.

Also known in Puerto Rico as “330 Primary Health Centers,” as they’re financed through Section 330 of the Federal Public Health Law, these private nonprofit organizations offer primary and preventive medical services, regardless of patients’ ability to pay.

They’re the lifeline for large swaths of residents in Puerto Rico. Many, particularly those outside the San Juan metro area, have limited access to medical providers, which are unevenly dispersed throughout Puerto Rico. For those communities most affected by Fiona — concentrated in the southern and western sides of the island — the community health centers are their go-to medical facilities. Sometimes they’re the only healthcare facilities these residents can access.

When directors at those centers in southwest Puerto Rico made calls to their regular diesel suppliers, they were told only that they were on a waiting list. Rodríguez Morales said her suppliers told her they had gotten orders from high up to ration their fuel, reserving it for hospitals. That left the 21 community health centers across the island uncertain about whether and how they would weather the diesel drought.

Adding insult to injury, local health departments called up centers such as Migrant Health and asked them to store vaccines for private medical offices that lacked generators. The municipal offices in Mayagûez, San Sebastian, Isabela, and other regions knew Migrant Health had solar-powered fridges. After Hurricane Maria, organizations such as Hispanic Federation, Project HOPE, and Direct Relief had invested in preparedness projects such as solar panels and radio communications with centers like theirs.

“We gladly took care of their vaccines, but they didn’t call us to say, ‘Let’s give you diesel,’” said Rodríguez Morales. “This always happens. Every time an atmospheric event occurs, they turn to us … They always expect us to say yes, and we do, because it’s about the people. We’re open to collaborate and help 100%. But in our hour of need, when it’s the other way around, we don’t enjoy an equal exchange.”

Some nonprofits that only recently received fuel for their backup generators or only just got electricity are worried that the rationed supply they have will run out, interrupting services during the next blackout, common with Puerto Rico’s power grid even before Fiona.

None of the sources who spoke with STAT knew exactly how decisions like diesel prioritization are made during emergency response situations in Puerto Rico, especially among different types of health care providers. As in any major disaster, the response is a mix of efforts from state and local governments, FEMA, the Army Corps of Engineers, and sometimes nonprofits like the Red Cross.

The operation may simply have been trying to be “flexible to the needs of the operation at the moment, doing their best in an effort to save lives and protect property,” said Jennifer Carlson, a professor of emergency management at Anna Maria College in Massachusetts. Annie Mayol del Valle, a former chief of staff for the Secretary of Puerto Rico Department of Health, agreed, likening the layers of prioritization to triage in an ER.

Costa Salud, a community health center headquartered in Rincón, finally got diesel on Oct. 5. The clinic sees an average of 300 patients a week in its ER alone, and offers a bevy of services ranging from internal medicine and family practice to children’s vaccines and Covid-19, monkeypox, and flu shots.

When STAT spoke to Susana Pérez, the facility’s executive director, their social workers, nurses, and a family practice doctor were getting ready to do their weekly home visits, a trip that entails trekking up mountainous terrain in a Jeep — running on precious diesel — to visit some 160 patients who can’t leave their beds.

While Costa Salud now has electricity restored in all its clinics, Pérez is worried about the next potential disaster.

“We shouldn’t be in a constant state of uncertainty,” she said in Spanish.

Migrant Health Center, like Costa Salud, has now gotten diesel, albeit in ragtag fashion. Its clinic in Lajas, an area devastated by flooding after Fiona, got electricity only two days ago. But for more than a week, Migrant Health was placed on the same waiting list as the local Walmart, says Rodriguez Morales. They would get their turn “in a limited way,” a major supplier told her. After all that waiting, the centers only got a fraction of the diesel they’d ordered.

Rodríguez Morales remains indignant, reflecting on how some hospitals that serve few patients get all the priority during critical times — while community centers in the same areas serving many more patients need to wait it out for basic resources. Some of Migrant Health Centers’ sites, such as Maricao and Las Marías, serve a medical desert, where they’re the only accessible healthcare facility for certain services.

She remembers just two weeks ago, when she was frantic with worry that her patients would run out of meds waiting for refills their centers couldn’t supply without working fridges. When she was panicked that her clinics’ nearly 300 patients with HIV might not get their treatment, and that nearly 1,200 unhoused patients would see their medical care disrupted, too.

The first weekend after Fiona, Rodríguez Morales called up and emailed everyone she knew in high places: officials from the mayor’s office, the executive director of the Primary Healthcare Association of Puerto Rico, a local emergency management representative, among others. She was hoping to get on their radar about diesel needs before everyone else.

Before Fiona, preparing for the island’s frequent blackouts was a no-brainer: they’d call up their regular diesel vendors and get the gas tanks faster than an Amazon prime delivery. Since Fiona, it didn’t matter how loyal a customer they were, or the fact that they had pre-ordered fuel to prepare for the hurricane. They were just another customer.

The waiting game wasn’t her only major concern. Generators, designed to back up centers for a blackout of just a few hours, weren’t meant to run 24 hours a day. In health centers that do, these generators “take a big beating,” as Rodríguez Morales puts it.

Even private hospitals have issues with generators when they’re overused in emergencies.

The lights went out at Hospital Pavía – Santurce, for example, when respiratory therapist Maria Casiano Ramos was in the middle of an open heart surgery. The facility was, by all measures, well-equipped to deal with the disaster. Generators were in place, and Pavía – Santurce had been among the first to get a supply of diesel while it was in high demand. But after 10 days of constant use, the generators were battered and prone to glitches.

This particular glitch lasted 7 minutes. Ramos’s heart raced with stress, making those minutes “feel like an eternity.” A physician in the OR reassured his colleagues their machines had 30 minutes of battery left. Nothing but a dim light from the hall — and Ramos’s cell phone flashlight — illuminated the rest of the open heart surgery until the hospital generator restarted.

“Up until now, in my workplace, everything has been operating fine — except for that 7-minute episode due to a mechanical failure, not a lack of diesel,” said Ramos, citing the persistent power grid issues.

Meanwhile, the community health centers’ demands for prioritization are charged. Some advocates are calling for the Puerto Rico government to overhaul the current diesel dispensing system to make it more equitable. Some centers are taking their fuel needs into their own hands, revving up their storage capacity for diesel so they’re not left hanging during the next diesel crisis.

“Many of these centers, if they had two tanks of X quantity before, now they’ll have three or four tanks,” explained Alicia Suárez, the executive director of the Association of Primary Health of Puerto Rico, which supports community health centers across the island, in Spanish. “Because now we’ve seen that they need a higher storage capacity … especially if they have a higher volume of patients.”

Still others say the future lies in a movement toward solar panels, particularly since the climate crisis is contributing to more intense disasters.

Some think any policy move should start with the language: community health centers need to be considered “critical infrastructure,” a term thrown around in policy spaces, municipal laws, and in the current emergency response operational plan for Puerto Rico’s healthcare but not used in reference to community health centers.

Feygele Jacobs, a longtime researcher and advocate for community healthcare centers in the U.S., said the Covid-19 pandemic, like Maria before it, laid bare how essential community health centers are in Puerto Rico and around the country — and argued that resource prioritization should reflect that.

Still, this shift in prioritizing community health centers likely won’t happen if they don’t get formal recognition from the territory’s government, said Pérez. Some community center advocates say the situation would look very different if they were represented in the Puerto Rico Health Insurance Services Administration, ASES, an administration-appointed board of directors that largely shapes healthcare policy in Puerto Rico and has been embroiled in transparency debacles for years.

Suárez wants people to remember that community health centers also keep hospitals from overflowing with patients who require emergency care during public health emergencies. Ignoring their needs only makes things harder on hospitals.

Greater public and government awareness is key, all the advocates said: knowing the breadth of care and communities served at these centers, grasping how many and which people are most affected, and learning what it’s like for centers running on fumes during disasters, might help the cause.

”We’ve got to keep knocking doors and collaborating when we can,” Suárez said. “In every emergency there are going to be some areas much more affected than others, and in those highest need areas, there’s got to be a collaboration so that hospitals and primary healthcare centers in those areas can both get resources.”

This post has been updated.