VIEQUES, Puerto Rico — Ana’s water broke at midnight.
They took her to a makeshift emergency room in an empty community center in Vieques. She was put on a stretcher and told that she was fine, that she still had no contractions. She was writhing in pain, sweating. They changed her clothes and gave her a robe to wear.
“From now on, you’ll stay wet,” said one nurse, the only thing she told Ana.
After hours of waiting in pain, Ana was transferred to an air ambulance in the dead of night to Puerto Rico—“the main island.” The plane ride should have lasted about 20 minutes, but in mid-air and mid-birth, the journey felt longer. The baby’s father didn’t want to come at first: The planes are unstable, and the wind hits in powerful gusts sometimes, shaking passengers.
“But I forced him,” Ana told Latino Rebels.
This is how Ana remembered the day she gave birth.
The Fajardo region, which includes the islands of Vieques and Culebra, had the worst maternal and child health status for 2018, according to the Comprehensive Maternal and Child Health Index for Municipalities of Puerto Rico (IISMIPR) created by the Department of Health of Puerto Rico. In the 2010 report, Vieques was already among the municipalities with the worst indicators in this area.
For years, Vieques and Culebra, which form part of the Puerto Rican archipelago, have not had delivery rooms or adequate maternal care or child health services. In 2017, Hurricanes Irma and María destroyed Vieques’ only hospital. Last week, the current governor of Puerto Rico, Pedro Pierluisi, presented a plan for the new facility, which is projected to finish an ambitious construction in just 36 months by 2024—an election year. It took four years to award an auction for the conceptual design of the new building. At least seven years will pass without having a complete medical facility on the island.
Since not everyone in Vieques and Culebra has access to an air ambulance like Ana did, it usually takes 40 minutes to an hour to reach the main island of Puerto Rico. Once there, it also can take around another hour to get to the nearest hospital. Residents suffer recurrently from a lack of access to sufficient health services, food, gas and other basic supplies, as the primary mode of transportation is an unreliable ferry service in the process of changing operations to a private company.
Highest Fertility, Low Birth Rates
Despite having the highest fertility rate in Puerto Rico (78.8%), Vieques was among the municipalities with the lowest birth rates. Also, among municipalities with mothers whose prenatal care began later, both islands have low percentages of average and above average births—Vieques with 54.6% and Culebra with 70% respectively, as revealed by the 2018 data.
Vieques has the highest perinatal rate in Puerto Rico. It is also among the municipalities that reported the highest rates of fetal deaths. Both Vieques and Culebra have one of the highest rates of teenage pregnancies in Puerto Rico.
In addition, Vieques has the lowest rate of prenatal care in Puerto Rico and one of the highest rates of fetal deaths per inhabitant. There are still no statistics on how the pandemic has impacted maternal and child care, nor births and infant deaths registered on the islands.
“Everything is so unnatural. We want to give birth here. The health department must provide us with a space. We need public health and prevention programs, nutritionists, mental health, geriatrics…. There are too many elderly people alone too,” Ana said.
There is a long history of struggle to remain on the islands. In the specific case of Vieques, the island was occupied by United States Navy as a training range for more than 60 years. Throughout several decades, repeated attempts were made to displace or relocate the local community. The Navy even considered removing the island’s dead from their graves to prevent residents from remaining and returning.
Despite intense pressure from authorities, many residents stayed. After decades of military bombings and exercises, most of the damage has yet to be cleaned. Vieques now suffers from Puerto Rico’s worst cancer rates, 27% higher than mainland Puerto Rico. Lands were used for training in every major U.S. military exercise since the 1940’s. The Navy has admitted to using napalm, depleted uranium and a host of other toxic chemicals and heavy metals as part of their military practices.
No Protection From the Pandemic
For Sarah, another woman who spoke to Latino Rebels, the scariest thing about her second pregnancy was being forced to go to the main island in the middle of a pandemic, where there were more cases of COVID and a higher risk of exposure. Getting to the main island meant waking up extremely early in the morning to board the Mr. Mason boat, where she said that “only 34 people fit, in an enclosed space, very unsafe. Even getting up early, arriving there before five in the morning, there was a line.”
She compares her experience with the delivery of her eldest son in 2015, who was born in Vieques at the old hospital.
“If I had to choose, I would choose here [Vieques], although there were no machines or luxuries or anything, but at least my son was born in Vieques, and that was something very important to us,” Sarah said.
She explained that “everything has gone well for me, and my children are healthy but if it were another case .. And I had a pretty sick baby with something, and that the baby would need a doctor or treatment regularly, one has to think… you cannot live here. I know that has happened to people.”
Shortly after the birth of Sarah’s eldest son, he injured his head, like children often do. Sarah had to be transported by air with her son to seek basic medical care. It is an experience that she hasn’t forgotten.
“They sent us by plane at around ten at night to go to the medical center [on the main island]. On that little plane, very little. It was very windy. And well, they sent us to do that because here they did not have the equipment to tell us if the baby was okay,” Sarah said.
She knew she could give birth at any moment, so in the case of her daughter, she remained on the main island, renting an Airbnb in San Juan and paying for transportation to and from her appointments until she gave birth. Many births from Vieques and Culebra end up getting registered in mainland municipalities as several mothers reported they have not been able to register their children due to delays at the local office.
Other basic elements of child healthcare like vaccines are only available in a temporary care room where a main island pediatrician visits once a week attending a limited number of patients. Mothers are forced to wait months or travel to the main island to get their children vaccinated.
Income demographics show a population of very low socioeconomic status, which becomes a crucial element when needing to obtain medical services in the islands. According to 2018 estimates, over 41% of both islands’ populations live below the poverty line.
These indicators have begun to change, however, as more outsiders move to the islands. Since the Navy left Vieques, the cost of living hasn’t stopped rising and services are tailored more and more for the benefit and enjoyment of tourists and new residents with higher income.
At the same time, pregnant women on the islands are facing a state neglect that does not provide health services and does not allow them to give birth on its islands, forcing women like Ana and Sarah to give birth away from Vieques and Culebra.
Human Rights and Maritime Transport
A 2020 report published by Santa Clara Law International Human Rights Clinic concluded that the lack of a reliable maritime transportation system between Puerto Rico and the municipal islands of Culebra and Vieques violates international human rights law.
As a result, the report argues, Puerto Rico has not guaranteed human rights, burdening or even making it impossible to arrive at a doctor’s appointment on the mainland in a timely manner. Deaths had resulted due to an inability to reach the mainland for life-saving services that are unavailable to them on the municipal islands.
Emergency medical transport from the two municipal islands is limited to one emergency plane, shared by both islands, which has been characterized by residents as cramped, unsanitary, and staffed by unprofessional attendants. The ferry system is not compliant with the Americans with Disabilities Act (ADA), as it presents difficulties for individuals with disabilities who must travel to the mainland for medical services.
The change of the maritime transport terminal was carried out hastily and without community approval, without planning, permits, or permanent structures. Travel time to hospitals and most doctors upon arriving in Fajardo, at the old terminal, used to be about 20 minutes. After changing the terminal to Ceiba, the distance by land has tripled, along with the cost. Inequality has also multiplied.
Pregnant women in Vieques and Culebra incur high economic, emotional, and psychological costs just to give birth and cover the basic needs of their children—a cost passed on to mothers after the privatization of hospitals carried out by ex-governor Pedro Roselló’s administration in the 1990s. In addition to the telephone industry, Roselló privatized the island’s health system by selling hospitals and municipal health services to private interests at fire-sale prices. Many municipalities, especially the small ones, lost their hospitals, as they were not profitable.
Vieques and Culebra, due to their geographical and political reality, have had a decades-long history of shortages of doctors, health services, and education—access to the most basic rights. The frustration has already displaced thousands from these islands.
To give life among all this chaos is to resist.
Diana Ramos Gutiérrez is a journalist and human rights advocate based in Vieques, Puerto Rico. Twitter: @dramosgutierrez