by Aida Haddad, MDiv at Indiana University School of Medicine
In-Training: https://in-training.org/lessons-from-puerto-rico-18871

This follow-up is built upon a reflection I wrote for the Fossil Free PCUSA blog and a presentation I gave to family medicine residents during a global health didactic session at Indiana University School of Medicine. 

In my last piece on Puerto Rico, we dug into the history of American imperialism and the resulting health care crises spanning from the colonial era to the present day. I presented my case that the U.S. empire plays a major role in the Puerto Rican peoples’ worsening exposure to the climate crisis, namely through the lens of limited health care access after Hurricane María. I promised to follow up, sharing how our August delegation impacted my worldview as a future physician. So here we are; I will do my best to follow through.

During our delegation we learned from Puerto Rican experts in their fields and acting first responders about implementing lasting social change since Hurricane María. Each expert’s lecture seemed to revolve around relief, recovery and resilience. Not one lecture began with María. Instead, each lecturer started with their work in community development that began long before and apart from the hurricane.

Right away, my first assumption on the implementation of disaster relief was proven wrong. What I thought would be lectures on the present state of relief implementation and its pitfalls were actually stories of building community through interpersonal relationships over many years. Every expert we heard from had a history of at least ten years of community engagement prior to María.

As a future physician, or at least someone who looks for unambiguous solutions to tangible issues, this left me feeling restless. But these lectures also offered a simple solution to lasting change: stick around, assess community health care needs, build a relationship with these community stakeholders and organize, or follow those already on the ground. Social change is an ongoing and meticulous process, not a reaction. Simple, yes. Easy? Not at all.

Iniciativa Comunitaria (‘Community Initiative’ in Spanish), founded by Dr. José A. Vargas Vidot, was “born out of necessity at a time when HIV/AIDS education on treatment alternatives was limited” in 1990s San Juan. As these local HIV/AIDS initiatives evolved into a hub for those seeking addiction health care, primary care and sterile needle exchange, the organization also sent health brigades to Guatemala during a continued time of political instability and to Haiti post-earthquake in 2010.

This combination of local community relationships and international disaster relief work qualified Iniciativa Comunitaria’s staff to offer health care relief to its own after María made landfall. According to Alex Serrano, Iniciativa Comunitaria’s head of community relations, the organization sheltered 95 homeless people in their detox center, provided 4,200 meals, offered health care to 2,615 Puerto Ricans by way of street medicine (including free psychology consults) and provided medical attention to 3,567 people at their Clinica de Salud Comunitaria B’antiox out of a daycare center in Toa Baja, Puerto Rico. Importantly, however, Iniciativa Comunitaria’s first response to Puerto Rico’s hurricane victims began in the 1990s, not in September 2017.

Dr. Vargas Vidot’s work taught me that a physician’s work requires intentional proximity to the patients. Yes, doing clinical work abroad or in disaster areas can be part of our vocation as future physicians, but those works of justice tend to benefit those far away at the expense of missing our neighbors’ daily health care needs. Iniciativa Comunitaria started in the underserved corners of San Juan — not in Guatemala. The organization did not forget about its neighbors for the sake of the wider world.

I am not trying to promote an ideology of scarcity by suggesting, “If our neighbors don’t have enough, then what are we doing giving to our global neighbors?” Rather, I am approaching said dissonance from a framework of abundance. We have enough resources to care for those within and beyond our borders; however, many physicians and health initiatives are compelled to travel abroad, offering the care everyone deserves to only a select few. Hypocrisy blossoms out of international medical brigade work when we have neighbors in need of the same health care — those who have fallen through the cracks, who are unfairly labeled unworthy or who are considered failures.

That said, Iniciativa Comunitaria learned how to better care for their neighbors, post-María, as a result of their expanded embrace to Guatemala and Haiti. Alex shared that their team was able to mobilize quickly because of their prior experiences abroad in addition to their relationships in the San Juan area.

We encountered another example of locally-rooted relief that not only reinforced the importance of proximity, but also introduced the concepts of interdisciplinary recovery and, ultimately, resilience. Proyecto ENLACE and the Fideicomiso Caño Martín Peña are two non-profits in San Juan that launched a cooperative endeavor to ensure the health and prosperity of the area’s vulnerable populations living along the Martín Peña Canal. Estrella Santiago, a biologist and lawyer who serves as Proyecto ENLACE’s environmental area manager, offered historical context on the Martín Peña Canal neighborhood and posed a significant question: why would a group of people choose to live on such inhospitable, flood-prone land?

The move to the Martín Peña Canal wasn’t so much of a choice as a chance at economic survival. According to Estrella, Puerto Ricans moved to this area in the mid-20th century searching for employment after the United States abandoned rural sugar cane industry subsidies, and their descendants now call this place home. For Proyecto ENLACE and the Fideicomiso Caño Martín Peña, the goal is to restore the canal to ensure home remains home.

Proyecto ENLACE has partnered with the U.S. Army Corps of Engineers to dredge the Martín Peña Canal, thus protecting families along the canal from flooding. Estrella predicts that the land on the canal will become highly desirable — especially for the tourism industry — and that the wealthy will attempt to gentrify as soon as the flooding is controlled. The Fideicomiso (‘land trust’ in Spanish) has promised to prevent predatory land-grabbing after the canal is restored.

In the wake of Hurricane María, the families living along the canal — a flood zone — were wholly neglected by the municipality, the commonwealth and the federal government for weeks. Estrella fought tears as she recounted fatalities in the area. Due to the lack of electricity and potable water, the community lost many elders who suffered from lung conditions, cancer or being homebound. She mourned the total rejection of Puerto Rico’s most vulnerable populations in the wake of climate disaster. We sat with Estrella as she continued to share. She told us the stories of round-the-clock work for weeks on end and the transformation of their headquarters to a storage facility for emergency supplies.

Finally, Estrella also confirmed the countless lives saved because of the organization’s community development work beginning 13 years before Hurricane María’s landfall. Here, it was salient that a long-standing relationship between a local organization and community leaders offered more relief than the municipality, the commonwealth and the federal government combined. Proyecto ENLACE and the Fideicomiso — neither organization intending to focus precisely on climate disaster relief or health care — saved countless lives by sticking around, assessing community needs, building relationships with community stakeholders and inviting community members into positions of leadership. So when disaster struck, people were saved and damage assessed before a government employee could, or even would, set foot in their neighborhood. They had the infrastructure and necessary relationships in place to be able to respond while others were stuck planning and discussing how best to deliver relief from afar.

From Proyecto ENLACE and the Fideicomiso, I learned that a physician’s work is not only about proximity but also extends beyond the practice of clinical medicine itself. Does this mean I have to be an environmental scientist, a lawyer, a public health professional, a professor and a congresswoman to be a good physician? Or even two of those professions? No. Instead, the physician’s work beyond medicine means that now, more than ever, we have to lean on each other and other helping professions to walk alongside underserved patients in the fight for their lives. In the age of climate change in addition to widening socioeconomic disparities, racism and disaster capitalism, no well-meaning professional or person with a mind for justice can do effective work alone.

I had this conversation with a physician mentor the other day. She was telling me about her new interdisciplinary medical education curriculum that coupled spirituality and medicine, and how this position required her to reach out to experts in religious studies, theology and spiritual formation to implement it. Reaching out to other disciplines for help was a newer experience for her. And that struck me because it reflects my own experience of isolation throughout medical school; we have been siloed from each other to prove ourselves worthy of a competitive residency program.

Unfortunately, medical school leaves us ill-prepared to make sustainable social change alongside other disciplines. Instead, we are marketed combined degrees such as M.D./M.B.A.’s, M.D./M.P.H.’s, M.D./J.D.’s and the like. Fortunately, the real world does not align with this methodology. Estrella and the people of the Martín Peña Canal community taught me to help where I can, to collaborate with experts when I can’t and most importantly, to lean on other professions when addressing a future patient’s health care values.

After Estrella’s presentation, some of us spent the afternoon wandering La Perla, a neighborhood on the coast adjacent to Old San Juan, with much to think about. As we walked its streets, we noted a juxtaposition between María’s destructive forces and gentrification that feigned resilience by way of disaster capitalism. Signs of humanitarian disaster and displacement overwhelmed the senses. Murals offered space for lament and visions of hope and justice for the future.

As I let my mind wander with my feet, I could not help but think of what was lost in La Perla — lives, health, homes and any sense of security — without the work organizations like Proyecto ENLACE and the Fideicomiso had done along the Martín Peña Canal, filling the first responder disparity and protecting the neighborhood’s families from ensuing disaster capitalism. I could not help but think of what else may have been lost without Puerto Ricans caring for other Puerto Ricans in the face of gross governmental negligence.

Puerto Rico is filled with biologists, physicians, laborers and organizers, all of whom acted as first responders after María and whose stories we should have shared sooner than this delegation. During the delegation, we asked the experts questions — potentially offering a new perspective to their already comprehensive recovery efforts but more likely reassuring them that they were not screaming futilities into a void. We attempted to convey that we see them, we aim to understand them, we offer our grief to them and we will carry their stories across time and geographies. In sharing these two delegation vignettes, I hope I have highlighted the local multidisciplinary community organizing necessary to properly respond to a disaster when no one else will — when all you have is each other and help will not come for months, if not years, if it comes at all.

With this in mind, I commit to cultivating the skill of proximity — of sitting in grief with members of frontline communities and future patients. I will build a medical career founded in local, antiracist disaster relief wherever life takes me. Climate disasters will only get worse. Brown, black, colonized and socioeconomically disadvantaged people, like the members of the Martín Peña and La Perla communities, will continue to disproportionately suffer from these disasters and subsequent disaster capitalism.

I want to recruit you in organizing for a just world through interpersonal relationships with neighbors and other professions in the face of the climate crisis, greed and, at times, hopelessness. I assure you hope can be found in relationships. And justice moves only as fast as relationship forms.