Weeks before the first reported case of Covid-19 in Puerto Rico, it was evident that our public health system was unfit to address the looming crisis. In January 2020, as news of a deadly and highly contagious virus that was ravaging cities across China began to circulate worldwide, the island’s then health secretary, Dr. Rafael Rodríguez Mercado, told the local press that he wasn’t concerned about the disease spreading via regular travelers because there were no direct flights between China and Puerto Rico. He was, however, worried that the virus might make its way to our shores through “illegal (migrants) from China.” By then, there were confirmed cases in several countries, including the United States, which is the point of departure for over 4 million yearly air travelers to the island.
Less than a month later, on March 17, Puerto Rico suffered its first suspected coronavirus-related death. It was a diabetic man who resided in San Juan’s Luis Lloréns Torres public housing complex. Although the details surrounding his infection and demise are unclear, since the cause of death was officially registered weeks after, the timeline suggests that the virus could have been circulating in the island since February, or even before. What did become clear by mid-March was that, despite all the governmental assurances to the contrary, we were about to experience another major disaster in Puerto Rico.“During this crucial period, the government failed to adequately prepare for the inevitable relaxation of lockdown directives.”
Lacking the necessary public health capacity, the government quickly turned to the most effective yet bluntest tool to fight the virus: an island-wide lockdown. The strict confinement measures lasted from mid-March until late May, and while it had an adverse impact on the local economy, it helped contain the spread of the coronavirus to levels that the island’s feeble health infrastructure could manage. Nonetheless, during this crucial period, the government failed to adequately prepare for the inevitable relaxation of lockdown directives. As a result, essential tools to contain the coronavirus were lacking, such as effective public education campaigns, widespread testing, reliable statistics, and a robust contact tracing strategy. What did transpire were a series of shady transactions and corrupt dealings in the procurement of essential materials and services that further revealed the crass ineptitude at the top levels of local government and contributed to the substandard public response.1See José Atiles Osoria, “The COVID-19 Pandemic in Puerto Rico: Exceptionality, Corruption and State-Corporate Crimes,” State Crime Journal 10, no. 1 (2021): 104–125. Once shelter-in-place directives were significantly relaxed, infections spiked.
There was, however, an important advancement, a bright spot, in the midst of the rapidly unfolding debacle. In the rural municipality of Villalba, located in the southern region of the island, a team of municipal workers, led by an enterprising molecular epidemiologist, were working intensively on designing and implementing a homegrown contact tracing operation that would prove widely successful and become the standard for the rest of the island. Given the complicated fiscal environment that most municipalities in the island are facing—especially small towns like Villalba with a declining population, a small economic base, and austerity budgets—it is somewhat puzzling that it became a seedbed of public health innovation during the coronavirus pandemic. How did they do it? And what useful lessons for other municipalities and the central government can be drawn from Villaba’s experience? These were some of the guiding questions that inspired me and a group of colleagues to conduct a series of in-depth interviews to delve deeper into this interesting and inspiring case.2The project is a collaboration between Ciencia Puerto Rico (Ciencia PR) and the Center for a New Economy (CNE). Collaborators include: Giovanna Guerrero, Marcos López Casillas (CienciaPR), and Raúl Santiago-Bartolomei (CNE).
Puerto Rico’s cascading disasters
Since 2006, Puerto Rico’s economy has been in a tailspin, due, in great part, to the absence of a coherent set of programs, investments, and policies that advance equitable and sustainable development opportunities.3See José Antonio Ocampo, Deepak Lamba-Nieves, and Sergio Marxuach, “Devising a Growth Strategy for Puerto Rico” (policy paper, Center for a New Economy, June 2016). For decades, politicians and policymakers have relied on strategies that depend heavily on the use of creative tax policies to attract foreign investments but produce very little in terms of jobs and socioeconomic opportunities for the majority of the population.“What we have today is a system that is fragmented, uncoordinated, prone to corruption, and consistently fails to deliver quality services and equal access.”
Throughout this period, Puerto Rico’s residents have endured the harsh impacts of an economic depression, a debt and fiscal crisis, the imposition of a control board by the US Congress that has carried out a draconian austerity agenda, two major storms—including Hurricane María, a devastating category 5 hurricane—and a swarm of earthquakes that destroyed many buildings across the southwestern part of the island. These cascading economic calamities and catastrophic events have steadily eroded the island’s feeble public sector, especially our health system, which began to be dismantled in the 1990s through a series of privatization reforms that sold most of its infrastructure to the private sector while it changed its role from a direct provider of services into a regulator of private insurance companies.4See Jessica M. Mulligan, Unmanageable Care: An Ethnography of Healthcare Privatization in Puerto Rico (New York: NYU Press, 2014); Joan Benach, et. al., “What the Puerto Rican Hurricanes Make Visible: Chronicle of a Public Health Disaster Foretold,” Social Science & Medicine 238 (October 2019): 1–10. Thus, what we have today is a system that is fragmented, uncoordinated, prone to corruption, and consistently fails to deliver quality services and equal access. In the aftermath of Hurricane María, the Puerto Rico Department of Health’s (PRDOH) prolonged decay was evidenced by its lack of an emergency response plan and its inability to adequately record and provide information on disaster-related deaths. By the time Covid-19 arrived, many had grown accustomed to distress and failure, and overused terms like “resiliency” had long outlived their popularity and usefulness.
Building public health capacity in the mountains
Concerned that her mother and many more elderly residents in the town were ill informed about municipal efforts to combat the novel coronavirus in the early days of the pandemic, Fabiola Cruz, a doctoral student in public health and Villalba native, reached out to the town’s mayor and proposed a series of measures that could be easily implemented. From then onwards, Cruz and Mayor Luis Javier Hernández Ortiz began working together and established a highly effective and trusting partnership that initially led to the development of science-based protocols, guidelines, and educational campaigns for Villalba. It wasn’t long before Cruz became convinced that the town could pull off building and deploying a contact tracing program. By late March, she began designing a program guide with materials developed for the Ebola crisis, and built a basic information management system using free, cloud-based platforms. Throughout the following weeks, municipal workers with backgrounds in social work and psychology, and with prior experience in the provision of direct services to the community, were recruited and trained to carry out the sensitive detective work, information gathering, and support that is at the heart of contact tracing efforts.
A key tool in public health, contact tracing involves getting in touch with infected persons, asking them about their symptoms and when they started, who they’ve come in close contact with, and taking the necessary steps to help patients and their contacts get tested and stay quarantined to prevent the disease from spreading further. During the early stages, data and information exchange between testing facilities, the PRDOH, and the municipal authorities was deficient and unreliable. As a result, Villalba’s contact tracing program relied on people voluntarily calling a designated hotline to seek help and information. Basic educational campaigns, focused on explaining the severity of the crisis, the importance of tracing and monitoring, and the services that the municipality was offering—like free testing, delivery of food and meals, counseling services, and the like—were instrumental in drawing participants to the program. These communication efforts led to a large volume of calls, especially from elderly persons, with basic questions about the virus and the services that the local authorities could provide.“Villalba’s tracers quickly became aware that compassion and building rapport with individuals, and sometimes not pestering them too much at the other end of the phone line was crucial.”
Because they were navigating in relatively uncharted waters, the team had to learn and adapt as they moved forward. Despite its widespread use across the globe, context matters greatly when trying to successfully implement a contact tracing operation. Villalba’s tracers quickly became aware that compassion and building rapport with individuals, and sometimes not pestering them too much at the other end of the phone line was crucial. These qualities would come in handy especially when, frustrated and fearful, some traced participants would lose their temper or become agitated. Furthermore, as they routinized tasks, tracers and other staff came up with strategies and tools to facilitate daily toils and troubleshoot any unforeseen situations. For example, to keep each other informed and build camaraderie, especially when everybody is working from home, the team set up an encrypted chat where they shared information about cases, concerns, asked questions, and received timely feedback from Cruz and Eva Gordián, another epidemiologist who also assisted the effort.
Collaborations also proved crucial to the success of Villalba’s contact tracing program, especially those with municipal dependencies. Local government employees not part of the tracing operation were in charge of meal preparation and delivery, as well as the provisioning of masks and sanitizing equipment, to anyone who requested them through the hotline. In addition, to deal with the significant influx of travelers from the US mainland to Villalba once the lockdown was relaxed, the contact tracing team established an anonymous tip hotline with the Municipal Police. If someone suspected a household was harboring a traveler from abroad, they could confidentially phone the police, who followed up with a home visit to inform recent arrivals about the importance of registering with the contact tracing program. As the deputy mayor, Marena Navarro, explained, the contact tracing program required coordination at multiple levels of the local bureaucracy. Thus, there was a collective sense of responsibility and commitment. In our interviews, tracers and other staff talked about the large volume of calls, extended conversations, and long workdays in ways that demonstrated a sense of pride in their work and knowledge of the responsibility that rested on their shoulders.
Taking it to scale and drawing lessons“Early on, Cruz understood that contact tracing efforts needed to go well beyond Villalba in order to effectively contain the spread of the disease.”
Shortly after Villalba’s program was up and running, word spread and mayors of nearby towns reached out to Mayor Hernández seeking guidance on how they could build their own programs. By May 2020, a partnership was established with the nearby municipalities of Yauco, Orocovis, and Guayanilla. Early on, Cruz understood that contact tracing efforts needed to go well beyond Villalba in order to effectively contain the spread of the disease. Thus, she began working with other epidemiologists from nearby towns and encouraged the mayor to convene his peers to share his insights and experience. Soon, new contact tracing initiatives began to surface across the island. As public attention grew, and the PRDOH struggled to build a robust centralized tracing program, Dr. Lorenzo González Feliciano—the fourth top executive to lead the agency since the start of the pandemic—decided to support the diffusion of the municipal model and take it to scale. Cruz was hired to lead these efforts, and the now centrally coordinated system, known as the Sistema Municipal de Investigación de Casos y Rastreo de Contactos (SMICRC), includes 77 out of 78 municipalities in Puerto Rico. According to their most recent report, SMICRC employs 647 persons across the island who are tracing and monitoring 98 percent of all confirmed Covid-19 cases in participating municipalities.
It’s easy to attribute the success of Villalba’s contact tracing operation to the zeal and dedication of a hometown epidemiologist and the leadership of a seasoned mayor. But those easy explanations blur out important aspects of a more complex story about experimentation, learning, and risk taking. In many ways, one of the keys to understanding what led Villalba to pioneer and undertake a contact tracing operation lies in how municipal officers across the island have, over time, devised effective responses to a series of challenges.
Most municipal governments have been hard hit by the protracted economic crisis and the austerity policies that have been implemented in Puerto Rico for a decade and a half. Puerto Rico’s Control Board, which unilaterally determined that cash transfers made by the central government to local towns would be phased out and ultimately eliminated, worsened the economic crisis. As a result, local governments have been forced to “do more with less”—especially those towns with small tax and economic bases. Belt tightening mandated from above has pushed municipalities to assume responsibility for tasks required of the central government, like basic maintenance and upkeep of state roads and green areas, and come up with ways to fill voids in services. But beyond filling in gaps left by the politics of austerity, they have also shown a unique ability to respond effectively in moments of crisis.“Working together with the Puerto Rico Electric Power Authority (PREPA) and Medtronic…they were able to fix a big section of a water pipeline that María had destroyed so that the Toro Negro Hydroelectric Plant could operate.”
When Hurricane María tore through the island, leaving a trail of destruction and the whole island without power, most municipalities were forced to step up and become the primary purveyors of emergency services, relief, and assistance. In Villalba, as weeks passed and electricity was not restored, Mayor Hérnandez saw an opportunity to put into motion a plan to generate electricity for the town that his team had drafted before the storm. Working together with the Puerto Rico Electric Power Authority (PREPA) and Medtronic, a multinational manufacturing firm and the town’s main employer, they were able to fix a big section of a water pipeline that María had destroyed so that the Toro Negro Hydroelectric Plant could operate. Built during the 1920s, the facility had been underused for decades. But once they got it working, it generated enough power to provide water for half the residents and electrify a third of the town, including schools, health facilities, the police precinct, and the manufacturing plant.
This exploratory case shines a light on some of the “pockets of effectiveness”5Erin Metz McDonnell, “Patchwork Leviathan: How Pockets of Bureaucratic Governance Flourish within Institutionally Diverse Developing States,” American Sociological Review 82, no. 3 (2017): 476–510. that exist in a colonial context and within a battered and “right-sized” public sector. While Villalba’s story demonstrates the ability of local leaders and volunteers to effectively troubleshoot and respond to disasters, more research and analyses are needed to identify similar examples both across municipalities and within the central bureaucracy, to carefully explain why innovative solutions flourish in certain contexts and not others, and to better understand how inventive municipal initiatives can be adapted and taken to scale.
At this point in our research endeavors, we have more questions than answers—and some initial hypotheses—on why a successful contact tracing effort emerged in Villalba and not elsewhere. As we move toward testing propositions and answering research questions, we are guided by Judith Tendler’s inspiring work on well-performing public sector initiatives.6See Judith Tendler, “Research questions for: The Ford-Foundation’s Innovations in Government Programs: Documentation, Evaluation, and Dissemination” (Department of Urban Studies and Planning, Massachusetts Institute of Technology, 1998); Judith Tendler, Good Government in the Tropics (Baltimore: JHU Press, 1997). As her meticulous research and analysis suggests, we must look at past trajectories and achievements (well before the program started) to uncover sources of inspiration that predate current administrations; explore links with other levels of government, universities, and groups outside the municipality that provided critical support to existing initiatives; avoid “easy” and incomplete answers based on popular or in-vogue policy and academic ideas (like decentralization and public-private partnerships, amongst others); and resist the temptation to consider Villalba’s experience as unique and special—and therefore hardly replicable.
Moreover, we must not lose sight of the fact that Villalba’s story is not just an uplifting tale in the face of mounting disasters in Puerto Rico but also a reminder that some of the solutions to our numerous predicaments can come from within our own shores, especially in small towns far from metropolitan hubs and at levels of government we tend to overlook.
Banner photo: Spc. Kevin Torres/U. S. Army National Guard/Flickr.