Summary

This article specifically analyzes the serious deficiencies in Puerto Rico’s emergency healthcare system, including the lack of a fully accredited Level I trauma center, as well as the broader consequences for public health and disaster preparedness. Puerto Rico has more than 3 million U.S. citizens, but no trauma network, which can leave patients without proper care, particularly in rural areas, where delays often turn survivable injuries into preventable deaths. The wreckage wrought by Hurricane Maria in 2017 exposed systemic failures in medical infrastructure, including understaffed hospitals, disrupted supply chains, and fragmented emergency coordination. These problems persist even in routine emergencies, exacerbated by remoteness, inadequate funding, and unequal access to care.

Special attention is given to pediatric emergency preparedness, a neglected sector of healthcare on the island. At the 2025 Emergency Preparedness Summit, it was reported that 46% of childcare centers had never conducted emergency drills. Many caregivers also lack training in basic life-saving techniques such as pediatric CPR and the Heimlich maneuver, leaving children especially vulnerable in critical situations. These disparities are embedded in Puerto Rico’s colonial status and lack of full political autonomy. The territory receives lower federal reimbursements, was excluded from Medicaid expansion, and has undergone privatized health reforms that have widened the access gap. The paper ends with an appeal for broad policy reform. Immediate recommendations include the development of accredited Level I trauma centers, mandatory pediatric emergency training in educational institutions, and the establishment of a centralized trauma registry. Long-term solutions require equitable federal funding and a serious reconsideration of the political relationship that constrains Puerto Rico’s healthcare sovereignty. In conclusion, this paper argues that Puerto Rico’s health crisis is not the result of unavoidable events but of structural failures. Resolving them demands systemic reform, accountability, and sustained investment in health equity and resilience.

Introduction

Puerto Rico, home to over 3 million U.S. citizens, currently lacks a fully accredited Level I trauma center, with only one partially established facility located in the metropolitan area. In contrast, trauma systems in the mainland United States typically provide definitive care within the critical “golden hour.” However, patients in Puerto Rico often experience substantial delays due to geographic isolation, limited infrastructure, and chronic underfunding of healthcare services. These systemic shortcomings raise critical concerns regarding the adequacy and equity of the island’s healthcare system. This analysis seeks to examine the underlying structural forces contributing to these disparities, identify the key stakeholders responsible, and explore what policy and administrative reforms are necessary to prevent continued, avoidable loss of life (Colón & Sánchez-Cesareo 2019; Rodríguez-Madera et al., 2021).

This concern is not hypothetical; it has already manifested in real crises. The devastation caused by recent natural disasters has exposed the severe vulnerabilities of Puerto Rico’s healthcare infrastructure. Hospitals were left without power, water, or functional communication systems, and many collapsed under the weight of patient need and logistical isolation. Even major academic institutions struggled to provide basic services, relying on improvised systems and overstretched personnel to deliver emergency care. The disaster did not create these weaknesses; it revealed and intensified them. As documented by frontline physicians, the island’s lack of disaster preparedness, underfunded facilities, and disconnected care networks placed thousands of lives at risk and forced patients to be transferred off-island for treatment that should have been available locally. These failures mirror the same systemic issues that limit access to trauma care daily. Without a fully integrated trauma system, equitable funding, and robust emergency planning, Puerto Rico remains perilously unprepared not just for the next hurricane, but for the daily emergencies that continue to cost lives in silence. Understanding what happened during Hurricane Irma and Maria (2017), is essential to understanding why Puerto Rico still lacks a functional, resilient trauma care system and why addressing it is no longer optional, but urgent (Zorrilla, 2017).

Background

The lack of a fully accredited Level I trauma center in Puerto Rico reflects a deeper and ongoing contraction of the island’s healthcare infrastructure, particularly hospital-based services. From 2010 to 2020, Puerto Rico experienced a measurable decline in the number of hospitals, hospital beds, and surgical procedures across nearly all health regions, with the steepest losses occurring in areas outside the San Juan metropolitan corridor (Figure 1) (Stimpson et al., 2024).

This spatially uneven reduction in care capacity has had significant implications for trauma care access, with many patients in remote or underserved areas facing extended delays for definitive treatment. The consequences are especially dire in emergencies where timely intervention is critical to survival. As hospital resources continue to shrink due to systemic underfunding, disaster vulnerability, and uneven federal reimbursement policies, the fragility of Puerto Rico’s trauma system becomes increasingly apparent. Coordinated health planning, equitable resource distribution, and infrastructure reinforcement are urgently needed to reverse this downward trend and build a trauma system capable of serving the island’s full population (Stimpson et al., 2024).

Pediatric healthcare readiness is another area of grave concern. The absence of pediatric-specific emergency protocols, limited CPR training among caregivers, and inconsistent disaster preparedness in schools and childcare centers further magnify the risk to children in emergencies (Gómez‑Cortes, 2025). These longstanding gaps in emergency infrastructure and pediatric preparedness are not isolated administrative oversights; they are symptoms of deeper structural inequities. To fully understand why Puerto Rico continues to face such critical health system failures, it is necessary to examine the broader sociopolitical context that shapes its public health landscape. Colonialism, as a structural determinant of health, offers a powerful lens through which to explore the root causes of the island’s systemic medical vulnerabilities.

Pediatric Emergency Readiness: A Critical Weakness in Puerto Rico’s Healthcare System

Puerto Rico’s healthcare deficiencies are not limited to hospitals or trauma centers; they extend into schools, daycares, and communities. The lack of pediatric emergency preparedness in Puerto Rico reflects a broader systemic vulnerability within the island’s healthcare infrastructure. At the 2025 Emergency Preparedness Summit, Prof. Abner Gómez-Cortés, during his presentation on pediatric emergency preparedness, cited: 

 “If a child cries, they’re breathing, if they breathe, they have a pulse,” 

– Doctor Martin de Pumarejo

emphasizing the urgent need for readiness in schools, childcare centers, and community settings (Gómez‑Cortes, 2025). This underscores the need for calm, trained responders; yet many, such as teachers, caregivers, staff members, lack even the minimum qualifications to act effectively. This failure echoes the island’s broader trauma care crisis, where delays in care and uncoordinated response mechanism regularly cost lives. Without the integration of preparedness drills, healthcare provider training, and public awareness campaigns, especially in pediatric settings, Puerto Rico remains perilously exposed to preventable loss of life, not only in hospitals, but also in classroom and community spaces. Alarmingly, 46% of childcare centers represented at the summit reported not conducting any drills for emergencies such as earthquakes or medical crises, in comparison with the National Center for Education Statistics in the US mainland, which reports that over 90% of public schools annually conduct at least one emergency drill, this includes more than actual medical emergencies, covering bullying, pandemic, lockdown, or fire drills (Waters, 2025). These gaps place children at serious risk during critical events.

Exploring the Roots of Health Disparities in Puerto Rico

One of the most significant and historically rooted drivers of Puerto Rico’s public health disparities is U.S. colonialism. As detailed by Pérez Ramos et al., more than a century of political subordination has directly shaped the island’s healthcare system, limiting its capacity to meet the needs of its population. Puerto Rico’s status as a U.S. territory has led to chronic underfunding of essential services, including Medicaid and Medicare, which are reimbursed at lower rates than in the states. The island has also been excluded from key federal protections and reforms, such as the Affordable Care Act’s Medicaid expansion. These structural disadvantages have been intensified by the privatization of health services through reforms like “La Reforma” (Puerto Rico Health Reform) (Puerto Rico Department of Health) , which prioritized cost control over equitable access to care.

In addition, the compounded effects of repeated natural disasters, Hurricanes Irma and María (2017), COVID-19 pandemic (December, 2019) and earthquake 6.4 magnitude (January, 2020), exposed and amplified the fragility of the island’s health infrastructure. Each crisis has led to short-term, patchwork solutions rather than long-term investment, leaving healthcare institutions in a state of perpetual recovery. This ongoing instability has contributed to a rise in preventable chronic conditions such as diabetes, hypertension, cardiovascular disease, and untreated mental illness, disproportionately affecting low-income and marginalized communities.

Most critically, Puerto Rico’s limited political power severely restricts its ability to respond autonomously to healthcare challenges. Lacking full congressional representation and voting rights in presidential elections, the island struggles to effectively advocate for equitable federal funding and policy reform. This absence of self-determination undermines its capacity to build a resilient and responsive healthcare system, leaving the population structurally vulnerable to both everyday medical needs and large-scale emergencies.

Addressing health inequities in Puerto Rico requires more than clinical or logistical solutions, it demands a direct confrontation with the colonial frameworks that continue to shape health outcomes on the island.

Discussion

Puerto Rico’s emergency healthcare system is both under-resourced and inequitably structured, particularly when compared to the mainland United States. The absence of a fully accredited Level I trauma center, especially outside the San Juan metropolitan area, leaves a significant portion of the population without access to timely, life-saving interventions. As emphasized, this systemic shortcoming is not just logistical; it is deeply rooted in historical, economic, and political inequalities that have long shaped the island’s public health landscape.

Hurricane María, as a real-world stress test, exposed the fragile nature of Puerto Rico’s medical infrastructure, revealing that the island remains dangerously unprepared for mass-casualty events. In the absence of non-disaster contexts, geographic isolation, staff shortages, and administrative fragmentation continue to delay critical trauma care. This fragility is compounded in pediatric settings, where gaps in CPR training, lack of emergency drills, and limited medical readiness in schools and childcare centers heighten the risk for the island’s most vulnerable population. 

Furthermore, the role of U.S. colonialism as a structural determinant of health cannot be understated. Chronic underfunding, exclusion from federal healthcare expansions, and limited political autonomy have rendered Puerto Rico’s public health system reactive rather than resilient. Policies such as “La Reforma” and privatization of essential services have introduced market-based barriers to care, often prioritizing cost-cutting over quality and accessibility. These factors disproportionately affect low-income, rural, and pediatric populations, those most in need of systemic support.

Conclusion 

Puerto Rico’s emergency healthcare crisis is not merely a failure of logistics or policy; it is the outcome of deeply entrenched structural and political inequities. From the collapse of trauma infrastructure to the inadequate preparation of pediatric care environments, the current system falls short in delivering equitable, timely, and effective medical responses. While high-impact events such as Hurricane María have spotlighted these vulnerabilities, they have only intensified long-standing issues that remain unresolved. The persistent lack of a fully integrated trauma care network, particularly in rural regions and pediatric settings, leaves the island dangerously unprepared for both everyday emergencies and large-scale disasters.

Immediate call for action:

Long-term solutions require policy level change, including: 

Future recommendations:

Establishing a centralized trauma registry would provide real-time data on injury trends, response times, and clinical outcomes, informing both clinical care and public health strategy across Puerto Rico (e.g. National Trauma Data Bank (NTDB) managed by the American College of Surgeons, it is the largest repository of U.S. trauma registry data). Puerto Rican medical schools should require training in trauma triage, pediatric CPR, and disaster response to strengthen both clinical readiness and community preparedness. Incorporating research and presentations can further highlight gaps within and beyond hospital settings.

In conclusion, health emergencies must not be viewed as inevitable tragedies, but rather as preventable failures of planning, policy, and equity. Puerto Rico deserves a healthcare system that safeguards its people not only in times of disaster, but every day. Achieving this demands urgent action, strategic investment, and an unwavering commitment to systemic reform.

References

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