Hobbled by government scandal and dysfunction at the start of the pandemic, Puerto Rico has done tests to diagnose the coronavirus at a far lower rate than anywhere else in the United States, a situation that public health experts fear could leave the island uniquely vulnerable once it attempts to reopen.

Puerto Rico has performed an average of 15 coronavirus tests a day for every 100,000 people, according to the Covid Tracking Project, a rate lower than any state and more than 10 times less comprehensive than the testing effort in New York.

More than in other places where testing has been insufficient, experts say that the huge lag has left Puerto Rico blind to where it lies on its infection curve.

The lack of data makes it difficult to know when to ease Puerto Rico’s lockdown, one of the strictest in the country, which has kept hospitals from becoming overwhelmed with Covid-19 patients but has also required much sacrifice from Puerto Ricans enduring the 14th year of an economic recession. Already this year they survived a flurry of earthquakes that left some people effectively homeless for months.

“Everything has been delay and disorganization,” said Dr Carlos Mellado, a physician in San Juan, the capital, who has been treating patients with the virus. “We’re still under a complete lockdown. People are starting to get desperate.”

Even the scant number of total tests, 11,848 as of Tuesday on an island with a population of nearly 3.2 million, is an overcount: a person who tested positive for coronavirus antibodies in a finger-prick blood test and then took a nasal-swab test for confirmation would have been counted twice.

Dr Lorenzo González, Puerto Rico’s health secretary — the third person in that position since the pandemic began — has promised to scrub the data to separate the commingled results.

“The Department of Health needs to step up to the plate,” González acknowledged in a phone interview.

Miscounting is particularly delicate in Puerto Rico, where the government took nearly a year to acknowledge that an estimated 2,975 people died after Hurricane Maria in 2017.

Puerto Rico police officers stand in front of the governor’s mansion as hundreds of private and municipal paramedics protest in their ambulances through Old San Juan (Getty)

The double-counting of coronavirus cases, revealed Friday by Puerto Rico’s Centre for Investigative Journalism, was only the latest controversy to hit the government. The former health secretary was removed on 13 March after initially downplaying the virus. His interim replacement stepped down 13 days later. The chief epidemiologist also resigned.

González took over on 26 March and soon afterwards disclosed to El Nuevo Día, Puerto Rico’s largest newspaper, that the department had previously entered into a $38m contract for 1 million antibody tests with Apex General Contractors, a small but politically connected local construction company that had no experience in selling medical supplies. The federal control board that has overseen Puerto Rico’s finances since the territory effectively declared bankruptcy in 2017 was not consulted.

The department paid $19m but the tests never materialised. The department cancelled the contract and asked for its money back. The deal is now under investigation by the Puerto Rico House of Representatives. Several federal agencies, including the FBI, the Food and Drug Administration and the Office of the Inspector General, have also requested contract records, González said.

Curfews and driving restrictions have been observed far more closely than testing regulations in the US territory (Getty)

Sen. Charles E. Grassley, R-Iowa, and chairman of the Senate Finance Committee sent Gov. Wanda Vázquez a sharply toned letter Monday demanding answers “as we examine continued aid for Puerto Rico”.

“It appears that procurement and contracting in Puerto Rico often passes through a filter of political connections before resources intended for the people of Puerto Rico actually reach them and achieve the intended use, depriving the people of Puerto Rico the primacy that they deserve,” he wrote.

Vázquez said she would have preferred he reach out directly “before attacking the people of Puerto Rico for situations that are replicated in other jurisdictions of the United States or foreign governments”.

The latest scandal has consumed the government, diverting attention from the paucity of diagnostic tests, said Daniel Colón-Ramos, a neuroscience and cell biology professor at Yale University who is Puerto Rican and has been working to increase testing. Antibody tests are important, if flawed, for monitoring the virus, but they are most effective when deployed once epidemiologists have a better grasp of how many people are sick.

“We’re squandering the time away,” Colón-Ramos said. “There’s insufficient testing, and then there’s insufficient testing. The word ‘insufficient’ is insufficient to capture it.”

PPE such as face masks have been pictured being improperly discarded all over Puerto Rican streets (Getty)

The Federal Emergency Management Agency sent 15 machines last week to quickly process diagnostic tests in hospitals. But González said Puerto Rico has only enough reagents, the chemical ingredients needed to process the tests, for a single machine to work for one full day.

The island was one of the first places to enforce a serious lockdown, shutting down the economy, closing beaches and imposing a nighttime curfew in mid-March. It has seen more than 1,200 cases of the coronavirus, and 64 people have died. Not all of them were tested.

The health department does not know how many cases exist at nursing homes and assisted-living facilities, González said. Over the next three weeks, the department plans to do antibody testing at some 28,000 residents and 9,000 staff at 1,000 long-term facilities.

The youngest person to die has been a 29-year-old man identified by his father as Joshua James Sánchez. He went to the emergency room twice with symptoms and was denied a test until the third time when he was already in respiratory distress, his father, Luis Ángel Sánchez, wrote on Facebook. The elder Sánchez wrote that his own father also succumbed to the virus.

“You cannot understand this pain unless you experience it,” he wrote. “And I don’t wish this disastrous experience on anybody.”

Hundreds of private and municipal paramedics protest to demand that they are included in the economic incentive package drawn up by the government (Getty)

Michelle García Mercado, a college student from Caguas, said her father struggled to get tested after learning that a co-worker had tested positive. Her father first had to test negative for flu and bacterial pneumonia.

“They told him to stay home,” she said.

Her father got a test only after coming down with body aches. While they awaited the results, García, who helps care for her grandfather and feared she might be a virus carrier, tried to get tested herself but was turned away because she did not have symptoms. Her father’s result came back negative.

Frustration over the slow testing has prompted some Puerto Ricans to protest from their balconies with pots and pans and from their cars in drive-by caravans. On social media, they address the governor with #WandaLasPruebas, demanding more tests. Some of the same activists led the protests that ousted former Gov. Ricardo A. Rosselló last summer.

“People are tired already of sitting at home without clear information,” said Zoan Dávila, a lawyer from Cayey who is a member of the Colectiva Feminista en Construcción, which organised a protest last week. “They don’t trust the state and what it is doing.”

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Physicians and public health experts have praised the rigid lockdown that Vázquez ordered on 15 March, before that of any state and most cities, as crucial to protecting Puerto Rico’s fragile health care system, which was severely strained by Hurricane Maria. It has also long suffered from a disparity in federal health care funding and from a loss of doctors and nurses to more lucrative jobs in the states.

Puerto Ricans are under a nightly curfew, and during the day they can leave their homes only to work in essential businesses; get food, medicine or gas; or go to to the bank or to doctors’ appointments.

Testing capacity has slowly improved. Private labs have made progress in part because more than a dozen scientists from the nonprofits CienciaPR and the Puerto Rico Science, Technology & Research Trust, including Colón-Ramos, meet via Zoom several times a week to troubleshoot problems, with little government help or coordination.

Resources tend to be scarce, but Puerto Rico once had a thriving pharmaceutical and medical supply industry fuelled by US tax breaks and still has an arsenal of researchers.

When labs needed nasal swabs, Riccardo Papa, an associate biology professor at the University of Puerto Rico in Río Piedras, who is Italian, emailed an executive at Copan Industries, an Italian swab manufacturer with a plant in Aguadilla, PR. The company donated 20,000 swabs.

With reagents in short supply, Marcos López, an assistant chemistry professor at the University of Puerto Rico at Humacao, worked with colleagues in Massachusetts and Nebraska to stretch the chemicals by figuring out how to test samples in pools, rather than individually.​