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The New York Times, The Washington Post, USA Today, the Associated Press, Reuters, ABC News, NPR, The Guardian, Al Jazeera, and Business Insider have all published maps tracking the spread of Covid-19 across the United States. None of them have included the entire country in their graphics. Missing are all or most of the five non-state US territories—four of which have confirmed cases of the novel coronavirus. Ad Policy

Even though they’re home to more than 3.5 million US citizens and nationals, and they’re administered by the US government, the territories—Puerto Rico, the US Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa—are often forgotten. During this crisis, inattention from the mainland—in the form of disregarded pleas for supplies, funds, or relief from the colonial framework—could spell disaster.

For Puerto Rico especially—the largest US territory, with 3.2 million US citizen residents—its second-class status is proving massively consequential as it tries to contain and treat a coronavirus outbreak. Decades of exclusion from the full benefits of federal programs has chipped away at its hospital network. Hurricanes Maria and Irma in 2017, earthquakes this year, and the federal government’s lackluster response to both have further damaged the territory’s health infrastructure. The island’s debt crisis and the swooping in of vulture funds has stripped Puerto Rico’s government of budgetary autonomy, which could hamper its ability to fund its emergency response. If coronavirus catastrophe hits, the federal government’s culpability will be undeniable.

Yet even with Washington and Wall Street working against it, Puerto Rico’s officials, health care workers, citizens, and diaspora are mounting a defense against the coronavirus. As of today, the island has 573 confirmed infections and 23 deaths. Facing its third major public health crisis in as many years, the territory is hoping to prevent a worst-case scenario: overrun hospitals, economic collapse, and thousands of deaths.

In now-ubiquitous epidemiological talk, preventing a health care system from being overwhelmed requires a society to do two things: “flatten the curve”—that is, slow the rate of infection so there aren’t too many cases that need hospitalization at one time—and “raise the line”—that is, boost the hospital system’s capacity to treat large numbers of patients.

In terms of raising the line, Puerto Rico is at a severe disadvantage, as decades of privatization, decreased tax revenue, and short-changing from federal programs have taken a toll on the island’s health care system.

In 1993, then-Governor Pedro Rosselló—father of Governor Ricardo Rosselló, who stepped down in August after a mass insurrection—launched an enormous health care reform project. His stated goal was to improve access for Puerto Rico’s poor. But instead of boosting the island’s public hospital infrastructure, he moved the system closer to the mainland model, privatizing most of the health care providers, while leaning heavily on federally subsidized programs like Medicare, Medicaid, and the Children’s Health Insurance Program. Today, roughly 45 percent of Puerto Rico’s population is covered by Medicaid or CHIP—compared to about 20 percent of the overall US population—while another 20 percent relies on Medicare. Current Issue View our current issue

Despite these federal programs being pillars of Puerto Rico’s and the other territories’ health care systems, the federal government denies them adequate and equitable funding. This is especially true of Medicaid. In the 50 states, Washington funnels money into each individual Medicaid program based on the state’s median income, paying anywhere between 50 and 83 percent of the annual bill. For the territories, however, the original 1965 Medicaid legislation stipulates that the federal government pay a set, low rate—only 55 percent—forcing cash-strapped territorial governments to front nearly half the costs.

On top of that, unlike in the states, federal Medicaid funds for the territories have an annual ceiling—so, after a territorial Medicaid program spends a certain amount of federal money, the local government is on the hook for all Medicaid costs for the rest of the year. Given its reliance on Medicaid, Puerto Rico almost always surpasses this ceiling; in recent years, the territory has ended up paying upward of 80 percent of its Medicaid bill.

Making matters worse, the Rosselló reforms coincided with an economic crisis. Beginning in 2006—the year Washington fully phased out a set of tax incentives for manufacturers on the island—the Puerto Rican economy began contracting, and with it the tax base that the local government used to pay its share of Medicaid and other health programs.

To prevent a health care catastrophe in the territories, Congress has provided billions of dollars in ad hoc funding in recent years. But it hasn’t been enough. On Puerto Rico, the average Medicaid enrollee receives less than $2,200 in benefits per year—lower than any state—while the median state’s enrollees average more than $6,700. Related Articles ‘This Isn’t Your Island’: Why Northern Mariana Islanders Are Facing Down the US Military Chris Gelardi and Sophia Perez America’s Colonial Climate Crisis Chris Gelardi ‘Biba Guåhan!’: How Guam’s Indigenous Activists Are Confronting Military Colonialism Chris Gelardi and Sophia Perez

Furthermore, additional funding from Congress often arrives on an emergency basis, relegating territorial Medicaid programs to a never-ending cycle of crises. In December, the territories narrowly avoided the most recent “fiscal cliff” when lawmakers allotted two years of additional funding just as existing funds were running out. They cut it so close that American Samoa’s Medicaid office—which covers four-fifths of the territory’s residents—had to pause a life-saving program that sends patients (including those with cancer) who need care beyond what the territory can provide to New Zealand for treatment.

This persistent underfunding, paired with the unpredictability of future funds, has taken a toll not just on the financial stability of the territories’ Medicaid programs, but on the integrity of their health systems as a whole—making it more likely they’ll be overwhelmed by Covid-19.

In Puerto Rico, the funding issues have yielded extremely low reimbursement rates for providers, which has led to low pay and an exodus of health care professionals. From 2006 to 2016, the number of doctors on the island fell from 14,000 to 9,000, a percentage decline four times greater than that of the general population.

“We only have 9,000 physicians; we have a shortage of nurses,” said Dr. Victor Ramos, president of Puerto Rico’s College of Physicians and Surgeons. “This is going to be an issue, especially when the health professionals start to get sick.”

The funding problems have also weakened hospital infrastructure. As Jaime Plá Cortes, executive president of the Puerto Rico Hospital Association, explained to Congress last May, the sporadic short-term payments to the territory’s Medicaid program have made banks hesitant to finance much-needed physical improvements. Many hospitals on Puerto Rico, for instance, haven’t been modernized since they were built in the 1940s, according to a 2017 study by the Urban Institute.

“We’re always responding, always reacting to when things happen,” complained Héctor Hernández-Delgado, staff attorney at the National Health Law Program. “We’re not providing the territories with the resources to put infrastructure in place for when outbreaks happen.”

Since raising the line is such an uphill battle for Puerto Rico, it is critically important that the territory succeeds in flattening the curve. But on that front, the Puerto Rican government’s response to the crisis has been, at best, chaotic.

As confirmed cases of the novel coronavirus began to spike on the continental US in early March, the administration of current Governor Wanda Vázquez received flak from advocates and the public for failing to take preemptive measures to slow its inevitable spread on the territory. In particular, residents blasted Puerto Rico’s health secretary, Rafael Rodríguez-Mercado, for comments he made in late February downplaying the likelihood that the coronavirus would even reach Puerto Rico. Rodríguez-Mercado stepped down on March 13, the same day the governor announced Puerto Rico’s first confirmed cases of Covid-19. Less than two weeks later, his replacement, Concepción Quiñones de Longo, also resigned.

Two days after Puerto Rico confirmed its first Covid-19 cases, Governor Vázquez imposed a curfew and ordered all non-essential businesses closed. But the rate of new infections on Puerto Rico is still accelerating: It took 15 days for the territory to register 100 confirmed cases, but only three days to register 100 more. If places like New York City and Lombardy, Italy, are guides, baseline social distancing measures may not be enough to avoid overwhelming an infected area’s hospital system—especially one as vulnerable as Puerto Rico’s.

To sufficiently flatten the curve, the territory may need to undergo a widespread testing and “contact tracing” campaign, similar to that seen in South Korea. However, neither the federal government nor any state government has anywhere near the number of Covid-19 tests needed to conduct such a campaign. So Puerto Rican officials have been attempting to procure tests from abroad.

After an initial debacle with the island’s first positive Covid-19 tests, the Puerto Rican government claimed that it was purchasing hundreds of thousands of rapid-result tests from China and Australia. But the procurement of the tests has been mired in confusion and doubt. For nearly a month, no one could confirm the details of an initial order of 200,000 tests—whether the order was actually being filled, whether tests were approved by the Food and Drug Administration, or whether the federal government would reimburse Puerto Rico for them. On Sunday, the newest health secretary, Lorenzo González, began telling media that the tests were finally arriving on the island—but it’s still unclear when they’ll be ready for use.

Amid widespread frustration regarding the state of the 200,000 tests, last week, the government announced that it had placed an order for 1 million more. But on Sunday, González revealed that the government was canceling that $38 million order because the tests weren’t FDA-approved, sparking further anger. Puerto Rico’s largest newspaper, El Nuevo Día, also reported that the company through which the government ordered the million tests—a small construction firm that has never before sold medical products—has close ties to the governor’s New Progressive Party. The newspaper also presented evidence that the companies selling tests to the government have been engaging in price-gouging. González faulted a previous health secretary for the fiasco, but didn’t specify which of his two recent predecessors is to blame.

In addition to what was supposed to be an ambitious testing campaign, the Puerto Rican government announced on March 23 an economic rescue plan. Totaling $787 million, the plan will fund the salaries of public employees, give cash to self-employed workers, extend unemployment benefits, deliver $30 million to public hospitals, and provide teachers $240 million to facilitate distance education, among several other measures.

Though the package will surely prevent economic devastation for many Puerto Ricans in the short term, it’s “still nowhere near enough,” according to Federico de Jesús, a senior adviser to Power 4 Puerto Rico, a coalition of liberal, labor, and advocacy organizations that includes UnidosUS, Make the Road New York, the Center for Popular Democracy, and the Center for American Progress.

To save their islands from economic and health disaster, US territories will need to keep implementing new measures. Unfortunately, they face hurdles in enacting such measures. The most glaring one for Puerto Rico is the Financial Oversight and Management Board—or la junta, as disapproving residents call it. Created in 2016 as a policing authority for Puerto Rico’s debt restructuring, the FOMB wields veto power over almost everything the island government does with its budget. In particular, the board’s loyalty to bondholders on Wall Street has been a massive impediment to Puerto Rico’s post-Maria and Irma recovery efforts—and there’s little reason to think that it won’t showcase the same behavior during a pandemic.

That’s why advocates are calling for the federal government to roll back the FOMB’s authority—or, in the case of Power 4 Puerto Rico, abolish it outright. “We’ve been calling for the abolition of the junta because, through these crises, austerity has been so incompatible with emergency response,” said De Jesús. He points to nearly $9 billion the board has forced the Puerto Rican government to earmark for future debt payments—money essentially sitting in a bank account that could help with the Covid-19 response. “It shouldn’t be going to bondholders and Wall Street,” he said. “They’re hoarding all this cash instead of releasing it to help people in their time of need.”

Power 4 Puerto Rico is also calling for the US government to cancel the island’s debt to its creditors. De Jesús called the money owed “an impediment to respond to the coronavirus, because that’s money not spent to shore up the health care infrastructure.”

In addition to debt, territories must overcome colonial provisions in federal law that can make it difficult to take swift action during an emergency. In March, for example, the Federal Emergency Management Agency waived a section of the 1933 Buy American Act that could have prevented the federal government from reimbursing certain territories for emergency supplies (like Covid-19 tests) that they purchased from foreign countries. However, the 1920 Jones Act remains in effect. This legislation mandates that only American-owned, American-made ships with American crews can carry cargo between US ports, making Puerto Rico’s imports disproportionately expensive. Advocates worry that it could make obtaining emergency supplies costly and complicated.

Meanwhile, the territories must watch out for ways in which they might be left out of federal emergency bills—a tall task given their lack of voting representation in Congress. Some such exclusion could be accidental: After Congress passed its $2.2 trillion emergency CARES Act in March, which included increased funding for unemployment benefits, Guam’s government had to scramble to find a way to become eligible, since the island has never had a traditional unemployment benefits program. Other times, however, the legislative marginalization is deliberate: While the CARES Act funnels no less than $1.25 billion in direct relief to each state, the five territories and Washington, DC, together have to split $3 billion—around $700 per capita, compared to, for example, more than $9,600 per capita for Montana.

US territories have a difficult battle ahead. And for Puerto Rico, this pandemic is just the latest tribulation.

“We have fresh lessons in our memories and in our minds that we learned during the management and response to Maria and Irma and the earthquakes,” said Antonio Fernandez, board member of Latinos for Healthcare Equity and a longtime health care administrator on Puerto Rico. “We discovered through our other experiences the spirit of solidarity and the tremendous sense of support that our local communities give to one another in times of crisis.”