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The leader of the Puerto Rico National Guard was still dealing with the aftermath of a 6.4-magnitude earthquake that displaced thousands of residents in January 2020 when island officials began hearing reports of people falling ill from the new coronavirus. Once again, they turned to Guard Adjutant General José J. Reyes.

Much of Reyes’ 37-year career has been in emergency response mode — from 9/11 to the devastation of Hurricane Maria in 2017 to the earthquake — but he sees all of those events as preparation for this one: helping to plan the island’s Covid-19 vaccination strategy and oversee its rollout.

“This is the critical mission. It’s the mission of my life,” he told STAT.

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That mission has been so successful it’s the envy of the mainland U.S. Puerto Rico has fully vaccinated a higher percentage of its population than any state. As of last week, 2.3 million people in Puerto Rico are fully vaccinated, or 89.7% of adults and 71.5% percent of the entire population.

The 3,500-square-mile island may seem an unlikely place to surpass all U.S. states and territories (other than tiny Palau), being poorer than all other states and more populous than similarly successful places like Vermont — and while still reeling from natural disasters, fiscal crises, and political upheaval.

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Puerto Rico achieved this with late-summer mandates that drove up vaccination rates, but also by making shots widely accessible for months, even at beaches and bars. And unlike on the mainland, political polarization over the vaccine was uncommon.

“The Republican/Democrat divide that is driving differences in vaccine hesitancy in the U.S. does not exist in PR,” said Rafael Irizarry, a professor of applied statistics at the Harvard T.H. Chan School of Public Health and the Dana-Farber Cancer Institute. That’s because “status” is the main political divider on the island, and the four major parties are proponents of vaccination, he said. Irizarry thinks this might also explain why vaccination rates are high in heavily Democratic states, such as Vermont, Massachusetts, Connecticut, and Rhode Island.

But the path to such high vaccination rates in Puerto Rico also took much planning and effort, which was led in large part by the National Guard.

José J. Reyes, adjutant general of the Puerto Rico National Guard, helped create the island’s vaccination strategy, which has gotten nearly 90% of the adult population fully vaccinated. Courtesy Puerto Rico National Guard

Reyes’ pandemic work started in early 2020. As vaccines went from a far-off possibility to a reality, the general was preparing a plan. He would read, at night or in the morning, about vaccine logistics, including the storage temperatures various manufacturers would require to preserve doses, and investigate potential solutions. Reyes quickly ordered 44 ultra-cold freezers from BioLife Solutions, which delivered them by mid-December 2020, when the first vaccines would be available. In total, the freezers cost less than $300,000, he said.

Puerto Rican officials developed a cost-effective and flexible “hub-and-spoke” model for vaccine distribution, BioLife COO and president Dusty Tenney told STAT. They created two main “hubs” for incoming vaccines: one in the northern part of the island and another in the south. Four large freezers capable of storing 300,000 doses each were placed at facilities with backup generators (consistent electricity can still be hard to come by post-Maria). From there, small, portable freezers were used to transport up to 5,000 doses at a time to clinics and other vaccination sites around the island. The idea was for Puerto Rico to be able to store 2.1 million vaccines at any given time, Reyes said.

By the time the U.S. health officials greenlit the Pfizer vaccine on Dec. 15, 2020, the island was ready, the general said. Doses left Pfizer warehouses for states and territories on December 14, and by noon the next day, all 64 major hospitals in Puerto Rico had received doses to inoculate health care workers. It was the start of what would be a monthslong, 5 million-plus-dose endeavor.

In weekly meetings with National Guard generals in other states, Reyes shared Puerto Rico’s strategy, and he said several adopted similar plans. The hub-and-spoke model in particular was a way to tackle a public health crisis in places with hard-to-reach corners and other logistical challenges, such as Veterans Affairs hospital campuses in North Carolina and sparsely populated states like South Dakota, Tenney said.

From December to July, the Puerto Rico Department of Health and National Guard established at least a dozen mass vaccination sites across the island, started inoculating Puerto Rican travelers arriving at the international airport, leveraged the ubiquity of Walgreens stores and other pharmacies, and organized events with large employers, such as the police and the department of education. Data show Walgreens alone administered more than 926,000 doses as of last month, and the Puerto Rico National Guard delivered over half a million doses.

In late April and early May, as shots became more widely available, Puerto Rico’s operation was generating a high of nearly 300,000 vaccinations per week.

So much of the eligible population had been inoculated by late July that it was no longer cost-effective to maintain the large, heavily staffed mass vaccination sites so the Guard shut them down, Reyes said. The island is now using a targeted approach, including going door-to-door and visiting nursing homes, for the 50,000 to 70,000 doses received every week. Officials administer 99% of the vaccines they receive, said Dr. Iris Cardona, chief medical officer of the Puerto Rico Department of Health.

In August, as vaccination rates slumped and the Delta variant was driving an exponential increase in new cases, the government issued vaccine mandates for schools, public employees, and some parts of the private sector, including restaurants. That jolted Puerto Rico’s vaccination rates up past New England’s, said Irizarry, who has been tracking Covid-19 in Puerto Rico as part of a scientific coalition convened by Gov. Pedro Pierluisi.

Irizarry said he thinks the mandates had the biggest impact on vaccination rates, followed by the availability of shots (there are now 975 vaccine providers on the island, and soon to be 300 just for children). Broad cohesion among political leaders and their public health messaging also helped, he said.

When asked whether he thinks apolitical messaging was key to the island’s success with vaccination efforts, Reyes said he sees the National Guard as an important and credible intermediary. “I certainly believe that the people of Puerto Rico know General Reyes by now, handling emergency responses in Puerto Rico. I’m an Army officer, I’m not a politician, so they know if I was behind the strategy, there was no politics involved,” he said.

Still, the mandates faced legal challenges in local and federal courts, several of which have upheld the public health directives and one of which is still outstanding, Cardona said.

“It should not be your first initiative, but sometimes you have to manage to put in place some mandates in order to make it easier for people to decide,” she said.

Puerto Rican officials also launched a robust media campaign, using prominent doctors, health workers, actors, and others to promote vaccination to various slices of the population on TV and radio and in newspapers. First responders, mayors of all 78 municipalities on the island, and leaders from over a dozen religious denominations were also recruited to spread the word.

“After the service on a Sunday morning, we were there to vaccinate people after finishing church,” Reyes said.

When people under 30 were driving Covid-19 cases, the general met with dozens of mayors to figure out how they could target the places where young people convened. Wherever young adults met and mingled — bar-hopping at La Placita de Santurce in San Juan or relaxing on Luquillo Beach, for example — is where Reyes wanted to be.

“We ended up vaccinating at those areas on Thursday nights and Friday nights. We were not giving beers to them, but we were there to orient them and to vaccinate them,” he said. “And we started going through the different beaches. We vaccinated on the Fourth of July in many beaches here in Puerto Rico. That was part of the strategy. It’s a military mentality of, ‘Get it done.’”

If “getting it done” meant Reyes walking in full uniform with a local official along a beach in the dead heat of summer, he did that.

The rollout wasn’t without its problems, though. Like in other states and territories, local authorities sometimes disobeyed the phased approach recommended by federal officials, or well-connected Puerto Ricans expedited vaccinations for themselves and their relatives, the Centro de Periodismo Investigativo found. The National Guard was one of the agencies that vaccinated contractors before some vulnerable populations, though Reyes defended the practice to CPI reporters. Inequitable vaccine access was also a problem, with poorer areas lagging behind wealthier ones, a separate CPI analysis found. Cardona said she believed the data were skewed because many health care and frontline workers resided in larger municipalities, and they had access to vaccines first.

A health care worker administers the Covid-19 vaccine to a patient in Puerto Rico. The island’s inoculation campaign included at least a dozen mass vaccination sites opened throughout Puerto Rico from January to early August 2021. Courtesy Puerto Rico National Guard

To mitigate those inequities, the health department worked with community health centers to set up more than 60 clinics across Puerto Rico to vaccinate vulnerable and remote populations. The agency, which has beefed up its staff from 15 to 50 people, also did multi-day pop-up vaccination clinics in all 78 municipalities, including on the eastern islands of Vieques and Culebra.

Adults over 85 and young people ages 20 to 29 have been the most challenging to reach, Cardona told STAT, but a health department door-knocking campaign is helping.

Reyes sees Puerto Rico meeting his goal of vaccinating 90% of the population by the end of November, bolstered by the vaccination of an estimated 200,000 children ages 5 to 11.

Early on in the pandemic, some academics theorized in a Lancet commentary that Caribbean nations might fare better during Covid-19 because people were used to states of emergency caused by natural disasters, and therefore more willing to follow government mandates. It makes sense to obey a stay-at-home order when an enormous hurricane is en route, so people would act the same way during an invisible catastrophe like the virus, the thinking went.

What has actually played out is “a complex scenario of course, and Caribbean diversity makes generalizations doubly awkward,” lead author Ian Hambleton told STAT, noting that Puerto Rico was not included in his analysis. “I think our message of compliance with stay-at-home orders remains broadly true. Acceptance of vaccination is another matter entirely,” said Hambleton, a professor of biostatistics at the University of the West Indies.

But Reyes thinks there might still be a kernel of truth to the idea in Puerto Rico.

“Experiencing so many natural disasters here in Puerto Rico for the past four years, starting with Hurricanes Irma, Maria, then the earthquakes, then the pandemic, tropical storms, wildfires … the message has [gotten] to the population that you need to be prepared,” he said.

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