"They think we wear loincloths": Spatial stigma, coloniality, and physician migration in Puerto Rico.

Puerto Rico (PR) is facing an unprecedented healthcare crisis due to accelerating migration of physicians to the mainland United States (US), leaving residents with diminishing healthcare and excessively long provider wait times. While scholars and journalists have identified economic factors driving physician migration, our study analyzes the effects of spatial stigma within the broader context of coloniality as unexamined dimensions of physician loss. Drawing on 50 semi-structured interviews with physicians throughout PR and the US, we identified how stigmatizing meanings are attached to PR, its people, and its biomedical system, often incorporating colonial notions of the island's presumed backwardness, lagging medical technology, and lack of cutting-edge career opportunities. We conclude that in addition to economically motivated policies, efforts to curb physician migration should also address globally circulating ideas about PR, acknowledge their roots in coloniality, and valorize local responses to the crisis that are in danger of being lost to history.

On leaving: Coloniality and physician migration in Puerto Rico.

Puerto Rico (PR) has a growing physician migration problem. As of 2009, the medical workforce was composed of 14,500 physicians and by 2020 the number had been reduced to 9,000. If this migration pattern continues, the Island will not be able to meet the recommended physicians per capita ratio proposed by the World Health Organization (WHO). Existing research has focused on the personal motivations for movement to, or permanence in, a particular setting, and social variables that encourage physicians to migrate (e.g., economic conditions). Few studies have addressed the role of coloniality in fostering physician migration. In this article we examine the role of coloniality and its impact on PR's physician migration problem. The data presented in this paper stem from an NIH-funded study (1R01MD014188) that aimed to document the factors associated with physician migration from PR to the US mainland and its impact on the Island's healthcare system. The research team used qualitative interviews, surveys, and ethnographic observations. This paper focuses on the data from the qualitative interviews with 26 physicians who had migrated to the USA and ethnographic observations, which were collected and analyzed between September 2020 and December 2022. The results evidence that participants understand physician migration as a consequence of three factors: 1) the historical and multidimensional deterioration of PR, 2) the idea that the current healthcare system is rigged by politicians and insurance companies, and 3) the specific challenges faced by physicians in training on the Island. We discuss the role of coloniality in fostering these factors and how it serves as the backdrop for the problem faced by the Island.

Red tape, slow emergency, and chronic disease management in post-María Puerto Rico.

This paper draws upon the notion of slow emergency as a framework to interpret ethnographic and qualitative findings on the challenges faced by Puerto Ricans with chronic conditions and health sector representatives throughout the island during and after Hurricane María. We conducted participant observation and qualitative interviews with chronic disease patients (n=20) health care providers and administrators (n=42), and policy makers (n=5) from across the island of Puerto Rico in 2018 and 2019. Many Puerto Ricans coping with chronic diseases during and after María experienced bureaucratic red tape as the manifestation of colonial legacies of disaster management and health care. They describe a precarious existence in perpetual "application pending" status, waiting for services that were not forthcoming. Drawing on ethnographically informed case examples, we discuss the effects of these bureaucratic barriers on persons with three chronic conditions: renal disease, opioid dependency, and HIV/AIDS. We argue that while emergency management approaches often presume a citizen-subject with autonomous capacity to prepare for presumably transient disasters and envision a 'post-disaster future' beyond the immediate crisis, Puerto Rican voices draw attention to the longer, sustained, slow emergency of colonial governance.

The impact of Hurricane Maria on Puerto Rico's health system: post-disaster perceptions and experiences of health care providers and administrators.

BACKGROUND: After its landfall in Puerto Rico in 2017, Hurricane Maria caused the longest blackout in United States history, producing cascading effects on a health care system that had already been weakened by decades of public sector austerity and neoliberal health reforms. This article addresses how health care professionals and administrators experienced the health care system's collapse and the strategies used by them to meet their communities' health needs. METHODS: Data were collected between September 2018 and February 2020. Ethnographic observations in health care facilities and semi-structured qualitative interviews with representatives of the health care system were conducted. This paper focuses on data from interviews with health care providers (n = 10) and administrators (n = 10), and an ethnographic visit to a pop-up community clinic. The analysis consisted of systematic thematic coding of the interview transcripts and ethnographic field notes. RESULTS: Results provide insight on how participants, who witnessed first-hand the collapse of Puerto Rico's health care system, responded to the crisis after Maria. The prolonged power outage and lack of a disaster management plan were partly responsible for the death of 3,052 individuals who experienced extended interruptions in access to medical care. Participants reported a sense of abandonment by the government and feelings of mistrust. They also described the health sector as chaotic and lacking clear guidelines on how to provide services or cope with personal crises while working under extreme conditions. In such circumstances, they developed resilient responses to meet communities' health needs (e.g., itinerant acupuncture services, re-locating physicians to local pharmacies). CONCLUSIONS: Participants' narratives emphasize that the management of Hurricane Maria was fraught with political and economic constraints affecting Puerto Rico. Ineffective planning and post-Maria responses of the local and federal governments were determinants of the disaster's impact. The findings contribute to a growing scientific literature indicating that Hurricane Maria revealed 'the collapse before the collapse,' alluding to the structural deficiencies that presaged the catastrophic event. In the context of governmental abandonment, the authors argue for the importance of developing alternative strategies in post-disaster health care provision among health professionals and administrators who work at the front lines of recovery.

Aging and thriving with HIV: a photovoice project with long-term HIV survivors in Miami, Florida.

BACKGROUND: Long-term survivors of HIV in Miami, Florida are facing critical health and social issues as they age with this disease. METHODS: Using PhotoVoice methodology, nine Latino/a activist-artists were recruited to take pictures depicting their everyday life-challenges to be used in several photography exhibits aimed at informing local policy direction. RESULTS: The group identified a positive approach to aging with HIV as a priority at the individual, community and policy level, emphasizing policy alternatives to the negative and disease-ridden stereotypes that embed current discussions on living and aging with HIV. The activists highlight specific community and policy solutions that respond to the growing needs of long-term survivors of HIV/AIDS among Latino communities in South Florida. CONCLUSIONS: The findings suggest that Miami (and areas with a large HIV-positive population) may benefit from community and policy solutions that take a successful aging approach and build upon the resiliency of this population.

Stigmatizing Experiences of Trans Men in Puerto Rico: Implications for Health.

Purpose: The past decade has seen an increase in efforts aimed at understanding the health needs of the transgender population. In the context of Puerto Rico (PR), those efforts have primarily focused on trans women due to their high human immunodeficiency virus (HIV) incidence. However, due to the low impact of the HIV epidemic among trans men, this remains an understudied population in PR. Thus, it is important that research efforts ad- dress the health care needs of trans men in a range of cultural settings, including PR. Recent literature emphasizes the role of stigmatization as a social determinant associated with deleterious health consequences for diverse groups. Despite this worrisome scenario, little is known about how trans men in PR experience and are negatively impacted by social stigma. The objective of this study was to document the stigmatization experiences faced by trans men in PR and its impact on their overall health. Methods: We conducted an exploratory qualitative study with 29 trans men. We implemented focus groups and in-depth qualitative interviews. Thematic analysis guided our interpretation of the findings. Results: Three categories of stigma are discussed: (1) structural stigmatization, (2) interpersonal stigmatization, and (3) individual stigmatization. The health implications of these stigma experiences are discussed. Conclusion: This study represents an initial step toward understanding the social context of this "invisible" community and its health and well-being. We provide recommendations to address social and health concerns related to this understudied community.

Decolonial visual resistance as a public health strategy in post-María Puerto Rico.

In this article, we explore the use of the image as a strategy to understand how natural disasters and coloniality impact the health of marginalized communities. We focus on the aftermath of Hurricane María in Puerto Rico and aim to describe how local people used the image as a strategy to challenge the invisibility fostered by coloniality and advocate for a more humane, equitable and effective public health response. We implemented a mixed methods research design including: (1) ethnographic observations, (2) qualitative in-depth interviews with 67 representatives of the health care system, (3) photographs they had taken as part of their experiences during and after the hurricane and (4) images from local newspapers and social media. In light of the findings we argue that Puerto Ricans engaged in decolonial visual resistance to manage the aftermath of the hurricane. Thus, while surviving the natural disaster, they challenged the traditional use of the image in public health endeavours.

An institutional ethnography of prevention and treatment services for substance use disorders in the Dominican Republic.

The Dominican Republic is thought to have significant epidemics of illicit drug use but lacks surveillance and formal analyses of the policy context of drug prevention and treatment services. We conducted an institutional ethnography of 15 drug service organisations in Santo Domingo and Boca Chica, Dominican Republic, to explore barriers and resources for drug abuse prevention and treatment. Here, we present a typology of drug service organisations based on their services, methods, and approach. We then draw on interviews with representatives of drug service institutions to describe the primary barriers to drug treatment and prevention services for drug users. We conclude with a focus on the policy priorities that could improve the conditions of health care for marginalised drug users in the Dominican Republic.

"Just Like Any Other Patient": Transgender Stigma among Physicians in Puerto Rico.

BACKGROUND: Transgender women (TW) in Puerto Rico (PR) face social stigmatization. Physicians' transgender stigma can have detrimental consequences for TW's health. PURPOSE: The objective of this study was to document physicians' knowledge, competencies, and attitudes towards TW in PR and study their associations with stigma towards TW. METHODS: We implemented an exploratory sequential mixed-methods study. We used in-depth interviews (n=30) and self-administered questionnaire (n=255). RESULTS: Qualitative results illustrated lack of recognition of the needs of TW; they also evidenced the impact of stigmatizing attitudes on clinical decisions. Quantitative results showed that more willingness and knowledge to provide health services to TW were negatively associated with stigma. Participants who reported history of training in working with TW presented significantly less stigma than participants who had not received such training. CONCLUSION: In order to provide stigma-free services for TW in PR, specialized training regarding the particular needs of this population is needed.

Introduction to the special issue: Applying a Caribbean perspective to an analysis of HIV/AIDS.

This introduction presents a special issue of Global Public Health with a collection of articles that offer multidisciplinary perspectives on HIV/AIDS in the Caribbean. Since the 1990s, poverty, marginalisation, and social stigma have been strong foci of much social science research on HIV/AIDS in the region. These three interrelated phenomena have been offered as explanatory factors contributing to the high prevalence of cases observed in this region. Contributors to this special issue take these emphases in new directions, asking multi-level questions that require unique combinations of epidemiological, social scientific, theoretical, and policy-oriented perspectives and methodologies. Together, they identify several topical areas that intend to create dialogue across disciplines and dialectics, with the fundamental principle that the factors relevant to HIV/AIDS are broad and require intersectional lenses. The articles in this issue offer multi-level interventions into HIV/AIDS in the region, from the varied social circumstances that shape heightened risk factors to patient adherence programmes, with emphases on structural, social, and policy-level approaches. Collectively, this special issue establishes the importance of transdisciplinary approaches to HIV/AIDS that are macro-level in scope, but simultaneously attend to how large-scale dynamics are inflected in situated contexts and histories.

An ethnographic study of 'touristic escapism' and health vulnerability among Dominican male tourism workers.

Health research on tourism has expanded over the past two decades, focusing on understanding how the social, economic, and political configuration of tourism zones might contribute to health vulnerabilities among the diverse populations that interact in these areas. While there are few studies of HIV and drug use interactions in the region, research has indicated that these two outcomes are often interwoven in tourism zones, potentially producing 'syndemics' of HIV infection and problematic drug use. One framework that has been used in public health research on tourism is one that we refer to as touristic escapism or situational disinhibition that may be heightened for some tourists while on vacation, potentially leading to the abandonment of normative constraints on behaviour and contributing to health risks such as unprotected sex or binge drinking. In this article, we draw upon tourism theory and ethnographic research with male tourism workers employed in two popular tourist areas of the Dominican Republic to explore whether touristic escapism offers insights in understanding health vulnerabilities within tourism spaces.

[MOBILE TECHNOLOGY AS A POTENTIAL TOOL IN RESEARCH ON STIGMA ASSOCIATED WITH HIV/AIDS AMONG MEDICAL STUDENTS]. / TECNOLOGÍA MÓVIL COMO HERRAMIENTA POTENCIAL EN LA INVESTIGACIÓN SOBRE ESTIGMA ASOCIADO AL VIH/SIDA ENTRE ESTUDIANTES DE MEDICINA.

The identification and reduction of manifestations of stigma associated with HIV/ AIDS among health professionals continues facing significant challenges. Some of these are the measurement of stigma in complex setting such as clinical scenarios. However, with the emergence of mobile technology in recent years, such as smartphones and tablets, possibilities for exploration and reduction of stigma manifestations are enhanced. This article aims to reflect on the ability of the iPad to help assess manifestations of stigma associated with HIV/AIDS within a controlled clinical setting with medical students. It is based on a research experience that was carried out to measure behavioral manifestations of stigma associated with HIV/AIDS among medical students in Puerto Rico. The study integrated the use of iPad in the data's collection, storage and analysis. This article highlights the use of existing applications (Apps) for iPad for the implementation of digital tools to measure stigma towards HIV/AIDS. In discussing the experience of researchers, the iPad's potential and it applications for research on stigma are highlighted. Also, implications for the use of mobile technology in social research are discussed.

Religion and HIV-Related Stigma among Nurses Who Work with People Living with HIV/AIDS in Puerto Rico.

HIV-related stigma among nurses can impact health care services for people with HIV/AIDS (PWHA). health care professionals' religious views can potentially foster stigmatizing attitudes. There is scarce scientific literature exploring the role of religion on HIV/AIDS stigma among nurses. This study aimed to explore the role of religion in the stigmatization of PWHA by nurses in Puerto Rico. We conducted an exploratory study using qualitative techniques. We conducted 40 in-depth interviews with nurses who provided services to PWHA. Three main factors emerged in the analysis as contributors to HIV/AIDS stigmatization: (1) nurses' personal religious experiences, (2) religion as a rationale for HIV-related stigma, and (3) religious practices during health care delivery. The results show that religious beliefs play a role in how nurses understood HIV/AIDS and provided service. Results point toward the need for interventions that address personal religious beliefs while reducing HIV/AIDS stigma among nurses.

Tourism Labor, Embodied Suffering, and the Deportation Regime in the Dominican Republic.

In this article, we use syndemic theory to examine socio-structural factors that result in heightened vulnerability to HIV infection and drug addiction among Dominican deportees who survive post-deportation through informal tourism labor. Through an ongoing NIDA-funded ethnographic study of the syndemic of HIV and problematic drug use among men involved in tourism labor in the Dominican Republic, we argue that the legal and political-economic context of the global deportation regime contributes to structural vulnerabilities among deportees in the Dominican Republic, most of whom are men with histories of incarceration in the United States and/or Puerto Rico. While Dominican laws and institutional practices work conjointly with foreign policies to reconfigure non-criminal deportees as hardened criminals unworthy of full citizenship rights, the informal tourism economy provides one of the few absorption points for male deportee labor, linking the deportation regime directly to the Caribbean tourism industry.

The social context of hormone and silicone injection among Puerto Rican transwomen.

This paper draws on ethnographic, qualitative and survey data with transwomen in Puerto Rico to examine the social and political-economic context of lay injection with hormone and silicone - common practices within this community. We describe specific practices of hormone and silicone injection, the actors that govern them, the market for the sale and distribution of syringes and the networks of lay specialists who provide services to a population that is neglected by and largely excluded from biomedical settings. Our data derive from ethnographic observations, sociodemographic questionnaires, surveys and semi-structured interviews conducted with a diverse group of transwomen in metropolitan San Juan, Puerto Rico. Our analysis focuses on four overlapping social domains or processes that shape the practices of lay silicone and hormone injection among transwomen: (1) the circulation of gender transitioning technologies within local and global markets; (2) the tension between the social exclusion of transwomen and their resilient sub-cultural responses; (3) the cultural meanings that shape transwomen's attitudes about injection; and (4) the perceived consequences of injection. We conclude with a discussion of the kinds of intervention and policy changes that would respond to the factors that most endanger transwomen's health.

Adaptation of PhotoVoice methodology to promote policy dialog among street-based drug users in Santo Domingo, Dominican Republic.

BACKGROUND: Like other epidemics, the current heroin epidemic in Santo Domingo, Dominican Republic is a largely invisible and devastating social problem linked to numerous structural and social determinants of health. METHODS: In this article, we connect a community-based participatory research methodology - "PhotoVoice" - with the theoretical orientation of critical medical anthropology to identify local interpretations of complex social and structural factors that are most salient to the well-being of local Dominican populations affected by drug addiction. RESULTS: Specifically, we describe Proyecto Lentes (Lens Project), a PhotoVoice initiative launched in 2014, which brought together active drug users to visually unveil and critically analyze the micro- and macro-factors shaping the marginalized and stigmatized drug addiction epidemic in Santo Domingo. CONCLUSIONS: While the synthesis of PhotoVoice and critical medical anthropology provides a powerful political analysis tool, this fusion is particularly apt in its ability to capture the "invisible voices" of marginalized communities, potentially contributing to future policy reform and social empowerment.

Experiences of Violence Among Transgender Women in Puerto Rico: An Underestimated Problem.

Violence is a public health concern faced on a daily basis by transgender women. Literature has documented how it adversely affects quality of life and health and in some instances leads to homicide. Considering the lack of research documenting the experiences of violence among transgender women, the objective of this article was to explore manifestations of violence among this population in Puerto Rico. The data presented in this article are part of a larger study on transgender/transsexual health in Puerto Rico. For the purpose of this article we focus on the quantitative data analysis. Participants (N = 59 transgender women) were recruited via respondent driven sampling. Implications and specific recommendations are discussed in light of these findings.

EXPLORING THE FEASIBILITY AND ACCEPTABILITY OF BIOMARKER COLLECTION FOR HIV INFECTION AND CHRONIC STRESS AMONG TRANSWOMEN IN PUERTO RICO.

The assessment of biomarkers related to HIV and chronic stress increases opportunities for the design of more comprehensive research and intervention efforts on the health of transwomen within the context of Health Psychology. In this paper, we present data from a study implemented in Puerto Rico that aimed to: document the feasibility/acceptability of collecting biomarkers for chronic stress and HIV among transwomen; qualitatively document the factors related to the collection of biomarkers in this population; and explore the feasibility of collecting other types of biological specimens from transwomen in future studies. We implemented an exploratory mixed-method study with a sample of 10 transwomen. Quantitative information was gathered via saliva and hair biomarkers for chronic stress and HIV, while qualitative data was obtained via in-depth interviews. Twenty percent had positive results for HIV antibodies and 30% had hair cortisol levels that exceeded the normal range. The main motivations behind the provision of biomarkers were the desire to know about their health; contributing to a better understanding of health in the transgender community; and having previous positive experiences with our research team. We discuss the incorporation of biomarkers as powerful tools to better describe and understand the health of transwomen.

FAMILY INTERACTION AND SOCIAL STIGMATIZATION OF PEOPLE LIVING WITH HIV AND AIDS IN PUERTO RICO.

This article aims to describe the manifestation of HIV stigma in the family context and how this could impact the life of people living with HIV (PLWH). The data derive from a larger phenomenological study addressing manifestations of stigma in the lives of PLWH when interacting with the health sector. Nine focus groups were carried out in 2011 with PLWH (N=67). Eight themes emerged from the qualitative analysis. For the purpose of this article, we focus on the categories related to family dynamics: the negotiation of disclosure and non-disclosure, fear of the HIV virus and family dynamics, and life as a couple. Socio demographic information showed that 53% were between 44 to 54 years old, 80% were single, 51% were male, 42% did not complete a high school diploma, 82% were unemployed. Also, 82% described themselves as religious persons and 41% had lived with HIV for 10 years or less. Qualitative results show stigma is still present in the family context. PLWH experience fear of disclosure, discrimination, avoid initiating families or couple relationships, experience physical and verbal abuse from relatives, and even separation from other family members. After more than 30 years of the ongoing HIV epidemic, stigma is still manifested by family members with detrimental social and medical implications for PLWH. Research and educational efforts should continue addressing manifestations of stigma among family members of PLWH.