Addressing Prostate Cancer Disparities in Puerto Rico: A Call for Action
Health Care Condtion in Puerto Rico
Puerto Rico (PR) is an archipelago located in the Caribbean with a population of around 3.2 million people, as recorded in the 2020 U.S. Census Bureau. It is a non-incorporated territory of the United States of America since 1898 and has been granted the same citizenship as those on the mainland since 1917. However, the medical situations in the United States of America and Puerto Rico are not the same. 43.1% of the population is living in poverty, and in 2017, children's poverty rate was 57.8%. The median household income also differs from that of the mainland United States. In 2017, it was recorded as USD 19,775, compared to the average income recorded in Mississippi (USD 42,009). The health conditions in Puerto Rico have been severely impacted by the aftermath of Hurricanes Irma and Maria. The number of migrations was nearly 100,000 people to the mainland, but only 4/5 of them returned. (1) .
There are four main infrastructure problems are happening in PR.
Privatization of the public health system
Aging of the PR population with the major poverties and chronic health condition threats
Economic instability and low private sector tax
High cost of living
Specifically, the health conditions in PR have worsened compared to the health infrastructure. The number of doctors has decreased by about 5,000, and they have never returned to PR. The decline rate of healthcare providers is much faster compared to the mainland, with a percentage decline of 36% in PR compared to 9% on the mainland (1). This phenomenon had a significant impact when the Zika virus epidemic occurred in PR, with over 35,000 cases reported in the archipelago (1). Does this inferior circumstance for health conditions only influence the quality of life? Are there any other diseases that they need to consider more?
Disparities in Puerto Rico regarding Prostate Cancer (PCa)
In the report of 2021, the incidence rate of prostate cancer remains not completely investigated yet but is suspected to be higher than the number of reported cases. Scientific studies have reported that African Americans have a higher risk of prostate cancer compared to other ethnicities. The population of Puerto Rico has a mixture of African, Indigenous, and European ancestry, leading to a high percentage of genetic African ancestry, approximately 23.6%. In comparison, the current percentage of admixture found in Mexico is 4%-6% (2).
In addition to the genetic risk in Puerto Rican men, factors such as PSA levels, BMI, and prostate cancer risk are higher (75%) than on the mainland. This means that they may be diagnosed with prostate cancer at a later stage, or they may undergo radical prostatectomy for localized prostate cancer more frequently. The recent COVID-19 pandemic outbreak has further worsened the health infrastructure and led to inequalities in health treatment. The impact of two hurricanes, Irma and Maria, has also resulted in a crushed surveillance infrastructure, leading to fewer preventive measures and cancer screenings among Puerto Rican adults (2).
Hard Situation in Puerto Rico
The situation in Puerto Rico is further compounded by the economic crisis and the deterioration of infrastructure. Reimbursement for physicians in Puerto Rico is relatively lower than on the mainland (40%), resulting in higher operational and diagnostic costs for patients who are living in poverty. The decrease in healthcare providers, especially experts in the clinical field, has led to a burden on urologists, with a ratio of 1 urologist to every 45,000 patients in Puerto Rico, compared to the mainland average of 1 urologist to every 34,323 patients (2).
Over 50% of urologists in PR are over 65 years compared with the mainland (29.8%) have made the lack of workforce in the urology in the archipelago. (2)
Medicare Does Not Cover Puerto Rico?
The residents of Puerto Rico pay the same tax rate for Medicare as those on the mainland United States of America. However, a study conducted in 2016 found that the Puerto Rican population receives less than 60% reimbursement compared to other states (3). Puerto Rican physicians also receive reimbursement rates that are 40% lower than those on the mainland. This issue is not limited to Medicare but also affects Medicaid. Despite having the highest poverty rate among the states, Puerto Rico is the least covered due to underfunding.
Suggestion on Puerto Rico Health Care System?
Puerto Ricans are vulnerable to geographic disasters and the lack of healthcare infrastructure. Merely being resilient or standing strong would not be adequate to support the system. Until health disparities are addressed and systemic changes are made at the local level, preventive healthcare and evidence-based strategies for diagnosis become even more important in order to reduce overtreatment or lack of treatment. It is crucial to encourage community engagement in promoting and taking care of their health conditions. The deeply rooted health disparities cannot be easily overcome through preventive healthcare alone, but it will pave the path to alleviate or reduce the pain caused by untreated chronic diseases.
Lafarga Previdi, Irene, and Carmen M. Vélez Vega. “Health Disparities Research Framework Adaptation to Reflect Puerto Rico’s Socio-Cultural Context.” International Journal of Environmental Research and Public Health, vol. 17, no. 22, 2020, p. 8544, https://doi.org/10.3390/ijerph17228544.
Health Care Disparities Related to Cancer, Social Economics, and Urological Practice in Puerto Rico - American Urological Association, www.auanews.net/issues/articles/2023/april-2023/diversity-health-care-disparities-related-to-cancer-social-economics-and-urological-practice-in-puerto-rico. Accessed 23 May 2023.
Colón, Héctor M., and Marizaida Sánchez-Cesareo. “Disparities in Health Care in Puerto Rico Compared with the United States.” JAMA Internal Medicine, vol. 176, no. 6, 2016, p. 794, https://doi.org/10.1001/jamainternmed.2016.1144.
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