"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.

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.

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.

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.

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.

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.

Report on Honduras: ripples in the pond--the financial crisis and remittances to chronically ill patients in Honduras.

The U.S. financial crisis has affected employment opportunities for Latino immigrants, and this could affect their ability to send financial assistance, or "remittances", to chronically ill family members in their home country. In a cross-sectional survey of 624 chronically ill adults conducted in Honduras between June and August 2009, respondents reported their receipt of remittances, health service use, and cost-related access barriers. Fifty-four percent of respondents reported relatives living outside the country, and of this group, 66 percent (37% of the overall sample) received remittances. Seventy-four percent of respondents receiving remittances reported a decrease over the prior year, mostly due to job losses among their relatives abroad. Respondents reporting reductions in remittances received significantly less per month, on average, than those without a reduction (US $170 vs. $234; p = 0.01). In multivariate models, respondents experiencing a reduction in remittances used fewer health services and medications due to cost concerns. Remittance payments from relatives resident in the United States are a major source of income for chronically ill individuals in Latin America. Most recipients of remittances reported a reduction during the financial downturn that affected their access to care.