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Este informe no está disponible en español. American Journal of Public HealthVieques, Puerto Rico: An Island Under SiegeBy Joyce WilcoxMay 1, 2001 American Journal of Public Health, Page 695 After 60 years of bombing and shelling by the US Navy, this tiny island is as cratered as the moon, said a medical intern in New York City. That the US Navy must get out of Vieques is so universally agreed upon in Puerto Rico it is called "the consensus," explained a Philadelphia psychiatrist. "We saw that the issues involving Vieques were not being adequately addressed," said a public health researcher in Puerto Rico . This article highlights public health practitioners who have engaged with their communities to improve the lives of the people in the Puerto Rican island municipality of Vieques . Each has "gone public" on this issue in different ways. New York City interns visited Vieques and then organized an informal meeting at the hospital where they work, inviting the neighboring Puerto Rican community. The Philadelphia psychiatrist explained her motivation for participating in conferences and demonstrations concerning Vieques . Researchers at the University of Puerto Rico Graduate School of Public Health sponsored a policy statement adopted by the American Public Health Association calling on the US Navy to leave Vieque . South Bronx, New York City The Paz-Peace para Vieques meeting was held in Montefiore Medical Center's main building. The audience of about 100 seemed to be mostly neighborhood people, along with some hospital personnel. When all were seated and the rustling and whispering had stopped, Drs Debbie Daniels, Steve Cha, and Joe Asbury walked to the front and took turns speaking behind a podium draped in the Puerto Rican flag. They described what they had seen and learned during a recent visit to Vieques . Daniels, Cha, and Asbury are interns at Montefiore. None is Puerto Rican . Joe Asbury, who had researched the literature, explained that after decades of bombing, "the eastern tip of Vieques has more craters per square kilometer than the moon."1 He listed and described the munitions-related toxic substances found on the island and in the marine life off its shores2,3 and linked them to the increased cancer rates found among the people of Vieques (see "What is the Public Health Crisis in Vieques ?" [sidebar, p 696]). "Toxic waste is leaching into the environment, into people's bodies, making them more susceptible to cancer, respiratory disease, skin conditions, and low birth rates," he said. Debbie Daniels explained, "The military occupation of Vieques and the effect on the environment didn't allow for fishing and tourism to flourish like it would have otherwise, which depressed the economy, not allowing the people to work." She added, "There was supposed to be a hospital there, but there are no doctors working on the island." Daniels, Cha, and Asbury showed slides of their visit to Camp Garcia, where the Committee for the Rescue and Development of Vieques holds Saturday vigils across from the military occupation zone. Then Puerto Rican activists, elected officials, community spokespeople, and artists were invited to speak, and Steve Cha opened the microphone to the largely Puerto Rican audience. People described family and friends living in Vieques , some fighting advanced cancers, others living on toxic land, still others facing restrictions imposed by the US Navy. Some speakers paused to contam their anger. Others paused to cry. To this reporter, Vieques seemed an immediate and visceral issue for these Puerto Ricans living many thousands of miles away. Money was collected for a young Vieques man unable to afford cancer treatment. The interns passed around a letter to then-President Clinton demanding that the US Navy get out of Vieques , which most of the audience signed. Interns don't usually organize meetings like this, especially at their place of work, and I had questions. Daniels, Cha, and Asbury took time from their 80-hour work week to supply the answers. How did they wind up in Vieques ? "We are in the social medicine program at Montefiore," Cha said. "The program has a month designated to learn Spanish and experience medical issues in a different fashion. Since there are many Puerto Ricans in the Bronx-more than in San Juan-we went to Puerto Rico for a week to learn more about the people." "We were staying with a Puerto Rican family," Daniels added. "The father, a reporter, was going to Vieques and invited us to come. We thought we'd go for the afternoon, and we stayed for 3 days. We came to learn. We ended up giving solidarity statements, helping around the camp, and making connections." What does Vieques have to do with practicing medicine in New York City? Going to Vieques gave Asbury "an enhanced sense of understanding and empathy for the Puerto Rican people and their culture, to better understand our patients." "I saw how health is affected by the sociopolitical and economic situation of the people involved, by factors like employment, housing, and stressors in people's lives," said Daniels. "In many ways, I learned more about the population of our clinic, being in Vieques , than I could by having spent time in the Bronx," Cha explained. "People there were incredibly open. We were able to learn about the issues that affected the whole community." "The Vieques experience was so powerful to us," Cha emphasized. "As we mentioned it to our patients and people around the hospital, it just increased our realization of how important the issue of Vieques was in the Puerto Rican community. What a contrast this was to how invisible the issue is to the larger US world! We felt that to be good doctors to our patients it was important to bring this forth. It was our hope and goal to connect the health community in the US and the Puerto Rican community and have there be a real interchange. We held the meeting to facilitate this connection." Philadelphia The Montefiore interns are not alone. Dr Berta Joubert, who lives and practices in Philadelphia, is another physician who has "gone public" on the question of Vieques . Joubert, who was born in Puerto Rico , has been participating in conferences and demonstrations and organized meetings to increase awareness about Vieques . "Being active in support of the struggle to get the Navy out of Vieques gives me the opportunity as a Puerto Rican and a psychiatrist to help alleviate in a concrete way the overwhelming oppression felt by thousands of people in that island," Joubert said. " Puerto Ricans here are affected by the political situation of Puerto Rico , that is, being a colony of the US," Joubert explained. "Even if it is not consciously recognized, this situation impacts upon on how we view ourselves and how we feel as a people." "In Puerto Rico , workers, students, prisoners, women's groups, poor grassroots community groups, social and civic associations, professional organizations, every religious formation, and of course political parties and organizations and even the new Governor, Sila Calderon, want the US Navy out." The call to get the US Navy to stop the bombing, to take responsibility for cleaning the island of all contaminants, to leave Vieques and turn the island over to its inhabitants is so universally accepted that "in Puerto Rico it's called el consenso [the consensus]," Joubert continued. "It's not surprising that Puerto Rican communities throughout the US should feel the same way." Joubert described some of the mental health consequences of the bombing. "In Vieques , there is a high incidence of behavioral problems in children, and depression and anxiety in the rest of the population. During the year without bombing, there was a noticeable decrease in the anxiety level in schoolchildren. But these levels went back up when the Navy restarted the military practices." This information was collected by Dr Silvia Rivera, a psychologist who practices part time on Vieques , and is based on observation of her own caseload in the year when there was no bombing and then when the bombing resumed in May 2000. Rivera told this reporter that the marked deterioration in the mental health of her clients when the bombing resumed motivated her to participate in civil disobedience. On February 2, 2000, she and others entered the bombing zone in an attempt to get the Navy to stop shelling Vieques . Puerto Rico Drs Carmen Albizu, Gilberto Ramos, Marlen Oliver, and Elena Bastista, all faculty members at the University of Puerto Rico Graduate School of Public Health in Rio Piedras, have also "gone public" on conditions in Vieques . They sponsored a policy statement on Vieques , adopted by the American Public Health Association (APHA) at its annual meeting in November 2000 (see "Excerpts From the APHA Policy Statement on Vieques "). The statement, signed by the APHA Board, was delivered to President William J. Clinton, with copies to members of Congress, the secretary of defense, and the governor of Puerto Rico , and was released to the press. Albizu teaches health services research at the University of Puerto Rico Graduate School of Public Health and represents its faculty on the liaison committee between that school and the Puerto Rico Department of Health, which was formed to facilitate the study of cancer on Vieques . "We in public health are interested in determining whether the disparities in health in Vieques are actually due to the presence of the US Navy. This would mean that these health issues have a political dimension and cannot be attributed primarily to individual risk behaviors, as the Secretary of Health implied when confronted with the data. Many Puerto Ricans feel they can't be critical of US political actions, as this would be interpreted as `disloyalty."' Albizu said, "We saw that the issues involving Vieques were not being adequately addressed by the health authorities. Public health officials in Puerto Rico were hesitating to do what was needed to eliminate these health disparities in Vieques . The Department of Health had the data showing that the cancer level on Vieques was at action level 8 years ago, but no action was taken. Pressure from the people of Vieques and increased public awareness in Puerto Rico were essential to move the health authorities to comply with their ministerial functions." (The concept of an alert or action level is taken from an analysis in which the Agency for Toxic Substances and Disease Registry software Cluster 3.1 was used to evaluate the alleged cancer cluster on Vieques .5 The analysis demonstrated that standardized cancer incidence rates in Vieques were higher than and significantly different [P <.01] from those on the main island of Puerto Rico . Agency guidelines for the evaluation of clusters specifically state, "[I]f several of the statistical methods all show marginal evidence of clustering, and you have reasons to be suspicious of the pattern [perhaps a recognized environmental hazard is nearby], you may wish to take action even in the face of limited statistical evidence of clustering.") "Like Love Canal, this is an extremely political issue," explained Dr Cruz M. Nazario. Nazario, who has directed much of the cancer research concerning Vieques to date, is currently involved in designing an epidemiologic study on cancer in Vieques along with other investigators at the Graduate School of Public Health. "Even though we have the government's mandate to study the problem of cancer in Vieques , the task has been very difficult and complex," Nazario said. "In 1999, the Legislature assigned insufficient funds to conduct an epidemiological study in one year and answer all the questions the community, the health professionals, and the politicians were posing. The Department of Health kept the assigned funds for 9 months and has refused to let us review the cancer data. We hope that the recently elected government will give us sufficient funds to study not only cancer but also other conditions that apparently also have higher rates in Vieques ." One of these conditions is thelarche,8 or premature sexual development in children, Nazario explained. Within this context, Albizu and her colleagues proposed the APHA policy statement. "We thought it would further legitimize this health and human rights issue if we went to other forums and public health associations. We also want to broaden public awareness outside of Puerto Rico in order to take the issue out of the context of Puerto Rican 'loyalty' or 'disloyalty' to the US, and keep it in the context of getting the health disparities in Vieques addressed." "Many health professionals from different disciplines have asked their own professional forums for a pronouncement on the situation in Vieques and on the need for action," Albizu continued. "Public awareness is needed to get the health work done in Vieques ." Author's note, The full text of the APHA policy statement (policy statement 200032) is available on the APHA Web site (http:// www.apha.org), in the March 2001 issue ofthe Journal, or from the author. To find out how you can help, and to find more information about Vieques , see http://www.viequeslibre. com. The community organization Comite Pro Rescate y Desarrollo de Vieques can be reached at bieke@coqui.net (will reply in Spanish or English); for information on toxic metal contamination of fish and vegetation in the civilian zone of Vieques , contact Casa Pueblo at casapueb@coqui.net. Acknowledgments I am grateful to Marcelo Venegas-Pizarro, Elena Bastisa, and Heather Foti for helping me gather information. A very special thanks to Cruz M. Nazario for taking an interest in this article and spending much time and effort helping me pull together the research on Vieques . The author is assistant editor of the Journal. Requests for reprints should be sent to Joyce Wilcox, Mailman School of Public Health, Columbia University, 722 W 168 St, Room 937, New York, NY 10032 (e-mail: jpswilcox@aol.com). This article was accepted January 31, 2001. What is the Public Health Crisis in Vieques? Vieques is an island municipality of Puerto Rico 7 miles southeast of the eastern coast of the main island. In 1941, the US Navy purchased 26000 of Vieques ' 33000 acres for use in training Navy and Marine Corps forces. The eastern end of Vieques is used for live fire bombing and shelling practice, while the western end serves as an ammunition depot and waste disposal. Sandwiched between are 9584 people (US Census Bureau, 1999) who face serious health, environmental, and economic disparities compared with other Puerto Ricans . For decades, the people of Vieques have called for the US Navy to stop bombing and leave the island. On April 19, 1999, during a Navy exercise to prepare for the bombing of Yugoslavia, two 500-pound US bombs dropped from a F-18 jet went off target and killed David Sanes, a civilian security guard. Sanes' death sparked large protests in Puerto Rico . Opposition to the US Navy presence on Vieques was strongly voiced from virtually every sector of Puerto Rican society. The bombing was stopped for a year, but in May 2000, after the arrest of hundreds of Puerto Ricans who had camped inside the bombing range, the US Navy resumed the bombing of Vieques . Economic and Health Disparities There are many issues of concern. Some 73% of the population of Vieques lives below the poverty line. While the overall unemployment rate on Vieques is 14%, among males aged 16 through 19 years the rate soars to 54%. In 1995, Vieques had the highest mortality rate among Puerto Rico 's 78 municipalities. The likelihood that a pregnant woman will give birth to an underweight infant is 65% greater on Vieques than in the rest of Puerto Rico . There are high rates of respiratory and skin conditions among Vieques students.3 High Cancer Rates From 1985 through 1989, standardized cancer incidence rates on Vieques were 27% higher than those in Puerto Rico overall (p<.01).4 The age-adjusted cancer incidence rate on Vieques , with the Vieques population during the period 1970 through 1974 used as the standard, rose from 154 per 100 000 in 1970-1974 to 254 per 100 000 in 1985-1989 (P<.05).5 In 1995, the last year for which published population-based government health data are available, the risk of dying from cancer was 1.39 times higher on Vieques than on the main island.6 Very little population-based public health research has been conducted to date on the situation in Vieques . In June 1999, in the midst of public outcry, the Puerto Rican legislature mandated that an epidemiologic study be conducted to investigate the reasons for the excess cancers found among the population of Vieques . The Graduate School of Public Health at the University of Puerto Rico is currently locating and assembling all relevant health and environmental data. Calculation and comparison of proportional mortality ratios, mortality rates, and age-adjusted cancer incidence rates on Vieques with those of the rest of Puerto Rico will help to establish working hypotheses. Calendar and birth cohort patterns are also being studied. Vibroacoustic Disease Preliminary findings from a case-control study undertaken by Puerto Rican heart specialists Roberto Torres Aguiar, Carlos Rios, and Guillermo Tirado, released in January 2001, implicate noise from ship-to-shore shellings in the high rates of vibroacoustic disease found among Vieques residents. This noise-associated disease is believed to affect internal organs, including the heart, lungs, and intestines, and the nervous and immune systems. Among 50 Vieques fisherman and their families examined, 49 showed a thickening of tissues in the pericardium, while 39 showed other heart abnormalities. All had been bathing or swimming in the water during ship-to-shore shelling. The Vieques residents were compared with a control group of 50 fishermen and their families in Ponce, on Puerto Rico 's southern coast. In Ponce, 25 people had heart concerns-a number considered normal for a group of that age and size. Only one of the Ponce children showed any sign of heart abnormalitieS.7 Although this was only a pilot study, these results argue for more research on vibroacoustic disease in Vieques and other areas where residents have been exposed to bombing. Excerpts From the APHA Policy Statement on Vieques The US Navy and Air Force use live ammunition to shell Vieques "eight miles from where the 10,000 inhabitants of Vieques work and live." The bombing is so intense that it "make[s] school buildings tremble, affecting the teaching activities and damaging the physical structures:' The live ammunition used by the US Navy and Air Force includes "depleted uranium ammunition without the authorization of the Nuclear Regulatory Commission." "[S]amples obtained by a group of marine biologists from the coral reefs in Vieques located in close proximity to unexploded leaking bombs reveal highly diseased and discolored coral specimens. .. ." "[Tlhe Environmental Protection Agency stated on August 27, 1999, that the US Navy has violated the norms established for the disposal of contaminated discharges and has, according to EPA officials, demonstrated an incapacity to comply with the agency's regulations...." The Cancer Registry of the Puerto Rico Health Department shows that "prior to 1979, Vieques exhibited cancer rates lower than those of the main Island, whereas the cancer rates for Vieques subsequently increased, generating standardized incidence ratios for the periods 1985-1989 and 1990-1994 that exceed the alert levels adopted by the surveillance system as defined by the Agency for Toxic Substances and Disease Registry of the US Department of Health and Human Services, prompting the Puerto Rican Legislature to mandate an epidemiological study of the cancer rates in Vieques .. . Realizing that "the current conditions to which the people of Vieques are exposed constitute serious threats to the environment and to their health," and recognizing "the right of the people of Puerto Rico to take the necessary actions to assure their well-being," the American Public Health Association "calls upon the President of the United States to *Order the permanent cessation of military exercises in the Island-Municipality of Vieques, Puerto Rico *Transfer the presently occupied land to the people of Vieques *Immediately establish a clean-up program that will facilitate the prompt restitution of the Island's environment and that will include the necessary steps that must be taken to mitigate the threats to the health of the people of Vieques for which the US Navy is responsible." ________________ References: 1. Seguinot-Barbosa I Vieques : the ecology of an island under siege [in Spanish]. In: SeguinotBarbosa J. Geography, Ecology, and Law of Puerto Rico and the Caribbean [in Spanish]. San Juan, Puerto Rico : First Book Publishing; 1994:111-123. 2. Guidelines for the Sustainable Development of Vieques , Part I. San Juan, Puerto Rico : Multidisciplinary Professional and Technical Group for the Sustainable Development of Vieques ; June 2000. Available at: http://www. vieques libre.com. Accessed March 28, 2001. 3. Perez RC. Contamination produced by explosives and residuals of explosives in Vieques , Puerto Rico . Dimension (journal of the Association of Engineers and Surveyors of Puerto Rico ). January 1988. 4. Puerto Rican Central Cancer Registry. Cancer Incidence in Vieques , 1960-1989. San Juan: Puerto Rico Dept of Health; November 7, 1997. 5. Nazario CM, Suarez EL, Perez C. Analisis Critico del Informe Incidencia de Cancer en Vieques . San Juan, Puerto Rico : Puerto Rico Dept of Health; March 1998. 6. Informe Estadisticas Vitales. San Juan, Puerto Rico : Departamento de Salud; 1995:table 9, p 182. 7. Becker E. Pentagon to examine heart illness on Vieques . New York Times. January 21, 2001. Available at http://archives.nytimes.com/ archives/. Accessed April 17, 2001. 8. Colon I, Caro D, Bourdony CJ, Rosario 0. Identification of phthalate esters in the serum of young Puerto Rican girls with premature breast development. Environ Health Perspect. 2000;108:895-900.
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