The video is memorable: Donald Trump, President of the United States, throwing rolls of paper towel at a group of dispossessed US citizens in San Juan, Puerto Rico, and noting that “there’s a lot of love in the room.”  Those flying rolls of paper towel make one of the most striking images of disaster relief in the aftermath of 2017’s Hurricane Maria, which caused widespread destruction in the US territory. The strange scene, which the mayor of San Juan called “abominable,” captured the federal response to Maria. 
This week Trump claimed that “The best thing that ever happened to Puerto Rico is President Donald J. Trump.” In reality, the inadequacy of the federal response is clear when it is compared to the federal responses to Hurricanes Irma and Harvey, which hit south Florida and Texas in the same few weeks.
As we showed in a recent article, the Trump administration responded unequally to Hurricanes Harvey, Irma, and Maria.  While the damage from Maria exceeded that of Irma in Florida and was comparable to Harvey in Texas, more money, resources, and logistical support was provided to the United States citizens in Florida and Texas, than to the United States citizens of Puerto Rico. The disparities in federal response will have long-term effects on the health and public health of the citizens in Puerto Rico.
One hundred and ninety five deaths were directly and indirectly attributable to Irma and Harvey combined. [4,5] Federal estimates document direct deaths from Maria at 65, with estimates of all excess mortality attributable to Maria at 2975 deaths.  The difference in the federal response that we document is almost certainly responsible for some of the excess mortality, whether it is limited boots on the ground in early stages, medical equipment rendered inoperable due to failed power grids, emergencies unattended due to destroyed road transport infrastructure, chronic diseases such as diabetes untreated due to infrastructure and health service breakdowns, or more indirect effects of the stress of living under such circumstances.
The lack of response to Puerto Rico’s plight, and the state of its public health and physical infrastructures, is the result of many different forces and legacies, from racism to the complex politics of the island and its distinctive fiscal regime. There is no easy policy to address racism or historic underdevelopment, though recognizing past injustices and their attribution to current inequities is a start and some municipalities and counties have begun building such policies.  But, in the case of Puerto Rico, the failed response to Maria highlights one problem with a solution that could benefit Puerto Ricans and all other American citizens.
Simply put, in our view Puerto Rico is not a state and should be one. Disenfranchisement is dangerous for public health. It is unlikely that any state, with senators, representatives, and electoral college votes, would have been treated with the disregard that was shown to the citizens of Puerto Rico. Some of the strongest voices speaking up for Puerto Rico, regardless of party, were politicians from states with large enfranchised Puerto Rican populations such as Florida, New York, and New Jersey. [8,9]
Without the voices of elected officials in Washington, D.C. during and after the natural disasters, the United States citizens in Puerto Rico were not heard. The United States Senate has not kept up with urbanization and shifting demographics of the nation, and is now grossly disproportionate, with only 17% of the vote currently required to win control of the chamber.  This distortion has immediate effects on health and disaster policy and legislation by making Puerto Rican problems matter less to the federal government than Texan and Floridian problems.
There are three reasons to support Puerto Rican statehood, and statehood for other disenfranchised parts of the US such as the District of Columbia and territories. First, it is only fitting that people in a democracy should have a say in their government, whether they live in Puerto Rico, the District of Columbia, or an existing state. It is nonsensical that a US citizen who moves from Puerto Rico to New York gains electoral representation and loses it travelling in the opposite direction. Second, it is only fitting that an elected chamber with the power of the Senate should reliably reflect national majorities. The present-day Senate does not, with the 3.3 million people in Puerto Rico having zero Senators while the 580,000 people of Wyoming enjoy two.
Third, as hurricanes and their aftermaths show, full citizenship and full statehood are the way to enjoy the full solidarity and reciprocity due citizens of a country. Citizenship and democracy, simply put, oblige leaders to promote public health and thereby save lives.  Conversely, as the example of Puerto Rico validates, disenfranchisement endangers public health. Democracy and equal political representation is not just a good in itself, for Puerto Rico and the rest of the United States; as the differential responses to the three hurricanes show, it is a public health policy.
Scott L. Greer, Professor of Health Management and Policy, Global Public Health and Political Science, Department of Health Management and Policy, University of Michigan School of Public Health.
Phillip M. Singer, Assistant Professor, Political Science Department, University of Utah.
Charley E. Willison, Doctoral Student, Department of Health Management and Policy, University of Michigan School of Public Health.
Melissa S. Creary, Assistant Professor, Department of Health Management and Policy, University of Michigan School of Public Health.
Competing interests: None declared.
- Nakamura D and Parker A. ‘It totally belittled the moment’: Many look back in dismay at Trump’s tossing of paper towels in Puerto Rico. The Washington Post. 2017 Sep 13. Available at: https://www.washingtonpost.com/politics/it-totally-belittled-the-moment-many-look-back-in-anger-at-trumps-tossing-of-paper-towels-in-puerto-rico/2018/09/13/8a3647d2-b77e-11e8-a2c5-3187f427e253_story.html?utm_term=.3c63d72a673c
- Sanders, L. San Juan Mayor slams Trump for throwing paper towels to hurricane survivors, calling it ‘terrible and abominable’. Newsweek. 2017 Oct 4. Available at: https://www.newsweek.com/san-juan-mayor-slams-trump-throwing-paper-towels-terrible-abominable-677369
- Willison CE, Singer PM, Creary MS, Greer SL. Quantifying inequities in US federal response to hurricane disaster in Texas and Florida compared to Puerto Rico. BMJ Global Health. Forthcoming.
- Issa A, Ramadugu K, Mulay P, Hamilton J, Siegel V, Harrison C, Campbell CM, Blackmore C, Bayleyegn T, Boehmer T. Deaths Related to Hurricane Irma—Florida, Georgia, and North Carolina, September 4–October 10, 2017. Morbidity and Mortality Weekly Report. 2018 Aug 3;67(30):829.
- Jonkman SN, Godfroy M, Sebastian A, Kolen B. Brief communication: Loss of life due to Hurricane Harvey. Natural Hazards and Earth System Sciences. 2018 Apr 19;18(4):1073-8.
- Audi C, Segarra L, Irwin C, et al. Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico. Washington DC: 2018. [cited 2018 Dec 31] https://publichealth.gwu.edu/sites/default/files/downloads/projects/PRstudy/Acertainment of the Estimated Excess Mortality from Hurricane Maria in Puerto Rico.pdf.
- Equity and Social Justice [Internet]. King County, WA: King County Executive; c2018 [cited 2018 Dec 31]. Available from: https://www.kingcounty.gov/elected/executive/equity-social-justice.aspx.
- ‘Rep. Zeldin calls for appointment of “National Incident Commander” in Puerto Rico’ [Internet]. Washington, DC: Representative Lee Zeldin; c2018 [cited 2018 Dec 6]. Available from: https://zeldin.house.gov/media-center/press-releases/rep-zeldin-calls-appointment-national-incident-commander-puerto-rico.
- ‘Smith says Trump must increase federal aid to Puerto Rico’ [Internet]. Washington, DC: U.S. Congressman Chris Smith; c2018 [cited 2018 Dec 6]. Available at: https://chrissmith.house.gov/news/documentsingle.aspx?DocumentID=400626.
- Philip Bump ‘The Senate may be developing an Electoral College Issue’ The Washington Post 10 April 2018. Available at: https://www.washingtonpost.com/news/politics/wp/2017/04/10/the-senate-may-be-developing-an-electoral-college-issue/
- Greer SL, Méndez CA. Universal health coverage: a political struggle and governance challenge. American journal of public health. 2015 Nov;105(S5):S637-9.