Back-to-school vaccination certficates. Dental check-ups. A psychologist and nutritionist. For a few hours in San Juan, Puerto Rico, they were all available – for free – to patients from all over the island.

Nearly 3,000 people poured into the city’s Centro de Convenciones on Wednesday, August 7, for a health fair designed to increase access to medical services for a largely low-income population.

More than 20 of Puerto Rico’s health centers were in attendance, and several provided medical services that ranged from general check-ups to nutritional consultations.

At one point, the line to access the health fair snaked through the vast convention center lobby.

Children receiving back-to-school vaccinations squirmed in their mother’s laps, while others swung their new book bags – souvenirs from the fair – around their heads. Friends of all ages sat together, waiting for examinations, and patients at tables held their fingers out to be pricked for rapid HIV testing.

More than a few healthcare providers, once the crowds thinned, took advantage of the opportunity to get accessible medical care.

Javier Claudio, who finished a bachelor’s degree in forensic science last year, had come to the health fair from the municipality Toa Baja, about a half-hour’s drive away. “I haven’t had medical care since December, since my dad had to leave his job,” he said. “I haven’t done any tests since that time, so I just want to get a checkup.”

Although Claudio works full-time, his job doesn’t include benefits.

For many in Puerto Rico, health care is a luxury. With a median household income of about $20,000  a year (compared to slightly under $58,000 for the 50 states), many Puerto Ricans struggle with even daily expenses. Although the island is a United States territory, its Medicaid eligibility standards are different, and fewer Puerto Ricans qualify than would in one of the states.

Unemployment in Puerto Rico is high – about 8 percent – in part due to the catastrophic effects of Hurricane Maria, which devastated the island in 2017. Doctors have left in droves – PBS reported that the number of doctors on the island decreased from 14,000 to 9,000 between 2006 and 2016 – which has increased strain on the healthcare system.

In addition, many Puerto Ricans live in isolated communities and can’t easily access a car.

To bridge the gap, Direct Relief organized a health fair, titled Ciudad de Salud y Bienestar (“City of Health and Wellness”), designed to bring the island’s healthcare resources together.

Rocamara Cruz, who had come to get a dental exam, explained that Maria had cost her both her job and her health insurance. When she went to the overcrowded health center where she generally got medical care, she said, her doctor had only a few minutes in which to see her.

Dr. Heriberto Borrero, medical director of the Centro de Salud Familiar, a health center located in Arroyo, said he expected to see a significant number of patients with diabetes, hypertension and obesity at the fair. “We decided to come to the convention because we wanted to bring services to the people,” he said through a translator.

Nyvia Sepuelveda, a retired nurse who’d driven an hour and a half from the municipality Yabucoa, was there to receive nutritional counseling. Although she said she liked the health center where she received care, “we don’t have a permanent OB-GYN, we don’t have nutrition…we don’t have things to promote our health.”

In Sepulveda’s experience, health literacy on the island is low. She said many people don’t know how to read nutrition labels or understand how to eat healthfully. “I think the public has to be taught more how to stay healthy. Promote vegetables, promote fruits. In Puerto Rico, very few people eat that.”

Direct Relief has provided over $100 million in medical aid to Puerto Rico, with support from AbbVie and others, and will continue to work with local organizations to bolster the healthcare system and increase access to care.

“It’s good to check up on yourself. You don’t know what you have unless you get some medical care,” said Claudio. “That’s why I took this opportunity, ‘cause it’s a free thing.”