While Hurricane María was a turning point for all of Puerto Rico, for residents in the central mountainous areas of Utuado, Ciales, and Jayuya, the hurricane changed the entire landscape of healthcare services in the region.

“The truth is that if you need to go to a doctor, it takes about a 45-minute drive. If it’s an emergency, the nearest hospital is about a 50-minute drive across winding roads. That has always been a great problem for us,” said Yesenia Medina, who was born and raised in Utuado.

Located in the central western region, Utuado – as its name derived from the Taíno word “Otoao” suggests, is perched “between the mountains.” For as long as Yesenia can remember, her remote community has existed isolated and removed from accessible healthcare services.

With this in mind, community residents joined efforts to help bridge healthcare access gaps and foster socio-economic development in the region. Established in 2013, the Corporación de Servicios de Salud Primaria y Desarrollo Socioeconómico El Otoao, or COSSAO, began from this grassroots effort.

The organization, which translates to Corporation of Primary Healthcare Services and Socio-economic Development El Otoao, serves residents from five communities in Utuado and two other communities in the municipalities of Jayuya and Ciales.

Neighbors mobilized to salvage and refurbish a nearby abandoned building, setting up a small medical office staffed by volunteers. Little did they know that a few years later, Hurricane María would serve as a catalyst that would forever change the region.

In the aftermath of the storm, as medical brigades and aid from international organizations deployed to remote areas such as Mameyes, community leader and COSSAO’s executive director Francisco “Tito” Valentín saw an opportunity to transform their small operation into a fully developed community clinic that would permanently broaden access to essential medical services.

For many, the idea seemed impossible. However, during her visits to the island after the hurricane, Dr. Antonia Coello witnessed the community’s commitment and understood Valentin’s vision, joining his mission.

As both the first woman and the first Hispanic person to serve as U.S. Surgeon General, Dr. Coello gathered support from the University of Puerto Rico’s School of Public Health and Direct Relief, among other organizations, to help shape what would become the Antonia Coello Community Clinic, which opened its doors in April of 2018.

In 2021, Direct Relief awarded COSSAO a $587,680 grant to expand the clinic and improve its facilities.

A Community Effort

During the past six years, COSSAO’s community-based workforce has been pivotal in serving over 18,000 patients, effectively breaching gaps in care. For Tito Valentín, it was important that this effort also served to promote the socio-economic development of community residents.

“Health is not only pills and vaccines. Community health is a holistic concept that ensures all our communities have the necessary resources and support system to feel that they are in a place where they can raise their family,” said Valentín.

COSSAO’s clinic has created close to 20 job opportunities in construction and healthcare roles. “All of these workers are young professionals, many of whom [if it wasn’t for the clinic] would have left because of the lack of opportunities here,” said Valentín.

Yesenia Medina, who was COSSAO’s first employee and currently works in human resources, has witnessed first-hand the immense impact the clinic has had on its people. She remembers when the clinic first opened, helping people who had never seen a dentist, women who had never received reproductive healthcare, and individuals who had never visited a doctor.

Medina recalls a family of eight members, some homebound and others living with disabilities, who were cared for by their 90-year-old mother. “They don’t go anywhere. We bring them dental and medical services and diapers, because we [at COSSAO] know they need all of this.”

This personalized treatment from the staff, especially from health promoters, has contributed immensely to the clinic’s success and has ultimately improved their patients’ quality of life. “Having the clinic here has changed the lives of a lot of people,” said Medina.

Currently, COSSAO has seven health promoters who are residents from each of its seven communities. Zulma Robles has been working as a health promoter in COSSAO for five years. She lives in the Frontón community in Ciales – one of the largest communities with a population of 1,500.

As part of her role, she regularly sets out to visit each of the 600 households that make up her community to educate patients about health-related topics and identify resources to address the social determinants of health. Having community members in such roles allows them to advocate for their fellow residents to find local solutions.

During one visit, health promoters identified a family with six children who lacked almost all the basic living essentials, including a refrigerator and stove. Most of the children and their parents needed glasses and medical evaluations. The team quickly coordinated medical visits with dentists, ophthalmologists, and pediatricians and reached out to partner organizations for donations of scholastic supplies and construction materials for repairs.

“There is a true commitment with our people, which is an incredibly isolated population. Our communities are extremely impoverished. We know what it is like to not have healthcare services. If it weren’t for the clinic, unfortunately, many of them would not have any medical attention or services,” said Robles.

“Lives are saved here,” said Robles. She shares that during the pandemic lockdown, her father suffered two small heart attacks requiring treatment in Centro Médico in San Juan. In order to be discharged, he needed access to oxygen therapy. COSSAO stepped in to provide an oxygen concentrator which has dramatically improved his quality of life.

A Model to be Replicated

As part of their efforts to address community needs, COSSAO has created a community census with a socio-economic and demographic profile of each household member. This information facilitated their response efforts during both the Covid-19 pandemic and Hurricane Fiona, making it easier to identify those most at risk. From this census, across all seven communities, health promoters have identified close to 30 homebound individuals and nearly 100 individuals living with disabilities.

Since its inception, COSSAO has received guidance from medical and public health academic institutions. With their support and expertise, the clinic has been able to leverage resources to address service gaps. Collaborative efforts with residents and trainees from NOVA Southeastern University and the University of Puerto Rico’s School of Medicine, among others, have provided physical and occupational therapy, dental care and specialty gynecology and pediatrics services.

“Everybody that arrives at COSSAO falls in love with the project,” said Robles.

Dr. Ralph Rivera Gutiérrez, a professor at the University of Puerto Rico Graduate School of Public Health, has been working with COSSAO since 2015. For him, COSSAO’s model, particularly the element of community health workers (health promoters), presents an important alternative that should be replicated to combat the ongoing health crisis, particularly in remote areas.

“This is a project that begins with and from the community. It is a valuable model. Seeing the dream of a community and seeing it achieved, it is spectacular,” he said.