“We need to recognize the dignity of the human condition and the entire ecosystem of people’s life experience. That includes the role of economic conditions in their wellbeing, and their ability to thrive and contribute to their community’s prosperity.”
Aerial view of The streets of Santurce, Puerto Rico.
Photo: Steve Osemwenkhae
A key but underrecognized economic driver: Behavioral health
By Suzanne Cummings
Last April, we posted about an unlikely partnership between the NY Fed and SAMHSA to address behavioral health issues and their impact on economic outcomes in Puerto Rico. For decades, the largest U.S. territory has struggled with high poverty rates, inflated cost of living, outmigration of the workforce, natural disasters, and drug and disease epidemics. These stresses have taken a heavy toll on the public health and ability to prosper of its residents.
We are pleased to offer this adaptation of our original post—a full transcript and audio narration—in Spanish. Our goal is to invite Hispanic populations in Puerto Rico and around the nation to join this important conversation.
Mental health and addiction issues have significant impact on the ability of individuals and communities to thrive and contribute both to their own wellbeing and to their local economy. We hope this translation informs a broader audience how disparate entities can collaborate toward improving inherently tied behavioral health and economic conditions in our diverse and vibrant communities.
Who doesn’t know someone living with a chronic health condition like heart disease, cancer, or diabetes? Today in the US, nearly 60% of Americans live with one, and four in ten adults have two or more. According to the Centers for Disease Control, these and other chronic conditions are leading causes of death and disability in America and top drivers of healthcare costs. They can also have profound impacts on America’s productivity and capacity for growth.
What we haven’t heard about so often in the daily discourse is the intrinsic connection between behavioral and physical health. The US Substance Abuse and Mental Health Services Administration (SAMHSA)’s annual survey shows that one in five US adults experiences mental illness each year. The trickle-down effects of mental illness and substance abuse flow from impacted individuals to entire communities.
“We need to recognize the dignity of the human condition and the entire ecosystem of people’s life experience,” said Dennis Romero, regional director for SAMHSA’s Region 2. “That includes the role of economic conditions in their wellbeing, and their ability to thrive and contribute to their community’s prosperity.”
Romero’s SAMHSA region includes Puerto Rico, where this connection between mental health and economic wellbeing could not be more evident. Facing persistent emotional and economic strains from the effects of natural disasters, poverty, the COVID-19 pandemic, and numerous drug epidemics, the island’s communities need relief and support.
Hurricane damaged roofs in Puerto Rico.
Photo: Javier Silva
Disparate entities find common cause to collaborate
In early 2023, Tony Davis and Javier Silva of the Federal Reserve Bank of New York’s Community Development team sat down to discuss the troubling conditions on the island. The largest US territory, Puerto Rico falls into the NY Fed’s regional district.
Davis and Silva considered how the NY Fed could best contribute to economic development efforts in Puerto Rico’s communities. What concrete steps could they take to work toward hope for recovery, stabilization, and even growth? The answer lay in an unlikely partnership with the national agency that oversees behavioral health issues—SAMHSA.
When Davis and Silva proposed teaming up with Romero and SAMHSA to strengthen and connect mental health and substance abuse services on the island, they discussed the positive economic outcomes their collaboration could spark. For Romero, the idea was a no-brainer. “Here is this entity known for regulating banks and setting economic policy, and they’re showing interest in the same goals we have at SAMHSA and committing to help us address them,” said Romero.
Fortifying behavioral health systems is one way to invest in human capital for building a stable and capable workforce. This SAMHSA-NY Fed collaboration, therefore, supports an inclusive growth strategy to improve the overall health and productivity of residents, which can lead to higher local wages and living standards.
The Big Uneasy
SAMHSA’s survey results reveal the prevalence of mental health and substance abuse conditions across the US. Evidence also shows these conditions grew still more difficult when intensified by the effects of COVID-19.
One positive outcome of the pandemic, though, has been heightened awareness of mental health and substance abuse disorders and their growing validity as health conditions. More people are now recognizing that these disorders are deserving of attention, understanding, coordinated support, and treatment.
There’s also greater awareness of how behavioral health significantly factors into the economic productivity, wellbeing, and potential of our communities. In Puerto Rico, where stress-inducing challenges have been especially unrelenting, the incidence of mental illness and substance abuse has reached crisis proportions.
Just 100 by 35 miles in diameter, Puerto Rico has long been plagued with more than its share of challenges including:
- persistently high poverty rates, especially among children,
- limited domestic industry and out-migration of the educated workforce,
- a higher cost of living, relative to cities in the mainland (San Juan recently ranked 9th most expensive place to live in the US),
- old, poorly maintained public infrastructure,
- numerous drug epidemics (Xylazine, opioids, heroin, fentanyl), and,
- recent natural disasters (hurricanes, earthquakes).
Over time, the confluence of these challenges and their impacts have created distinctly unfavorable conditions for this beautiful island to reach its full economic potential.
Gathering steam and stakeholders to address behavioral health issues
SAMHSA and the NY Fed are working to improve mental health and substance abuse awareness and services in Puerto Rico and forging partnerships with other stakeholders on the island. Last fall, the Puerto Rico Public Health Trust (PRPH Trust) hosted a conference of around 500 attendees to discuss pressing issues and share promising practices in the field.
“This was a wonderful opportunity to underscore that behavioral health is essential to public health,” said Romero. “The PRPH Trust including behavioral health in the pillars of its mission really speaks to its significant role in the general wellbeing of society.”
Silva offered a takeaway from the conference’s keynote address by Carlos Quesada, former president of Costa Rica. Quesada discussed his country’s focus on prioritizing the health of its citizens. “Over time, Costa Rica has been able to put a system in place to upgrade public health, because their government considers a healthy population key to economic development,” Silva explained. “These investments in health-driven policies have had impact.”
“We in the NY Fed’s Community Development team are especially interested in the effects of mental health on economic outcomes.”
– Javier Silva, senior associate director, Community Engagement, Federal Reserve Bank of New York
“We in the NY Fed’s Community Development team are especially interested in the effects of mental health on economic outcomes,” added Silva. “Similar approaches to those Costa Rica employed could make cost-effective but substantial changes in the way behavioral health issues in Puerto Rico and the rest of the US are addressed.”
The streets of Old San Juan. San Juan, Puerto Rico.
Photo: Steve Osemwenkhae
Marking progress in Puerto Rico’s behavioral health strategies
One innovative effort the NY Fed and SAMHSA teams are contributing to is the mapping of all mental health and substance abuse services in Puerto Rico. “Creating a print and digital tool—similar to a subway map—is a goal of the PRPH Trust,” said Silva.
“If you’re feeling stressed or suffering a relapse of some kind, you can reference this map to find resources near you, anywhere on the island,” Silva explained. “The map would serve both practitioners and patients, while the resources can be continuously updated online.”
Silva described how the NY Fed connected PRPH Trust with the local small business ecosystem that uses a similar tool created by Colmena66. “The map, called Tu Camino Empresarial, is successful in connecting entrepreneurs to the resources they need, whether it’s financial, marketing, sales, etc.,” he said. “By applying that concept to mental health, we are leveraging an existing tool in another field and customizing it for this sector.”
The idea came from previous scans of behavioral health resources conducted on the island by Romero’s agency after the hurricanes. “This is a great example of the collaboration between SAMHSA and the NY Fed,” Silva remarked.
Another local partnership between SAMHSA and Puerto Rico’s Menonita Hospital stems from last fall’s conference. “The hospital is currently one of three recipients on the island of large SAMHSA CCBHC grants” Romero noted. “The grantees are helping us test the newest iteration of an integrated model of primary care and behavioral health care.” By linking these health services together—a whole-person approach—they hope to demonstrate the potential benefits of a “continuum of care” to the overall wellbeing of residents, and ultimately, to residents’ ability to contribute to local economic prosperity.
A path forward doesn’t mean reinventing the wheel
Seven years after hurricanes Maria and Irma, Puerto Rico is still recovering from the devastation. Fly over the island today, and you can still see the blue tarps covering damaged roofs in many places. Romero acknowledges that there’s lots of trauma out there.
“Resilience is a great quality, but one that Puerto Ricans unfortunately know too well. The truth is they’re exhausted from having to be resilient. They need coordinated support from many different sectors to help them with their interconnected issues.”
– Dennis Romero, regional director, US Substance Abuse and Mental Health Services Administration (SAMHSA)Region 2
“Resilience is a great quality, but one that Puerto Ricans unfortunately know too well,” he said. “The truth is they’re exhausted from having to be resilient. They need coordinated support from many different sectors to help them deal with their interconnected issues.”
The NY Fed and SAMHSA teams continue to explore behavioral health and economic intersections in their respective community-building work. When you look at economically thriving communities, they point out, you often see that they’re thriving in terms of public health. They hope elevating this conversation will lead to new partnerships, better use of proven strategies, and more buy-in and backup from diverse sectors.
Romero noted, for example, that the Puerto Rico Chamber of Commerce brought behavioral health into its conversation for the first time last year. He presented to that audience and considers it a milestone in efforts to shine light on the connection between the economy and mental health and addiction.
Society doesn’t need to reinvent the wheel to find a path forward. There are opportunities to share, adapt, and expand what’s already working. It’s an approach that acknowledges and leverages the connections between different aspects of human wellbeing and links together entities in different but related fields.
Drawing out data to inform solutions
To find effective solutions, stakeholders also need accurate data on the roots and extent of these problems. More local data would be particularly valuable.
As mentioned earlier, SAMHSA conducts an in-depth national survey on substance abuse and mental health indicators each year. Yet US territories are currently not represented in those numbers, so they can only rely on local data collection. This is something that SAMHSA is actively working to change.
Silva agrees. “That kind of data is vital. There’s a huge, missed opportunity in not including the territories in robust, national datasets,” he said.
On the economic side, Silva noted that employment on the island is starting to improve, and FEMA dollars also offer growth potential. “Funds for hurricane rebuilding will create many jobs over the next 10 years, as we’re already starting to see in the data,” he said. “But federal recovery money has been slow to make it to the ground. Of Puerto Rico’s $85+ billion allocation, only around $32 billion has currently been disbursed.”
“That gets back to residents’ stress over how long it’s taking to rebuild,” Silva added. “When you know there will be more natural disasters, folks develop ‘eco-anxiety.’ Getting the money out faster to address critical needs is important to healing the emotional and economic scars of these events.”
Polo Norte Soda Factory located in Old San Juan, Puerto Rico.
Photo: Steve Osemwenkhae
Continued conversation and collaboration will benefit both economic and behavioral health conditions
The NY Fed has ongoing dialogue with US Surgeon General Vivek Murthy on issues of mental health. Murthy recently visited Puerto Rico and met with the PRPH Trust and other stakeholders, giving much-needed attention to the importance of behavioral wellbeing. Romero is also planning a first-ever convening of the island’s entire prevention and harm-reduction community this spring.
SAMHSA and the NY Fed continue to raise awareness of mental health and addiction issues as chronic health conditions that need public attention and coordinated intervention. The consequences of inaction are devastating for the many individuals who suffer from these treatable disorders. Inadequately addressing peoples’ needs also can contribute to harmful economic ripple effects for communities, territories, states, regions, and the nation. That’s worthy enough cause for two unlikely partners—and hopefully many more—to work together to strengthen and connect the systems around behavioral health.
The views expressed here are those of the author and interviewees and do not necessarily reflect the views of the Federal Reserve Banks of Boston and New York, the Federal Reserve System, or Fed Communities.
