Invisible by Design: How Colonialism Drives Political Determinants of Health in Puerto Rico

Public health cannot be separated from politics. Although the relationship is often analyzed in democratic contexts, that framing limits the discussion to populations under colonial or neocolonial rule. Here I contend that colonialism functions as a higher-order determinant that influences the political determinants of health and, consequently, affects lower-level determinants, thereby hindering health equity. Colonialism operates through multiple mechanisms, disrupting the feedback loop in advocacy tools that connect community needs to political actions for health equity. Focusing on Puerto Rico, I use a legal determinants model to illustrate how laws and jurisprudence have institutionalized colonialism and affected health. This article expands Dawes's political determinants of health framework to demonstrate how a lack of sovereignty empowers external interests, shapes health, and filters local voices. Moreover, it shows that data invisibility and the systemic exclusion of US territories from federal data infrastructures constitute a form of epistemic erasure. The article concludes that achieving health equity and liberation requires dismantling colonial power structures, as the "double burden" of harmful policies and political impotence cannot be resolved without addressing lack of sovereignty and genuine representation. (Am J Public Health. Published online ahead of print August 27, 2026:e1-e10. https://doi.org/10.2105/AJPH.2026.308639).