Cases are found in the Puerta de Tierra neighborhood, an extremely impoverished and overcrowded community that has become the dumping grounds and horse stable area for the city.

Puerto Rico, which became a U.S.-occupied territory in 1898, is only just beginning to establish a U.S. health care system in the 1910s. Response to the plague focuses on destroying rat nesting sites, establishing sanitation protocols, and monitoring community health.

The U.S. is reluctant to direct resources to its new colony, and instead focuses on "cleaning up the dirt" of those living in poverty, thereby placing the blame on the poor, rather than the conditions surrounding the community.