It’s difficult to overstate the logistical challenge of responding to the humanitarian crisis facing Puerto Rico and other islands in the Caribbean after Hurricanes Irma and Maria hit. As of September 28, just over a week after Maria struck Puerto Rico, clean water, food, and fuel for generators were still hard to come by, most cell phone sites were out of service, and emergency officials struggled to distribute supplies throughout the island of 3.4 million people.
These circumstances have compounded what’s being called a “slow motion medical disaster.” It’ll be months before Puerto Rico’s power infrastructure is repaired, and in the meantime, the country is largely running on generators. But if you don’t have fuel to run those generators, you can’t deliver medical care. You can’t operate X-ray machines or keep medicines cool. Without water, people can’t stay hydrated or clean. Without roads, they can’t move patients to hospitals in time, get them food and other life-saving sustaining supplies, like fuel. The death toll is very likely to rise in the coming days.
But there is a bit of progress to report. Early in the week, only 11 of Puerto Rico’s 69 hospitals had power or a fuel supply. As of Thursday, 57 out of 69 were at least partly operational. And while the situation for the sickest and most vulnerable remains dire, particularly those in more isolated parts of the island, there are also stories of hope and resilience.
I went looking for doctors and nurses working on the ground in Puerto Rico and reached three who were dispatched from the continental US as part of the National Disaster Medical System, a Department of Health and Human Services civilian organization that goes into federally declared disaster zones to help care for patients and rebuild medical systems. From San Juan, Puerto Rico’s capital, on phone calls that kept dropping, they described the incredible strength of the islanders, their own worst fears about the recovery, and the public health crises that could hit next.
“I have yet to see a community with more resilient people as I have seen here”
Gina Smith is a nurse who usually works at the UMass Memorial Medical Center, but for the past 20 days she’s been a team leader with the National Disaster Medical System in Puerto Rico. When we talked, about half of the island still didn’t have drinking water. I asked Smith what that meant for delivering health care and meeting the needs of her patients.
“Those patients who have medical problems to begin with, their symptoms and medical problems are getting worse because they’re not getting fluids, and they are dehydrated,” she said. Even though bottled water is available, it can be difficult for people to access. “People are unable to purchase the water unless they have cash since credit cards and ATMs aren’t working,” Smith said. “Beyond that, there’s no air conditioning. It’s very hot.”
When I asked Smith what’s been keeping her up at night, she said “the duration of the recovery.”
“We have seen a couple of the patients coming through the tent with existing medical problems but this [hurricane] tipped them over the edge,” she said. “There have been people who have come in with high blood sugars, and they don’t their medications, they’ve run out of their medications, their blood sugars are not in balance for many reasons. They are not getting fluids they need. They are not able to eat because they don’t have the food sources they had.” And the end seemed very, very far away.
Communications with her team were also challenging. “[We] pretty much stay together, and a lot of times we use runners and word of mouth to get messages back and forth. I also have three phones — one for each cell phone service in Puerto Rico — and we use satellite phones.”
But Smith wasn’t hopeless. She’s inspired by the people she’s met in Puerto Rico. “I’ve responded to many disasters and many hurricanes — Charley, Frances, Katrina, Rita — and I have yet to see a community with more resilient people as I have seen here. I cannot state that strongly enough,” she said.
She was also careful to explain that despite the descriptions of Puerto Rico looking like a war zone, that’s not true for the entire island. “Maybe in isolated areas [it looks like that], but not in every area. There will be ongoing challenges. This will not be over soon. But I do believe that it will happen that people will be able to get back to where they were and be in a better place.”
“It’s a slow process but it’s a process of gradual improvement”
James Lapkoff is an emergency department physician at Harris Regional Medical Center in Sylva, North Carolina, but he’s left his home to work as one of the chief medical officers with the National Disaster Medical System in San Juan, Puerto Rico’s capital. When I asked him about the needs of the people he’s been caring for, he described two waves of patients coming through.
“The cases we’re seeing follow the typical pattern after hurricanes: Initially we saw traumatic injuries — broken bones, lacerations, blunt trauma — and a week after that, we started seeing a lot of decompensation of chronic illnesses,” Lapkoff said. “So COPD [Chronic Obstructive Pulmonary Disease] patients who ran out of medications, insulin that went bad for diabetics, cardiac patients who can’t get their medications.”
The looming health crisis he was most concerned about was the fact that a combination of no power and scarce drinking water meant vulnerable people might die from dehydration.
“There are three populations most susceptible to heat: the very young, the very old, and those who have concurrent illnesses that make their ability to tolerate heat more difficult,” he said. They’re all affected by the fact that there is no power, no air conditioning.
When we spoke, he had been helping run the tent hospital outside of the Centro Medico hospital in San Juan. He didn’t know when his team might be able to close the tent down, but he said he already saw signs of progress.
“When the hurricane came through, this hospital [Centro Medico] had about 45 surgical suits. After the hurricane, only two of those were functional. Yesterday and today I’ve been told they are slowly starting to get them all up and running again,” he said. “It’s a slow process but it’s a process of gradual improvement.”
“There’s nowhere to send [our patients] in Puerto Rico after we see them”
Sovann Yong is another emergency room doctor, from Massachusetts, caring for patients as part of the Disaster Medical Assistance Team in San Juan. She had also been struggling with limited supplies and the lack of water, but more than that — she found it difficult to balance patients’ medical and mental health needs.
“When people came into [the medical tent],” she said, “They would be tearful and crying about their loss. I feel like when we’re in the tent, we never get to treat them as a whole person.”
One patient stands out: an elderly man who staggered into her tent the other day on the arm of his wife. He had difficulty breathing and speaking. “He was confused. His blood sugar was very, very high — too high to read. He had a history of diabetes. He was not getting the routine care that he needs and he had run out of his medications.” The man had already had symptoms for a few days already but couldn’t get to the hospital for help, and had been getting sicker.
She helped him in the limited way she could, but worried about where he’d go after he left the hospital. “The folks are here, they are not evacuated from somewhere else. This is their home and they are still living through it,” she said. “The folks we saw in Hurricane Sandy, they were in a medical shelter. They had been evacuated from an unsafe environment and to the medical shelter where we took care of them. There’s nowhere to send [our patients] in Puerto Rico after we see them.”