The physical and mental health needs of the people of Puerto Rico cannot be underestimated. Just think of what they have been through over the last few months.

When Hurricane Maria barreled onto the island on Sept. 20, 2017 – just 2 weeks after Hurricane Irma reportedly left more than 1 million residents without power – it ripped off roofs and left behind massive flooding, roads washed out, and utility poles and transmission lines knocked down. Whole forests were defoliated, a massive loss of flora and fauna occurred, and 80% of the crop value was destroyed, along with massive loss of stray dogs and cats, dairy cows, industrial chicken coops, and tropical birds, including endangered species. Beloved pets were displaced.

Hospitals lost power. Some had generators, but some of the generators had been damaged by the storm, and those that were functional could not be run 24 hours a day, for risk of destroying them. Six hospitals shut down completely and at least two operated for weeks without full power. Among these was Centro Médico, Puerto Rico’s largest medical provider, which did have power back within the week. But the power was sporadic and unreliable. Obtaining adequate supplies of diesel to operate the generators proved an ongoing problem. When the generators were running, they were polluting the air with diesel fumes, exacerbating respiratory illnesses. People on respirators could not be maintained; people in need of surgeries could not get them; dialysis patients had to be airlifted off the island – to the extent possible. Medications such as insulin could not be consistently refrigerated.

The official death toll as a result of Maria was 64 in December, but according to reporting by The New York Times , that number could be as high as 1,052. Most of the people who died reportedly were men and women over age 50 in hospitals and nursing homes suffering from illnesses such as diabetes, Alzheimer’s, kidney disease, hypertension, pneumonia, and other respiratory diseases.

One grassroots organization that mobilized to provide supplies and medical assistance was Doctoras Boricuas, a group of all-female doctors in the United States and Puerto Rico that formed after the hurricanes to coordinate the delivery and distribution of supplies directly to Puerto Rico and the Virgin Islands. Two groups affiliated with the University of Missouri at Columbia joined forces to help: Global First Responder or GFR , a nonprofit, secular international medical relief organization founded in 2011 by Adam Beckett, MD, and the International Center for Psychosocial Trauma, or ICPT, a group established in 1995 by Syed Arshad Husain, MD , to help war-traumatized children in Bosnia. I joined Dr. Husain’s group of professionals – Kathryn Dewein, PhD; Andra Ferguson, PhD; and Cathy Grigg, PsyD, – all of whom have traveled broadly in the field of disaster psychiatry – to see how we could help the people of Puerto Rico in Maria’s aftermath.

What we did

ICPT and GFR were a combined team, but we served different functions. As part of ICPT, I focused on the mental health component and helped to train doctors, psychologists, social workers, and other mental health workers in both San Juan and Ponce. All told, we worked with about 50 people using the model of “ Training the Trainers .” Many of our students were participants in the outreach teams. Our hope is that they will be able to train their peers to recognize and alleviate symptoms of acute and chronic stress disorders. Some of the techniques taught include patient education, relaxation training, breath work, visualization techniques, mindfulness training, narrative therapy, art therapy, and other expressive techniques.

What the PMSF did

Before Maria, the Ponce Medical School Foundation was in the process of facilitating the transfer of medical records into an electronic format. After the hurricane hit, however, PMSF’s program director, Antonio Fernandez, led a shift to disaster recovery work. PMSF got involved in airlifting dialysis patients off the island to safety, provided health care, and also collaborated with the Primary Care Psychology Program at Ponce Health Services University to assist in locating patients, identifying their health needs – including mental health – and providing for those needs to the extent possible.

At the time of our visit, Puerto Rico’s network of more than 90 largely rural federally funded primary care clinics mostly had reopened, but nearly half remained on back-up generators. Even with the medical centers open, patients were not coming in for one reason or another. People had medical problems, but the daily reality of survival, obtaining food and water, took precedence. Some patients were not showing up because they had left the country, or they were in shelters without transportation. Some people did not have fuel. Some could not keep track of their appointments without cell phones and electricity allowing them to access electronic planners. Some, having been without their medications since the storms, were too sick to travel. Outreach teams were necessary to locate patients, identify their needs, and provide medical and psychological care.

Community outreach

Nydia M. Cappas, PsyD , director of the Primary Care Psychology Program, told us that the outreach teams – consisting of doctors or other medical professionals, social workers, and psychologists, were being sent out to communities once a week. They visited homes for the elderly, orphans’ homes, and children in foster care, as well as individual patients. A similar service was provided by Vargas Medicine (VARMED) in the San Juan area.

Team members found that many people were suffering symptoms of posttraumatic stress disorder, even people who did not have prior psychiatric symptoms. They were having flashbacks and nightmares. Those flashbacks and nightmares were being triggered by clouds, by rain, by supplies beginning to run out.

Some people were avoiding taking their medications and socializing with others, and were experiencing anhedonia. People were experiencing affect dyscontrol, anger, irritability, impatience, intolerance.

Another trend we observed is that terrain changes prompted by Maria triggered PTSD symptoms among many veterans. The defoliated trees and brown earth were causing them to have flashbacks to the deserts of Afghanistan and Iraq. Children were showing regressive behaviors, loss of developmental milestones, and symptoms of separation anxiety such as wanting to sleep with their parents. In severe cases, they were having psychotic symptoms and auditory hallucinations. The children were grieving the loss of their homes, toys, pets, and family members, in some cases. The teams were able to provide psychological first aid, help people fill out their forms for Federal Emergency Management Agency relief, and distribute medical supplies, including medications, food, toiletries, and other household goods.

Puerto Rico’s future

Two and a half months after Maria, we learned from our students that things gradually had begun to improve. For example, the public schools had just reopened, and that change was expected to have a stabilizing effect on the children. We also learned that, of the 80 shelters that had been set up housing about 12,500 people, 40 shelters had closed. The five medical shelters that had been set up and funded by FEMA also were in the process of closing, and private donations were beginning to slow down. People were slowly returning to their tarped or otherwise repaired homes, albeit all too often without power.

During the storm, nearly 500 homes were destroyed. FEMA offered to airlift about 3,000 people who had no home 2 months past Maria to the U.S. mainland – either Florida or New York.

According to our students, people living in the mountains, mainly coffee growers and retired people and comprising about one-third of the population, remain in acute crisis. Part of the challenge is being able to reach this population: Some roads are still impassable, and supplies – such as drinking water – can be delivered only by helicopter. Despite current conditions, FEMA reportedly has announced that it would end emergency operations on the island.

Our team is currently involved in applying for grant funding that will enable us to return to provide additional training to physicians’ and teachers’ groups. Over the course of the next year, we would like to make six trips to Puerto Rico and focus each trip on a different region and different group of professionals so that the entire island has resources. In addition, we will offer follow-up consultations to professionals we trained previously. The regions to be trained would be San Juan, Ponce, Utuado, Mayagüez, Guayama, and a sixth to be determined upon need. We also would like to address the needs of any ongoing relief workers so that they will be more effective in their ongoing role. Meanwhile, financial assistance from the mainland remains uneven.

Many months after Maria (and Irma), the physical and mental health needs of the Puerto Rican people remain great. However, as mental health professionals, we have the tools to help them move forward.

Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee and Membership Committee for the American Academy of Child and Adolescent Psychiatry.

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