A Healthy Renewal for Puerto Rico
SAN JUAN, Puerto Rico – Amid the still-not-fixed physical damage to Puerto Rico after two powerful hurricanes hit late last year, the island is in a health care crisis.
After Hurricane Maria made landfall Sept. 20, clinics and hospitals were unable to function, and some are still at partial capacity because of structural and water damage. Physicians are leaving the island for the U.S. mainland. Suicides have surged, and post-traumatic symptoms are afflicting children as well as adults. Months after a power outage classified as the biggest in U.S. history and likely the second-largest in world history, there are still people in mountain areas that have not had power since Hurricane Irma, which hit two weeks before Maria. That makes it even harder for residents of those areas to get medical care.
All of it creates a daunting task for Puerto Rico's health secretary, Dr. Rafael Rodríguez Mercado, as he endeavors to heal an island after storms that not only injured Puerto Ricans physically, but damaged the island's ability to take care of its people as well.
Rodríguez, however, says he's not aiming to bring the status of Puerto Rico's health infrastructure back to where it was before the hurricanes. He wants to take the opportunity to make it better.
"Just imagine that we went to sleep on the night of Sept. 19, 2017, and woke up on Sept. 20, 1950," the year the commonwealth was established, Rodríguez says of Maria's impact. "We were without communication, without power." A Puerto Rico Health Department that had 5,000 employees was down to 10 who were available – including the secretary, his press assistant and his driver. The number of hospitals that could see patients went from 69 to fewer than 20.
Assessing the damage – which the health secretary stresses could not have been done without the help of the U.S. Defense and Health and Human Services departments, as well as the Federal Emergency Management Agency and hordes of nonprofits and volunteers – Rodríguez, a neurosurgeon and active military reserve doctor, figured the rock-bottom situation gave him a chance to address problems in the system that existed long before Maria.
"What we are trying to do now in the recovery is to make resilient those centers for diagnostic treatment, some private and some owned by the government," he says, referring to medical centers known as CDTs. That includes modernizing them, he says.
For hospitals, the process entails making some very basic upgrades, such as acquiring satellite phones, backup generators and generators that have bigger capacities. "You'd think these are little things, but in the case of an emergency, they are very big things," Rodriguez says. "They make a difference."
In the more vulnerable mountain areas, Rodríguez wants to use technology to expand health care. As the clinics are being rebuilt to be sturdier, they also can be equipped with solar power, so they can operate even if another storm takes out power lines, he says. Telemedicine – which allows doctors to treat patients remotely, using telephones and computers – is also a goal for the mountain regions, where even in calm weather people may find it hard to travel to cities for physician visits.
"All of the new technology can bring resilience, and in the case of another emergency, we can be connected with them," Rodríguez says.
The health department, in concert with NGOs, has been pushing a massive vaccination effort as well, preventing what could have been an influenza epidemic after the 2017 storms. Some 300,000 people – and pets, too – have received vaccinations from mobile units that are visiting remote regions of the island, Rodríguez says.
Mental health, meanwhile, is an acute problem, with both youngsters and adults struggling with depression and post-traumatic disorder not just after the hurricanes, but amid a painful economic crisis. The added troubles come at a time when the island is already suffering from a dearth of medical specialists, says Mekela Panditharatne, a fellow at the Natural Resources Defense Council who works on environmental and health issues.
"Maria has made a really bad situation even worse," she says.
Suicides spiked last year, with Puerto Ricans age 55 and older accounting for about half of such deaths on the island. Repeat suicide attempts are also up, Panditharatne says, suggesting there is not enough, or adequate enough, therapy for depressed people. Calls to the government-run suicide hotline also skyrocketed: More than 3,000 came in from November 2017 to January 2018 – more than three times the amount seen during that three-month period the previous year.
The elderly are more at risk because they lack the ability to depart the island – or even the house – when things get tough, says Dr. Karen Martínez González, a psychiatrist and director of the University of Puerto Rico's Center for the Study and Treatment of Fear and Anxiety.
"For a lot of people, their response to mental health issues was to pack up and leave. We have that flexibility," but older people do not, she says.
But the crisis also could provide a pivotal opportunity to expand diagnoses and treatment and to change the very way Puerto Ricans view mental health, Martínez says.
"For Latinos, going into therapy is culturally very foreign to them. We're not used to talking about our emotions. We express our emotions," she says with a chuckle. "But we're not used to thinking about them. It's a problem because it's not something they see could be helpful, talking to a stranger about this. That's one of the things we're trying to get out there."
Martínez is working on a project to train community health workers in mental health screening and basic treatment. "We can't expect them to come to our offices," especially when even in the best of weather conditions, the trip to the capital of San Juan can be long, she says.
Specialists are also working with schools to train teachers to identify behaviors in children that could indicate post-traumatic stress and associated traumatic disorders – a role that's unusual for Puerto Rican schools. "Mental health services at school at this time are mostly nonexistent," Martínez says.
A team from the Medical University of South Carolina's Department of Psychiatry and Behavioral Sciences went to Puerto Rico soon after Hurricane Maria to conduct workshops for teachers and school staff, focusing on key areas including how to handle the doubled stress of dealing with their own trauma while aiding others.
Now, the medical school group is training teachers and social workers how to identify and help children who are having mental health problems stemming from the hurricanes. Most of the affected children's behavior comes in the form of bullying and aggression, says Rosaura Orengo-Aguayo, a clinical psychologist and assistant professor at the Medical University of South Carolina who is among those leading the effort.
The Puerto Rico Department of Education "wanted mental health training that doesn't require full-blown therapy," Orengo-Aguayo says. "It's how to help a kid or parent engage in a more positive way, how to deal with triggers and different thoughts and feelings." A team is returning in August for a more intense, third phase of training, she says.
Long-term, experts say, Puerto Rico has deep structural problems in its health care system, most of them caused or exacerbated by a lack of resources. Unlike U.S. states, the island gets capped block-grant funding for Medicaid, and the fund is perpetually running low, says Dr. Luis Toro-Figueroa, a retired pediatrician and critical care physician who now leads an organization called ECOPA, a team of businesses providing health care to needy islanders.
And for physicians, "it doesn't take a lot of brains to say, 'I'll go to Florida, where there are better facilities and I'll have a better quality of life,'" says Toro-Figueroa, a native Puerto Rican who worked on the mainland but retired in Puerto Rico. "You have to be a monk-like person" to stay and practice.
U.S. Rep. Darren Soto, a Florida Democrat whose district includes many Puerto Ricans, says he is sending a letter to the Centers for Medicare and Medicaid Services, asking the agency to address the lower federal matching rate for Medicaid that the island receives – a disparity Soto says will be even more problematic as another hurricane season approaches.
"It's a starved system," he says. "They need a long-term solution."
Still, more than seven months after Maria landed, Puerto Ricans have some hope that the commonwealth can be rebuilt stronger and healthier, even if the journey – like so many on the ravaged island – may be long and treacherous.
"We can rise like the phoenix," Rodríguez says. "Puerto Rico has a great heart. The way that we fall down is also the way we can stand up and move forward."
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