The influence of government negligence on the way people experienced the essential services of hospitals, clinics, and pharmacies after Hurricane Maria

Abstract

Hurricane María had a profound impact on the way essential health services were given during the emergency period that followed its landfall on Puerto Rico. The main objective of this research was to find out what people with health conditions in need of essentials services from hospitals, clinics, and pharmacies did during the emergency period. Furthermore, we wanted to know people’s view about the government’s response to the aftermath of the hurricane. By conducting a series of interviews with different health specialists, students at the University of Puerto Rico-Cayey, and citizens of the community of Jájome Alto in Cayey, Puerto Rico, we were able to better understand aspects of the physical and social impact caused by Hurricane Maria. Interviews made at Casa Pueblo in Adjuntas, Puerto Rico, served as an inspiration for how we can prepare better for future natural disasters.

Introduction

Over the years, the government system and political management of Puerto Rico have laid the foundation for the precarious situation of the medical services infrastructure. The Department of Health has suffered significant budget cuts and public policy changes have forced it to perform more functions with fewer resources (Alertan sobre “inminente colapso” del sistema de salud de Puerto Rico, 2015; Cotto, 2015; Estades, 2015; Gonzalez, 2015; Soto, 2017). This was the situation in Puerto Rico when Hurricane María hit on 20 September 2017. Just two weeks earlier, Hurricane Irma had passed, causing considerable damage (Huracán causa estragos a su paso por Puerto Rico y deja destrucción en Caribe, 2017; Johnson et al., 2017). However, the night of September 20 caused irreparable damage that, even years later, it continues to be of urgent concern for Puerto Ricans. The National Oceanic and Atmospheric Administration (Pasch et al., 2019) has estimated that “the damage caused by the hurricane in Puerto Rico and the Virgin Islands is 90 billion dollars … making Maria the third costliest hurricane in the history of the United States.” In many ways, the magnitude of the damage and the crises that have followed have contributed to a failure to meet people’s essential needs, including the needs related to public health.

After the hurricane, many people with health conditions did not receive the services they needed in their daily lives (Chandra et al., 2020). Diabetics, bedridden-people, patients receiving dialysis, and those with respiratory problems or conditions that require them to be regularly taking medications are some of the most vulnerable populations who are severely affected by natural disasters. According to statistics, the lack of access to medical services, treatments, medications, among others, contributed to “16,608 [people] dying between September 2017 and February 2018” (Santos-Burgoa et al., 2018). Therefore, what did people in these populations do during the emergency period following the hurricane’s passage? How did they get their medications? How did they manage to receive their treatments? Our research suggests that finding a solution to these situations was a challenge after Hurricane Maria and will continue to be a relevant one for Puerto Rico as long as the preparatory measures are not assumed as a priority. While it is true that each citizen is responsible for adequately preparing for these atmospheric events, it is the government’s responsibility to prepare the country as a whole to address those needs that the citizen cannot meet alone (Cotto, 2020). Electric service, medications, drinking water, and fuel are just a few examples of the services that the government is responsible for and must ensure that they provide to the public. This research aims to evaluate people’s perceptions regarding the government’s performance when confronting the essential needs of everyone affected by Hurricane María. We also investigate what people with health conditions that required services from hospitals, pharmacies, or clinics did during the emergency period following Hurricane María. Finally, we examine how different health professionals offered their services.

This research is based on interviews with 12 people affected by the Hurricane and service providers in the city of Cayey. The municipality is about 60 miles south of San Juan and also home to the University of Cayey where we were enrolled as students at the time of Hurricane María. We conducted interviews with residents of the Jájome Alto neighborhood in Cayey, with staff from a local pharmacy, students fron the University of Puerto Rico in Cayey, healthcare professionals who work with patients that are at greater risk during these events, and staff at Casa Pueblo, a community-based organization in nearby Adjuntas. As a result of our reseach, we argue that in order to solve the problems facing vulnerable communities, it is required that each town’s needs are carefully studied in order to equip more efficiently when facing future hurricanes and other similar atmospheric events. We also emphasize the active role government must take by improving the infrastructure of Puerto Rico in order to respond to the basic needs of the population. This study focuses on the struggles that Puerto Ricans endured and overcame after Hurricane María. Through our inteviews and conversations with people adversely affected by the Hurricane, we identify what went wrong and why. This research is timely and important since it identifies how we can efficiently prepare for future atmospheric events and by doing so, reduce the casualties and losses. The findings of this study can also be used to improve the overall quality of essential services that are being offered. The limitation of this study is the quantity of people interviewed. Future reseach would benefit from interviewing more people to develop a deeper analysis that shows hidden fundamental flaws in our emergency response systems.

Literature review

Hurricane Maria required Puerto Ricans to demonstrate various types of resilience as a way to meet their basic needs. For example, the hurricane left many houses without roofs, separated them from family members, and also without a way to feed themselves adequately (Narayan, 2017). The government provided aid in different ways to many families across the island. However, it is impossible to deny that the government failed to carry out actions that were important to the country’s well-being. Therefore, people, motivated by their own needs and the needs of their families, were moved to act when the government was absent and failed to do so. Still, the help was not enough. We know this because families were left with absolutely nothing, and unfortunately, many people died. The aftermath of the Hurricane reveals the government’s limited response and how vital institutions such as hospitals, pharmacies and clinics were not prepared to meet the needs of people on the island.

Hospitals had to go through a rigorous process of preparation and anticipation for the hurricane. Those who make up the Southwestern Regional Medical Center or SW – RAMC (the Centro Médico Regional del Sudoeste) are examples of hospitals complying with preparation protocols (De Arzola, 2018). These protocols included reducing, as much as possible, the number of patients admitted to the hospital and carrying out inventories of the hospital’s resources to determine if they needed to restock or if they had what was necessary for an emergency. They formed work teams that had clear instructions on what they should do before, during, and after the event to guarantee the safety of the professionals and the health of the patients. Also, in case of an emergency occurring, lists were made with important information about the doctors and residency students.

Days after the event, a newspaper reported: “of all the problems that María caused, with winds of 155 mph, in general, the situation in hospitals and clinics, and health services is one of the most worrying for officials leading recovery efforts” (Associated Press, 2017). News article following the hurricane documented the conditions the hospitals were in during the first weeks after María’s passage. For example, one news article mentioned that a cook who was shot in the hand and had to wait five days at Centro Médico.¹ This shows how unprepared health service centers were for these events. The press release explains that only a few operating rooms were enabled due to the lack of electricity. The media also shows how the health system of Puerto Rico was damaged even before Hurrican Maria. This is why the aid mechanisms were inadequate and faced many problems to meet patients’ needs in an emergency. In comparison, the Puerto Rican health system is significantly more impoverished than the continental United States. This is the effect of the island’s economic situation, which has been present for several decades. The economic crisis had already led to the neglect of public facilities and extensive cutbacks to save money (Holpuch, 2017). As news articles, some patients could not refrigerate insulin and other medications after the hurricane. The air conditioning equipment was not working due to the general lack of electricity. There were also difficulties due to the lack of transportation to take people to the doctor (Associated Press, 2017). Another article focused on a mother with a paraplegic son who required an artificial respirator, oxygen tank, and a feeding tube and was transferred among different hospitals for 40 hours because they were unable to locate a ventilator. María left the entire island without power, and only a handful of the 63 hospitals in Puerto Rico had electricity generators running at full power (Associated Press, 2017). Meanwhile, the sick overflowed the hospitals (Abrams, 2019; Acevedo, 2020; Bluth & Heredia Rodriguez, 2017; Dorell, 2017; Hall et al., 2018; Jeffrey, 2017; Valdés Prieto, 2018).

Methodology

The population of interest

This research evaluates people’s perception regarding the government’s performance when confronting the essential needs of everyone affected by Hurricane María. Through our interviews, we also also learned how people with significant health conditions coped in the absence or limited access to required services from hospitals, pharmacies, and clinics. Our rsearch also shows how different health professionals offered their services during the crisis. By focusing on the municipality of Cayey where we studied at the University of Puerto Rico, we were able to draw on our networks to interview people from the neighborhood of Jájome Alto, students at the University of Puerto Rico, and healthcare professionals in the city. These data allowed us to determine how they handled the situation and the scarcity of resources while seeking services during this emergency period. Our research also includes insight from our conversations with staff at Casa Pueblo, a community-based organization in Adjuntas that foucses on sustainable energy and community empowerment.

In Cayey we interviewd: two (2) members of the Jájome Alto community, two (2) students from the University of Puerto Rico—Cayey (UPR -Cayey), two (2) pharmacy technicians who work in a community pharmacy in the town of Cayey, one (1) nephrologist who works in Cayey, one(1) psychologist from the UPR-Cayey, one (1) pharmacist and one (1) gynecologist. Our interviews with Casa Pueblo included the two (2) staff members who provided important information about effective strategies that can be implemented in throughout Puerto Rico to ensure communities have reliable resources during emergencies, such as atmospheric events of the magnitude of María.

According to the 2010 census, the town of Cayey has a population of 48,119 inhabitants, of which 37.9% are below the poverty line (Oficina del Controlador de P.R., 2019). The town includes Cayey and part of the Jájome “sierras,” which are part of the “Cordillera Central” (Central Mountain Range) (Portal Oficial del Gobierno de Puerto Rico, 2017). Among the locations in Puerto Rico that suffer the most from these atmospheric events are the mountainous regions. Many of its areas are difficult to access due to challenging topographies, making it more difficult to provide help and restore normalcy after the passage of a hurricane. This is the case in neighborhoods like Jájome Alto in Cayey. As students from the University of Puerto Rico, Cayey, we were familiar with many of the communities around the university. And because of our training in Youth Participatory Action Research, we spent time considering which community to work with and learned about several areas that had suffered extensive damage after the hurricane and had been without electricity for nearly a year. For this reason, we focused our study on the community of Jájome Alto. As we learned more about the community, we went door to door to meet people, explained our research to them, and asked if they were interested in participating. In the first house we went to, the participant referred us to her neighbor, and we were also able to interview him. We also had the opportunity to visit a community pharmacy in central Cayey where we interviewed two pharmacy technicians at the same time. Later, we interviewed a nephrologist since his patients represent a highly vulnerable population to atmospheric events.

As students at UPR-Cayey ourselves, it was not difficult to interview fellow student who shared her experiences with us. The UPR-Cayey was founded in 1967 and officially became a university in 1969 (Historia de la UPR Cayey, n.d.) and is part of the 11 campuses that make up the University of Puerto Rico system. In the first semester of the 2019–2020 academic year, UPR-Cayey had a total enrollment of 2880 students (Oficina de Avalúo e Investigación Institucional, UPR-Cayey, 2018). Additionally, the campus has a group of psychologists who are accessible to students and professors. We interviewed one of them, and she narrated her experience working with the students after Maria’s passing. Lastly, we visited Casa Pueblo in Adjuntas because this was an essential place for people with medical conditions that required machines or electronic devices. Unlike the vast majority of Puerto Rico at the time, Casa Pueblo had electricity following Hurricane Maria, thanks to the fact that they operate with a solar energy system. In Casa Pueblo, Adjuntas, we interviewed an engineer and staff who have been working for the town of Adjuntas for many years. The age range of our participants was between 21 and 70 years approximately.

When visiting Jájome, we observed the state of the community’s houses and businesses and noted whether they had apparent signs of abandonment. We also observed how frequented the area was (for example, if cars passed regularly) and other factors that influenced how quickly aid was mobilized to this community. We also took notes about the reactions interviewees demonstrated when we posed questions to them, paying particular attention to their feelings when we talked about how they were impacted by the hurricane. By going to Casa Pueblo, we wanted to talk with people who had a different experience from the crisis. The kind of oasis that Casa Pueblo built could be useful in understanding how their approach could be applied to others in Cayey and other towns on the island.

Methods and data collection

This project relied primarily on participant observation and semi-structured interviews for data collection. Our review of the literature and our observations led us to develop the questions we used for the interviews and then analytic categories. The selected categories cover the field of health on a spectrum, from the physical to the mental, and considers traumatic events, such as Hurricane Maria, affects people not only physiologically but also emotionally. Similarly, we also addressed the healthcare professionals’ perspective of the hurricane and after and we asked questions to capture each individual’s experience. This, taking into consideration that even the medical personnel who had to attend to the population during the emergency experienced the hurricane and, in other ways, were affected by it. We often forget that health professionals had their own situations happening at their homes and with their families. Despite having to deal with the consequences of Hurricane Maria in their lives, they offered their services the best they could. As previously stated, we approached houses in Jájome Alto in a random manner, explained to the participants the purpose of our research and asked permission to interview them and record their responses. We assured them that everything would remain confidential and that we would maintain their anonymity. Anonymity was maintained so that participants could feel confident and express their concerns freely. The same protocol was followed for the students and healthcare professionals. Each interview lasted approximately 15 min. We conducted a total of 12 interviews and conducted observations over the course of 8 weeks (June–August of 2019).

We divided participants of the study by categories and created questions that were related to each category (Table 1). The designated participant categories were: general citizens, healthcare professionals (the healthcare professionals were also asked the general citizens questions to capture their experiences outside of their workplace), and Casa Pueblo personnel. The questions were also divided by categories in the following manner: mental health, public health, healthcare professionals (a special subset of questions were prepared for the pharamacy staff and were included here), and Casa Pueblo. Questions of general scope were asked to every participant and addressed our initial study question: to evaluate what was people’s perception regarding the government’s performance when confronted by addressing crisis-level health care needs. We recorded responses to the degree of agreement/disagreement with the management of the emergency by the government. The participants were allowed to elaborate on why they agreed/disagree with the management of the emergency. It was also documented what they had found to be the most impressive occurrence regarding the situation, taking into consideration the experience of each participant/interviewee. The six (6) questions categorized as relating to mental health were directed to the interviewees in communities so that through them not only their experiences are captured, but also the factor of resilience. The community prespective also helped with documenting the crisis management by the government as opposed to the management of the citizens. The mental health questions generate additional data on how the atmospheric event, by itself and without the humanitarian crisis, affected the general population. The three (3) public health questions respond to the factor of medical attention required by citizens. The seven (7) questions intended for the healthcare professionals and pharmacies address the same situation, from the viewpoint of the distribution of services, such as consultations, medical care, or medicines. On the other hand, the two (2) questions assigned to Casa Pueblo staff sought to inquire about the role of the organization as an aid agency for the community. And how they mobilized after Hurricane María to attend to needs and be of assistance.

Table 1.

Questions used for the interviews.

Themes	Questions
Mental Health	Do you feel any kind of animosity when an atmospheric event is announced that you did not experience before María? How do you feel when talking about Hurricane María? How did Hurricane María affect your mental health? What resources provided by the government, helped you manage the emotional effects caused by Hurricane María? How do you feel about them? Did your experience after Hurricane María lead you to seek help for your mental health? If so, how do you feel about the services you received? Did you lose someone or do you know someone who lost a loved one with an illness, what role do you think María played in that loss?
Public Health	What medical services did you receive during the country’s emergency period after Hurricane María? If you suffered from any medical conditions before Hurricane María, how did you keep your condition under control during the emergency period? Do you consider that your medical condition remained the same, improved or worsened during the emergency period after Hurricane María? Explain. If you are responsible for the health of a family member, what measures did you have to take to help take care of the family member?
Healthcare Professionals	How did you offer your services after Hurricane María? How do you think the passage of Hurricane María impacted the mental health of your patients? What resources have you provided to improve the mental health of your patients? Do you think the health services offered to your patients have improved or worsened. Explain. What can we do to help people’s mental and physical health? In what physical and mental state did you observe the people you saw? *Pharmacies: If your resources (medicines or essential products) were in short supply after Hurricane María, which of your resources were in short supply? How did you distribute resources after Hurricane María?
Casa Pueblo	How did Casa Pueblo acted when they saw the need of the people around them? If you could make changes to how Puerto Rico prepares for atmospheric events, which one(s) would they be?
General	What was the most shocking thing you saw or witnessed after Hurricane María? How did it affect you? Do you think there was government negligence before, during or after Hurricane María? Explain. In light of the topic, how did you handle your personal situations as a result of Hurricane María?

^*The significance of this question is that we also asked a psychologist to provide their expert opinion (as seen in page 9). Mental health is also an important part of Healthcare and was affected significantly after the hurricane.

The analysis of the interview recordings was made by transcribing the interviews and analyzing what were the common topics that we kept encountering in each interview. The following topics were the most emphasized by our participants: accesibility to resources, resilience and citizens coming together for one common goal, and the government’s response to the crisis.

During the research and during our interviews, we positioned ourselves as both outsiders and insiders of the community. This is because in some of the areas studied, we were active participants, while in others we were not. For example, our focus on the experiences of university students positions us, university student researchers, as insiders who have shared many of the situations students describe in their interviews. Importantly, we were also insiders because we, too, lived through Hurricane Maria and the subsequent crisis, even if we experienced it in communities different from the ones in Cayey. In the case of Jájome, however, although we are students at the UPR-Cayey, we are outsiders to that specific neighborhood. However, our status as outsiders didn’t make it difficult for us to sympathize and understand the experiences of the Jájome community, because we lived through the hurricane ourselves. On the other hand, while none of us are health professionals and are outsiders, we have a close connection to this community of workers in our role as patients and individuals looking for services. Therefore, we could consider the medical personnel and the citizens—and thus the interviewers—as part of a macro community divided between those who offer and those who receive medical services on the island.

As previously mentioned, the limitation of this study relates to the quantity of participants interviewed. The opinion and concerns of more people have to be addressed to capture the core problems of a system that needs improving. This study does not mention every problem that happened during the emergency period following the hurricane, but indicates some examples of the major ones.

Results

Accessibility: a fundamental problem after the passage of Hurricane María

One of the most immense and most profound consequences of Hurricane Maria passing through Puerto Rico was how it made it extremely difficult for people to access medical and mental health services. The interviews with a nephrologist, a pharmacy technician in Cayey, pharmacist, and a gynecologist, show a clearer picture of how the lives of thousands of people were impacted. Similarly, interviews with a psychologist who offers services in the town and pharmacy technicians, give a perspective of the situation and and how they managed the crisis.

Cayey nephrologist

I would arrive at the hospital in the morning, and they would tell me: ‘Look, there you have ten patients in the emergency room who came from other towns that do not have dialysis.’ And we dealt with those patients during the day and at night, and during the early morning hours, and we continued to treat them.

Another instance he mentioned that

What they did was [the patients] went to the hospital emergency room, and there they alleged what was happening to them, that they had no electricity and they could not use the oxygen, they couldn’t use the therapy machine, they couldn’t use the BiPap. Even there were people who used mechanical fans in their homes, and they could not use them either. Many died from this during those days.

The nephrologist relates how were his typical days shortly after the hurricane hit. Healthcare workers had to deal with an increased amount of patients coming from different municipalities because a lot of the medical facilities had been destroyed or couldn’t offer their services at that moment. This potentially affected the care that was offered. Patients couldn’t treat their conditions as they normaly did at their homes because they didn’t have essential services like electricity and water.

Pharmacy technician at a community pharmacy in Cayey

We went down to the Caguas area, which was where there was a [cell phone] signal as such, and there, well, with a computer and several refills, we processed the refills, which people came the next day, and looked for them.

On the other hand, when we went to the town of Cayey and interviewed in one of the community pharmacies, we were able to recognize the importance of these smaller, local pharmacies. It is important to note that these pharmacies have years of being established and provide services to the town in which they are located. Hence, they know their patients well, and there is a more personal dynamic than in a big chain pharmacy. This fact was of great help when the computer systems containing the patients’ personal information were not available due to the lack of internet service. Since they had ordered medicines to have stored in case of an emergency, one of the community pharmacies was able to open on the third day after the hurricane and provide services to its patients. They verified if patients had refills for the prescriptions, waited for instructions from the governor or the Board of Pharmacy concerning how they would be working, and some of the pharmacy staff traveled to the neighboring town of Caguas where there was an internet signal. With the computer in hand, they verified the information in the system so that people could go the next day to get their medications. In other places, since these pharmacies know their patients very well, they would write down in a notebook when the medication was dispatched in advance if they knew the patient would need them soon. We will not know precisely the magnitude of the impact of having an accessible pharmacy ready to meet their needs.

Cayey psychologist: “When we opened, almost two months had passed since the hurricane. So a lot of psychological needs aligned with the hurricane had already been addressed in those first two months.”

He also added that: “We spread the voice, to a limited extent. Because we did not have electricity, internet, to reach the whole world. So we were available to the extent that we could be available.”

Regarding mental health services, one psychologist from Cayey noted in an interview with us that access to these services was limited. He indicated that not only did it take time to open and start offering services, but stated that the problems related to mental health, “had already been seen.” He added that it was also difficult to spread the word that they were able to provide services. This was due to the lack of resources, especially the lack of electricity service.

Cayey’s psychologist: “What we see is that many symptoms or [mental health] problems before the hurricane stand out. They aggravate.”

The mental health of a lot of people declined significatively during the emergency period that followed the hurricane. Many didn’t have the resources to cope with the trauma in a healthy manner. In the interview, he also expressed that he considers pertinent the government’s action towards mental health. However, he ponders and reflects that they were, almost certainly, mis-timed— late—; leaving us with other factors to consider due to the effects of not having accessibility to these resources.

Pharmacist: “Medicines that required refrigeration, it was very difficult to get them. It took me 4 hours to go down to Caguas every day.”

In the interview with the pharmacist it was also stated that

There were five hospitals [to which] we were not able to give medicine for months due to [the problem of] telecommunications. But because of this, we had to create new modes of communication on our own to be able to offer our service.

Once again, it is shown that it was difficult to access essential items like medications, even for healthcare providers. In order to have a better understanding of this example, depending on where you are coming from, a trip from Caguas to Cayey would normally take about 25 min aproximately, but as seen from the pharmacist’s quote: “ … It took me 4 hours to go down to Caguas every day.”, travel time was significally increased.

Gynecologist: “The most shocking thing was not being able to get to my work, help to carry out deliveries or cesarean sections, due to not having access because of the destruction of the roads.”

The state in which some of the roads were left, made it difficult and close to impossible for healthcare professionals to offer services and citizens to access those resources. It is not hard to imagine the state of despair that some people may have been through.

UPR-Cayey student: “The emergency rooms, at least here in Cayey, were practically closed for people that it was not a real emergency.”

This student narrated how services were perceived in Cayey. She even adds that her sister, pregnant at that time, had difficulties getting the medications she needed for her pregnancy:

She [a pregnant young woman] did not have prenatals [medicines], we had to buy her those that were over the counter, and she was at high risk …. She had to put suppositories, and they were not available.

The problem of accessibility and the availability of resources is clearly reflected in these interviews as they work with highly vulnerable populations. By vulnerable populations we refer to those who need special medical devices in their daily routine such as ventilators and people who need dialysis, pregnant women, among other examples. By interviewing the nephrologist, the pharmacist, and the gynecologist, we were able to get a clearer and grimmer picture of this vulnerability. We then learned that many patients traveled long distances from neighboring towns (such as the doctor who traveled four hours a day to search for medications that required refrigeration) to find dialysis centers, hospitals, or companies that had medications available. In the case of some patients who needed dialysis with little time between one dialysis and another, they were “hospitalized.” Hence, there were not enough resources available to serve everyone efficiently. It is not surprising then to hear that many had to go to the United States to seek urgent medical care and that others died due to lack of services. These people lived through traumatic times facing the reality of not having access to what keeps you alive. Stories like the one from the student are not uncommon tales from this period of time; unfortunately, many struggled to find essential items or services.

Resilience and the importance of citizen action to face the crisis

Puerto Rico was not prepared for a hurricane the magnitude of Hurricane María. For this reason, finding themselves amidst an emergency period whose duration was not known, Puerto Ricans had to unite to face the day-to-day challenges. Having gone almost a year without electricity, the residents of Jájome Alto in Cayey are a clear example that a united front was necessary to survive the crisis. Next are examples of the experience in their own words:

Citizen #1 of the Jájome Alto community

A family [in addition to mine] took refuge here because their house was destroyed. Well, because of that, I had to consider more water or restrict what I had of water, of food, until, after five days, we gained access to the [center of the] town.

He also added that: “I have many neighbors who are elderly people, and we had to do that, help the elderly people because we could not depend on the government.”

For communities like Jájome Alto in Cayey, accessibility was a fundamental issue during the emergency period: Due to the topography (mountain region) of these places, it was difficult to get to or from them after the hurricane. Thus, we see how citizens had to be very wise when it came to consuming the resources they had available and share many of these with those in greater need. Some took five days or more to get out of the community to get necessities due to the debris on the roads. We often found that these community actions were a direct result of the lack of action on the government’s part in responding to the emergency. Community action, therefore, was an act of resilience where the community found help within itself. They found help within the community for themselves (among neighbors), sharing, supporting, and solving problems and situations among neighbors without government involvement. This gave birth to a new sense of unity and solidarity.

If we take the case of the residents of the community of Jájome Alto in Cayey, we can talk about the importance of knowing who lives in your community and feeling part of it. When we interviewed one of the residents of Jájome, he (citizen #1) told us that since he was aware of some older adults in the area where he lived, he decided to make it part of his responsibility as a resident of that community to look out for the welfare of people who were in a position of greater vulnerability when compared to others. He made sure that the basic needs of these people were being met and that they did not lack the essentials because he saw that the government was not helping the community get back on its feet,. In addition to this, we know that after Hurricane Maria hit, everything was in short supply. So, in order for these people to be able to get a little of what they needed for their health, they decided to share what little they had with each other. Still, a community’s ability to respond to an emergency has its limitations, so there were deaths in the area despite local efforts.

Psychologist Patricia Noboa relates that a month after Hurricane Maria hit the island, she “was struggling with a sense of loss, helplessness, and anger. These feelings arose every time she heard on the radio or read in the newspaper about the poor response on behalf of the local and federal government to the disaster” (Bonilla & LeBrón 2019, p. 217). These feelings led her to join brigades of health professionals and use her knowledge to help communities in Utuado, Canóvanas, and Humacao. This is an example of how people came together to move the island forward regardless of socioeconomic status. However, just as the feeling of resilience was collective, the dissatisfaction with how the government handled the situation became collective as well.

In July 2019, a chat from the Telegram platform was made public and became infamous. In it, then-Governor Ricardo Rosselló Nevares and close associates mocked severe issues facing Puerto Ricans, including events that occurred after Hurricane María, accompanied by sexist and homophobic comments, among others (Romero et al., 2019). The chat was the trigger that finally caused the collective disgust to transform into a collective resistance. That feeling of loss, helplessness, and anger that psychologist Patricia Noboa describes and which many of the participants could also feel, became the driving force of historic protests in the summer of 2019. We see a gradual process in which the resilience needed to survive the damage caused by the hurricane becomes the resistance we needed to achieve change.

The Puerto Rican government’s response

Politics will always be a topic that creates spaces where different opinions coexist about how a country’s affairs should be conducted. This means that evaluating a government’s response in an objective manner, without falling into preferences or prejudices, is a task that must be carried out with the utmost care. The response or stance the government assumes when confronting the emergency that a country is facing will be reflected not only in the present but will also have repercussions on its future. Only the results of action or inaction will show us whether the decisions made were the right ones. The results of the action (inaction), as well as the hurricane, did not discriminate and affected all the inhabitants of Puerto Rico, and we can see this evidenced in the testimonies given in the interviews. Each interviewee was asked if they considered that there had been negligence on the part of the government before, during, or after Hurricane María and below are some of their responses. Some believed that the government could have prepared better before the hurricane hit, for example:

Citizen #1 of the Jájome Alto community

I blame the government a lot in ‘the pre,’ in the preparation. Because [the] post [pause]. Well, remember that the one guiding the ambulance has the [same] needs that you have, and he has a family, and he has to recover at the beginning for him to then react. However, I understand that we are still the same … And that comes ‘pre. You have to prepare before. After that, the reaction was slow, and we [the people] raised Puerto Rico. That the help came later? Well, we have to say ‘yes.’ We really cannot be ungrateful, but in reality, eighty percent of us cleaned the roads, we were able to organize each one of the neighbors, and that we did ourselves.

Others believed that there was no way to prepare adequately for the hurricane:

Cayey nephrologist

The government, like all the places we have seen, did not expect something like this, no one expected something so strong …. The government tried. Maybe they did not try right, maybe they tried wrong, but all of us at Puerto Rican did what we could.

On the other hand, there were others that believed that the response was gravely ineficcient.

UPR Cayey student

Of course, … during the emergency, many things could have been prevented if they had acted in time. And after? We can spend four years talking about [the] aftermath because at this time, we can still see that the resources did not reach where they should have reached.

Citizen #2 of the Jajome Alto community

Always. With Maria or without Maria, there is always [negligence]. Look how we are right now … [Ricardo Rosselló, governor of Puerto Rico during Hurricane Maria] he did not suffer anything. That is why I say he does not know what the poor people, or not even the poor, [what] the middle class suffered at that time.

Much like the student, many felt that the government could have made a lot of things different if they had utilized more efficiently the resources that they had at hand at the moment. Many citizens felt like the government, or those that compose it, did not have to face the same hardships as the rest of the people, or at least not at the same degree.

Pharmacy technician at a community pharmacy in Cayey

There was negligence in many places. There was negligence in how they attended to the emergency. There was negligence in hiding many things from … you know, from Puerto Rico as a whole. There was negligence in everything.

The insights shared by the interviewees in July 2019, make it seem as if the hurricane has just recently passed. The trauma and helplessness caused by the hurricane are still latent in the minds of many. On this occasion, the people of Puerto Rico lost a lot. The generation of Puerto Ricans who lived through Hurricane Maria had never experienced an atmospheric phenomenon of such magnitude, and while it is true that it is almost impossible to prepare for something never lived through, the people expected more from the government. So much so that the summer of 2019 was a historic one for the country. The people united and denounced many of the outrages and injustices that occurred due to Hurricane Maria. Supplies were withheld, information was hidden, and million-dollar contracts were awarded to people who were not qualified to perform the work they were required to do, among many other outrages (Ortiz & Minet, 2019). The collective indignation was so great that on 24 July 2019, Ricardo Rosselló, the governor of Puerto Rico at the time, resigned from his post in response to the country’s public manifestations (protests). The impact that Hurricane Maria had on Puerto Ricans was manifested in more ways than could be appreciated at first glance.

It can be said that the Summer 2019 manifestations (protests) and the resulting resignation of the governor during these historical events are a direct product of the people’s resistance. This resistance was expressed through movements that included but were not limited to marches, congregations, social media use, and other creative forms of protest. While it has been mentioned that a large part of the claims raised were related to government actions or inactions in the face of the crisis left by the hurricane, we could also consider that this process of resistance was a cumulative one that began with the resilience of the people, of which we spoke earlier, during these same times of crisis. With this in mind, we catalog summer 2019 as one of resistance, for being an uprising against the outrages that citizens were already experiencing. We consider that it is from resilience and resistance that the commitment arises, in addition to the collective indignation as a shared feeling. This collective indignation moved them to hurl themselves into protests for a total of 15 days, achieving not only their main objective: the resignation of the elected governor from his position for the first time in history, but also that of several officials involved in the corruptioin.

Reliving Hurricane Maria: reflections about our experience

Every person who experienced Hurricane Maria in Puerto Rico has a story to tell. Although many of us had similar experiences, each person has their particular way of seeing things. This results in different narratives for the same event. To better understand the analysis that a person may have about a particular topic, it is crucial to see the relationship between their experience and the topic discussed. For this reason, the following are short reflections regarding the things that most impacted the lives of the authors during and after the hurricane. They also share a bit of their experience reliving the hurricane with the other participants. This provides a better understanding of the government’s negligence during the emergency period and how it directly affected the provision of essential services, such as access to hospitals, pharmacies, and clinics, among others.

Deyaneira Laboy Baiz:

Hurricane Maria touched each of our lives in different and particular ways. One of the memories that impacts me the most is listening on the radio to hospitals asking for diesel fuel for their electric power plants to provide some of their services because we know that, in those conditions, it was practically impossible to provide services as usual. It is frightening to think that the place where emergencies are supposed to be attended, a place as important as a hospital, has to beg citizens over the radio for something as essential as fuel for the electric plants. We know that electric power in a hospital is a matter of life and death for many of the patients being treated there. This is why we can imagine the environment of tension that must have formed in the hospitals in the face of such uncertainty. Also, I remember hearing months after Hurricane Maria hit, stories from a doctor who spent the hurricane in the hospital and what the situation was like after the hurricane. Every decision on how resources were spent and to whom they were given was carefully premeditated and contemplated. Priority was given to those patients with more severe health conditions as certain medications and treatments were limited.

Now, not only hospitals suffered, but also clinics, pharmacies, and laboratories had to face the challenges of the new reality created by Maria. I know of doctors who had to attend their patients outside their office because the heat inside was unbearable, and they had no electricity to access the electronic patient record system. They had no way of knowing the medical history of the patients who came in. In those early days, they were open until noon. Only those who brought evidence that they used and needed the medication (a prescription or the medicine container in which it had been dispensed before) would have their prescriptions renewed. So it is not hard to imagine how limited services were during the emergency period. This is without considering how the hurricane had left the physical structure of the clinic, pharmacy, or laboratory, the state of the roads, and how difficult it was to move from place to place. I also remember standing in line to get into the pharmacy and how they moved us in small groups to get inside. I know of people who had to leave the country because it was difficult to treat their health conditions on the island.

We often forget that these health professionals had their situations at home, and yet every day, they gave their best to help lift a country that had already lost too many things. I would like to think that this situation has taught us to prepare better, both the people and the government, and with it, the health system. To think that the obstacles and challenges we had to face were not in vain and that we can learn from our mistakes.

Karelys J. Delgado Cabrera:

I spent Hurricane Maria at home, with my family, and today I can recognize that while we were waiting for it, I had no idea that it was going to change our lives in such a way that it seemed to have stopped dead in its tracks. In the aftermath of the hurricane, studies, jobs, businesses, and something I would never have thought possible, essential services came to a halt in the country. Throughout this process, uncertainty was the order of the day, and, in this way, it began to affect the collective mental health. It was noticeable in the atmosphere when you met people who, while looking for food, shared experiences of how they had lost homes, jobs, income, and resources. With the loss of electric power service, everyday things such as communication became difficult, so much so that the population resorted to the use of the radio. I remember hearing news from the towns, reports of damage, possible deaths, the state of the hospitals, and the fatalities in them. I remember listening to sad stories, horror stories, other people’s experiences, and those of essential service providers, which to this day cause me to shiver. On the radio, I also remember a time was dedicated to messages along the lines of ‘We are family X of such and such town,’ ‘To let our relatives know that we are well.’ Alternatively, they would go more along the lines of ‘please, if anyone in town X can contact such and such people, in such and such sector, we want to know if they are okay.’ This, to this day, still hurts me. I think that the most saddening and infuriating thing about the whole experience is knowing that, had they received more efficient -at the very least, more honest- handling, many people would have survived. I believe that it is pertinent and of utmost importance to carry out this research because having lived through the experience and recognizing that at any moment, another hurricane could pass through the island, I think that there are ways to improve the handling of these situations. Thus, it is necessary to assess the places where the defects are found and where improvements, reinforcement, or attention are needed. I also understand that the process must not be one of reaction and response but one of preparation and prevention so that, when the time comes, we do not have to relive these experiences and go through the same needs.

Recommendations

The experiences we had during and after the hurricane will accompany us for the rest of our lives. The more we reflect on them, the more we will learn from them. Puerto Rico will continue to be an island frequented by hurricanes, so it would be irrational to think that a hurricane of Maria’s magnitude will never pass through our lands again. Therefore, our experiences take on a value that goes beyond the sentimental. These experiences will guide us in the future when it comes to preparing ourselves better. It is time to turn our gaze to those places that were effective in handling the emergency left behind by the hurricane. One such place was Casa Pueblo, in the municipality of Adjuntas, Puerto Rico. Casa Pueblo is “a community self-management project” (Historia de Casa Pueblo, n.d.) that has taken several environmental projects under its wings, working with the Department of Natural and Environmental Resources. In addition to its commitment to community, environment, and culture, one of the reasons we were attracted to and impressed by Casa Pueblo is its solar energy system. This system provided electric power to those who came to Casa Pueblo during the emergency period after the hurricane, while the rest of Puerto Rico lacked this essential service. Because of their constant commitment to the community, Casa Pueblo opened its doors and was at the service of the people who arrived seeking help. They were mindful of how social inequality affected the people at that critical time, especially those living in mountainous regions. In our interview with staff, they described rural communities as being “isolated from government protection, from the health system, from the communications system, from the mayors.” The also explained how solidarity and community support were key to overcoming the challenges they faced.

According to one of its founders, Casa Pueblo became an “energetic oasis” since people could go there for their respiratory therapies. There was a refrigerator available for medicines. Through a satellite phone, people were given the opportunity to communicate with people outside Puerto Rico. The Casa Pueblo team wasted no time. Once they discovered the country’s needs that the hurricane had laid bare, they distributed 14,000 solar lamps in Adjuntas and educated people on how to use them and what renewable energy is. They have made homes and grocery stores fully powered in remote locations. This has positive implications for the economy and social change. One of the phrases that struck us most in the interview was “resilience has to come with change and transformation.” Certainly, that is an inspriring insight about how we might proceed in Puerto Rico. While resilience helped Puerto Rico get back on our feet, we belive now is time for change and transformation. This analysis of the value of resilience, its limitations, and the need for structural change is advanced by many scholars, including Yarimar Bonilla, Marisol LeBrón, and the writers, artist, community workers and activists whose reflections apper in the anthology Aftershocks of Disaster: Puerto Rico Before and After the Storm. Our findings confirm an important argument from their book:

The economic crisis … set the state for what Puerto Ricans could and would come to expect after María. The public services and infrastructure that failed with deadly results during and after Hurricane María were already severely weakened after being depreived of the funds necessary to perform even minimal maintenance, let aloe desparately needed upgrades (Bonilla & LeBrón, 2019, p. 9).

In other words, the coloniality of disaster—“the way the structures and enduring legacies of colonialism set the stage for María’s impact and its aftermath,”—including the incredible resilience Puerto Ricans demonstrated (Bonilla & LeBrón, 2019, p. 11). But those personal dispositions and admirable qualities do not enact meaningful social and policial change.

The people of Puerto Rico need more places like Casa Pueblo to provide help and support to those who need it most. In order to help have a country better prepared for future atmospheric events or those that may cause similar emergencies, we recommend the founding of a project similar to Casa Pueblo that works together with the University of Puerto Rico to serve low-income communities that are most vulnerable in these situations. The project would seek to build places where the primary source of energy is solar light so that they can always count on the service. In addition, workshops would be provided to educate the community on a wide variety of topics. These workshops could be organized in conjunction with student organizations from the different University of Puerto Rico campuses. These workshops would provide an income to keep the project running and bring more resources to educate the community. The headquarters of this project should be located in a town and a low-income region, and its services should be directed first to the community in which it is located. The project would also create jobs because, although it is mainly based on community work, the construction work and other projects will be carried out by professionals employed to do the work. Information provided by the most recent Census would be used to determine which sites are most in need of these services, and the site most in need of these services would be identified. In the beginning, we would work with a single project, but as we are able to obtain the necessary resources, we would install different sites in other places with scarce resources.

Casa Pueblo’s community self-management was not merely a form of resilience to the neglect of the Puerto Rican government but also a resistance to Puerto Rico’s dependence on the United States. This dependence is a direct product of hundreds of years of colonialism on the island and is firmly rooted in our history. Colonialism has made many Puerto Ricans believe that they cannot build a decent future for their homeland or their family with their own hands. Colonialism has sowed fear at the moment of thinking about a future where we are the ones who have the absolute authority over what happens in the country and the responsibility that comes with making decisions without first having to ask for authorization from higher entities. Nevertheless, by seeing and learning from this type of project, such as Casa Pueblo, we can see that it is possible. We have the capacity to make decisions that favor Puerto Rico and all its inhabitants and that have a positive impact on the future.