One can never be adequately prepared for a natural disaster, particularly on an island, as all the commodities one takes for granted as essential for functionality can disappear with a sudden gust of wind. After Hurricane Maria battered Puerto Rico on September 20, 2017, the island was thrust into the 1800s—no electricity, water, or transportation, and minimal phone communication for most of the island. One tends to focus on the physical destruction to buildings from flood damage and storm surges, but great devastation occurs from the effects of destroyed electrical, communication, radar, and water systems, coupled with blockage of roads and isolation of entire communities.

The eye of Hurricane Maria passed through the island 13 days after Hurricane Irma, a Time when the citizens of Puerto Rico were sheltering neighbors from Caribbean islands, and when many towns already were lacking reliable electricity. The strongest hurricane to hit the island in 80 years, with recorded wind gusts of up to 200 miles per hour, collapsed the electricity grid leaving the entire island without any electricity for several days.  Toppled communication towers and radar equipment caused 95% of the island to be without cellular service and left an international airport inoperable without radar control. Many bridges collapsed and roads were covered with debris.

The supra-tertiary center for medical care is the university complex (Centro Médico), which has more than 35 operating rooms and where most ocular trauma on the island is managed. After the hurricane, only 2 operating rooms were functioning with generators for all emergency and trauma cases of all specialties, requiring triage of life-threatening operations over any globe injuries. Two patients with open globes were admitted for antibiotics but only could undergo repair 3 days later, unlike responses typical of eye-related emergency department visits. Three premature infants were airlifted by the army to Miami and Louisiana for treatment of stage 4 ROP.  Retinal detachments had to be transported to Miami, and supplies of many refrigerated drugs for treatment of endophthalmitis and anti-VEGF agents were ruined due to power failures.

In the chaotic situation, many humanitarian flights brought drugs and supplies to the island and took patients needing care to the mainland United States. To date, it is estimated that more than 3000 persons have left on humanitarian flights for care. These included cancer patients receiving chemotherapy, patients with other chronic conditions, and patients receiving dialysis. Many patients older than 75 years living alone with macular degeneration or other potentially blinding conditions were left without water and electricity for weeks, and many who had lost their homes also left for different cities on the mainland, often to join their families there.

Four days after the hurricane, power was restored to the medical center and airport only, and patients were shifted to hospitals with more resources and generators. The first weeks, waiting times at gas stations could be 6 hours and only cash was accepted in the few stores open, since credit card systems were down. Electricity is the cornerstone of everything, including water pumping and purification. In addition, generators are only meant to function as backups and not as an efficient alternative to electricity. The logistics of coordinating efforts without communication capabilities has been difficult and demoralizing.

During the first 4 days after the hurricane, communications within the health system and hospitals were nearly impossible due to the fact that only land lines were working. The ports and main airport were closed. Fifteen thousand people were in shelters, and there was no mail service. The Centro Médico was the first to receive electricity, and slowly the operating rooms and clinics have reopened. A week after the hurricane, only 11 of 69 hospitals had power, the airport started functioning during daylight, and mail began arriving.

Despite all the difficulties of dealing with a total collapse of services, underscored by the challenges of bringing aid to an island, the island also has been fortunate because so many acts of altruism have occurred. Water, food, medicines, and supplies have been received from countless cities in the mainland and from countries as diverse as Israel and Cuba. Volunteer doctors have arrived in droves and the US Armed Forces have provided invaluable aid, as has the US Navy hospital ship. Royal Caribbean provided free travel to Fort Lauderdale on its cruise ship and Dr Eduardo Alfonso from the Bascom Palmer Eye Institute flew in to bring supplies and coordinate transfer of patients. Several universities have offered spots to students and researchers whose universities are severely damaged. Still, the challenges ahead are daunting.

As of this writing, approximately 26 days after Maria hit, ophthalmology is a challenge, but medicine in general has even greater hurdles. Only 13% of the island has electricity, 67% has water, and half of the roads are viable. Water processing plants are down because of electricity outages and more than half of the hospitals and dialysis centers are working with generators. Water has to be boiled for consumption. The formal death toll from the storm is 48, but this does not take into account more than 100 people who are unaccounted for and the many corpses in morgues waiting to be identified. Only 20% of schools have reopened, and the university system is closed due to severe damage. There are more than 5000 people in shelters still, but many areas in the mountains are out of communication and are receiving water and food via helicopters. Floods continue to be a problem; 3 tropical waves have passed through the island in the past 2 weeks, with the rain delaying all rescue efforts. More than 250 000 homes have been severely damaged or destroyed, 80% of the crops have been lost, and more than 60 000 people have left the island since the hurricane, many without intentions to return. Patients have difficulty getting to clinics due to the damaged roads, damaged cars, and lack of gasoline and communication. The few clinics with electricity experience frequent shutdowns from a very frail grid. As physicians, we are trying to reach patients, communicating availability through radio and social media, and often working  in dark offices without air conditioning. Keeping services afloat is a key priority, as well as tackling the bouts of leptospirosis, conjunctivitis, and diarrhea from contaminated water.

Compounding the current difficulties is the economic reality. Puerto Rico never recovered from the 2007 economic recession. The unemployment rate is 11%, almost half of the population is below the poverty level, and the population has been reduced by 12% in the last decade, due to lack of jobs on the island. The exodus has been particularly dire in the medical field, where the number of physicians in the island has been reduced by 36% in the past decade. Two thirds of the population receive Medicare or Medicaid but Puerto Rico, being a territory, does not have parity with states. Medicaid funds are matched to a cap of 19% in Puerto Rico vis a vis 76% in Mississippi.  Total Medicare reimbursement is 42% bellow the national average, but the cost of goods in the island is 20% to 40% more than in the states due to transportation costs and the restrictions of the Jones Act.

The domino effect of this natural disaster will affect all realms and specifically health care. All the physicians on the island are trying to avert the downward spiral. Many offices are partially open, some surgical centers have electricity and are beginning to operate, and daily expeditions by ophthalmologists and other physicians to shelters and remote areas to bring medicines and basic care are the norm. Great tragedies ironically provide gifts. In this case, we have seen the resiliency, kindness, selflessness, generosity, and sense of community not only of the Puerto Ricans (islanders used to hardships), but of the global community, which has showered us with help, water, food, and volunteers. In the midst of the devastation, it is reassuring to see the power of the human heart in all its splendor and how wonderful it is to be alive to experience it.

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