This year’s hurricane season starts in one week. But in Puerto Rico, where the healthcare system devolved into chaos in the aftermath of Maria last September, there appears to be no comprehensive government plan in case of another natural disaster.
The ravages of Maria laid bare the sorry state of the health sector in the island. Dozens of cases documented by Quartz and the Center for Investigative Journalism of Puerto Rico (CPI) paint a picture of chronic disorganization, lack of resources, and general incompetence at the places charged with helping the people in more desperate need after the storm.
One man, 73-year-old Gaspar Cruz Agosto, spent more than a month and a half in overcrowded hospitals without getting a mass on his lung diagnosed or treated. Instead, his health deteriorated, to the point of having to have a leg amputated due to poor circulation. Shortly after, he was whisked away to another facility, his daughter chasing the ambulance that transported him in her car because she wasn’t informed where they were taking him. Nobody at the hospital where he landed had information on his case; his medical record had not been transferred. He died there. The cause of death, according to his certificate: “malignant neoplasm of prostate,” a diagnosis he never received.
“Everything got complicated; he never received treatment or therapies. Nothing that he needed was done,” said his daughter, Jazmín Cruz Corporán.
That and other grim accounts were obtained through an online survey launched by Quartz and CPI in December to tally Maria-related deaths in Puerto Rico. The responses, many of which were verified with follow-up calls and death certificates, confirm that the government vastly underestimated the number of victims. They also show the utter lack of preparation and capacity at healthcare facilities.
A preliminary analysis shows that roughly 60% of Hurricane Maria’s victims died in state-licensed facilities, including hospitals, nursing homes, and diagnostic and treatment centers. Many of the deaths, which were reported directly by relatives and acquaintances of the deceased, were related to problems with basic services at these places. They include medical equipment failures—as well as the inability to use them due to the lack of electricity; unhealthy conditions due to humidity and heat; lack of supplies such as oxygen and medicines; and no means to refrigerate medications. These kinds of problems continued weeks and months after María’s passing, according to the sample.
Official statistics back the findings from the survey: The average rate of death at hospitals shot up by 38% in the first six weeks after Maria compared to 2016. It jumped by 77% in nursing homes during the same period, according to statistics from the Department of Health.
All of these facilities, including the island’s 68 hospitals, are licensed by the government. It is charged with inspecting them and ensuring they have a plan in place in case of a catastrophe. But for years before Maria hit, officials had been skirting those responsibilities, according to a CPI investigation based on documents and interviews.
Puerto Rico’s Health Department has long lacked the personnel to carry out inspections of all those institutions every two years, as required, according to CPI’s findings. It currently has 10 inspectors. “The facilities are too many for the inspectors and clearly it’s impossible; that’s why not all of them are inspected,” the official in charge of the division that carries out inspections, Verónica Núñez, told CPI.
The lack of oversight appears to have contributed to dismal conditions at some facilities, even before the hurricane. A Puerto Rico House of Representatives commission that started investigating government-owned hospitals and diagnosis and treatment centers in 2017 deemed the state of some of them unsuitable for patients and employees. They found overflowing waiting rooms, broken mattresses, and areas without air conditioning.
Before Maria, the island’s Health Department did not have a comprehensive emergency response plan to care for patients and minimize death in case of a massive catastrophe, according to CPI’s reporting. This kind of planning is recommended by federal Department of Health and Human Services at the state and territory level.
Puerto Rico had obtained more than $33 million in federal grants starting in 2009 to create regional plans that would be the basis for a comprehensive plan for the whole island. But those plans were never developed, according to Liza Millán, the Department of Health official in charge of overseeing their creation. “There was no regional plan, so they had to communicate informally during the hurricane. When I say ‘informally’ I mean that there was nothing written, there were no assigned responsibilities,” she said.
The lack of a plan to coordinate a public health response to the hurricane was one of the main shortcomings identified by an independent commission coordinated by the non-profit Caribbean Human Rights Institute and the law school at Puerto Rico’s Interamerican University, which documented conditions after Maria. Because of that, individual healthcare providers were unable to network to prevent injuries and disease, or treat those affected by them, the commission said in a December report of its findings.
“Clearly there was inadequate monitoring of institutions so they had the necessary emergency equipment. The severity of many of these examples points to a dehumanized system that provides a blank check to violate rights in a routine and normalized way,” it added.
It’s only after Maria that the government has organized meetings with local health providers, the Federal Emergency Management Agency (FEMA,) and other agencies to discuss how to respond to future natural disasters. Puerto Rico Hospital Association president Jaime Plá, who’s attended some of those meetings, said the government should be presenting a plan in the coming weeks, but that he hasn’t seen a document yet. Spokespeople for the Health Department did not respond a request for comment on the status of the comprehensive healthcare plan.
The island’s overall emergency response plan, which should have a healthcare component, is still being reworked as part of an overall review launched after Maria, according to Karixia Ortiz, a spokeswoman from Puerto Rico’s Department of Public Safety. “The plan is in final revision because the document is worked on jointly with recommendations and validations from FEMA,” she said.
The island’s Emergency Management Agency wasn’t able to immediately provide the plan that is being revised, the one that was supposed to be rolled out during María.
FEMA did not immediately respond to requests for comment. We will update this story if we hear back or get additional details from any of the agencies.
Jeniffer Wiscovitch and Omaya Sosa Pascual are reporters with Puerto Rico’s Center for Investigative Journalism.