Puerto Rico is home to more than 3.4 million American citizens who have been battling a gargantuan budget deficit of over 80 billion dollars, a deficit that has negatively affected essentially every corner of the island. This economic crisis prompted the deterioration of an already fragmented and fragile health care system incapable of providing adequate care to its population because of the exodus of physicians and other professionals, the shrinkage of medical training programs, the closure of hospitals and ambulatory care clinics, and an inadequate health care insurance support system (1–3). Considering the above, it was difficult to fathom how anything could further worsen this situation. Yet worsen it did. Within a period of a few weeks two category 5 hurricanes traversed the Caribbean Sea, ravaging the British and U.S. Virgin Islands before hitting Puerto Rico; the island had not witnessed such a forceful hurricane since the 1928 San Felipe Segundo hurricane. Hurricane Maria made touchdown in the southeastern part of the island at 155 miles per hour and exited the northwest end, but not before destroying everything in its path. Hurricane-force winds enveloped the entire 100 × 30 miles of the American territory. Despite weeks of preparations, few anticipated what was to follow.

The news of few storm-related deaths were soon thwarted by the widespread devastation encountered hours after Maria’s passage. Information and images unveiling a disaster of historic proportions slowly emerged through amateur texts, videos, and news releases generated from the island’s capital, San Juan, in the northeast to Mayagüez on the west coast. Hundreds of islanders and tourists were trapped at the main airport, while thousands waited in shelters suffering through the sweltering heat and high humidity of the Caribbean summer. Communication was almost entirely wiped out, preventing relatives from learning about the fate of their loved ones and inhibiting the swift implementation of comprehensive rescue operations (4, 5). Unnecessary delays in the delivery of much-needed power, water, and food prompted memories of Katrina, which devastated the Gulf coast of the United States in 2005 (6).

Emergency rooms were rendered inoperative and hospitals were forced to close surgical suites. Patients incapable of fending for themselves were transferred to other locations when possible. Clinics remained closed, while patients waiting for dialysis, chemotherapy, and transfusions became impatient. For those with chronic respiratory disorders, the lack of electricity to power mechanical ventilators, oxygen concentrators, and nebulizers further exacerbated their anxiety and their conditions.

Island leaders diligently worked to rescue those in need, and the U.S. administration sent thousands of volunteers and military personnel with the objective of buttressing Puerto Rico’s broken infrastructure. After much debate, the administration finally, but temporarily, waived the Jones Act, a 1920 law requiring that goods shipped from one American port to another be transported on a ship that is American-owned, American-built, and crewed by U.S. citizens or permanent residents. This protectionist law was intended to support American ship owners, but for Puerto Rico it increases the cost of living and prevents the rapid delivery of much-needed goods after a natural disaster, and will continue to impede addressing the island’s economic progress as it costs at least two to four times more to operate ships compliant with the law (7). All interventions would prove insufficient as time went by and the crisis aggravated. Ten days after the storm, news media outlets announced that only 5% of the power had been restored on the island, only 11% of cell phone towers had been fixed, only half of the supermarkets were open, only 9 of 69 hospitals had been connected to the electric grid, and less than 50% of water services had been re-established (5). Supplies remained untouched in thousands of sealed shipping containers, and delivery of supplies to those in need remained hampered by the lack of trucks, fuel, drivers, and importantly, a clear, comprehensive, and implementable plan of action (8). Not surprisingly, rare accounts of looting and violence started to emerge.

Critiques of the U.S. government’s handling of the disaster grew (9, 10). The mayor of San Juan begged for help and wept in front of television cameras, while an entire nation watched her compatriots fall into despair. Meanwhile, while playing golf at his New Jersey estate, the U.S. president lashed out at the San Juan mayor over her response to the hurricane (while she was up to her chest in flooding waters), and accused Puerto Ricans of not doing enough for themselves and expecting others to take care of their problems (11). Unfortunately, these inflammatory words lacking empathy were all too familiar to a people that had been fighting to overcome the feeling of second-class citizenship since the Foraker Act, which established a civilian government in the island in 1900, and the Jones-Shafroth Act, enacted in 1917, which granted U.S. citizenship to anyone born in Puerto Rico after April 25, 1898.

Two weeks after the passage of Hurricane Maria, Puerto Ricans continued to struggle through the effects of a natural disaster that caused a humanitarian crisis not seen since over a century ago when “Boricuas” were being exterminated by rampant hookworm infection and malnutrition. Most disheartening is the fact that this crisis was foreseeable and preventable as the island’s fragile infrastructure, financial foes, and health care deficiencies have been allowed to deteriorate for decades. Federal funding provided to support the island’s health care system is only a fraction of that provided to the 50 states and the District of Columbia and promotes disparities in access to health care and its delivery (1–3). More than half of islanders depend on Medicare, Medicare Advantage, or Medicaid (12); however, the Medicare reimbursement rate in Puerto Rico is 70% less than that in the mainland United States. During the implementation of the Affordable Care Act (ACA), or “Obamacare,” subsidies provided to Puerto Rico were disproportionately lower than health insurance subsidies granted to Puerto Ricans and other Americans in the states. In Puerto Rico and other U.S. territories, insurers are exempt from the coverage required by the ACA, thereby allowing insurers to refuse to cover applicants (13). In addition, limited funding and cost sharing reductions, among other causes, prevented the establishment of exchanges. These and other problems encouraged physicians and other health care providers to leave the island years before Hurricanes Irma and Maria developed in the southern Atlantic Ocean. This, despite the fact that Puerto Ricans pay for their share of Social Security and Medicare taxes and are subject to both the Federal Insurance Contributions Act (FICA) tax and the Federal Unemployment Tax Act (FUTA).

In 2015, the author published an article in AnnalsATS that summarized the Puerto Rico economic crisis and its impact on health care (3). That article summarized recommendations provided by the Puerto Rico Healthcare Crisis Coalition to fix the crisis, including that Medical Advantage reimbursement rates be restored by the Center for Medicaid and Medicare Services (CMS), that federal funds be provided for local health insurance to meet the Medicaid/Medicare match obligations, that the Health Insurance Tax on small businesses to help pay for the ACA in the island be eliminated, and that the local health plan (called Mi Salud) be stabilized, requiring Congress to increase federal payments. Implementation of these recommendations would not entirely fix the problem, but could have laid the foundation for a more robust health care system capable of addressing needs created by natural disasters such as Hurricane Maria. To our knowledge, none of these recommendations has been implemented. Clearly, Maria was not alone in causing devastation as years of neglect, disparities, and poverty contributed to deliver its deadly blow.

Nearly 3 weeks after Hurricane Maria, the death toll had risen to 45 with many people unaccounted for, 89% of the island remained without electricity, 47% of islanders had no phone service, almost half of the island’s bank branches remained closed, and hospitals and clinics continued to struggle to deliver suboptimal care; recovery toward some kind of “normality” seemed distant (14, 15). As of this writing, over 50% of the island remains without power and the official death toll related to Maria is around 50, yet the government acknowledged that the real number is over 900. The latter is not surprising to Puerto Rican doctors on the island, who cared for an increased number of patients with hyperosmolar coma, hypernatremia, decompensated obstructive airway disease and heart failure, hypertensive crises, and end-stage renal disease with fluid overload and hyperkalemia from delayed dialysis. Many elderly patients arrived at available emergency rooms beyond help. Visits to sleep clinics increased as patients could not power their continuous positive airway pressure machines and their sleep habits were distorted. Admissions related to airway hyperreactivity increased, prompted by humidity and overgrowth of mold related to flooding and damage to buildings, and excess diesel/gasoline exposure from generators. Many trainees were asked to stay in-house during calls because of increased patient workload, but also because of inaccessible roads and security risks due to dark hospital parking lots. These and related accounts including the impact on research, and the rising concern for the development of potential infectious disease outbreaks related to dengue, Zika, and chikungunya, have been documented by others (15).

Throughout this crisis, however, we saw uplifting images of islanders helping each other, and learned about the heroic efforts of friends and strangers alike. Puerto Ricans have overcome hurricanes and famine, neglect, annihilation of its native people the Taínos, slavery, cholera, and colonialism. Yet they remain. As inconceivable as it may seem, this indomitable people will survive this crisis too, while shouts from Agüeybaná, the powerful cacique (chief) of the Taínos, continue to echo through the mountain El Yunque in this island continent where dancing and singing have been put aside, but not for long. Perhaps then, a constructive dialogue about the future of this island’s political, financial, and health care status will ensue, informed by years of experience and fully aware of its people’s potential. Above all, this is a health disparities issue that requires timely action by individuals through donations and calls to Congress, and by professional organizations like the American Thoracic Society through their advocacy and lobbying arms. Let’s not forget that the 2018 Atlantic hurricane season is just around the corner.

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