Mental health stressors still loom for Puerto Ricans after Maria


The physical and mental health needs of the people of Puerto Rico cannot be underestimated. Just think of what they have been through over the last few months.

When Hurricane Maria barreled onto the island on Sept. 20, 2017 – just 2 weeks after Hurricane Irma reportedly left more than 1 million residents without power – it ripped off roofs and left behind massive flooding, roads washed out, and utility poles and transmission lines knocked down. Whole forests were defoliated, a massive loss of flora and fauna occurred, and 80% of the crop value was destroyed, along with massive loss of stray dogs and cats, dairy cows, industrial chicken coops, and tropical birds, including endangered species. Beloved pets were displaced.

Members of Global First Responder and the International Center for Psychosocial Trauma joined forces to assist the people of Puerto Rico after Hurricane Maria. Courtesy Dr. Milner

Members of Global First Responder and the International Center for Psychosocial Trauma joined forces to assist the people of Puerto Rico after Hurricane Maria.

Hospitals lost power. Some had generators, but some of the generators had been damaged by the storm, and those that were functional could not be run 24 hours a day, for risk of destroying them. Six hospitals shut down completely and at least two operated for weeks without full power. Among these was Centro Médico, Puerto Rico’s largest medical provider, which did have power back within the week. But the power was sporadic and unreliable. Obtaining adequate supplies of diesel to operate the generators proved an ongoing problem. When the generators were running, they were polluting the air with diesel fumes, exacerbating respiratory illnesses. People on respirators could not be maintained; people in need of surgeries could not get them; dialysis patients had to be airlifted off the island – to the extent possible. Medications such as insulin could not be consistently refrigerated.

The official death toll as a result of Maria was 64 in December, but according to reporting by The New York Times, that number could be as high as 1,052. Most of the people who died reportedly were men and women over age 50 in hospitals and nursing homes suffering from illnesses such as diabetes, Alzheimer’s, kidney disease, hypertension, pneumonia, and other respiratory diseases.

One grassroots organization that mobilized to provide supplies and medical assistance was Doctoras Boricuas, a group of all-female doctors in the United States and Puerto Rico that formed after the hurricanes to coordinate the delivery and distribution of supplies directly to Puerto Rico and the Virgin Islands. Two groups affiliated with the University of Missouri at Columbia joined forces to help: Global First Responder or GFR, a nonprofit, secular international medical relief organization founded in 2011 by Adam Beckett, MD, and the International Center for Psychosocial Trauma, or ICPT, a group established in 1995 by Syed Arshad Husain, MD, to help war-traumatized children in Bosnia. I joined Dr. Husain’s group of professionals – Kathryn Dewein, PhD; Andra Ferguson, PhD; and Cathy Grigg, PsyD, – all of whom have traveled broadly in the field of disaster psychiatry – to see how we could help the people of Puerto Rico in Maria’s aftermath.

What we did

ICPT and GFR were a combined team, but we served different functions. As part of ICPT, I focused on the mental health component and helped to train doctors, psychologists, social workers, and other mental health workers in both San Juan and Ponce. All told, we worked with about 50 people using the model of “Training the Trainers.” Many of our students were participants in the outreach teams. Our hope is that they will be able to train their peers to recognize and alleviate symptoms of acute and chronic stress disorders. Some of the techniques taught include patient education, relaxation training, breath work, visualization techniques, mindfulness training, narrative therapy, art therapy, and other expressive techniques.

What the PMSF did

Before Maria, the Ponce Medical School Foundation was in the process of facilitating the transfer of medical records into an electronic format. After the hurricane hit, however, PMSF’s program director, Antonio Fernandez, led a shift to disaster recovery work. PMSF got involved in airlifting dialysis patients off the island to safety, provided health care, and also collaborated with the Primary Care Psychology Program at Ponce Health Services University to assist in locating patients, identifying their health needs – including mental health – and providing for those needs to the extent possible.

At the time of our visit, Puerto Rico’s network of more than 90 largely rural federally funded primary care clinics mostly had reopened, but nearly half remained on back-up generators. Even with the medical centers open, patients were not coming in for one reason or another. People had medical problems, but the daily reality of survival, obtaining food and water, took precedence. Some patients were not showing up because they had left the country, or they were in shelters without transportation. Some people did not have fuel. Some could not keep track of their appointments without cell phones and electricity allowing them to access electronic planners. Some, having been without their medications since the storms, were too sick to travel. Outreach teams were necessary to locate patients, identify their needs, and provide medical and psychological care.


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