Hurricane Maria in Puerto Rico has become a man-made disaster, with a death toll threatening to eclipse Katrina’s.

http://nymag.com/daily/intelligencer/2017/12/hurricane-maria-man-made-disaster.html

Maria’s Bodies

The hurricane in Puerto Rico has become a man-made disaster, with a death toll threatening to eclipse Katrina’s.

On Wednesday, September 20, the eye of Hurricane Maria cut a slash directly across the island of Puerto Rico, from the southeast to the northwest. It arrived shortly after six in the morning, near the harbor at Yabucoa. Wind gusts peaked at 155 miles an hour, bending palm trees like straws and snapping others off near the roots. The storm’s center was 50 to 60 miles across — more than half the length of the island. It rolled at the leisurely pace of about ten miles an hour and hovered above the island’s mountainous center well into the morning. The wind tore hundreds of electrical-transmission towers from the ground and carried some of them through the air. Sheets of earth fell from the hillsides, smashing houses and erasing roads. The death toll began immediately: In the town of Utuado, a landslide came through the wall of a house where three elderly sisters had taken refuge, burying them alive. The island’s electrical grid and mobile-phone networks went down. At the headquarters of the bankrupt electric utility, the backup generator stopped working, as did the computer server, cutting off the chief executive from his own records. For the next few hours, the highest levels of the Puerto Rican government were paralyzed as officials struggled to obtain accurate information. But the scope of what had happened began to reveal itself soon enough. Bodies began to pile up beyond the capacity of the dark and fetid morgues.

During those first hours at Centro Médico, Puerto Rico’s largest, most sophisticated hospital, Maria tore off part of the roof and flooded the neonatal-intensive-care unit, forcing the evacuation of newborns to another floor. Around that time, the engineers in charge of the emergency room’s electric plant heard a crash. Outside, the wind had pulled a tree up from the concrete sidewalk and thrown it across the roof of the boiler room, where it smashed the exhaust vent of a Caterpillar 3512 diesel generator. This was one of three generators, each the size of a station wagon, designed as a backup system for temporary blackouts. It began to overheat. The crew threw a switch and took it offline. Two generators were enough to power the building, but each would need to be taken offline regularly for maintenance. One generator would be enough for only the most essential, critical systems. The chillers on the air-conditioning system would go dark. So would the computers, all but one of the elevators, most of the overhead lighting, and many of the electrical outlets.

Six months’ worth of rain fell in less than four days. The deluge cracked the spillway beneath the Guajataca Dam, near the western end of the island, prompting the government to order the evacuation of 70,000 people who lived downstream. In Aguada, the swollen Culebrinas River drowned two police officers. Closer to San Juan, the rains poured through the open gates of the La Plata Dam, swelling the La Plata River and overflowing the canals around the lowland pastures and cane fields of the municipality of Toa Baja. Trapped on the second stories of inundated homes, residents watched as torrents of water formed rapids above cars and the tops of trees. Near the center of town, a man who lived alone went outside to buy cigarettes, and the silt-colored water swept him off his feet. A police officer would find him the next morning, his body pinned against a chain-link fence. A second man drowned on the far side of the river. A third died a mile or two away, apparently of a heart attack, in his bathtub.

After the Storm: Puerto Rico’s Morgues Are Overflowing

That morning, Carmen Chévere Ortiz, a 41-year-old pharmacy manager, looked out the window of her two-story home in a neighborhood of Toa Baja called Villa Calma and saw her neighbor’s patio under inches of water. Chévere Ortiz, who goes by Milly, lived with her mother, one daughter, and five sons. She remembered when Hurricane David had struck the neighborhood in 1979 and her father had carried her under his right arm as they fled. On that day, the water had been high enough that it splashed against the bottoms of her feet. This is a place that floods, Milly thought. She grabbed the car keys and gathered her family. Outside, the water was already approaching the top of the rear wheels of her family’s RAV-4. It reeked of sewage. On her way up the street, she shouted out the windows, “The river is coming! Get out! Get out!”

On reaching the highway, Milly saw that seawater from the ocean, whipped up by the winds, was coming in from the Caribbean to the north and meeting the canal waters rising from the south. The rows of houses behind her looked like islands in a muddy lake. Villa Calma, she decided, would need to take refuge inside the neighborhood school, a two-story building surrounded by fences that were sealed with heavy gates.

A crowd gathered around the gates. Some said that the school was government property. “Fuck it,” Milly said. She knew the law, having earned a degree in criminal justice and worked for many years as a security guard. “I would prefer to get arrested,” she said. She took a hook from the back of a red tow truck parked nearby and began to smash it against the locks. The gates opened, and dozens of people from Villa Calma, many soaked by floodwaters and shaking from the wind, took refuge inside. They brought their animals, as well. By nightfall, there were 16 dogs, two cats, a pig, and a half-dozen horses milling around in the courtyard. Inside, the refugees decided to call the school el Arca, the Ark.

An Overflowing Morgue: A body at the Casanova Funeral Home in Manatí. Edwin Casanova, the home’s owner, typically receives one or two requests for mortuary services a day. Since the hurricane, he’s gotten as many as 12. December 3. Photo: Matt Black/Magnum Photos
The Never Ending Darkness: Old San Juan. November 7. Photo: Matt Black/Magnum Photos
A Graveyard Upended: The hurricane toppled gravestones and uprooted trees at San Juan’s Villa Palmeras cemetery. November 5. Photo: Matt Black/Magnum Photos

On that first day, when Hurricane Maria still raged with apocalyptic force, the destruction wrought by the storm was gruesome — and also familiar to anyone who had seen a tornado shuck the roofs off an Oklahoma town or watched Houston flood only a few weeks earlier. When Hurricane Katrina hit New Orleans in 2005, more than 1,800 died, many by drowning, as levees and flood walls failed and the city’s poorest neighborhoods were submerged. Puerto Rico has fewer low-lying areas, so the immediate death toll from Maria was substantially smaller.

But Puerto Rico’s population of 3.4 million is more vulnerable, and its infrastructure weaker, than anywhere on the mainland. The island’s per capita income is $11,688, roughly half as much as the poorest of the 50 states. Its government has let its roads, emergency services, and electrical grid decay as it struggles under massive debt obligations and federally imposed austerity measures. These two factors — poverty and rotting infrastructure — combined with the storm to trigger a second disaster, this one entirely man-made and far more deadly than the storm itself.

December 29 will mark 100 days since the storm ravaged the island, and it appears that at least half of Puerto Rico’s population is still without electricity. The damage caused by the extended electrical outage is most acute in the island’s hospitals. A study of power outages in Ghana over a five-year period found a 43 percent increase in patient mortality on those days that a health-care facility loses power for more than two hours. But the absence of electricity leads to problems all across society — more stress, more disease, more accidents. In developing countries, electricity consumption correlates with lower infant mortality, higher life expectancy, and higher economic output. In August 2003, just one day without electricity in New York City caused a daylong 28 percent increase in overall mortality.

The ripple effects of a long-term blackout can be deadly in ways that are difficult to measure directly. No electricity means no pumping stations moving clean drinking water into higher elevations. It means no electronic forms of communication, forcing entire communities to rely on word of mouth to stay informed. It means no electric heating, no air-conditioning, and no refrigeration. It means taking three cold showers spread across the night so one’s body will be cool enough to sleep. It means buying ice by the kilo to store food and insulin. It means an increase in burns and explosions as people switch to candles, propane, and oil lamps. It means generators for the few who can afford them, and darkness for everyone else.

All of this has led, inarguably, to hundreds upon hundreds of deaths. After months of sticking by an implausibly low-double-digit death toll and ignoring his own official statistics, Puerto Rico’s governor announced in mid-December that there would be a review of post-Maria deaths that had been attributed to natural causes. Among the deaths that are still waiting to be added to the official count is that of a resident at a small nursing home outside of San Juan who, according to an employee, somehow strangled herself with her oxygen tubes a few hours after the power went out. The police marked the case down as a suicide. (According to police reports, the rate of suicide on the island has nearly doubled since Maria, approaching one per day.) Another is the patient who died in the emergency room of a hospital in Aguadilla, days after the storm. There was no air-conditioning, and, according to visiting doctors, the patient died of the sweltering heat. And yet the government’s official list of storm-related deaths does not attribute a single one to heat.

Multiple news organizations have calculated that the death toll from Hurricane Maria exceeds 1,000; the New York Times, reviewing mortality data from previous years, identified an increase of 1,052 deaths during the first 42 days alone. This, too, is surely an incomplete reckoning. Even as the federal government winds down its response, withdrawing personnel and equipment, some homes are not expected to regain electricity for months. Experts are warning that, with the ballooning mosquito population and lack of clean drinking water, Puerto Rico is at risk of an epidemic. Though Donald Trump has mostly ignored it, he is presiding over a historic tragedy. By the time the island returns to normalcy, Maria could easily have surpassed Katrina to become the country’s deadliest natural disaster in living memory.

The Unofficial Mayor: Carmen Chévere Ortiz, “Milly,” at home in Villa Calma. November 30. Photo: Matt Black/Magnum Photos

On September 22, Pedro J. Reyes Martínez, a 58-year-old orthopedic surgeon, showed up to work at Centro Médico and found the hospital in disarray. Centro Médico is a complex with more than 1,000 beds spread across six hospitals. The main emergency and trauma building, called ASEM, with 230 beds, was running on a single Caterpillar generator. Most of the lights were dark. Three out of four elevators were still not running. A small number of red emergency plugs, connected to critical patients, provided power. The building was too hot and moist for Reyes Martínez to perform any surgery. He returned on the 26th to find 57 patients awaiting surgery; he handled four of them. “There was no sterile equipment left,” he told me. “With a proper facility, I could have done ten or 15.”

Reyes Martínez calls ASEM “the safety net for the entire island.” For the first nine days after the hurricane, he told me, only two of its 18 operating rooms were functional, mainly because of a lack of air-conditioning. He would return nine days later to find that little had improved. He remembers performing surgery on five patients, less than half of what he would have been capable of had there been the normal amount of equipment and electricity. At the same time, the hospital was seeing more fractures — wrists, shoulders, hips — as people tried to acclimate to the darkness on the roads and in their homes. “You cannot have the main medical center in Puerto Rico, which serves 3.5 million people, without a reliable source of power for an entire month,” he said.

After the Storm: One Family’s Road to Recovery in Puerto Rico

Jorge Matta González, the CEO of Centro Médico, had requested that the Department of Health and Human Services send a backup generator for ASEM on September 22. The date of Centro Médico’s request is noted by official U.S.-government documents obtained by ProPublica and was confirmed to me by both the hospital’s staff and Captain Chester Kraft of the Army Corps of Engineers. The Corps, he said, inspected ASEM’s plant on September 24 and did nothing because two of the three generators were working. “We did not consider it a critical need,” he said. Thomas J. Field, a spokesperson for the Army’s power-restoration task force, told me, “Just because you ask for something doesn’t mean you’re going to get it. FEMA has a responsibility to the taxpayer.”

While service to Centro Médico from Puerto Rico’s troubled electric utility, PREPA, came back online later in the first week, there continued to be intermittent blackouts in the operating rooms. Whenever the hospital lost power from PREPA, it would go completely dark for a minute or two as the system switched over to the diesel generators. PREPA’s power was so inconsistent that Juan Robles González, the engineer in charge of ASEM’s power plant, eventually decided to rely on the two generators instead and to treat the grid power as a backup.

The federal government was slow to address the crisis at Centro Médico, but the hospital’s size and importance meant that it did get some attention, and its generators received enough diesel. Elsewhere on the island, however, many small hospitals were facing the loss of power and dwindling supplies of food, water, and medicine. Six hospitals shut down completely; at least two, in Arecibo and Aguadilla, reportedly operated for weeks without full electricity. A Florida-based doctor who visited the hospital in Aguadilla told me that temperatures in the emergency room regularly reached 97 degrees Fahrenheit, and that, later, the hospital was closed because of mold. Hospitals lucky enough to be equipped with reliable generators desperately searched for sources of diesel. With morgues quickly filling to capacity, the Army deployed battlefield MIRCS — olive-drab Mobile Integrated Remains Collection Systems — to hospitals in San Gérman, Ponce, and Fajardo, where they remained for more than a week.

Shortly after the storm, Dr. Antonia Novello, a former U.S. surgeon general who was born in Fajardo, began touring the island’s medical facilities with the 101st Airborne, resupplying hospitals and vaccinating as many children and first responders as she could. “We had all the inputs for an epidemic,” she told me. “Stagnant water, mosquitoes, a history of dengue, of chikungunya, of Zika.”

And even as conditions stabilized at Centro Médico, health risks swelled. I spoke to several doctors who worked there during the first weeks after the storm. All described a staff struggling to provide competent care under deteriorating conditions. Most recalled the electricity’s failing at least ten times for a half-hour or longer during the first month. “The floors were slippery,” one told me. “The patients were sweating. It was the perfect environment for bacteria to grow. You try and do your best under these conditions, but that’s just not possible.” “The power went down,” said another, “and the temperature went up. The sterile conditions were lost. And they did their operations anyway, because they had to.” I asked whether any patients died owing to the intermittent electricity. Dr. Carlos Gómez, the director of ASEM’s emergency room, emphatically denied that any had. But one doctor estimated that Maria-related electricity outages had caused 15 patient deaths. They were “in very bad condition already,” the doctor acknowledged. “Losing the electricity pushed them over the cliff.”

The Fisherman: Ernesto Matos Santana, “Teté,” 79, who rescued 15 families from their flooded homes. November 30. Photo: Matt Black/Magnum Photos

All over Puerto Rico, people were improvising solutions, attempting to supply for one another the basic services Americans in crisis typically expect from their government. Especially outside San Juan, Puerto Ricans set about rebuilding bridges and clearing roads. But first, many dedicated themselves to an even more urgent task — rescuing their neighbors.

In Toa Baja, a short way down the highway from the Ark, a 79-year-old fisherman named Ernesto Matos Santana, known as Teté, entered the period after Maria at a certain advantage: He had never installed electricity in his house. (He believed that turning lights on at night was an invitation for people to bother you.) Around the time that half of Toa Baja was underwater, with nightfall a few hours away and neither the mayor nor the police able to access a single boat, Teté decided to go out in his rowboat and see who he could find. The wind was still very strong — well over 50 mph, he believed — and he struggled to anticipate the obstacles that might be hidden directly beneath the waterline. He was especially worried about the power lines and whether they were still live, since he knew his boat would conduct electricity. (When he fished at sea during electrical storms, he would often climb out and swim beside it, sometimes for an hour or more.)

Teté soon found people huddled on their second-floor balconies and rooftops. “You need help?” he would call out. He could fit five or six people in the boat at a time, rowing them up to the highway, where the water was only waist high. They would embrace him and thank him profusely. Then he would go back to search for more.
When he got tired, he would take short naps at his house. By the time the waters receded, 60 hours later, he had carried 15 families from their homes to the road.

“Whoever needs the help, we have to help,” Teté said. “Porque son mi gente. Because they are my people. It got so dark in there when I would go in that people would say that I was dead. There are still people today who think that I am dead.”

Some of the neighbors Teté recovered made their way to the school, where people soon began to get hungry. “Nobody is going to come for us,” Milly said, as she huddled with a few dozen of her neighbors there. She broke into the kitchen. Inside were cans of tuna, bread, fresh milk, and six cases of water. After they ate, they broke into classrooms to find places to sleep. Milly assigned 20 people to each room, along with a captain. A sick man was floated in on an inflatable mattress.

A Town Ablaze: In Toa Baja one night, the darkness was punctuated by a trash fire. November 26. Photo: Matt Black/Magnum Photos
Tending to the Sick: Ismael Ramos Serrano, 38, has epilepsy and lives with his mother, Esther, and many other family members. Their house can be stifling (they can only afford to run their generator for a few hours a day), and so Esther uses sponge baths to keep him cool. November 25. Photo: Matt Black/Magnum Photos
Alone in the Mountains: In Utuado, Manuel González holds a flashlight to illuminate the kitchen of the Serrano home, where as many as 10 people are still living without electricity. November 24. Photo: Matt Black/Magnum Photos

The older people began to get cold as night fell. They wrapped themselves in heavy curtains torn from the windows. Milly’s son Kenny took a big pot from the kitchen, filled it with scraps of cardboard and hand sanitizer, and made a fire. That night, Milly did not sleep. She felt grateful that the worst of the flood had come during daylight. If it had come during the night, she believed, thousands would have died in their beds. She paced up and down the halls of the school as more people kept arriving, many of them strangers. She filled new classrooms, assigned new captains, created a registry. By morning, there were some 200 names.

The next day, people began venturing across the road to a pizzeria with a working landline. They called overseas and let their families know that they were still alive. Others went out from the school in kayaks to scavenge food and water from their old homes. They had no idea how long it would be before help came. “We were prepared to die,” Milly told me.

On the third day, a convoy of cargo trucks, their four-foot-high wheels almost completely submerged in water, drove through town. They did not appear to want to stop in Villa Calma, but the people from the school blocked the road and forced them to take some of the elderly and children aboard. On the fifth day, the mayor came. There were still around 200 people in the school, and he said he wanted them to remain together, with Milly as their leader, but that they needed to move to another shelter several miles away. About 70 people opted to stay. The rest were brought to an official shelter on an open-walled basketball court. There was no running water in the bathrooms and little privacy in the bathing area. Milly spent most nights in her car, trying to stay awake and watch for signs of trouble. She met Major Mark East, an Army chaplain stationed at Fort Buchanan, and convinced him to provide her community with religious services in his spare time. “She told me that after this is over, people are going to need something for their soul,” East told me. More than once, she drove to the local Walgreens, bought what the Villa Calma refugees needed (diapers, especially), and paid for it out of pocket. Most of the group from Villa Calma would sleep beside the basketball court for three weeks.

Maribelle Ramos Serrano, Esther’s oldest daughter, at the Serrano home. November 24. Photo: Matt Black/Magnum Photos

October

President Trump made his first visit to survey the damage on October 3. Sitting beside Governor Ricardo Rosselló, he used one of the earliest official death tolls, 16, to downplay the damage. “I hate to tell you, Puerto Rico, but you’ve thrown our budget a little out of whack,” he said.

Puerto Rico is by far the largest of the “unincorporated territories,” a euphemism for the American colonies of the Pacific and Caribbean. It belongs to — but is not among — the United States. Puerto Ricans cannot cast votes for the presidency, nor can their “resident commissioner” cast a vote on the floor of Congress. And yet it is Congress that has final authority over Puerto Rico.

In 1899, less than a year after the United States conquered the island in the Spanish-American War, Puerto Rico was hit by a hurricane named San Ciriaco. The storm looked a lot like Maria — high winds, rains, flooding, and a devastating path across the middle of the island. “We have accepted these people as our share of the burden,” wrote Major John Van Hoff, director of the official relief effort, in a letter to Puerto Rico’s military governor. “We will keep them alive; we will lead them slowly, gently toward the light.” At times, the racism was even more explicit — the governor had called Puerto Ricans “a horde of human beings … only a few steps removed from a primitive state of nature” — but the response from the mainland was undeniably massive. On the tenth day after San Ciriaco, a U.S. transport ship arrived in San Juan carrying 1.2 million pounds of food and 19,000 pounds of supplies. The federal relief effort continued at full throttle for the next ten months.

The 2017 hurricane-relief effort got going slowly. “The response during the first three weeks was nonexistent,” said Carmen Yulín Cruz, the mayor of San Juan and an outspoken critic of Trump. “I got my first 12 pallets of food from FEMA on October 12. What do you do with 12 pallets of food and water in a city of 350,000 people?”

It took two weeks after the storm for the USNS Comfort, a 1,000-bed hospital ship, to arrive in Puerto Rico and only after Trump was prodded to deploy it by a tweet from Hillary Clinton and a change.org petition. Even after the Comfort was deployed, confusion and bureaucratic mismanagement limited the number of inpatients to an average of six each day, according to the Times.

An Island Without Power: Broken utility lines throughout Puerto Rico. Photo: Matt Black/Magnum Photos

There is no clearer indication of how Trump regards Puerto Rico than the number of federal, military, and National Guard personnel who were sent to improve conditions on the ground. In August, within a week of Hurricane Harvey’s landfall, Trump had sent 31,000 to Texas. One week after Hurricane Irma made landfall, there were 40,000 personnel on the ground across the southeastern U.S. For Maria, the federal force peaked at around 15,000. And when Trump signed a $36.5 billion disaster-relief package on October 24, only $1.2 billion was earmarked specifically for Puerto Rico.

But the federal government’s parsimony toward Puerto Rico goes beyond the current administration. Over the past few decades, Puerto Rico has become an offshore tax haven; at the same time, the island’s government continued to struggle with massive debt. A report on PREPA published last year called the utility “an emergency in the present day.” “PREPA’s distribution systems,” the report found, “are falling apart quite literally: they are cracking, corroding and collapsing.” In 2016, with some $70 billion of Puerto Rican public debt trading at junk status, President Obama signed a law that put the island’s budget under the control of an austerity-minded Fiscal Control Board. Seven of its eight members are appointed by the president. In Puerto Rico, it is known as la junta.

Perhaps mainland Americans would have been more alert to the crisis unfolding in Puerto Rico had the government’s estimate of the death toll caused by the storm not stalled in the low 50s. The island’s overall mortality rate, as logged by its health department, rose by roughly 20 percent in September and October. The gap between the official body count and the reality on the ground may have hampered public-health efforts during the hurricane’s aftermath. “The response has not been adequate,” said Jeremy Konyndyk, who oversaw U.S. aid after the 2013 Philippines typhoon, the 2014 Ebola outbreak, and the 2014 civil war in South Sudan. “Unless the government got a handle on the actual death toll,” he told me, “you could have something really bad going on under your nose and not know about it.” As Puerto Rico faces difficulties with clean water and vaccine supplies, knowing who is dying in real time can mean the difference between an outbreak and a pandemic.

Nieves Bauzó Otero, a professional embalmer whose funeral parlor in San Juan is near Centro Médico, has seen an increase in business that outstrips the official statistics. During a normal month, he would have five orders from the city to embalm a body. In October, he had 20. In another town, immediately after the hurricane, he did a month’s worth of business in a week. “I don’t believe it’s just 50 or 60,” he said. “I’ve seen it — in the institute, in the hospital morgues, in the communities.” When he drove to the Institute of Forensic Sciences in San Juan during the first days, he said, he would join a line of vans that stretched up the hill to the train station, all of them coming from funeral homes and crematoria, carrying the dead.

A Fireball of Propane: On October 25, José Pérez Santiago was returning from refilling the propane tank he used to power his camping stove when it caused a fire inside his truck. He died a week later at Centro Médico, where he had developed an infection. November 7. Photo: Matt Black/Magnum Photos

By the end of October, it became clear that the increase in island-wide mortality was being driven by unusually high concentrations of deaths among the elderly, in nursing homes, and in hospitals. The Times reported on the October 4 death of Harry Figueroa, a 58-year-old man who had gone two weeks without the oxygen machine he wore while sleeping. In a Lajas shelter, according to Puerto Rico’s Center for Investigative Journalism, Leovigildo Cotté, the father of the town’s former mayor, died for lack of electricity and oxygen. The family of 80-year-old Isabel Rivera González told CNN that she died awaiting a critical procedure in a hospital where the backup generator failed. Elsewhere, generator failures meant that patients on mechanical ventilators had to have air pumped into their lungs by hand. At least two patients died at a hospital near San Juan when there weren’t enough staff on hand to operate the pumps, a doctor who was present told me.

In the 42 days after the storm, 3,660 people over the age of 60 died, compared to 2,760 during the same period last year. Deaths recorded in hospitals rose by 26 percent; deaths recorded in asylums, retirement homes, and long-term-care facilities rose by 65 percent. Mayor Yulín Cruz told me about a San Juan–area hospital urgently seeking to transfer more than a dozen patients on ventilators. She said that she did not know where they ended up. In Toa Baja, according to Mayor Bernando Márquez García, the municipality had to rush emergency fuel to a dialysis center and a nursing home. Both of Toa Baja’s emergency clinics closed, Márquez García said. Their patients were transferred to nearby hospitals in Bayamón. “Then they refused to take any more patients from Toa Baja,” he said. He fell silent for a long moment, then started to cry.

“If you have a bedridden patient who has no power, no water, and develops an ulcer, a patient who cannot go to a hospital, because they lost their car, because the hospital is not working, and this person develops sepsis or shock and then they die? That’s a death that has to be attributed to the disaster,” said Jorge Gabriel Rosado González, a 30-year-old pediatrician who helped to organize a free clinic in Toa Baja. The clinic treated 2,000 walk-in patients in October alone. “People are dying because proper medical attention is not being provided to them. Hospital administrators are not going to tell you that it is true. But it is true.”

The New Normal: Even through December, the residents of Punta Santiago endured long lines to receive food from the local Catholic church. December 2. Photo: Matt Black/Magnum Photos

At the end of September, Trump’s Homeland Security adviser, Tom Bossert, sent an email to his senior White House colleagues laying out a messaging strategy for the following weeks. First would be “stabilizing … basic government services, including temporary power.” Then would come “restoration” and “recovery.” “Power is being restored to hospitals,” he wrote.

At the time of Bossert’s email, a week had passed since Centro Médico had requested a new generator to power its emergency room. Three weeks after that, shortly after noon on October 20, the existing generators shut off in the middle of the day, leaving the ER completely dark with the exception of a few emergency lights. Patients were sewn up in the middle of surgery by the light of their surgeons’ phones. Ventilators shifted to backup batteries as doctors rushed to transfer critical patients to nearby buildings.

Juan Robles González, ASEM’s chief engineer, rushed down to the power plant to see what had gone wrong. For more than half an hour, he and his team of engineers struggled to diagnose the problem. “It was a nightmare,” Robles González told me. “You’re thinking about all the people who are connected to the machines that are connected to the electricity.” Finally, they located the source of the problem: Two 24-volt batteries had been moved from the broken Generator 1 to generators elsewhere in the complex, even though they had been providing power to a control panel that governed Generators 2 and 3. One of Robles González’s men ran out to retrieve them. “When the generator came back on, the sound was like music,” Robles González said. There was still a circuit breaker and a blown fuse that needed to be repaired on Generator 2, resulting in another three hours of limited emergency power and darkness in the hospital before it came back online.

According to the plant’s official log, ASEM spent 35 minutes in complete darkness. During that time, Kermith Ayala Muñiz, a resident, posted a live video to Facebook. More than a month had passed since Maria. He’d had enough. “This is the fourth time the lights have gone out today,” he said. “Patients are going through surgery, and they’re being operated on with flashlights.”

“I was frustrated,” Muñiz told me when I found him outside one of the hospital’s cafeterias. “I had to say something.” He was reluctant to elaborate, however. Two days after Muñiz’s post, on the morning of October 22, the Army Corps of Engineers drove up to the power plant with a new Caterpillar generator. Thirty days had passed since Centro Médico first asked for it.

The Rural Crisis: The collapsed bridge over the Río Viví has been one of the biggest obstacles for delivering aid to a neighborhood of survivors in Utuado. Neighbors built a makeshift ladder and a pulley system for moving supplies across the gap. November 19. Photo: Matt Black/Magnum Photos
Angélica Negrón, 28, and her children, Josué Gonzáles and Gabriel Gonzáles, lacked electricity and clean water; they washed laundry in a creek behind their home. November 9. Photo: Matt Black/Magnum Photos
A Shoreline Remapped: Punta Santiago, on the eastern end of the island, was close to the eye of the storm and has lost vast amounts of beach to the sea. November 7. Photo: © Matt Black / Magnum Photos. All rights reserved

José Cheo Ortiz, Milly’s uncle, a restaurateur and community organizer, had flown to San Juan from his home in Oakland, California, a week after the storm. He brought boxes of food and flashlights and $3,000 in cash. The most urgent problem, he found, was hunger, and he organized a group of restaurants in neighboring Levittown to donate 200 box lunches a day. Then, as his niece slept in her car beside the basketball court, he set about getting the mud and ruined furniture out from the first floor of her house. “It was an empty shell,” he said. “There was garbage in the street and dead animals all over — horses, cows, ducks, chickens, everything.”

When Milly moved her family back into Villa Calma in late October, her house was one of the first to return to a semblance of order. Some of her neighbors were sleeping inside tents erected in their living rooms. On her street, she saw mothers digging through inches of cracked and caked mud for pots and pans and their children’s toys. Piles of debris lined the streets and attracted hordes of mosquitoes, which bred quickly in pools of standing water.

Maria had claimed a fourth life in Toa Baja: an 18-year-old named Jesus Miranda Matos, who had worked diligently during the cleanup effort, clearing debris and handing out water. He died of leptospirosis, a bacterial infection caused by contact with animal urine. There are currently more than 70 suspected cases in Puerto Rico and two confirmed deaths.

The dead continued to pile up as October passed. At the Institute of Forensic Sciences in San Juan, FEMA brought 11 refrigerated trailers to hold the excess. Specially trained Army morticians tended to the bodies of dead U.S. civilians, cleaning their wounds and preparing them for autopsy. “It’s an honor,” said Sergeant Luis Quiñones, who grew up in Puerto Rico. “I never thought I’d be doing it here at home.” The government had not yet assigned a cause of death for 313 of September’s dead, not to mention the 527 of October’s. For the previous two years, deaths by unknown causes were in the single digits for both months.

The Mud: Mudslides caused devastation throughout the municipality of Maricao. Miriam Sánchez lost her home during Hurricane Maria and was squatting in this room, with no electricity or clean water. November 4. Photo: Matt Black/Magnum Photos

November

One morning in early November, I sat in the institute’s air-conditioned lobby as, one by one, families in tearful huddles gathered to identify their relatives and sign the necessary paperwork. Iris Báez Lugo, a middle-aged woman from San Germán, emerged from the entrance, having just identified the body of her 57-year-old brother, Héctor. He died, she told me, while being treated for burns at Centro Médico. She had heard from the funeral home about a fire in a house that he had been working to renovate, but she had no idea what started it or how it led to his death. “I don’t know nothing,” she said. “They told me he died. But they didn’t say how.”

Another case awaiting a determination by the institute was that of José Pérez Santiago, a 55-year-old man with bipolar disorder who had once had a promising career in San Juan’s film industry. Living alone, he had done his best to keep his spirits high. He would belt out salsa and bomba tunes with a microphone, karaoke style, over speakers that he recharged with a neighbor’s generator. The sense of crisis seemed to energize him, which worried his daughter, Gabi. “He didn’t have access to his doctors or medicine,” she told me. “I noticed a major change in his behavior. He was more aggressive and confused.”

On October 25, Pérez Santiago’s portable camping stove ran out of propane, so he loaded the empty canister into his pickup truck and drove to the hardware store, where he traded it in for a refill. He put the new canister beside him in the cab, on the passenger’s seat, and on his way home, the gas leaked and ignited. His body caught on fire. He died one week later at Centro Médico, where he had contracted an infection. (After Maria, deaths from sepsis, which can be caused by infections in non-sterile hospitals, rose by 50 percent.) “Instead of a recovery phase, we’re still in an emergency,” his former partner Julia told me. “Almost two months after the storm. It’s unacceptable.”

Pérez Santiago had a cousin, Milton Molina, 40, who fell dead from causes more mysterious but hard to separate from the hurricane. Molina’s wife heard shouting in the bathroom and found him collapsed on the floor. What the hurricane had brought into his life was stress. His wife’s parents had lost their homes and moved in with him. The night before, they had all gathered in the living room and laughed over a game of dominoes. “He was carrying the rest of the family,” said his brother Joel, an Army private stationed in Germany who got to leave to attend the funeral. The institute had returned Molina’s body to the family, but it held on to his internal organs for further study. “We haven’t gotten any closure,” Joel said. “There’s been no explanation about what happened.”

The Waterline: José Soto, 75, in his house in Toa Baja, where the flood reached almost to the ceiling. November 23. Photo: Matt Black/Magnum Photos

Two months after the storm, it was apparent that the most vigorous recovery efforts were concentrated around the capital. Many stores were open for business, including the lavish Mall of San Juan. With few streetlights operating, drivers were still improvising left-hand turns across four lanes of traffic, but conditions were nothing like in the rural areas, where the only aid many received were handouts of bottled water and military rations from the local mayor.

In Villa Calma, Milly packed her children into bunk beds as her own house became a refuge. Her relief operation was getting more organized. Individual houses were targeted for volunteer cleanings that were organized over WhatsApp. Drinking water was still a problem, however. Sometimes the taps flowed dirty; other times they stopped altogether, and Villa Calma had to rely on bottled water and whatever people could collect from the rain. Milly gave four bucket-size filtering cisterns to her helpers, block by block, and another to her neighbor Luisa, who had made her own home into a community kitchen.

All over Puerto Rico, the privations of the crisis were stretching out into something more permanent, and the afflicted were settling into their new living arrangements. In Orocovis municipality, I found a makeshift intensive-care unit housed in a one-story building that had formerly been rented out for weddings and quinceañera parties. Inside, separated by sheets hung from bare pipes, seven elderly, bedridden patients clung to life with the help of ventilators and oxygen masks. Before the hurricane, they would have been able to remain at home and be looked after by family members. Now they were miles away from home, their existence at the mercy of the mayor’s ability to keep fuel flowing to a generator that rattled away in back.

“You can’t think about what’s going to happen tomorrow, or when this is going to stop,” said Angelita Torres, a woman in her 60s who was visiting her 98-year-old mother. She was staying with her daughter an hour’s drive away, having lost her own home in the storm. She and her mother planned to move to somewhere nearby, wherever the electricity came back online first.

Farther to the west, in the municipality of Utuado, Pastor Félix García noticed that the turnout for his Sunday services had fallen by half. Some of his parishioners had left the island. Others could no longer spare the gas or the time.

One day, García took me to visit one of the humblest houses in his community, where nine members of Esther Serrano’s extended family were crowded into four stifling rooms on a hillside road. At 72, Esther cared for three grown sons who were too developmentally challenged for paid work and a fourth, Ismael, who has epilepsy and was confined to his bed. Nevertheless, she felt lucky. The Holy Spirit had entered her body in the middle of the storm, she said. “I am here!” she had shouted. “Estoy aquí! I am! I am! I will protect you!” The hurricane had spared Esther’s house but tore the roof from the one next door, which belonged to her daughter Ruth, so she and her husband moved back in. Esther was cooking over scraps of wood and scrubbing the laundry by hand. In the next room, Ismael stared up wordlessly at the ceiling, clutching a stuffed lion. A church group had given the Serranos a generator, but they could only afford to run it for a few hours a day. In the stifling afternoon air, Esther tried to keep Ismael cool with sponge baths.

A short ways down the road from the Serranos, a group of workingmen had banded together to rebuild a concrete bridge. They had taken the job on themselves, using community donations and their own free labor. One by one, they lifted rocks up from the riverbed and hammered them into a web of old rebar. “I can’t blame the delay on anyone,” said their organizer, José Pérez Pagán. “There are 14 bridges in Utuado. Maybe this is the last one they can fix. Now we’ll be the first. The mayor is going to have to come and celebrate with us.”

The New Economy: Juan Manuel López Bonilla, a farmer in the town of Adjuntas, converted two of his toppled guava trees into charcoal, which he intended to sell for $15 per sack. November 21. Photo: Matt Black/Magnum Photos

In mid-November, the USNS Comfort packed up and left, along with Jeffrey Buchanan, the three-star general sent to lead recovery efforts. “I think we’re in the right place to transition,” he told CNN. It had been more than a month since Trump had signaled that his interest in Puerto Rico was wearing thin. “We cannot keep FEMA, the Military & the First Responders … in P.R. forever!” he had written on Twitter early one October morning. He delivered on this promise three days before Thanksgiving.

A few days later, I spoke with José E. Sánchez, who is leading efforts by the Army Corps of Engineers to restore the island’s electricity. I asked him when power would be restored to the most remote, rural areas. Sánchez declined to answer. He noted that some of the most important repairs can be done only by helicopter. Whitefish Energy Holdings, the small Montana company that won the initial $300 million contract to fix Puerto Rico’s grid, is in the process of winding down its operations after it was found to be charging more than $300 an hour for linemen. (Exactly how the relatively unknown company, one with reported ties to Trump’s Cabinet, won the most lucrative and critical contract during the first days of the recovery remains to be determined.) In late December, General Diana Holland said that the goal of the Corps was to fully restore power across the island by the end of May. But Sánchez told me that status.pr, a government website, was giving an overly optimistic view of the grid’s recovery. The site measures progress in terms of megawatt capacity, which was then over 60 percent. It neglected to mention that the recovery has been concentrated around cities and industrial sites, leaving more than half of PREPA’s customers in the dark. “People on the mainland might take a look at that site and think things are going well,” Sánchez said. “They’re not.”

The Return: Maribel Villalobos Colón points to the waterline at her home in Toa Baja. She recently returned to find her home caked in mud. The bear belongs to her seven-month-old nephew Kahel Figueroa. The family is still living with four others in a neighbor’s house, waiting for theirs to be cleaned out. November 30. Photo: Matt Black/Magnum Photos

December

Trump’s response to Hurricane Maria has been successful in one respect: Pushing Puerto Rico out of the news. At first, his description of the hurricane bordered on braggadocio: “It was one of the most serious storms anyone has ever seen,” he said the day afterward. As criticism mounted over his handling of the crisis, he turned the size of the job into an excuse not to do it, complaining about how difficult it was to ship supplies to an island, how devastating the storm had been, how unfair it was to judge his response by images of devastation.

But soon Trump settled into a strategy of deflection. The casualties, he said, were nowhere near Katrina’s death toll. If there were delays, they were because Puerto Rico’s governor had not yet made a formal request. If there were supply shortfalls, they were due to the vigor of ongoing federal efforts in Florida and Texas. If the electricity was not yet on, that was due to Puerto Rico’s spendthrift ways. “Puerto Rico survived the Hurricanes,” the president tweeted in October, quoting a conservative commentator. “Now a financial crisis looms largely of their own making.” These days, Trump hardly discusses the island. “They’re doing well there and it’s healing and it’s getting better,” he said on November 29, the last time he mentioned Puerto Rico. He appears unaware that the crisis is nowhere near over, or that the deaths caused by Hurricane Maria have never actually stopped.

The same can be said of much of the country. Of the many curses that befell Puerto Rico this year, the most infuriating may be invisibility. Because of its isolation, its lack of political representation, and the deceptively low number of casualties counted by early reports, the island had mostly faded from public consciousness throughout the fall. There are now only 5,405 federal personnel now providing assistance. Governor Ricardo Rosselló once promised that power would be restored to 95 percent of the island by December 15, but that deadline passed with little notice. On December 20, Congress passed a tax bill that will subject businesses in Puerto Rico to higher taxes than their mainland counterparts. “Many senators and congressmen came to Puerto Rico and they pledged their support. But when the time came to support Puerto Rico, they essentially bailed,” Rosselló said about the bill, warning that it will lead to fewer jobs and more relocations. Already, over 200,000 Puerto Ricans have left for the mainland, and one study estimates that 470,335 — 14 percent of the island’s population — will be gone by 2019.

The Empty island: At the beginning of December, the municipality of Arecibo was still dark, with many of the residents evacuated. December 3. Photo: Matt Black/Magnum Photos

Those who stay will face the challenges of recovery largely on their own. As Christmas approached, the neighborhood of Villa Calma remained a patchwork of darkness and mud-covered rubble. Many houses were still empty. The sick and elderly neighbors would sometimes disappear, and it would take weeks to piece together what had happened to them. The school was open again, but the students, lacking light, had trouble doing much homework after five o’clock. There were 15 generators spread across the neighborhood’s 300 families. At night, people gathered around the lights of the stores and the bars along the highway. The owners duct-taped power strips to the walls for their customers.

Rebuilding was proving to be exhausting. One resident, a woman named Maribel Villalobos, had lost her roof in the storm and had to ask a neighbor to let her move into his house with nine members of her extended family. Her son had been shot in the hand by a pellet gun while walking in the darkness. Her husband had broken his leg in three places while trying to fix the roof; he had worked for the city on a garbage truck and now could no longer drive. Both men had complications after waiting weeks for surgery. I asked Villalobos whether the government had been of any help. “Injusto,” she replied with quiet anger. She said FEMA had told her it could do nothing about her roof because she had purchase papers for the property but no title. This was a common problem in Villa Calma. Hilda Vilá, a sociologist, had made a census of the neighborhood and found that almost all of the 118 families owned their homes but lacked deeds. As of mid-November, only 23 of them, in one of the island’s most flood-ravaged neighborhoods, had gotten money from FEMA. In most cases, it was a onetime $500 handout for “critical needs.”

Standing in her garage one recent afternoon, juggling her cell phone and a can of beer, Milly spoke, in an eager, anxious voice, about her plans for 2018. She wants to rent an office down the street and get the aid depot out of her garage. She wants to start a program that will pair families in Villa Calma with families on the mainland. She wants to bring in volunteer lawyers to get the neighborhood’s homeowners proper deeds. She was considering taking a tent, starting an encampment in front of the governor’s house, and staying there until some real help comes.

In the meantime, she was preparing Villa Calma’s holiday celebrations. There will be a feast. On Christmas Eve, the missionaries will bring a gift for each parent so that the children have something to open the next morning. At dusk, everyone will gather, pray, and light candles. “Ser luz en medio de la oscuridad,” she said. “To be light in the midst of the darkness.” Across her balcony, visible from the street, Milly had already draped a string of blue Christmas lights. She put them there as a sign that Villa Calma could transcend the rudiments of survival. “The message is: It’s Christmas,” she said. “Thank God, we are alive. We didn’t die. We have to move forward.”

Additional reporting by Rebecca Banuchi

*This article appears in the December 25, 2017, issue of New York Magazine.

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