I was recently sitting at dinner with my family in downtown Los Angeles when my phone began to vibrate. My classmates in Puerto Rico were sending me pictures from their balconies in the metro area of San Juan as the power plant went up in flames. I scrolled through photos of exasperated students trying to study by candlelight and remembered my own final months of clinical science rotations in Puerto Rico before I returned to California in December and the feelings of powerlessness and frustration of living without basic resources I experienced.
Laughter brought my attention back to my niece, beaming with the glee of a girl who was about to see Aladdin, thousands of miles from my friends and colleagues who were again entering a world of darkness.
More than 175 days have passed since Hurricane Maria, the second of two back-to-back hurricanes, made landfall in Puerto Rico. In many places on the island, convenience and access to resources remains the same as it was on day one. Relief teams are still providing filters for clean water and bringing solar lighting into the mountains. In rural regions, farmers' incomes are suffering because their fields were destroyed, which makes local crops unavailable in urban markets. Washouts and mudslides on roads to mountain communities keep utility trucks and gasoline tankers from getting in. Logistical failures continue to keep supplies from reaching people who need them. Blue tarps from the Federal Emergency Management Agency cover gaping holes in roofs everywhere, but they were designed for temporary use and are starting to give out.
Despite these dire conditions, Puerto Ricans continue to be kind to one another. Many have opened their homes to others who are without electricity, and people are quick to pass resources on to those who need something more than they do. The needs have stratified Puerto Rico, but also solidified it, in a way.
The hurricanes presented unique challenges to us as medical students. Now the challenge is to continue giving Puerto Rico the resources required to permit physicians and others provide needed health care.
When the hurricanes struck, our diligence to our studies never waned. Once power and the Internet were restored -- via generators and satellite connection -- we took our National Board of Medical Examiners shelf exams and our objective structured clinical exams, as per the syllabus. Our peer-taught clinical classes and reviews came between call shifts and curfew, and we learned to be efficient in the humidity with headlamps.
The situation also allowed us opportunities to provide care with limited resources. In our neonatal intensive care unit, we lost power when the generators failed, and we watched our infant patients being prepped to be airlifted to other hospitals. I have friends who saw surgeons close under the lights of cell phones when blackouts hit. When electrical pumps didn't have power to move water higher than the first floor, we learned to adapt without running water. We learned to provide care without modern technology, and to provide good outcomes with creative solutions.
It also gave us front-row seats to emergency situations and crisis response.
Medical students from San Juan Bautista volunteer at the P.E.C.E.S medical clinic in Humacao, Puerto Rico.
After the first hurricane, Irma, our students volunteered in triage clinics set up in hotels near the convention center in San Juan. Puerto Rico received patients evacuated from the Virgin Islands and those on cruise ships to San Juan. One of the reasons Puerto Ricans weren't as prepared for Hurricane Maria is that many people had taken private boats and resources to our neighboring U.S. Virgin Islands after Irma hit there. When Maria came to our island, our supplies of water and canned food were already low.
After Maria, students volunteered with projects such as mud-out teams, village clinics and supporting visiting doctors. Pediatricians and primary care physicians took the initiative, staffing daylong community clinics through organizations such as P.E.C.E.S.,(www.pecesinc.org) a local community development program.
In Humacao, cars destroyed by seawater and homes flooded with black water from septic tanks left access to even routine medications limited and made the area dependent on response teams. Some of the greatest needs are simply clean water and sanitation.
I worked to obtain local endorsements for medical licenses and needed medication requisitions for medical teams like those with Christian Emergency Relief Teams International.(certinternational.org) I coordinated project logistics for several of the dozens of volunteer groups with Send Relief(www.sendrelief.org) and watched as they provided more than 600,000 hot meals. My dad even organized a chainsaw team from his church in California, and volunteers spent a week opening access to community centers, homes and medical clinics in Bayamón, Guaynabo, Carolina, Humacao, Punta Santiago, Caguas and Toa Alta. I believe I was placed in Puerto Rico at the perfect time to be a part of immediate solutions.
Today, as Puerto Rico moves from recovery to rebuilding, the playing field has changed. The supplies exist, the immediacy of the response has quieted, but the need is ever present. As the months drag on, there is a general sense of unease and impatience after living so long without the basic conveniences of food in the refrigerator or hot showers. I've seen these challenges manifest as an increase in residual stress, and patients who come to the hospital are looking for more than medical treatment. Desperation is closer to the surface, and patience is thinner. My classmates tell me they see a rise in depression and anxiety, and an uptick in crime.
I remember writing home in November that our teams of caretakers are resilient, working hard and moving forward. I believe that our students and attendings are still resilient -- many having worked through the heat and without running water for months -- but as time presses on in this new normal, patients' emotions are subtly but constantly on the grindstone. The blackout I got news of during that dinner in Los Angeles resolved for some in as little as half a day, but it reset the clock on the feelings of comfort that so many were just starting to relax into. We need to maintain an acute awareness of the added pressures to our physician family on the islands, and the students tasked with straddling the urgent needs and the duties their education demands.
You can help the island recover. The AAFP Foundation continues to collect donations to support disaster relief efforts.(www.aafpfoundation.org)
James Eggert is a fourth-year medical student at San Juan Bautista School of Medicine. He is a former member of the Puerto Rico AFP's student and resident committee.