In the dark on health care in Puerto Rico

In Puerto Rico, locals say, the best way to know whether someone died because of Hurricane Maria is to turn up at a morgue or funeral parlor rather than consult official sources.

Six months after Maria hit, the hurricane’s death toll is still a subject of controversy. After seismic investigations by the island’s Center for Investigative Journalism and the New York Times late last year showing that the true death count was probably several times higher than the official toll — more than 1,000 hurricanerelated deaths, compared with the 64 deaths reported at the time — the Puerto Rican government asked a team of experts at George Washington University to review the numbers. But insufficient details were collected about causes of death by the island’s Demographic Registry. And as months go by, it becomes harder to trace the families of the deceased and ask questions about how a death occurred.

These mistakes are symptomatic of a broader trend. Recently, the island’s Institute of Statistics has found itself at the unlikely epicenter of a public outcry, as the cash-strapped local government considers ending the independent agency’s tenure. Now sidelined from participating in Maria’s maligned death count, the institute has historically played a critical role in correcting tendencies by local agencies to underreport health risks.

Last month, I traveled to Puerto Rico to get a handle on what doctors are seeing on the island now, six months after the storm. Doctors there say that poor data collection and underreporting are hiding a health crisis whose true scale eclipses official accounts.

The problems are particularly acute for chronically ill patients. Wendy Matos, a physician who supervises nearly 470 doctors as the executive director of the University of Puerto Rico’s faculty practice plan, said that her clinics are seeing increases in cardiac arrest and intracranial hemorrhage (bleeding inside the skull), more waterborne and infectious disease and swelling numbers of suicides since Maria.

Matos, whose doctors comprise the largest network of specialists and subspecialists on the island, also said her medical clinics have lost track of what has happened to tens of thousands of patients since the hurricane. From Sept. 1 to Dec. 31, doctors at Matos’s clinics saw nearly 25 percent fewer patients than they had the previous year — just under 91,000, down from about 117,000 patients in a comparable period in 2016. Some of these high-risk patients have left the island. Others are struggling to access care, immobile or unable to travel the long distance to San Juan on deteriorating roads. Some have died.

These issues, doctors think, either aren’t fully reflected in data put out by Puerto Rico’s Department of Health, or fail to surface because data on disease and injury isn’t being published at all.

An example: Under federal Centers for Disease Control and Prevention guidelines, Puerto Rico, like other states and territories, must publish weekly reports on influenza outbreaks. In January, officials on the island claimed that influenza cases had not reached epidemic proportions. But doctors told me that diagnoses were artificially low because influenza test kits weren’t readily available after the storm. In February, several deaths were investigated for their possible connection to the influenza virus.

How frequent and severe have other health conditions been after Maria? The answer isn’t fully known because the numbers simply aren’t yet published. That’s typical in Puerto Rico, which periodically publishes annual health data in a lagging fashion, but doctors I spoke with said that after an emergency like Maria, the government should make information more readily available. With parts of the island still without power, though, reporting remains difficult for remote hospitals and health centers.

The testimonial data I collected suggest that Maria did make a dent. Hector Villanueva, a physician and medical director of HealthPro Med, a federally qualified community health center based in Barrio Obrero, one of the poorest neighborhoods in San Juan, said his staff took over maintaining the island’s vaccine inventory for nearly two weeks after Maria hit, receiving and distributing vaccines from satellite centers across the island. His clinics also saw increases in waterborne and infectious disease in the months after the hurricane hit. Higher rates of mental illness linger.

Federally qualified not-for-profit clinics like Villanueva’s are now faring better than other private health-care providers on the island. Puerto Rico’s health infrastructure is glued together by private health clinics and offices; several of these have shuttered since the hurricane. As these clinicians pack up shop, their patients, set adrift, strain the capacity of an overburdened health system.

Even before Maria, rural and isolated areas in Puerto Rico didn’t have enough doctors and nurses. Specialists were in short supply. The hurricane has left more patients without care, or waiting longer for care. The island’s Center for Investigative Journalism found that after the storm, hospitals’ operational capacity had been overstated by the governor.

In some cases, capacity has still not returned to pre-Maria levels. Villanueva, who oversees a satellite health clinic in the area, told me that there still is no functional dialysis center in Vieques, where residents suspect that poor health outcomes are linked to toxic substances deposited by the U.S. Navy in decades past. To get treatment, dialysis patients must undertake a day-long trip three times a week, typically by boat, to the nearby metropolises of Fajardo or Humacao.

To fix these problems, the Federal Emergency Management Agency and the local government should direct federal aid to outreach tools such as telemedicine and to rebuilding the island’s regional health and water infrastructure. Accurate data collection and analysis, too, is key. Underreporting, or nonreporting, of hurricane-related disease and deaths in Puerto Rico means that resources aren’t being directed where they’re needed.

Meanwhile, the picture of the island’s health crisis is still precariously opaque.

Hurricane Maria has left more patients without care, or waiting longer for care.