Her memories came rushing back: José Daniel, her partner of 10 years, getting sicker by the hour during Hurricane Maria, both of them trapped in their second-story apartment as the street flooded. José Daniel being rushed to a hospital the day after the storm, both slowly realising the devastation everywhere was worse than they thought. José Daniel in a filthy hospital room for over 45 days, with barely any power or even enough doctors to treat him. José Daniel dead at 46, the cause of his illness still unknown to this day.
Alone at home, Agneris had a major panic attack.
“As soon as the power went out, it was like going back to the days where he was in the hospital and I came back home to pick up clean clothes or rest,” the 34-year-old told Refinery29. “It was a trigger and I couldn’t stop it, even as I tried.”
Anyone who lives in Puerto Rico can tell you that life is divided in two chapters — before and after Maria. The Category 5 storm ravaged the US territory on September 20 and the aftermath was worse than anyone imagined: months during which hundreds of thousands were without water or electricity, food shortages, a lack of medical resources, and an unofficial death toll of more than 1,000 people. Since then, an unknown number of Puerto Ricans were forced to leave the island in search of a better life, with the government estimating that about 200,000 more people — or about 5% of population — will move stateside by the end of 2018. Six months after the hurricane, about 250,000 people are still without access to electricity. And there are other ways in which life has been interrupted: Many have lost their jobs, children have missed weeks of classes, and entire families have been separated, many indefinitely.
But while the chaotic aftermath of the storm and the efforts to rebuild the island have been front-and-centre, there’s another crisis brewing in Puerto Rico, though less visible. The Puerto Rico Department of Health found that in 2017 there was a 29% increase in the number of cases of people dying by suicide, and that calls to the government suicide hotline tripled in the last three months of the year. Officials said that Maria is likely to be one of the factors for both increases. Some Puerto Ricans confirm it anecdotally, too.
“Everyone I know has sought out help. My doctor even told me she has more patients now seeking treatment than ever before,” Agneris said. “It’s been so hard. We’ve all seen even the suicide rate skyrocketing.”
Refinery29 spoke with three Puerto Rican women about the mental health difficulties they’ve faced in the days after Hurricane Maria. Their experiences, while deeply personal, also paint a scene of what type of struggles boricuas have encountered since the storm and how they’re dealing with them in a place where there’s still great stigma attached to mental illness.
“The smallest things hurt”
In early September, Ana* expected Hurricane Irma to leave Puerto Rico in very bad shape. The San Juan resident imagined the storm would have an impact similar to Hurricane Georges in 1998, when her family was without water for three months. But the Category 5 phenomenon changed its course at the last second, and only a handful of areas in the island were affected.
Two weeks later, Maria was supposed to come around. And even though the government and the media warned the hurricane could devastate the island, the 25-year-old was skeptical.
“Part of me was hopeful that it would be an overblown, dramatic situation — like always. But part of me was like, ‘Oh, shit. This might get bad,’” she told Refinery29. “Nothing really prepared me for it, though.”
“First, I spent weeks trying to reach my family. And then, I was without power for months. So the struggle was trying to find food elsewhere — finding all my meals, because I couldn’t cook or refrigerate anything. I was also unable to go to work for a long time, therefore I was not getting paid so I didn’t have a lot of money,” she said. “I also ran out of my meds and I was not able to contact my therapist. I ended up spiralling.”
She recalls being at home all day, every day for what felt like weeks on end. In the evening, she would light candles in her dark apartment and spend all night awake, overthinking about her dire situation. And going outside during the day was just as traumatising, since so many of her surroundings were destroyed.
“I felt like someone drained my will to live. The smallest things hurt,” she said. “Imagine not having food. Or trying to drink out of a bottle of water, and the water feels like it’s almost boiling because it was so hot outside and you didn’t have a fridge or ice. Everything weighed on me.”
Ana’s experience with mental health difficulties after a natural disaster is consistent with the research of Dr. Rebecca Schwartz, an associate investigator at the Feinstein Institute for Medical Research**.
After Hurricane Sandy hit the New York area in 2012, Schwartz studied the mental health impact of the storm among adults living in hard-hit parts of Queens, Staten Island, and Long Island. Participants filled a 30-item survey in which they answered how the hurricane had affected them — questions included whether they'd experienced displacement, damage to their property, loved ones who went missing, flooding, fear for their lives, and more.
“Increased exposure to the hurricane — the more negative effects, the more negative impacts the hurricane had on you — the more likely you were likely to experience symptoms of anxiety, depression, generalised stress, and most importantly, post-traumatic stress disorder,” she told Refinery29.
Her research also found that people who have experienced mental health difficulties in the past, like Ana, and those of a low socioeconomic status were among the most vulnerable when it came to experiencing symptoms post-hurricane.
Ana left Puerto Rico in early January and moved to North Carolina, where she’s been slowly trying to start a new life. She said that despite the uncertainty, she is doing better now.
“The change in scenery — going from a place where I struggled every single day without power to a place where I have access to basic necessities — has made me feel better,” she said. “I feel more under control.”
When she left, almost five months after the hurricane, she still didn’t have power in her apartment.
“He might have been alive if not for Maria”
The lack of electricity is something that comes up often in conversations with people who survived Hurricane Maria. For women like Ana, not having power was directly linked with the disruption of normalcy and her descent into a deep depression. For Agneris, the collapse of Puerto Rico’s electrical grid is one of the causes of her partner’s death.
A few days before Maria struck, Agneris’ partner José Daniel Sánchez Rivera had an ongoing fever that wouldn’t subside, even after being prescribed medication. Since he didn’t have any other symptoms, his doctor let him go home. But the day of the hurricane, his fever spiked and he turned yellow — a sign of jaundice, which meant he was having an issue with his liver.
“Knowing there’s someone sick in your home, and being unable to go out and seek medical help for more than 24 hours, was a nightmare,” she said.
The day after the hurricane José Daniel still showed the same symptoms, so the couple got out of the house and went to a nearby hospital — which was partially destroyed. Unable to find phone service to contact the rest of their family, they were unaware of the magnitude of the devastation and made their way to another hospital in the area. After more of 12 hours waiting, José Daniel was admitted because his liver and spleen were inflamed. He would never go home again.
Agneris did her best to deal with the external circumstances while José Daniel was in the hospital. She said that she had bouts of depression and anxiety before, but her condition was under control with the help of her therapist. And she needed to do her best to stop herself from unraveling, even if she felt like it, just for the sake of her partner.
She said that Jose Daniel’s 45-plus days in the hospital mirrored the health crisis that developed in the island after the hurricane. The first hospital they went to only had a generator partially powering the entire building. There was no air conditioning, or even ice, to try to manage José Daniel’s fever, and things like doing blood work, a CT Scan, or MRI were out of the question. The doctors told Agneris that since his condition was not critical, he was not a priority for a transfer to a better-equipped place. After a week or so, they left and went to a different hospital in the area — one of the few with power in the entire island.
That didn’t mean things got better for José Daniel, however. The power was not stable, so sometimes there would be a blackout that interrupted the medical screenings and doctors would have to repeat the procedure, while warning them the results might not be entirely accurate. It was also hard to do blood transfers, the building was not always entirely sanitary, and even the food was at times lacking. Primary doctors and specialists were also hard to come by. According to Agneris, there was only one gastroenterologist treating all the patients in the hospital.
On Nov. 8, a month-and-a-half after Maria, José Daniel died after suffering from liver failure following a biopsy. Despite the countless studies and procedures, doctors were never able to figure out what was wrong with him. Agneris is convinced the conditions after the hurricane contributed to his death.
“Those first days in that first hospital — the ones we spent without power, without doctors, without being able to do procedures — were crucial,” she said. “He might have been alive if not for Maria.”
José Daniel’s death and living through the hurricane destabilised Agneris. Her anxiety and depression, until then controlled, returned in full force. She was hospitalised for five days in order for her to manage her loss. Panic attacks like the one she suffered in early February are still common in her everyday life. She said she’s functional now, but she still struggles four months after losing José Daniel.
“I have good days and bad days,” she said, her voice breaking. “But I know that as long as I recognise that I have a mental illness, and I seek help to work through that, I’m gonna have a better quality of life — even under these horrible circumstances.”
“We had the unrealistic expectation that life would normalise in the island”
Death is not the only type of loss that many Puerto Ricans have experienced in the aftermath of Hurricane Maria. For Isabel*, leaving the island 10 days after the storm is the type of loss that triggered her mental health difficulties.
The 31-year-old mother of two has never struggled with long-term mental illness. She said she suffered postpartum depression after her first pregnancy but it never got to a point where it was unmanageable. Experiencing the storm, however, changed everything.
“The day after the hurricane, my family and I went to a local shelter to help out,” she told Refinery29. “In Toa Baja, where I am from, most of the town was practically underwater. We basically spent those 10 days there before leaving the island, so I left without even seeing the conditions of my house or packing up our stuff. I had no closure.”
According to Dr. Schwartz, the researcher, people who were displaced during a natural disaster are more likely to face post-traumatic stress disorder and other symptoms.
“More specifically, people who were displaced to a temporary shelter as opposed of having friends and family to stay with,” she said. “That’s another thing to think about as it applies to Puerto Rico.”
Isabel’s family was able to relocate to Florida, but the sudden change of scenery sent her into a depression. She wasn’t able to adapt to the Sunshine State and the family packed up their bags a second time, this time heading to Arizona. That’s when the anxiety attacks began.
“There’s no way to win. Those who stayed are suffering because of the situation back home. But those who left are suffering because of the circumstances under which they were forced to flee,” she said.
While her husband and two young children have been quicker to adapt to life in Arizona since they moved there in December, Isabel still struggles with the fact that this is her life now. The worst thing, she said, is the idea of not being able to go back to Puerto Rico.
“I left thinking that we would be able to return. But there’s no power, there’s no jobs, so the exodus keeps extending,” she said. “Accepting that I will never go back is one of the reasons that I’m facing issues with my mental health. We had the unrealistic expectation that life would normalise in the island, but that’s not the case.”
Isabel is undergoing treatment now, which she said is starting to help her manage her condition. But that’s only possible because with a full-time job and being the acquaintance of her doctor, she can afford it. That’s not the case for Ana, who just started a part-time job that naturally doesn’t offer health insurance. Before going to North Carolina, she illegally bought a supply of meds to last her until she’s able to pay for a doctor and treatment again.
“The only thing I didn’t get was antidepressants, because I was afraid to start on them again without a doctor’s supervision,” she said.
Struggling to get the adequate care could potentially be the situation for the thousands of Puerto Ricans that have escaped the island in the last six months without a plan in place and who have struggled to obtain healthcare since relocating stateside. It might also be the case for everyone who was left behind, particularly when considering the stigma surrounding mental illness in the island.
“We’re a far way from normalising the conversation around mental illness,” Agneris said, “even under these circumstances.”
Isabel, Ana, and Agneris are just three of the unknown number of people who have faced mental health difficulties since Hurricane Maria. And if the focus on the six-month mark of the storm and afterwards is only on issues of infrastructure, the economy, and politics it will be a disservice to every Puerto Rican struggling to keep going.
“No one outside of Puerto Rico has any idea of how deeply the hurricane affected the mental health of people in the island. They think of the macro: The electrical grid was fucked, there’s no trees, and so on,” Ana said. “But when you’re used to so many little things — a fridge, bathing with warm water, having service on your phone — losing them will take a toll on you. No one outside of the island gets that if you’re without your basic needs for months, it’s likely you will go down a dark path. And that’s without even looking at everything else that’s wrong.”
* Names have been changed to protect their identities.
** Dr. Rebecca Schwartz is also an associate professor at the Department of Occupational Medicine, Epidemiology and Prevention in Northwell Health and the co-director of the Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook, and Northwell.
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