The Silent Crisis Killing Puerto Ricans Months After Hurricane Maria

Ruiz-Goiriena, Splinter News, April 2, 2018

There’s a
big, early-season storm blowing itself out in the Gulf of Mexico…There are
over 700 known dead so far…That’s nature. Is it God? Most of the dead are the
street poor who have nowhere to go and who don’t hear the warnings until it’s
too late for their feet to take them to safety. Where’s safety for them anyway?
Is it a sin against God to be poor?

Butler, 1993
abandoned car in the town of Naranjito, Puerto Rico

Stephen Yang
change affects everyone, but in the immediate aftermath of “natural” disasters
and extreme weather, the poorest among us suffer the most. In Splinter’s
series, Fault Lines,
we explore the many ways our society’s most vulnerable people get hurt by
climate-related crises—and how they become canaries in coal mines while staring
down our environment’s uncertain future.
For the
first time in three days, Hector Ramon Ortiz left his room. At his parents’
house, no one had spoken to him, let alone seen him; they’d only heard the door
close behind him when he went to the bathroom. But it was Thanksgiving morning.
And for many Puerto Ricans like Ortiz, this adopted mainland holiday kicks off
a marathon of revelry, where families feast on a pork-filled turkey called
pavochón and roving parties known as parrandas happen every week until Three
Kings’ Day.
Ortiz was
known as a jolly man who was constantly helping others. Everyone knew of his
love for live music, that he would sometimes pick up a güiro, a traditional
Caribbean percussion instrument, and join in with local bands at his
restaurant, Tiempo Vuestro Bar and Grill. The eatery was strategically placed
at the busiest intersection in Naranjito, a rural town in the lush highlands of
central Puerto Rico about an hour’s drive from the capital. Between his
restaurant and his charisma, Ortiz was a big name in this small town. Any other
Thanksgiving, Ortiz would have arrived at his business well before opening
hours to start seasoning full pigs and preparing other criollo dishes.
But this
wasn’t like other years. Two months earlier, the strongest hurricane to hit
Puerto Rico in more than 80 years turned whole towns into rivers, unearthed
trees, and wiped the island’s entire electricity grid. As winds roared and
doors were torn off their hinges, people called local radio stations to report
the petrifying sights before cell towers were knocked out completely. In a
matter of hours Hurricane Maria had besieged the already-beleaguered island of
3.4 million people. The Category 4 storm flattened Puerto Rico, leaving $94
billion dollars in damages.
later, without running power or water, Ortiz’s business remained closed. He
struggled to reopen, and failed, every week. “He would tell me so warmly, ‘Next
week we’re going to get back out there,’” said Maria Virginia Montanez, one of
the restaurant’s cooks.
Thanksgiving morning Ortiz drove his pickup truck down. In the short 20-minute
drive from his parents’ home in nearby Corozal, reminders of the devastation
were everywhere. He passed still-damp piles of debris, shuttered schools and
businesses. The main road was still blocked with downed utility poles and
trees. He wove in and out looking for impromptu passageways through the
detritus. Ortiz made a sharp left at the light and parked his truck on the side
of the restaurant building.
Padilla, Tiempo Vuestro’s cleaning lady and occasional caretaker, saw him drive
in from her house across the street. Immediately, she walked over and knocked
on the door but nobody answered. She went back later and tried to open the
door, but it was locked. This time Ortiz came to the window and signed to
Padilla, who is deaf, to go home. At 11am, when Padilla went back for the third
time, she saw Ortiz’s feet dangling mid-air. Ortiz had tied a yellow rope and
used milk crates to prop himself up. Then he let go. He was 51 years old.
Houses in
the hills of Naranjito, Puerto RicoPhoto: Stephen Yang

death sent shockwaves through the working-class town known for its tropical
fruits, poultry, and garment factories. There were no media reports of his
chilling death because towns were still largely cut off due to the hurricane.

“I had
problems sleeping for months,” Padilla signed with her hands, as her sister,
Maria Luisa Padilla, interpreted for her. “It’s just so sad.”
Ortiz is
one of 236 Puerto Ricans who killed themselves in 2017, according to a report released
by the Commission for the Prevention of Suicide.
His death also
belongs to a growing number of suicides on the island that increased by 55
percent in the last four months of 2017 following Hurricane Maria, compared to
the same period in 2016.
Ortiz is
an extreme case of what happens when mental illness goes undiagnosed or
untreated. And he isn’t alone. Underneath the debris, a silent mental health
crisis is burgeoning in Puerto Rico, with a record number of people reporting
anxiety and depression. Others with pre-existing mental health conditions are
finding little solace, as they are unable to keep their routines and have had
difficulty refilling their prescriptions. According to local authorities, the
territory was already struggling with an increasing onset of mental illness
brought on by poverty, soaring unemployment, and family separation amid a
decade-long recession.
Stephen Yang and I arrived five months after the storm hit. Every community we
visited outside the capital of San Juan was without power. At night you could
hear the sound of gasoline-powered generators. Areas were still completely
ravaged, as if a hurricane had passed just days before. But it was more than
just food shortages and wreckage. Many Puerto Ricans experiencing flashbacks
and panic attacks gave a minute-to-minute replay of the horror they now felt
helpless to overcome. It was harrowing glimpse into an island struggling to
rebuild—and its dangerous stigma around mental illness.
When the
water reached her chest and the mattresses were floating inside of her house,
Ivette Estrada believed she would die. She yelled at the top of her lungs to
wake up her 18-year-old daughter, Hennessey Del Valle. As the water continued
to rise inside their shuttered home, they surfed atop a sofa. They called for
help, but at the height of the storm no one could hear them. “God help us,”
pleaded Del Valle while banging on the front door, attempting to open it.
When it
was finally ajar the sights terrified the both of them. The water was
everywhere. Confined to a wheelchair and fearing the worst, Estrada did what
any other mother would do: “I looked at her and said, ‘Save yourself.’”
eventually, the water stopped rising. They spent another three days inside
their home buoyant, wet, and unable to eat. It took that long before
55-year-old Estrada, who suffered both kidney and respiratory failure in 2016,
could alert others she was alive, let alone get help.
Estrada in Punta Santiago, Humacao Puerto RicoPhoto: Stephen Yang
In the
days and months since, Estrada relives the memories daily. “I can’t stop
thinking, I can’t stop crying,” she said. Still without electricity and clean
water, she feels abandoned and questions whether the authorities care about
her. Her health issues even affect her ability to go to the bathroom on her
is also estranged from her other five children—all of whom live close
by—because of her romantic involvement with two violent drug addicts while they
were growing up. (One of them was Del Valle’s biological dad, who died of a
drug overdose.) Born in New York City to parents who also were drug users,
Estrada was raised in Puerto Rico by her grandparents. She says that during one
of the only times she visited her biological father, he raped her. Living in
shambles after the hurricane has triggered all this past trauma.
“I feel
alone,” she said. “I have thought, what’s the point of living?”
Del Valle, 18, lights a candle in the house she shares with her mother,
Estrada.Photo: Stephen Yang


lives in Punta Santiago, a neighborhood in the Humacao province on the
easternmost part of Puerto Rico where the hurricane first made landfall. The
Army Corps of Engineers considers Humacao “ground zero.”
By comparison, it means the poor fisherman village of Punta Santiago is worse
off than the other glitzier areas in Humacao, which draw tourists to places
like the island’s iconic Palmas del Mar resort. The average household income in
Punta Santiago is $13,195 and unemployment rate is almost at 25 percent,
according to the 2010 Census.
Cataran in Punta Santiago, Humacao Puerto RicoPhoto: Stephen Yang
A few
blocks down from Estrada, Hurricane Maria also consumed Alba Cataran’s wooden
house, which sat next to an inlet. The front doorway remained intact, but the
entire back of the house was torn asunder. Although it was condemned, Cataran
is unable to move forward. She rented a room in a neighbor’s house down the
street. She can’t bear the thought of being far away.
“I go
down there every day,” Cataran said. For weeks she refused to pick up any of
her items scattered all over the front yard and on the street. The majority of
her most precious possessions were mementos belonging to her late mother. “I
promised her I would take care of these things. And now Maria has left me so
empty inside.”
Cataran’s belongings at her house, which was destroyed.Photo: Stephen Yang
Americans would recognize Estrada and Cataran as suffering from depression.
They were diagnosed at the time of their respective suicide attempts years ago.
People don’t openly discuss depression on the island. It was such a low
priority that when the University of Puerto Rico and Puerto Rico’s
Administration for Mental Health and Anti-Addiction Services commissioned a
report, it hadn’t been studied by health officials in more than 30 years. That report found
that one out of every 10 Puerto Ricans suffers from depression and anxiety disorders.
The study also found that services are not available to people still considered
mainland Americans are far more open about depression. Although the stigma is
far from gone, attitudes toward depression and PTSD have changed
dramatically over the course of the last two decades, especially among veteran
advocates—so much so that President Trump faced significant resistance from
Congress when he proposed $700 million in budget cuts to mental health services
last year. Under the approved budget,
his administration slated $10 billion in government funding for substance abuse
and mental health. There’s also $8.6 billion earmarked for mental health
services at Veteran Affairs.
Estrada and Cataran could speak stoically about the horrors they faced in the
storm and its after-effects, when the conversation turned to their suicide
attempts, they became emotional. “I feel such shame about it,” Cataran said in
tears. “Because when it happened, I didn’t stop to think that my daughter needed
Estrada, 55, at her home in Punta SantiagoPhoto: Stephen Yang

If it’s
bad for these women, it can be even worse for men. Because of pervasive macho
expectations, mental health issues can go untreated for years. Of the people
killed by suicides in Puerto Rico in 2017, roughly 86 percent were men. The
reticence of men to discuss depression was reflected in Ortiz’s family: His
sister Nilma said she never imagined something so horrible would happen, but
“there had to be something wrong.” His nephew Luis, on the other hand, skirted
the issue, blaming suicides in Puerto Rico on financial pressures small
businessmen were facing. “Those businessmen that owe a lot of money get
depressed and they think this is the easiest way out,” he told us. He never
referred to his uncle directly: “I’d rather not know anything about it.”
is on disability because of her Crohn’s disease. As such, her healthcare is
fully covered by the U.S. Social Security Administration, which gives her the
ability to see a psychiatrist and psychologist regularly. People with
disabilities also receive Medicare. In Puerto Rico, the process of qualifying
can often take two years, compared to 90 to 180 days on the mainland. After
Hurricane Maria, Cataran increased her visits after recognizing that her
symptoms were worsening. She had also taken pre-emptive measures by refilling
multiple prescriptions.
In a
catastrophe, access is everything.
is on prescribed anti-depressants but does not see a therapist. She is covered
by Puerto Rico’s government-run program, which provides services to
impoverished citizens by means of contracting private health insurance
companies. It’s commonly referred to as “La Reforma.” And although mental
health services are available to Estrada, healthcare professionals on the
island we spoke to mentioned the exodus of medical personnel and prolonged wait
times compromising the level of care. Her best-case scenario is seeing a
therapist once a quarter.
with the largest bankruptcy in U.S. history, Puerto Rico has $120 billion in
bond and pension debt. As a result, the government had already
implemented austerity measures
and appointed a Congressional
financial oversight board with a goal to curb spending on healthcare. One of
the commission’s letters last year to Puerto Rico Gov. Ricardo Rosello proposed
eliminating public housing and nutritional assistance, both of which Estrada
benefits from.
this backdrop, mental health had already been falling by the wayside.
And the
invisibility of these conditions makes them harder to treat. But austerity
measures and a brutal hurricane demolished whatever safety net was left.
Hurricane Maria laid bare structurally racist and anti-poverty policies. And in
a catastrophe, access is everything.
In the
days following the storm, images of people begging for water flooded social
media. Many were horrified to learn that although Puerto Ricans are U.S.
citizens, archaic laws restricting shipping between two U.S. ports foiled
relief efforts. That’s because Puerto Ricans are second-class citizens. A
series of U.S. Supreme Court opinions known as the Insular Cases
argued in 1901 that Puerto Rico and other territories ceded by the Spanish were
“alien races” that couldn’t understand “Anglo-Saxon principles.” The
Constitution not only did not apply to them, but it blocked any real path to
statehood. It was the same Supreme Court that allowed for “separate but equal”
segregation that would later be overturned by Brown v. Board of Education.
that is, for every
state except the Insular Cases
legacy carries over to policy and the island’s deteriorating health care
system. Part of Puerto Rico’s financial crisis stems precisely from a vast
disparity in federal funding. Puerto Rico can receive funds for Medicaid up to
55 percent. Once it hits this ceiling, the territory must come up with its own
funds. This is a problem for a territory that is twice as poor as Mississippi,
the poorest state in the U.S. This means Puerto Rico relies more heavily on
public programs. Under the Affordable Care Act, Puerto Rico does not have a
state marketplace; instead they were given additional Medicaid dollars, but at
a different reimbursement formula than other states.
cite the disparity in medical funding as responsible for $25 billion of Puerto
Rico’s debt. “Even pre-hurricane, the 55 percent match rate was a major issue,”
explained the Kaiser Family Foundation’s associate director Robin Rudonowitz.
As a result, the government was forced to borrow money over time to keep
Medicaid afloat.
A fallen
tree rests on a house in Punta Santiago.Photo: Stephen Yang


And when
austerity measures hit, they deeply overwhelmed the system. First they set off
an exodus of about 12 percent of medical personnel. The impact was dire. A U.S.
Department of Health study
prior to the hurricane reported that a
patient could wait up to nine months to see certain specialists. This includes
access to mental health professionals.
situation is just impossible,” said Miriam Delgado, a clinical psychologist who
provides services in Humacao through the area’s largest non-profit Programa de Educación Comunal de
Entrega y Servicio
, known by its acronym P.E.C.E.S. “Not only have
the numbers of patients tripled, but the government wants to pay therapists $14
a visit,” she said.
And if
history is any indicator, the numbers seeking treatment for mental health will
keep increasing. PTSD, depression, and anxiety roughly doubled in the months
after Hurricane Katrina hit the Gulf Coast in 2005, a federally
funded study
published by the World Health Organization found.
Hurricane Katrina became a landmark example of how pervasive mental health
issues become after a major natural disaster. Carissa Caban-Aleman, a
psychiatrist that works with various organizations in Puerto Rico and is a
member of the Climate Psychiatry Alliance, says that what became clear since
Katrina is that mental illness and substance abuse are not secondary
problems—they are the long-term effects of climate change-induced disasters.
access for those who need it could get worse for Puerto Rico, whose Medicare
program is on track to be depleted by April. Although Congress approved a deal
for both Puerto Rico and the U.S. Virgin Islands, which earmarked $4.8 billion
to replenish Medicare, the funding falls tens of billions of dollars short of
what Puerto Rico needs to take care of those ailing with an increasingly
elderly population. “In terms of mental health, there is always the potential
for environmentally-produced stressors,” said Angel Munoz, psychology professor
at the Pontifical Catholic University of Puerto Rico. “But when people face
complications including access to basic services—like those we’re seeing as a
result of Hurricane Maria—these numbers soar.”
We drove
around the Puerto Rican highlands of Naranjito looking for answers as to why
Hector Ramon Ortiz would have ended his life. According to the research,
suicide affects middle-aged men disproportionately. More than 5,000 people with
suicidal thoughts had called the Linea PAS, the only suicide helpline on the
island, from September to January. As far as we know, Ortiz had never asked for
We went
to places he’d regularly visit. Townspeople recalled what a caring man he was.
They said he “would take the shirt off his back if he knew you needed it.” When
we got to Vuestro Tiempo Bar and Grill, it was a far cry from the landmark
locale it had once been. Construction workers had torn down the old
infrastructure and were renovating: taking down panels, fixing the roof.
We found
Hector’s father, Angel Luis Ortiz, at a bar he once owned. His grandson runs it
now. Passing the slot machines amid the smell of homemade guava liquor, he sat
on the back porch overlooking a ravine. “My chest still locks up. It’s a
terrible thing, a terrible thing,” Angel Luis Ortiz repeated over and over. He
said he had no idea why his son would have committed suicide.
Luis Ortiz, 84, retired business owner, at his family’s bar in NaranjitoPhoto:
Stephen Yang

In town,
however, there were rumors that Hector’s financial situation had taken a turn
for the worse. He had moved back home with his parents and had cut back hours
for restaurant employees last August, even before the hurricane. Maria was the
last straw.

it filled those close to him with regret. “I would have asked him to come with
me,” said his sister Nilma Ortiz, who said she had seen him that morning before
going to serve meals with a church group.
Her sense
of regret and fear was not lost on me. My own father, who I suspect has
wrestled with mental health issues for much of his life, also attempted suicide
in the months following Hurricane Andrew in 1992. Most people in my
neighborhood lost their homes. Ours was the only one standing for miles. I still
remember the tent city in Homestead, Florida where my family would go eat hot
meals served by the Army while I played with displaced children my age.
morning after the hurricane flattened Miami, I saw my immigrant father cry for
the first time in my life. I was more concerned, however, with the fact that my
mom had canceled my Barbie-themed birthday party the night before. (I was six.)
So he went to fetch bottled water all over Miami. Hours later he arrived with
water, provisions, and a birthday cake. In the darkness, all you could see were
those six candles. “The most important thing is to be together,” I remember him
saying. It’s one of the most beautiful moments of my childhood.
But as
was often the case with my dad, the intensity that makes him vibrant also came
with a vengeance in bad times. Months later, he was often dazed. It had taken
more than two months to get power and we had no phone line. In the months
before, my dad was already facing significant financial and personal issues,
including that mother wanted a divorce. It was all a downward spiral after the
morning he had a fight with my mom. It lasted hours. My dad turned violent.
Later, I went to look for my dad in his room and all over the yard but couldn’t
find him. I went into the garage and that’s where I saw him. He had tied a
yellow rope around the garage door’s electric motor. The rope was around his
neck and he was standing on a chair. I screamed “Mamá!” at the top of my lungs.
I remember her yelling that he was the most selfish person in the world. The
next day we sat on the porch, and he asked me to forgive him. I said no.
We never
spoke about it again.
On the
evening returning from Naranjito to San Juan, Stephen and I heard on the radio
that there had
been another two suicides
. This time, it was a 14-year-old teenager
in Carolina and Alexander M. Ramos, a 28-year-old from Juncos. We attempted to
contact the Ramos family, but they decided to hold funeral services in a
different town for privacy.
There was
a lingering sadness and worry that many would not be able to overcome the
trauma Hurricane Maria uncovered. There were clear cries for help. It was
evident people needed support with more than rebuilding electricity posts. And
with a new hurricane season upon them, the worse might be far from over.
This past
weekend I got a text message from a community leader in Naranjito that
introduced us to people who knew Ortiz. She sent me a link to a suicide
of an 11-year-old reported in the news on April 1. Two weeks earlier, tragedy
had hit close to home: Her friend’s son had taken his life at 24 years old. He
lived in her same neighborhood we had driven through together.
sigue,” she wrote. “It just keeps happening.”