Opinion: The staggering toll of this constant state of emergency

Editor’s note: Brenda Rivera-García, DVM, MPH is Senior Director of Latin America and Caribbean Programs for Americares, former Visiting Scholar for the Dengue Branch of the United States Centers for Disease Control and Prevention, and Territorial Epidemiologist for the Department of Puerto Rico health. The opinions expressed in this commentary are his own. See more opinion pieces on CNN.


Around the world, mental health is having a moment, thanks in large part to the Covid-19 pandemic. Never before have we focused so much on emotional well-being. Months of isolation, fear and distance learning have changed the way we define our health.

But here in Puerto Rico, we had already been through so much before the virus even reached our shores.

The constant state of emergency that characterizes life in Puerto Rico has taken enormous toll. Almost 10% suffered from major depressive disorder before 2017’s Hurricane Maria made landfall – slightly more than the US average – according to data analyzed by researchers from the University of Puerto Rico, Harvard Medical School and the New York University. And in the months following the storm, mental health issues escalated dramatically, with calls from people with suicidal ideation or decompensated mental health issues to the Puerto Rico Mental Health Hotline having tripled – 3,050 calls from November 2017 to January 2018 compared to 882 over the same period the previous year.

Maria hit Puerto Rico on September 20, 2017. It was the biggest shock our island had suffered in a generation. Millions have been left in the dark, some for months. Thousands of people died, especially in the aftermath, due to lack of communication, running water and electricity. Never before have we seen ourselves so vulnerable and helpless. We are resilient people, yes. But the storm really tested our mettle and showed us that we needed to review preparedness plans at all levels. These circumstances and ongoing recovery work appear to have undermined the optimism that characterizes the Puerto Rican community.

Almost five years to the day since Maria hit our island on September 18 of this year, Hurricane Fiona delivered another knockout blow. With Maria, we thought we were living through a hundred-year flood. But, after only half a decade later, it seems another century of water has enveloped us: Maria has given up more than three dozen centimeters of rain in parts of the island for two days and last week Hurricane Fiona drowned us with 31 inches within 72 hours. A week after the storm, almost 20% of the island was still without drinking water, and almost 60% still without electricity, according to Puerto Rico government data. Once again our air is filled with a familiar lullaby – the hum of generators.

More and more, I hear family members, friends, neighbors and people on the street say, “I’m tired. It’s one crisis after another. I can’t take it anymore.” With multiple generations often living together, family members have always been each other’s rock. But what happens when that rock is broken?

What happens to people with mobility issues or conditions that weaken the immune system, who need access to water? For them, access to water is a vital necessity to avoid infections and maintain good hydration. Or those who need electricity to power medical devices that allow people with respiratory illnesses to breathe or to refrigerate life-saving drugs such as insulin?

I can certainly understand and empathize. I was born and raised here and, after spending some time in the United States, returned almost 30 years ago. In the months following Hurricane Maria, I led relief efforts for Americares and saw the physical destruction, loss of life, and emotional toll firsthand.

By the time we heard about Covid-19, we were over two years into the hurricane’s recovery, still struggling with frequent power outages and daily intermittent blackouts. A series of earthquakes in late December 2019 and January 2020 – over 300 including 10 of magnitude 5.0 or greater, according to the US Geological Survey – had just shaken the southern part of the island, and families were sleeping in tents outside for fear of being trapped between the walls of their homes.

It’s no wonder the need for mental health support continues unabated, especially for our first responders and caregivers. Health workers, firefighters, police officers and teachers have been on the frontlines of this new state of steady recovery, while themselves being survivors of multiple disasters.

Thanks to Americares, we have set up programs to help caregivers learn coping skills so they can take care of themselves and continue to help others. We bring psychological first aid knowledge and tools to first responders across the island. More recently, we launched a pilot program to train teachers and other members of the school community to better support their students in dealing with the psychological impact of disasters and to link these schools to local community health centres.

This allows people in school settings to provide that initial assistance, but also connects them to the next level of care, creating a pathway for those affected to receive the services they critically need. We started by training 154 school employees – teachers, counselors, social workers, psychologists and more – in our first session this summer, and we plan to continue the sessions throughout the school year. We are receiving requests from schools, community health centers and other health organizations across the island to implement the new program in their communities.

Our children are particularly at risk. In reality, more than 7% of children on the island meet clinical standards for post-traumatic stress disorder (PTSD), according to a study from the Medical University of South Carolina published in the Journal of the American Medical Association.

Researchers found that 45% of public school students surveyed in the months following the storm reported damage to their homes, nearly a third experienced a shortage of food or water, and nearly 30% believed that their lives were in danger.

While the mental health programs provided by relief organizations like Americares are essential to Puerto Rico’s recovery efforts, more can be done at all levels – from government to local schools and health centers. This includes:

  • Provide more support to Community Health Centers, which play an important role in supporting local communities in the aftermath of emergencies. They need accessible tools and training to strengthen their disaster response plans by considering the particular vulnerabilities of their patients through the lens of climate change-induced disasters and adverse health effects.
  • End the stigma surrounding mental health care. We need to change our thinking to integrate mental health training, developmental and social needs and support as an integral part of primary health services.
  • Integrate trauma-informed care concepts into the training of primary health care providers and first responders, not only in Puerto Rico but in many parts of the world. We must also strive to make psychosocial support and mental health key elements of preparedness and response plans.

Puerto Ricans – and anyone at risk from climate-related disasters, that is, most of society at large – can never again be as unprepared as we were when Hurricane Maria struck. struck. As our changing climate contributes to storms, droughts, heat waves, rising sea levels and outbreaks of mosquito-borne diseases and other even bigger and stronger conditions, we need to rethink our emergency preparedness plans and have a more holistic understanding of health.

An emergency preparedness plan should mean more than filing cabinets full of plans that few know exist and even fewer are prepared to implement. And at the heart of all these plans is the need for psychosocial preparedness and mental health.

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