Since Hurricane Maria struck Puerto Rico a week ago, Isabello Aponte’s life has been confined to the four concrete walls of his modest home. The storm tore holes in the roof, but there was little inside for it to damage.

Aponte, 70, suffered a stroke five weeks before the hurricane, and uses a wheelchair to get around. On Tuesday, he had no food or drinking water and only enough medicine for another seven days.

His primary company was a pack of barking dogs – the smallest of which is tinier than a shoe.



Life in Puerto Rico has been stripped bare: in much of the island all that remains standing are concrete structures and trees flayed to the bark. Streets are quiet but for the omnipresent throb of generators. Few people can work, contact their loved ones or even find clean water.

Aponte lives in the Loíza municipality, which was still reeling from Hurricane Irma when Maria unleashed a 12-hour barrage of wind and rain. “Irma caught me already sick and now Maria has caught me and I’m sicker,” he said.



After the storm, some nuns visited Aponte, and later brought a doctor and nurse. Once in a while, his cousin also comes by with food and drinkable water – but in his neighborhood, just 40km outside the capital San Juan, there has been no sign of government aid.

Hours before community health workers reached Aponte on Tuesday, Donald Trump repeatedly praised his administration’s relief efforts. “Everybody has said it’s amazing the job we’ve done in Puerto Rico,” he said. “We’re very proud of it and I’m going there on Tuesday.”

But it is difficult to find justifications for this positive assessment on the island where millions of Americans are trapped in a disaster zone.

Neighbors sit on a couch outside their destroyed homes as sun sets in the aftermath of Hurricane Maria, in Yabucoa, Puerto Rico Tuesday. Photograph: Gerald Herbert/AP

The island’s few functioning hospitals are at capacity and face frequent power outages. The emergency telephone number does not work.

Debris and household waste form human-size piles outside homes. Downed power lines rest in fetid floodwaters that stink of sewage. About 44% of residents don’t have clean drinking water. Lines outside gas stations stretch for a mile and more.

The federal government has sent millions of meals and liters of water and dispatched thousands of emergency responders and technicians. Aid is pouring in from celebrities and Puerto Rico’s diaspora community on the mainland.

But Puerto Rico’s health infrastructure was already in crisis before the most powerful hurricane to hit Puerto Rico in nearly a century, and in many cases the immediate response has been left to local people.



If you don’t take this crisis seriously this is going to be your Katrina. Nydia Velázquez to Donald Trump

“This has been building up, we’ve had health issues for years,” said Lourdes Inoa Monegro, a community health activist. “This is the outburst.”



Monegro works for Taller Salud, a community health center in Loíza which normally focuses on providing reproductive healthcare and support to victims of domestic violence.

On Tuesday, however, Monegro and other activists were going house to house in the baking heat, in an attempt to gauge the community’s most pressing needs.

A woman called them over, and ushered them into the patio – the only cool spot in her home. She asked the activists if they could get a doctor to the home, where a sick, bed-ridden woman was inside. Monegro noted down her name and address, but later admitted that it was impossible to know when medical help would arrive.

An hour later, she and L’Orangelis Thomas Negrín had filled pages with a laundry list of basic human necessities: food, water, medicine.

“These people already needed a lot,” said Negrín.

Bernadina Ortiz, aged 89, is released from the hospital in San Juan after a three-day stay. Her family member says: ‘Tell Trump we need more money to help with repairs.’ Photograph: Carolyn Cole/Getty Images

Before the hurricanes hit, Puerto Rico had a health systen which the Urban Institute described as “financially unstable”.

The territory went from having a public, regionalized health system in the 1960s to a privatized, for-profit one similar to the mainland US. A key difference between the two systems is that commercial healthcare is much less popular and consumers largely use Medicaid and Medicare – government insurance programs that help cover low-income and older Americans.



To pay for these services, the territory routinely borrowed money by issuing municipal bonds – as it did in other branches of government. As the island’s debt ballooned, the government kept issuing bonds.

Now, the island faces a $73bn debt and a humanitarian crisis.

Damage caused by the storm is likely to make a difficult situation worse Stephen Zuckerman

Earlier this week, Donald Trump switched his attention briefly from his spat with black NFL players, and tweeted that the debt “sadly, must be dealt with”.

On Tuesday Nydia Velázquez, a Democratic representative from New York, said she was concerned that Trump’s continued focus on a row over protesting sportsmen reflected a misunderstanding of the severity of the crisis.

Referring to criticism of George W Bush following the hurricane that devastated New Orleans in 2005, she warned the president: “If you don’t take this crisis seriously this is going to be your Katrina.”

So far, Maria has been linked to more than 30 deaths across the Caribbean – including at least 15 in Puerto Rico – but Dr Rafael Rodríguez-Mercado, Puerto Rico’s health secretary, has said it’s fair to assume people that the number will rise.



The majority of the island’s 69 hospitals are without electricity or fuel for generators, according to the US Department of Defense.

Hospital employees and nurses gather to pray for a co-worker who was critically injured in a violent attack during the chaos post-Maria. Photograph: Carolyn Cole/LA Times via Getty Images

San Jorge children’s hospital, the largest private children’s medical center in the Caribbean, has run out of diesel to fuel its generator several times in the last week. It was without electricity for more than three hours on Monday and its staff had been at work for more than 72 hours.

On Monday, Jeffrey Martinez and Adelisse Martínez, public relations managers for the hospital, were quick to assure the Guardian everything would be fine. “We can handle it like this for one or two days,” Jeffrey Martinez said.

Less than 24 hours later, the hospital needed diesel again.

Stephen Zuckerman, co-director of the Urban Institute’s Health Policy Center, said that before Maria, access to healthcare was already strained, especially outside of San Juan. “The commonwealth has been under pressure to under-invest in its health infrastructure for some time and damage caused by the storm is likely to make a difficult situation worse,” Zuckerman said in an email.

Even in San Juan’s wealthier neighborhoods, the medical situation is causing anxiety.

The streets of Condado, a tourism center, are lined with mangled trees and crushed glass, but many of its beachfront hotels, restaurants and apartment complexes have returned to relative normality.

The neighborhood hospital, however, is closed, and the only signs of life there are at a chain restaurant just outside its entrance, which attracts a constant crowd of people because it has wifi and power outlets.

Millie Rivera, a Condado resident, said she and her family had a much safer set-up compared with most people on the island but was worried: “What do you do if there’s an emergency?”

Her comment underlines the general uncertainty in Puerto Rico right now.



Unable to work, most people are stuck indoors or crowd under the shady side of buildings – with lawn chairs parked next to mountains of mangled other debris.

Children seem unbothered. Local parks – covered in damaged flora and debris – present new adventures and young cyclists thread back and forth on the streets where – for once – there is little traffic.

A fireman fills containers with water for residents in Toa Baja, Puerto Rico, on Sunday. Photograph: Carlos Garcia Rawlins/Reuters

The neighborhood survey in Loíza, which covered a little over 1,200 meters in two hours, ended with a long list of needs and warning that water-borne illness was on the rise.

Some of the most vulnerable, inlcuding Aponte, were given food and water; others would have to wait. A 1,000lb aid delivery from Los Angeles to Taller Salud was stuck at San Juan’s international airport.

Despite the dire situation, some Loíza residents were reluctant to accept help.

José Ciuro, 94, did not want to ask Taller Salud for anything, but eventually he said: “whatever you can afford, I will take”.

He was especially interested in a potential delivery of broccoli and mixed vegetables.

Ciuro had not spoken to his daughter in Orlando since the storm, so the group also offered to check in with her when they returned to San Juan, where the cellphone reception is better.

So Ciuro, who is half-blind and uses a cane, went inside and brought back a shoe box which held his most important papers. Across the lid were dozens of names and telephone numbers, inked in different colors, overlapping and tilting in every direction.

Eventually he found the number he was looking for.

“What do you want us to tell her?” asked Monegro.

He replied: “I’m still alive.”

This article was amended on 27 September 2017 to correct the amount of Puerto Rico’s estimated debt.