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Luisa Roque went to sleep with a roof over her head for the last time on a Tuesday in September nearly one year ago. The next morning, Hurricane Maria raged outside her home in Vega Baja, Puerto Rico. Luisa and her husband wept and screamed, and drank rum with anise to calm their nerves. Her asthma acted up. At one point, the aluminum roof flew off, wrenched from the frame of her home and landed God knows where among the debris.

Luisa, a 50-year-old jewelry designer, waited nine months for a new roof, making do with tarps and scavenged aluminum. After nine months of applying for FEMA aid, getting denied FEMA aid, getting rejected for full coverage by her insurance company, and finally accepting a partial loan from the Small Business Association, she got it: concrete this time. It was hurricane-proof, if seven months too late. Her mother had died under the makeshift roof in November, her body giving out when there wasn’t electricity to keep her breathing machine plugged in or a solid structure above her head to give her peace of mind.

On the day Luisa’s mother joined the death toll, President Trump was on Twitter calling LaVar Ball an “ungrateful fool” because he refused to thank Trump for getting his son out of Chinese jail after being arrested for shoplifting. When Luisa got her roof, we were locked into other scandals, as immigrant children were forcibly separated from their parents at the border, and Trump praised the leadership qualities of North Korean dictator Kim Jong-un.

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As the Trump administration pinballs between crises of its own making, it has barely acknowledged that an entire island of United States citizens are doing very badly from a disaster it had no hand in creating. We’ve almost hit the one-year anniversary of Hurricane Maria, and some Puerto Ricans find it difficult to access healthcare. Conditions like diabetes, which we consider low-risk, have turned dangerous. Many Puerto Ricans—a lot more than were first officially reported—have died. Almost all are waiting, either for the government to do its job, or for another hurricane to start brewing in the Atlantic.

“That's second-class citizenship to me,” Luisa said. “Although our passports read American citizens, we are a colony.”

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America all but deserted Puerto Rico, leaving its own citizens stranded without basic care. Almost 3,000 people died, most not from hurricane winds or rising flood water, but because they couldn’t stay healthy on a broken island. Trump refuses to acknowledge his administration’s response as anything but a “fantastic job,” an “incredible, unsung success” despite so many dead. He shot off two tweets in the early morning hours Thursday in which he claimed that the official death toll in Puerto Rico was little more than a hit job on his reputation.

“When I left the Island, AFTER the storm had hit, they had anywhere from 6 to 18 deaths. As time went by it did not go up by much. Then, a long time later, they started to report really large numbers, like 3000,” he wrote. “This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico… Bad politics. I love Puerto Rico!”

One week before the one-year anniversary of Hurricane Maria hitting Puerto Rico, and the president of the United States is trying to erase nearly 3,000 lives.

Hurricane Maria made landfall in Puerto Rico on September 20, 2017, as a Category 4 storm. Luisa’s was one of more than 300,000 homes significantly damaged or destroyed. The electrical grid went down, starting the longest blackout in U.S. history. Not long after the storm had passed, the official death toll was announced: 16 people, which anyone in Puerto Rico could tell you was bullshit.

Trump, however, thought 16 deaths was pretty good, considering. In October, he compared those deaths to the 1,833 lives taken by “a real catastrophe,” Hurricane Katrina. “Sixteen people versus in the thousands,” Trump told Puerto Rican governor Ricardo Rosselló during his one and only visit to the island. “You can be very proud of all your people, all of our people working together. Sixteen versus literally thousands of people.”



In December, the official death count rose to 64. Then, in late May, Harvard released a study estimating that at least 4,645 Puerto Ricans could have died as a result of Hurricane Maria. “Interruption of medical care was the primary cause of sustained high mortality rates in the months after the hurricane,” the authors wrote. Finally, in August, a report from George Washington University commissioned by the Puerto Rican government estimated 2,975 people died in the five months following Maria because of Maria, making it one of the deadliest natural disasters in U.S. history.

Trump has patted FEMA on the back for its disaster relief effort, bragging that “there’s no better model anywhere in the world.” But FEMA is “a useless lot” if you ask Aníbal Llende, who is 58 and retired. He was denied FEMA aid to fix water damage in his house in Bayamón, Puerto Rico, and instead told to apply for a loan, which he declined to do. He says FEMA did not give him a specific reason for denying the aid. “It’s like when the IRS audits you; they just audit you. They don’t tell you why,” he said.

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Aníbal still had a roof after the hurricane, and the old man next door had a monster generator the size of a Mini Cooper. The neighbors brought extension cords, and Aníbal hooked up his refrigerator. Then the neighbors brought water bottles and insulin to keep cold.

According to official reports, Puerto Rico saw a 46 percent higher rate of diabetes-related deaths in September and October of 2017 compared to the same time period in the previous two years. Though the rise can’t conclusively be tied to Maria, the evidence connecting them is plain to see.

Six months after Maria, the Kaiser Family Foundation (KFF) published a report on health care in Puerto Rico that found that gaps in medication and care after the storm led to aggravated chronic conditions. Puerto Ricans had difficulty managing diabetes or using oxygen and dialysis machines, partly due to inconsistent power. Without electricity—or a neighbor like Aníbal—people couldn’t store their insulin, which isn't supposed to be used if it sits around in temperatures warmer than 86 degrees Fahrenheit. Without refrigeration, it was also harder to get a healthy diet of fresh food; preserved foods that don't go bad in the heat are usually sodium rich. Without good food, managing diabetes is made much more challenging. Without insulin, it’s nearly impossible.

There’s also been a massive lack of public education. As one Puerto Rican endocrinologist observed in a recent article in the Journal of the American Medical Association, some Puerto Ricans threw out their insulin because they didn’t know it could last for days without refrigeration, as long as they kept it at room temperature.

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People with diabetes are among those Oxfam International, an organization that helps impoverished communities in the wake of disasters, has identified as being vulnerable if a storm blows through Puerto Rico and takes out the electrical grid again. So are people with respiratory problems.

Luisa’s mother had a chronic lung condition, pulmonary fibrosis, that kept her on a respirator. In the months after the storm, Luisa was able to plug the machine into her neighbor’s generator for her mother’s respiratory therapy, but not for a full night of sleep.

“I knew she was deteriorating. I knew it. I saw it. We spoke about it, but I never saw it coming that fast,” Luisa said. “I got so scared. I told myself I was going to be a statistic, because I had no roof. Mold was going to just come and eat me up, and eat my mother up.”

Her mother grew weaker in that house, despite antibiotics and a visit to the doctor. She died there on November 22. The day before she died, she had told Luisa, “Maria vino joderme.” Maria came to fuck me up.

“It's not until it touches you personally—your roof is gone, your mom is gone—that you realize how fragile life is, how poor we can be, how the resources you thought were there and how simple life was just vanishes in front of you,” Luisa told me the day after her new concrete roof went up in June. “And how that at the same time pushes you to keep strong or build more courage to keep on going through your life. You have no other choice.”

Martha Thompson, Oxfam’s program manager for Puerto Rico, says a census should happen to find the homes where people with medical machines live. Should another hurricane come through—NOAA predicts up to four more hurricanes will form in the Atlantic this season, not including Hurricane Florence; and the season’s busiest month of September is well underway—these people will need aid dearly. FEMA does not appear to have this census.

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Meanwhile, thousands of Puerto Ricans are still living under tarps.

“A hurricane's going to rip those right off,” Thompson said. She says even the strongest plastic sheets, those installed by the U.S. Army Corps of Engineers, are only supposed to last a month. People have had them up for several months longer at least, and they’ve weakened under the sun and rain.

Many in Puerto Rico are still waiting for money from FEMA to repair their homes. As of May 1, FEMA said it had received almost 1,119,000 registrations for disaster assistance; it had approved 452,290 and denied 335,748 (many were denied because the applicants did not have proper documentation for their homes), according to NBC. That means only two of every five Puerto Ricans who applied for aid had been approved for it.



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More Puerto Ricans still don’t have a strong electrical grid to reply upon. In April, the entire island was blacked out, again, for a stupid reason: an excavator struck a power line. Power restoration was supposedly completed mid-August, but CNN reported it didn’t cover all of the island.

Aníbal finds fault with Trump and Rosselló’s lack of strong leadership. “It's that level of imbecility so high up the chain,” he said. “They're so aloof, or so spiteful, or so completely useless that they cannot either choose the right people to head the agencies or just don't have the interest to follow through to make it happen.”

One year after Maria, Puerto Rico is being partly held together by dilapidated tarps and a shoddy electrical grid. It’s a Scotch tape island, and people whose health depends on functioning electrical sockets and sound infrastructure will die if another hurricane blows through the Atlantic.

Some in Puerto Rico are done waiting for help. They’re moving, if they’re able.

In a grim twist, the KFF report authors noted that healthcare providers (including specialty providers) moved off the island in higher numbers after the hurricane than before it. Puerto Ricans with chronic conditions were left with fewer places to seek healthcare, and in some cases, less assistance at home.



“Family structures have been disrupted,” said report co-author Robin Rudowitz. “Some may have migrated to the States, and that makes it even more difficult for individuals and those who remain with the chronic conditions to manage those circumstances.”

An updated KFF report coinciding with the one-year anniversary of Hurricane Maria is forthcoming, and co-authors Samantha Artiga and Rudowitz, both associate directors focusing on Medicaid and the uninsured at KFF, say many of the problems with lack of providers persist. “Things have not gotten miraculously better,” Rudowitz said.

It’s difficult to track the Puerto Rican exodus in full, but one estimate says as many as 75,000 permanently moved to Florida in the six months after the hurricane. And there, they’ll have a vote in a contentious swing state, whereas now they have no vote and no consequential representation in Congress.

Back home, serious time and money needs to be poured into the healthcare system so it can keep up with its population. There needs to be a plan for identifying and helping the most at-risk residents should another disaster strike, and a general emphasis on preventative care and education. Diabetes was the third leading cause of death before the hurricane, which the hurricane only exacerbated. Now, there’s an even greater shortage of doctors. Congress voted to help fund Medicaid coverage in the territory, but that money likely won't last through 2019, NPR reports.

“Already there are threats that services are going to be cut off. It has even been thrown around that medication coverage might be drastically decreased or eliminated,” said Dr. Sarah Huertas, a psychiatrist and healthcare activist on the island.

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Lida Orta Anés, a professor at the University of Puerto Rico’s Graduate School of Public Health, added, “There were issues in the island dealing with chronic illnesses that were there before Maria. Maria just lifted up the lid and everything boiled into the surface.”



She works alongside Huertas to try to figure the healthcare mess out. “We felt that if we can develop some sort of an infrastructure that helps the community gather services and have access to information, they could do this and in spite of the local government structure. Politics are terrible in Puerto Rico,” she said.



So they muster their resources, much of it courtesy of supplies and manpower from colleagues at the graduate school, and intervene in communities, setting up dental cleanings, educational seminars, mental health clinics, and more. Their efforts started right after Maria, and they continue today. There’s no way they can address an entire island’s healthcare into the future, though.

Blame can spread far after a crisis, but it starts at the federal level, where elected officials are supposed to keep citizens safe and secure. The Trump administration is the face of the disaster relief effort in Puerto Rico, and it is an ugly face. Trump descended upon the island almost two full weeks after the hurricane and proceeded to joke, in the midst of destruction and human suffering, that Puerto Rico had “thrown the budget out of whack.” Then, he threw some paper towels into a crowd of Puerto Ricans and left the island. At best, he was dismissive of lives and livelihoods lost to the storm and the healthcare crisis that followed. At worst, he was barbaric in his disinterest. His attitude did not improve.

Instead, he waddled from one crisis to the next in the space of a tweet, dragging our national attention with him. Nationally, we cared about Puerto Rico after Maria hit, and again when news broke that almost 3,000 people were dead as a result. But Trump’s attention span is short, and so is ours. While Puerto Ricans lined up pairs of shoes in front of the territory’s capitol building in June, each representing a life lost and uncounted in Puerto Rico, whether from disease or disaster, we debated tariffs, trade wars, and a possible Roseanne reboot (sans Roseanne).

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FEMA’s failure began before the storm and persists to this day. An internal memo from FEMA released in July was rich with damning details: warehouses almost empty of supplies before Maria hit, emergency aid personnel who were never sent to Puerto Rico, and faulty supply chains on the island. And new reports reveal that the Trump administration diverted millions from FEMA and the Coast Guard (among others) and funneled them into ICE’s immigrant prisons along the border, just as the summer hurricane season started.

While we dissect this tweet or that interview, Puerto Ricans are still waiting—waiting for life-saving healthcare, waiting for real roofs, waiting for recognition. FEMA administrator Brock Long wrote in the internal memo that the 2017 hurricane season was “an opportunity to learn.” He said FEMA was bulking up on supplies and local staff. But has it really learned? Or will it take a second hurricane and a few thousand more graves for Puerto Ricans to get first-world treatment?

The afternoon after Trump tweeted his death toll conspiracy theory, Luisa told me: "It's a freak show, and I feel disgusted. I feel disgusted that him and whoever else is just playing around with numbers and playing politics. We are their puppets." She still considers herself in recovery from Maria. Her home has a roof but isn't yet finished, so she can't move in until the end of September at the earliest. Her mom is still dead.

And so the wait continues, whether for help or for bad weather or both.