Carolina Pichardo, a pediatrician working shifts at both the neonatal intensive-care unit at the University Pediatric Hospital in San Juan and at the pediatric emergency room at the HIMA San Pablo Hospital in nearby Caguas, is one of those doctors. Pichardo lives in a complex in San Juan where power is still tenuous, and she’s had to balance a survival routine with the extraordinary demands of her job.

During the night, when the generators run, she and her husband take cold showers; cook their canned food rations on a charcoal grill for dinner; and try to, by turns, avoid the heat and mosquitoes—keeping their door open to let in the breeze as they put their four-year-old daughter to bed, and closing it to hold off the insects. In the mornings, Pichardo sometimes braves standstill traffic in the capital’s newly congested transportation grid; sometimes it takes up to two hours just to get to Caguas, which is only 20 miles away.

At both hospitals, Pichardo has faced new challenges. At first, doctors and nurses dealt with a total collapse of power, which Pichardo said was the “scariest change” immediately after the storm. Hospitals couldn’t communicate with other hospitals; specialists often couldn’t be reached if they were needed; and patients were transferred to trauma centers or other facilities without any knowledge of whether those institutions could handle more patients.

While lines of communication have at least partially been restored, Pichardo said that problems still abound. “At this point, everything has become challenging,” she told me by email. “Many primary-care physicians are unable to provide services at their practice locations, so more and more people are using the emergency rooms for everyday medical problems. This places a larger burden on the emergency rooms and increases wait time among patients. Children have fallen behind on their immunization schedules, because either their pediatricians are not currently practicing or they have lost their refrigerated vaccines due to power outage.”

The collapse of primary-care structures on the island was a common theme of my conversations with medical professionals there. Primary care was already a bottleneck point for the Puerto Rican health-care system before this season’s hurricanes—with a mass exodus of doctors to the mainland and an increasing concentration of children, pregnant women, and elderly people back on the island. But now, with many doctor’s offices and smaller facilities closed, people with chronic health needs often have to go without care or seek it in emergency rooms, which can mean sitting in triage for hours. The shortage exacerbates the burden of both chronic and acute conditions as patients compete for space and resources.

Carmen Zorrilla, a professor of obstetrics and gynecology at the University of Puerto Rico, and one of the island’s expert voices on managing the health-care needs of women with HIV, echoed those concerns. “The whole health-care system for the past 35 days has switched from primary care, prevention, and provision of basic services to emergency and acute care,” Zorrilla told me. Her clinic, one of the only facilities on the island dedicated to women and mothers with HIV, has seen its volume of patients drop and health problems intensify. The clinic serves high-risk pregnant women who have other potential childbirth complications in addition to HIV. They have to follow closely managed health plans in order to survive childbirth and avoid HIV transmission to their infants.