The cancer patient waited 32 straight hours — sleeping in her car, snacking on chips and soda from the vending machine, going to the bathroom off the side of the road — before securing a spot on the ferry that took her across the water and then to her doctor in San Juan.

Velez’s struggle to secure medical treatment reflects one of the many ways residents of Vieques, and Puerto Rico more broadly, have been frustrated with the pace of federal disaster recovery and its implications for their health.

More than 19 months after Hurricane Maria hit in September 2017, the Federal Emergency Management Agency has not decided whether to reconstruct Vieques’s only hospital amid conflicting estimates about how much the federal government is required to rebuild.

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Reconstruction experts say it often takes FEMA months or years to decide how to reconstruct facilities damaged by natural disasters, noting similarly long deliberations slowed efforts to rebuild hospitals and other infrastructure after Hurricane Katrina and Hurricane Sandy. Additionally, there is no evidence the Trump administration’s attempts to restrict the amount of money going to Puerto Rico has slowed the reconstruction of the Vieques hospital.

But the delay has drawn sharp criticism from congressional Democrats and Puerto Rican officials, who say FEMA is taking too long to get critical infrastructure repaired on the island, highlighting Vieques and its hospital as what they call a particularly egregious example.

“FEMA’s excessive bureaucracy and callousness in Vieques borders on the criminal,” said Luis Vega Ramos, a lawmaker in Puerto Rico’s House of Representatives. “Puerto Rico has got the short end of the stick from FEMA. Vieques has got the short end of the short end.”

In a statement, a spokeswoman for FEMA pointed out that the agency set up a temporary hospital for island residents soon after the hurricane hit. Several residents on the island and two academics said in interviews that the temporary facility still lacks the ability to safely perform key medical procedures.

FEMA also set up several “mobile” dialysis treatment centers for island residents. Previously, Vieques residents on dialysis were airlifted sometimes several times a week to the main island, prompting several news articles documenting patients’ frustrations.

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FEMA’s spokeswoman also said the agency has not decided whether the hospital needs to be rebuilt and is still awaiting an evaluation from a separate group of experts.

“Long-term recovery is never easy,” FEMA’s statement said. “With the massive devastation throughout Puerto Rico, getting the right cost estimates, scope of work and individuals to do the projects can always cause delays.”

Rep. Raúl M. Grijalva (D-Ariz.), chair of the House Committee on Natural Resources, said the committee would be probing FEMA’s handling of the hospital.

“They are walking away from their responsibility to build a new hospital,” said Rep. Nydia M. Velázquez (D-N.Y.), who said she has discussed the hospital with FEMA. “It’s a disaster.”

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The uproar over the Vieques hospital serves as a microcosm of the broader political fight over Puerto Rico.

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President Trump has been convinced that too much taxpayer money is flowing to the island, and officials in the Office of Management and Budget have ordered a review of federal dollars to ensure money that is not being wasted, according to senior administration officials who spoke on the condition of anonymity to discuss internal affairs.

The Department of Housing and Urban Development was recently accused by the agency’s watchdog of delaying emails and other records related to HUD’s handling of hurricane relief. (FEMA is under the Department of Homeland Security, a separate federal agency.)

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Hurricane Maria caused thousands of deaths and an estimated $90 billion in damage to Puerto Rico. Vieques, population 9,000, was among the hardest hit. The island, seven miles east off the main island of Puerto Rico, has already suffered from cancer rates close to 30 percent higher than the rest of Puerto Rico, according to the Atlantic. Experts say Vieques’s unusually high cancer rate stems from the U.S. Navy using it as a military testing ground for more than a half-century.

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Residents of Vieques protested three months after the hurricane after the ferries critical for supplies stopped running. Puerto Rico’s governor repeatedly called the National Guard in for emergency deliveries of food, gas and medical supplies to Vieques amid recurring shortfalls.

This weekend, Puerto Rico Gov. Ricardo Rosselló called the National Guard to help after ferries responsible for taking cargo from the main island to Vieques were temporarily shut down. The problem was fixed quickly, according to a spokesman for the governor, adding that the government is looking into “longer-term solutions,” such as buying a new ship.

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“It’s the colony within the colony,” said Jorge L. Colón, a professor at the University of Puerto Rico who studies health issues on the island.

The temporary hospital set up by FEMA is not certified for childbirth, and the mobile dialysis suffers from a lack of adequate water filtration, which makes it dangerous to use, said Cruz María Nazario, a professor at the University of Puerto Rico’s Graduate School of Public Health. Its new telemedicine unit has also not been working, she said.

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“The people of Vieques don’t feel comfortable going there. It’s not fulfilling the health needs of the citizens of Vieques,” Nazario said.

Eight dialysis patients also died while waiting for the restoration of treatment on the island, according to the Renal Council, a nonprofit health-care agency in Puerto Rico.

“For over 18 months, thousands of Americans in need have been desperately waiting for medical services in Vieques,” said Anthony Maceira, secretary of public affairs for Rosselló. “We have worked tirelessly to provide FEMA any and all necessary information to rectify this urgent need, only to be met with delay and bureaucracy again and again.”

Part of the frustration from Puerto Rican officials stems from their belief that they had secured a commitment from FEMA more than a year ago to rebuild the hospital. An August 2018 report about the hospital, signed by a FEMA caseworker, says: “On a previous date, FEMA personnel determined that this project qualified for the FEMA 50 percent rule, or a building replacement,” which would require the federal government to tear down the hospital and build a new one.

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“The whole time — the whole time — they told us they were going to destroy the old hospital and build a new one,” said Daisy Cruz, the deputy mayor of Vieques, who was the town’s acting mayor in 2018. “People are asking for a hospital where they can get help. It’s infuriating.”

A later report found the hospital required only repairs, rather than a full reconstruction. FEMA is in the process of finalizing a third assessment about the hospital.

Experts say these kinds of frustrations are not unique to Puerto Rico’s reconstruction. FEMA’s inspector general issued several reports after previous hurricanes and disasters faulting FEMA for being too generous in its damage estimates, which can cause agency officials to be skittish about doling out federal funding too quickly, said W. Craig Fugate, a former FEMA administrator under President Barack Obama.

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“FEMA starts getting antsy about their decisions, and then start to work to prevent an adverse finding by the [inspector general] later,” Fugate said. “Initially, information often gets presented saying the damage was far worse than it was.”

Elizabeth Zimmerman, former associate administrator at the Office of Response and Recovery at FEMA, added: “This can be a very lengthy process. … There are a number of communities trying to recover, but they’re in limbo until they get that final approval to go forward with their projects.”

But as the delays continue, frustrations among Vieques residents are mounting. Norma Torres, 72, recently traveled for the first time to the makeshift emergency room after her husband’s blood pressure rose sharply. Torres was stunned by the lack of equipment in the facility, particularly for pregnant women who may not be able to fly to the island in time.

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Diane Rivera, 61, who takes the ferry for chemotherapy treatments to Puerto Rico very week, lamented the death of her neighbor — Edgardo Felix, 42, a young father. “He was young, like a son to me,” Rivera said. “I think if we had the right facility in Vieques, he may not have had to be transported and may have had survived.”

Velez, the cancer patient who waited 32 hours for the ferry, said her son served in the U.S. military for two years in Afghanistan, and her father spent years working for the U.S. military as well. She taught physical education to kindergarten students before retiring a few years ago, but is despairing from the weekly trips, which exacerbates her scleroderma, a disease that causes pain throughout the body.

“This is killing us,” Velez said. “They are killing our community.”