If you need evidence that the situation in Puerto Rico is still dire, look no further than the reports this week of islanders who have been forced to turn to water mixed with raw sewage for hydration and hygiene.

It’s been almost a month since Hurricane Maria struck Puerto Rico, and municipal water services have still not been restored for about a third of the people on the island. Meanwhile, nearly half of the island’s sewage treatment plants remain out of service, so wastewater isn’t necessarily being purified as it runs through the island’s water system.

In desperation, Puerto Ricans are bathing and washing their clothes in rivers that have raw sewage pouring into them, the Associated Press reported, exposing them to bacteria like Leptospira, which causes leptospirosis. Some Puerto Ricans are even drinking from condemned wells and Superfund hazardous waste sites, which contain potentially dangerous chemicals.

The EPA cites reports of Puerto Ricans “obtaining, or trying to obtain, drinking water from wells at hazardous waste “Superfund” sites” pic.twitter.com/UW4ZW7RBUG — David Begnaud (@DavidBegnaud) October 11, 2017

Let’s be clear: This would not be happening unless people were desperate and had no other options.

Thousands of Federal Emergency Management Agency personnel and 14,000 members of the military are on the ground right now distributing bottled water, food, and other supplies. But many Puerto Ricans’ basic needs — like clean water — are still not being met.

The water crisis is directly related to, and reinforced by, the electricity problem. More than 80 percent of the island’s electricity customers still have no access to power after the electrical grid was wiped out in the storm. As my Vox colleagues Eliza Barclay and Brian Resnick explained, “No electricity means no power to pump water into homes, no water to bathe or flush toilets.” Electricity is needed to clean and distribute water too.

Even islanders who do have access to running water are being warned by the territory’s water utility to boil the water or use chlorine tablets first, since many water treatment plants are out of commission. But of course, with most Puerto Ricans without power in their homes, it’s not so easy to boil water.

As of October 18, the government had restored water services for 69 percent of people on the island — a number that mysteriously declined on Tuesday from 72 percent, according to Food & Water Watch. FEMA has provided 23.6 million liters of water since September 20 — but that’s less than 10 percent of the drinking water needs for the territory, according to a new CNN report, and an even smaller fraction of their consider cooking and hygiene needs. They’ve also passed out water purification tablets and mobile filtration systems. But the efforts aren’t enough, CNN said:

Lines for water — potable or not — are long in many parts of the island. Rumors of contamination are rampant. Even as some taps turn back on, residents worry about drinking from faucets, which sputter and, in some locations, produce hazy liquid.

“This will be the most challenging environmental response after a hurricane that our country has ever seen,” Judith Enck, an Environmental Protection Agency administrator who worked in Puerto Rico under President Obama, told CBS News on Tuesday.

The water situation is compounding Puerto Rico’s “slow motion medical disaster”

The water and electrical situations have compounded what’s being called a “slow-motion medical disaster.” Puerto Ricans now face a much higher risk of health problems related to a lack of access to electricity and clean water — from dehydration to leptospirosis, a bacterial disease spread by drinking water contaminated with animal urine that’s already been breaking out.

Oh God. It is hard to overstate how dangerous this is. 1/ https://t.co/8Z2XJbAQYb — Jeremy Konyndyk (@JeremyKonyndyk) October 17, 2017

The public health situation could quickly deteriorate even further, warned Jeremy Konyndyk, senior policy fellow at the Center for Global Development. Outbreaks of cholera, a deadly diarrheal disease caused by eating food or drinking water that’s been contaminated with a bacterium called Vibrio cholerae, often emerge after people have been living without access to clean water. Puerto Rico doesn’t currently have cholera disease, but if it turns up, the island’s mixture of a collapsed public health infrastructure and patchy access to clean water could be a recipe for an outbreak.

“When you have a population that has been accustomed to being able to rely on clean potable water sources, and a new danger is introduced in the environment or their standard sources are no longer reliable, that creates a real risk,” Konyndyk told Vox.

For now, thousands of Puerto Ricans will have to continue to wait for bottled water to be distributed, rely on an unsafe water sources (what’s coming out of their taps), or turn out of extreme desperation to other water sources that are also unsafe (wells, rivers, Superfund sites).

There’s already strong evidence that the Maria-related death toll is much higher than has been officially reported, Vox’s Eliza Barclay and Alexia Fernández Campbell reported. If cholera hits the island because people can’t access clean water, the toll may be poised to grow even more.