VIEQUES, Puerto Rico — Weeds and horse dung surround the Family Health Center Susana Centeno. Across the entrance of the emergency room, respirator masks and blue latex gloves are scattered from a fallen trash can. Inside, medical supplies, like cots and wheelchairs, remain abandoned in the hallways. Since Hurricane Maria ravaged Puerto Rico in 2017, the only hospital on the island of Vieques has been shut down.

If the Trump administration had approved the funds to restore the hospital anytime over the past three years, Jessica Moraima Ventura Perez said, it could have saved her 13-year-old daughter Jaideliz Moreno Ventura, who died last month.

Jaideliz first showed flu-like symptoms in early January. But with no hospital on the 52-square-mile Vieques, the Ventura family had to visit a hospital on the main island — a two-hour journey away that includes a ferry and a car ride. When she tested negative for influenza, they returned home.

On the morning of January 12, however, Jaideliz began convulsing and had difficulty breathing. The local clinic, a temporary outfit with commuter specialists that was expected to fill the void of the destroyed hospital, didn’t have a respirator. Doctors had to fly her to a main island hospital in an air ambulance while family members were asked to assist with manually pumping oxygen into Jaideliz. She died on the way there.

“She lived all her 13 years as if it were her last day,” Jessica told me in Spanish. “Most importantly, she had courage. She was a warrior who took on any adversity.”

The community in Vieques, an island with a population of about 9,300 people, mourned the death of Jaideliz, who was known for her love of horses. On the day of her funeral, the family organized the largest horse ride in the modern history of Vieques — about four dozen people — to accompany her casket. It would have been Jaideliz’s wish to have been sent off this way, her mother said.

Jaideliz’s death is also heart-shaking to the people of Vieques for another reason: The threat of an emergency is always looming. Without a proper medical facility to save them, anyone could become the next victim.

After Jaideliz’s death, members of the community started bringing out cement blocks to Vieques’s main plaza in protest. The blocks were to be used for the reconstruction of the hospital, according to Carmen Valencia, a health care activist on the island. Several of the blocks were labeled with the names of Puerto Ricans who had died since Hurricane Maria, at least 2,975 in total, including Jaideliz.

“It’s a message for [the government] to be ashamed,” Valencia said. “We have to give whatever we have because they don’t do it on their own.”

About two weeks after Jaideliz’s death, the Federal Emergency Management Agency finally approved $39.5 million to rebuild Vieques’s only hospital — almost three years after it had been shut down.

“It is tragic that this funding was not released until after we lost one young life due to inadequate medical service on Vieques. I’ll continue watching to see that this project moves forward quickly,” said Rep. Nydia Velázquez (D-NY), one of the key lawmakers who had been pushing the government to release aid for the Vieques hospital for months.

While approval of funding for the Vieques hospital is welcome news, it points to a larger problem of access to health care in Puerto Rico since Hurricane Maria. Jaideliz’s death isn’t an isolated incident, and people from rural areas outside the bustling San Juan area struggle to book an appointment with specialized medical professionals. Without guaranteed treatment from these specialists, health care is becoming out of reach for some in Puerto Rico.

A mass exodus of health care professionals has made access to care more difficult

Puerto Rico had already been losing health care professionals and medical students to the mainland US before Hurricane Maria. That number, however, increased rapidly following the natural disaster, as more than 130,000 people left the island in the past three years.

By 2018, the island had lost about 15 percent of its medical specialists, according to data provided to Vox by Puerto Rico’s College of Physicians and Surgeons, leaving the island with only about 9,500 to serve the entire population of about 3.2 million. There’s been a slow increase of health professionals since — there were 10,580 in 2019 — but it’s still not enough for patients to seek timely long-term treatment, according to Dr. Wendy Matos, a professor at the University of Puerto Rico’s medical school. Currently, it can take four to six months to see professionals like neurologists, she added.

This becomes an even bigger problem when coupled with an inefficient system muddled with bureaucracy, Matos explained: Patients will receive mandatory referrals from their primary care physician to seek a specialist; by the time the patient can book an appointment with the specialist, the referral will expire; the patient will have to go back to their primary care physician to seek another referral and repeat the entire process.

Ever since Hurricane Maria, issues with insurance reimbursement have become one of the major factors behind the mass exodus of doctors, Matos said. Physicians in Puerto Rico are already paid a low wage, and when insurance companies fail to reimburse them in full, the financial woes become impossible to ignore.

“That’s not fair for the physicians because they have to pay their offices and their staff,” she said. “There’s no regulatory organization or agency to oblige the insurance companies to pay for the services.”

This isn’t the only sector where the island is battling with insurance companies: The New York Times estimated $1.6 billion in unpaid insurance claims since Hurricane Maria for damages to buildings such as houses, hospitals, emergency facilities, and government properties.

When asked how many clinics have shuttered since Maria, Matos said it’s difficult to keep track of the numbers, especially in rural areas. In Vieques, the reconstruction of medical clinics in rural areas has remained stagnant — there simply isn’t enough money to rebuild. Puerto Rico has only received $1.5 billion of the $20 billion it was promised by Congress for relief aid. And the local government doesn’t have much money to spare considering its financial crisis (the island’s debt is about $74 billion).

“It’s too many things together that are making a bad mix for the well-being — not only for the mental health,” Matos said. “We cannot have good health in these circumstances.”

Even after Hurricane Maria, the government’s response to health care following natural disasters remains woefully inadequate

Puerto Rico saw a delay in immediate disaster relief after Hurricane Maria hit in 2017 because FEMA was unprepared for the storm — a fact the agency acknowledged in an internal report released a year later. As a result, Puerto Ricans failed to receive the treatment they needed while hospitals were in critical conditions. After power went out, backup generators failed to work, fuel was scarce, and some medical staff simply could not get to work because of damaged infrastructure.

Activists have since prepared themselves for coming natural disasters by stocking up on supplies and building a network of health professionals willing to volunteer, said Helga Maldonado, regional director of Escape, a nonprofit organization that works to prevent child and domestic abuse in Puerto Rico. These arrangements helped the community swiftly provide aid when a magnitude 6.4 earthquake hit the southern part of the island on January 7, damaging more than 800 homes.

However, FEMA’s and the local government’s responses to the January earthquakes — there were almost-daily aftershocks of at least magnitude 3 — have made it clear that officials have not learned from their mistakes after Hurricane Maria, Maldonado said. The government failed to provide immediate aid to hospitals, which is why about half of the clinics remain closed in the affected areas, she said. While they wait for help to restore their practices, some doctors have set up tents as makeshift clinics in parking lots.

The aftermath of the recent earthquakes has added a unique health concern, Maldonado said: the spread of infectious diseases in the tent shelters, where hundreds of earthquake victims have been seeking refuge for more than a month.

In a statement to Vox, the Puerto Rico Department of Health said it has educated tent inhabitants on how to prevent infectious diseases, as well as provide additional care for those that need treatment.

On the ground, however, Maldonado said the department has failed to live up to its promises: “There’s so many people living together, and it’s easier to spread viruses from diseases because people are living so close together,” she said. “But during this time, the health department has been completely invisible and hasn’t stepped up.”

People’s mental health needs are also being neglected, Maldonado said, even though she’s seen the trauma to be more immediate and intense than post-Hurricane Maria.

“After Maria, people might not have had a roof, maybe not a window in their home, but they were still able to see their homes, and they were able to find a solution as to how they were going to fix it,” she said. “When the earthquakes came, people weren’t allowed to stay in their homes. They had to sleep outside in front of their homes. And so seeing your home and knowing that you can’t physically go in there is very traumatizing.”

To fill the void of the government, volunteers have once again stepped up. Maldonado said she has a WhatsApp group filled with psychologists and social workers who are willing to travel across the island to provide psychological assistance to earthquake victims.

Matos is doing her part to help rural areas with inadequate access to health care by building a telemedicine program with the Puerto Rico Public Health Trust. Under the initiative, patients will be able to remotely receive a diagnosis and treatment instructions from a doctor. A telehealth program will also teach users how to prevent diseases and look after their health in extreme situations, such as natural disasters.

Meanwhile, the people of Vieques will have to take advantage of these telemedicine programs or continue traveling to the main island for the next four years as they wait for the hospital to reopen.

Although it’s easy for Puerto Ricans to feel hopeless due to their lack of access to health care, Matos said she hopes the program reminds them that they are not abandoned.

“Something we learned from the natural disasters is that it’s in us — the force to stand up,” she said.