The Silent Crisis Killing Puerto Ricans Months After Hurricane Maria

Ortiz is one of 236 Puerto Ricans who killed themselves in 2017, according to a report released by the Commission for the Prevention of Suicide. His death also belongs to a growing number of suicides on the island that increased by 55 percent in the last four months of 2017 following Hurricane Maria, compared to the same period in 2016.

Ortiz is an extreme case of what happens when mental illness goes undiagnosed or untreated. And he isn’t alone. Underneath the debris, a silent mental health crisis is burgeoning in Puerto Rico, with a record number of people reporting anxiety and depression. Others with pre-existing mental health conditions are finding little solace, as they are unable to keep their routines and have had difficulty refilling their prescriptions. According to local authorities, the territory was already struggling with an increasing onset of mental illness brought on by poverty, soaring unemployment, and family separation amid a decade-long recession.

Photographer Stephen Yang and I arrived five months after the storm hit. Every community we visited outside the capital of San Juan was without power. At night you could hear the sound of gasoline-powered generators. Areas were still completely ravaged, as if a hurricane had passed just days before. But it was more than just food shortages and wreckage. Many Puerto Ricans experiencing flashbacks and panic attacks gave a minute-to-minute replay of the horror they now felt helpless to overcome. It was harrowing glimpse into an island struggling to rebuild—and its dangerous stigma around mental illness.

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When the water reached her chest and the mattresses were floating inside of her house, Ivette Estrada believed she would die. She yelled at the top of her lungs to wake up her 18-year-old daughter, Hennessey Del Valle. As the water continued to rise inside their shuttered home, they surfed atop a sofa. They called for help, but at the height of the storm no one could hear them. “God help us,” pleaded Del Valle while banging on the front door, attempting to open it.

When it was finally ajar the sights terrified the both of them. The water was everywhere. Confined to a wheelchair and fearing the worst, Estrada did what any other mother would do: “I looked at her and said, ‘Save yourself.’”

But eventually, the water stopped rising. They spent another three days inside their home buoyant, wet, and unable to eat. It took that long before 55-year-old Estrada, who suffered both kidney and respiratory failure in 2016, could alert others she was alive, let alone get help.

In the days and months since, Estrada relives the memories daily. “I can’t stop thinking, I can’t stop crying,” she said. Still without electricity and clean water, she feels abandoned and questions whether the authorities care about her. Her health issues even affect her ability to go to the bathroom on her own.

Estrada is also estranged from her other five children—all of whom live close by—because of her romantic involvement with two violent drug addicts while they were growing up. (One of them was Del Valle’s biological dad, who died of a drug overdose.) Born in New York City to parents who also were drug users, Estrada was raised in Puerto Rico by her grandparents. She says that during one of the only times she visited her biological father, he raped her. Living in shambles after the hurricane has triggered all this past trauma.

“I feel alone,” she said. “I have thought, what’s the point of living?”

Estrada lives in Punta Santiago, a neighborhood in the Humacao province on the easternmost part of Puerto Rico where the hurricane first made landfall. The Army Corps of Engineers considers Humacao “ground zero.” By comparison, it means the poor fisherman village of Punta Santiago is worse off than the other glitzier areas in Humacao, which draw tourists to places like the island’s iconic Palmas del Mar resort. The average household income in Punta Santiago is $13,195 and unemployment rate is almost at 25 percent, according to the 2010 Census.

A few blocks down from Estrada, Hurricane Maria also consumed Alba Cataran’s wooden house, which sat next to an inlet. The front doorway remained intact, but the entire back of the house was torn asunder. Although it was condemned, Cataran is unable to move forward. She rented a room in a neighbor’s house down the street. She can’t bear the thought of being far away.

“I go down there every day,” Cataran said. For weeks she refused to pick up any of her items scattered all over the front yard and on the street. The majority of her most precious possessions were mementos belonging to her late mother. “I promised her I would take care of these things. And now Maria has left me so empty inside.”

Many Americans would recognize Estrada and Cataran as suffering from depression. They were diagnosed at the time of their respective suicide attempts years ago. People don’t openly discuss depression on the island. It was such a low priority that when the University of Puerto Rico and Puerto Rico’s Administration for Mental Health and Anti-Addiction Services commissioned a report, it hadn’t been studied by health officials in more than 30 years. That report found that one out of every 10 Puerto Ricans suffers from depression and anxiety disorders. The study also found that services are not available to people still considered “functional.”

Comparatively, mainland Americans are far more open about depression. Although the stigma is far from gone, attitudes toward depression and PTSD have changed dramatically over the course of the last two decades, especially among veteran advocates—so much so that President Trump faced significant resistance from Congress when he proposed $700 million in budget cuts to mental health services last year. Under the approved budget, his administration slated $10 billion in government funding for substance abuse and mental health. There’s also $8.6 billion earmarked for mental health services at Veteran Affairs.

Although Estrada and Cataran could speak stoically about the horrors they faced in the storm and its after-effects, when the conversation turned to their suicide attempts, they became emotional. “I feel such shame about it,” Cataran said in tears. “Because when it happened, I didn’t stop to think that my daughter needed me.”

If it’s bad for these women, it can be even worse for men. Because of pervasive macho expectations, mental health issues can go untreated for years. Of the people killed by suicides in Puerto Rico in 2017, roughly 86 percent were men. The reticence of men to discuss depression was reflected in Ortiz’s family: His sister Nilma said she never imagined something so horrible would happen, but “there had to be something wrong.” His nephew Luis, on the other hand, skirted the issue, blaming suicides in Puerto Rico on financial pressures small businessmen were facing. “Those businessmen that owe a lot of money get depressed and they think this is the easiest way out,” he told us. He never referred to his uncle directly: “I’d rather not know anything about it.”

Cataran is on disability because of her Crohn’s disease. As such, her healthcare is fully covered by the U.S. Social Security Administration, which gives her the ability to see a psychiatrist and psychologist regularly. People with disabilities also receive Medicare. In Puerto Rico, the process of qualifying can often take two years, compared to 90 to 180 days on the mainland. After Hurricane Maria, Cataran increased her visits after recognizing that her symptoms were worsening. She had also taken pre-emptive measures by refilling multiple prescriptions.

In a catastrophe, access is everything.

Estrada is on prescribed anti-depressants but does not see a therapist. She is covered by Puerto Rico’s government-run program, which provides services to impoverished citizens by means of contracting private health insurance companies. It’s commonly referred to as “La Reforma.” And although mental health services are available to Estrada, healthcare professionals on the island we spoke to mentioned the exodus of medical personnel and prolonged wait times compromising the level of care. Her best-case scenario is seeing a therapist once a quarter.

Faced with the largest bankruptcy in U.S. history, Puerto Rico has $120 billion in bond and pension debt. As a result, the government had already implemented austerity measures and appointed a Congressional financial oversight board with a goal to curb spending on healthcare. One of the commission’s letters last year to Puerto Rico Gov. Ricardo Rosello proposed eliminating public housing and nutritional assistance, both of which Estrada benefits from.

Against this backdrop, mental health had already been falling by the wayside.

And the invisibility of these conditions makes them harder to treat. But austerity measures and a brutal hurricane demolished whatever safety net was left. Hurricane Maria laid bare structurally racist and anti-poverty policies. And in a catastrophe, access is everything.

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In the days following the storm, images of people begging for water flooded social media. Many were horrified to learn that although Puerto Ricans are U.S. citizens, archaic laws restricting shipping between two U.S. ports foiled relief efforts. That’s because Puerto Ricans are second-class citizens. A series of U.S. Supreme Court opinions known as the Insular Cases argued in 1901 that Puerto Rico and other territories ceded by the Spanish were “alien races” that couldn’t understand “Anglo-Saxon principles.” The Constitution not only did not apply to them, but it blocked any real path to statehood. It was the same Supreme Court that allowed for “separate but equal” segregation that would later be overturned by Brown v. Board of Education.

Overturned that is, for every state except the Insular Cases.

This legacy carries over to policy and the island’s deteriorating health care system. Part of Puerto Rico’s financial crisis stems precisely from a vast disparity in federal funding. Puerto Rico can receive funds for Medicaid up to 55 percent. Once it hits this ceiling, the territory must come up with its own funds. This is a problem for a territory that is twice as poor as Mississippi, the poorest state in the U.S. This means Puerto Rico relies more heavily on public programs. Under the Affordable Care Act, Puerto Rico does not have a state marketplace; instead they were given additional Medicaid dollars, but at a different reimbursement formula than other states.

Economists cite the disparity in medical funding as responsible for $25 billion of Puerto Rico’s debt. “Even pre-hurricane, the 55 percent match rate was a major issue,” explained the Kaiser Family Foundation’s associate director Robin Rudonowitz. As a result, the government was forced to borrow money over time to keep Medicaid afloat.

And when austerity measures hit, they deeply overwhelmed the system. First they set off an exodus of about 12 percent of medical personnel. The impact was dire. A U.S. Department of Health study prior to the hurricane reported that a patient could wait up to nine months to see certain specialists. This includes access to mental health professionals.

“The situation is just impossible,” said Miriam Delgado, a clinical psychologist who provides services in Humacao through the area’s largest non-profit Programa de Educación Comunal de Entrega y Servicio, known by its acronym P.E.C.E.S. “Not only have the numbers of patients tripled, but the government wants to pay therapists $14 a visit,” she said.

And if history is any indicator, the numbers seeking treatment for mental health will keep increasing. PTSD, depression, and anxiety roughly doubled in the months after Hurricane Katrina hit the Gulf Coast in 2005, a federally funded study published by the World Health Organization found. Hurricane Katrina became a landmark example of how pervasive mental health issues become after a major natural disaster. Carissa Caban-Aleman, a psychiatrist that works with various organizations in Puerto Rico and is a member of the Climate Psychiatry Alliance, says that what became clear since Katrina is that mental illness and substance abuse are not secondary problems—they are the long-term effects of climate change-induced disasters.

Still, access for those who need it could get worse for Puerto Rico, whose Medicare program is on track to be depleted by April. Although Congress approved a deal for both Puerto Rico and the U.S. Virgin Islands, which earmarked $4.8 billion to replenish Medicare, the funding falls tens of billions of dollars short of what Puerto Rico needs to take care of those ailing with an increasingly elderly population. “In terms of mental health, there is always the potential for environmentally-produced stressors,” said Angel Munoz, psychology professor at the Pontifical Catholic University of Puerto Rico. “But when people face complications including access to basic services—like those we’re seeing as a result of Hurricane Maria—these numbers soar.”

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We drove around the Puerto Rican highlands of Naranjito looking for answers as to why Hector Ramon Ortiz would have ended his life. According to the research, suicide affects middle-aged men disproportionately. More than 5,000 people with suicidal thoughts had called the Linea PAS, the only suicide helpline on the island, from September to January. As far as we know, Ortiz had never asked for help.

We went to places he’d regularly visit. Townspeople recalled what a caring man he was. They said he “would take the shirt off his back if he knew you needed it.” When we got to Vuestro Tiempo Bar and Grill, it was a far cry from the landmark locale it had once been. Construction workers had torn down the old infrastructure and were renovating: taking down panels, fixing the roof.

We found Hector’s father, Angel Luis Ortiz, at a bar he once owned. His grandson runs it now. Passing the slot machines amid the smell of homemade guava liquor, he sat on the back porch overlooking a ravine. “My chest still locks up. It’s a terrible thing, a terrible thing,” Angel Luis Ortiz repeated over and over. He said he had no idea why his son would have committed suicide.

In town, however, there were rumors that Hector’s financial situation had taken a turn for the worse. He had moved back home with his parents and had cut back hours for restaurant employees last August, even before the hurricane. Maria was the last straw.

Regardless, it filled those close to him with regret. “I would have asked him to come with me,” said his sister Nilma Ortiz, who said she had seen him that morning before going to serve meals with a church group.

Her sense of regret and fear was not lost on me. My own father, who I suspect has wrestled with mental health issues for much of his life, also attempted suicide in the months following Hurricane Andrew in 1992. Most people in my neighborhood lost their homes. Ours was the only one standing for miles. I still remember the tent city in Homestead, Florida where my family would go eat hot meals served by the Army while I played with displaced children my age.

The morning after the hurricane flattened Miami, I saw my immigrant father cry for the first time in my life. I was more concerned, however, with the fact that my mom had canceled my Barbie-themed birthday party the night before. (I was six.) So he went to fetch bottled water all over Miami. Hours later he arrived with water, provisions, and a birthday cake. In the darkness, all you could see were those six candles. “The most important thing is to be together,” I remember him saying. It’s one of the most beautiful moments of my childhood.

But as was often the case with my dad, the intensity that makes him vibrant also came with a vengeance in bad times. Months later, he was often dazed. It had taken more than two months to get power and we had no phone line. In the months before, my dad was already facing significant financial and personal issues, including that mother wanted a divorce. It was all a downward spiral after the hurricane.

One morning he had a fight with my mom. It lasted hours. My dad turned violent. Later, I went to look for my dad in his room and all over the yard but couldn’t find him. I went into the garage and that’s where I saw him. He had tied a yellow rope around the garage door’s electric motor. The rope was around his neck and he was standing on a chair. I screamed “Mamá!” at the top of my lungs. I remember her yelling that he was the most selfish person in the world. The next day we sat on the porch, and he asked me to forgive him. I said no.

We never spoke about it again.

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On the evening returning from Naranjito to San Juan, Stephen and I heard on the radio that there had been another two suicides. This time, it was a 14-year-old teenager in Carolina and Alexander M. Ramos, a 28-year-old from Juncos. We attempted to contact the Ramos family, but they decided to hold funeral services in a different town for privacy.

There was a lingering sadness and worry that many would not be able to overcome the trauma Hurricane Maria uncovered. There were clear cries for help. It was evident people needed support with more than rebuilding electricity posts. And with a new hurricane season upon them, the worse might be far from over.

This past weekend I got a text message from a community leader in Naranjito that introduced us to people who knew Ortiz. She sent me a link to a suicide of an 11-year-old reported in the news on April 1. Two weeks earlier, tragedy had hit close to home: Her friend’s son had taken his life at 24 years old. He lived in her same neighborhood we had driven through together.

“Esto sigue,” she wrote. “It just keeps happening.”

Romina Ruiz-Goiriena is a senior reporter, producer and digital media entrepreneur who has worked in Paris, Cuba, and Israel for France24, El Mundo, and Haaretz. Most recently, she worked for CNN out of Guatemala and The Associated Press, where she reported on key regional issues such as migration and drug trafficking.

This feature is part of Splinter’s project to recruit local, embedded reporters, essayists, and photographers across the country. Read more from our Think Local series here.