Rafael Negrón Santos did not lose his home or his job after Hurricane María, but the storm was the end of his relationship with his partner. The struggle to survive in the days and weeks that followed, coupled with the despair caused by life without electricity, the frustration at the number of deaths that the government refused to acknowledge, and the time he devoted to taking care of his mother’s needs, weakened communication with his partner. One day he came home, and she was gone.
The number of stress factors he faced took a toll on his mental health. In the months that followed, he lost his appetite, lost nearly 40 pounds, and had panic attacks. A supervisor at his job told him he needed to seek help and, six months after the hurricane, he was diagnosed with depression and post-traumatic stress syndrome.
During the same period, Lisandra Cruz Marín began to feel constantly nervous, had trouble sleeping, also lost her appetite, found it very difficult to concentrate, and was always worried about something. She was diagnosed with anxiety disorder.
The only thing fictitious about these testimonials is the names of the people. Their stories are real and were compiled by the Center for Public Integrity, Columbia Journalism Investigations, and 12 other news outlets, including the Center for Investigative Journalism (CPI, in Spanish), which asked people affected by hurricanes, floods, and wildfires, and the professionals helping those survivors, to share their experiences through an online form that was answered by 230 individuals. Of these, 74 said they had experienced one or more disasters in Puerto Rico. There were also 27 mental-health professionals from Puerto Rico who filled out the survey.
Their responses are a cross-section of some of the situations frequently experienced by disaster survivors in Puerto Rico. Many are related to losses in the context of the devastation. These include symptoms related to anxiety, post-traumatic stress, adjustment difficulties, major depression, and substance abuse, according to the World Health Organization (WHO).
Like Negrón Santos and Cruz Marín, thousands of Puerto Ricans faced emotional difficulties as a result of the blow dealt by Hurricane María. Some were later diagnosed with mental health disorders.
Most of the people who responded to the questionnaire said they had not received mental health services after their experience. Their reasons vary, ranging from cost to the belief that they didn’t need help. However, they revealed that they have faced situations that are linked to the disaster such as symptoms of anxiety, depression and sleep problems, which are treatable with mental health services. More than half reported having faced four or more emotional challenges in the first year after the disaster. And almost all (78%) in Puerto Rico answered that they still regularly face some of these symptoms.
Traumas related to natural disasters will continue to recur as global warming leads to the development of storms and hurricanes with an increasing potential for destruction, as the scientific community has warned. In the 10 years prior to Hurricane María, weather-related disasters increased by 46%. In addition to material losses, the displacement of poor and vulnerable communities, the climate crisis also translates into a mental health crisis.
But, more than a warning, the effects are already a reality.
From 2008 and until María hit in 2017, Puerto Rico, in whole or in part, has been designated as a major disaster area six times due to torrential rains, floods, landslides, storms and hurricanes: Floods in southern towns in 2008; floods and landslides in central, northern and eastern towns in 2011; Hurricane Irene in 2011; Tropical Storm María in 2011; and Hurricanes Irma and María in 2017.
Each event of this type causes symptoms in the population, according to Psychiatric Epidemiologist Glorisa Canino, director of the Research Institute of Behavioral Sciences of the University of Puerto Rico’s Medical Sciences Campus.
Canino confirmed that people with a psychiatric history are the most likely to develop a new disease or to experience worsening of the condition they already have.
Meanwhile, those who live in vulnerable situations, who suffer losses as a result of the disaster, are at greater risk of developing symptoms related to post-traumatic stress syndrome, anxiety or depression. These symptoms, she said, can persist between six months and two years. Only when several of these symptoms persist at the same time, for a certain period of time, is it considered a mental health disorder.
“The people who are going to develop symptoms are almost always the poorest because they’re in floodplains or in unsafe homes. If they were affected by the disaster, the higher the degree of impact, the more likely they are (to develop symptoms). And that’s the case in every disaster throughout the world,” she said.
Canino acknowledged that after Hurricane María, the Mental Health and Anti-Addiction Services Administration (ASSMCA, in Spanish) “did what it could” and that the response would have been different and much more efficient if Puerto Rico had a more robust mental health infrastructure.
ASSMCA expanded the services of its Psychosocial Assistance Program line (Línea PAS, in Spanish). The record of calls received in the months following Hurricane Maria, after mobile service started to recover, reflects sustained growth since November 2017.
Other peaks showed during the threat by Hurricane Dorian in 2019, after the earthquakes in January 2020, and when the COVID-19 emergency began, when the government offered the Línea PAS as a reference for information on the epidemic, beyond the service that it usually offers. Since January 2020, the number of calls has increased every month, the CPI confirmed.
ASSMCA received $35.9 million from FEMA’s Crisis Counseling and Training Program (CCP), which can be requested by the governments of states and territories affected by natural disasters. As the agency revealed, it used the money to hire 320 mental health facilitators and start the “Anímate” program to provide emotional support and crisis counseling.
Established in the 1980s as a short-term disaster relief grant, the CCP program funds free emotional assistance for anyone affected by a major disaster. It has been used in all states, in addition to Puerto Rico and other territories, in more than 400 traumatic events in total.
New York is the state that has received the most CCP funding since 1985, the date since FEMA data is available for that program. It’s aid includes its response to the events of September 11, 2001 and Hurricane Sandy in 2012.
In the last five years, Puerto Rico has led the jurisdictions that have received the highest amount of money, with an obligation of $35,945,000, which is 63% of the total that the island has received in the CCP’s history. The figure relates only to the allocation after Hurricane María, the disaster for which FEMA has obligated more funding under its Crisis Counseling Program than all but four other events.
For Medical Anthropologist Adriana Garriga López — who has studied the social effects of epidemics over the past 20 years — this number, as well as all the funds that the United States allocates to Puerto Rico, must be analyzed in the light of the political relationship that prevents the government of Puerto Rico from participating or advocating with sovereignty for the rights of its citizens in any international health organization, such as the WHO or the Pan American Health Organization (PAHO, in Spanish).
As part of this joint investigation, the CCP program’s response to six major disasters was evaluated, including Hurricane María, floods in Missouri and Iowa; wildfires in California; and Hurricanes Harvey and Florence in Texas and South Carolina, respectively. FEMA’s program had little reach when considering the scale of the disasters, according to data obtained through a request under the federal Freedom of Information Act (FOIA).
While more than 1 million, of the 3.2 million island’s population, applied to FEMA for individual financial assistance or housing in the wake of Hurricane María — an indicator of the number of people who suffered some loss or were left in need by the disaster — about 578,734, or 18% of the population, received individual, family, or group counseling during the two years that the CCP program was active. Also, 18% is the prevalence of mental health diseases in Puerto Rico, Psychiatric Epidemiologist Canino said.
41% of the people benefited were in individual counseling sessions.
At least 25% of residents received counseling in most towns, according to data provided by FEMA. But in some towns, like Ponce, far fewer people received these mental health services. There, 35% of residents applied for financial assistance from FEMA, and only 7% received at least one counseling session.
Given the findings on Puerto Rico and the states that were evaluated in this investigation, a FEMA spokesperson said that the CCP complements local mental health services, and noted that “there’s no universal ideal or adequate level of counseling after a disaster; it varies not only according to the location, but also according to the disaster.”
For ASSMCA administrator, Social Worker Suzanne Roig Fuertes, the scope of the initiatives that her agency developed with these funds can be classified as a success in light of the catastrophic context. According to her records, the work performed by her staff, which includes about 2,000 employees and contractors, began on September 24, 2017 and strengthened thanks to the response of volunteers who responded to her call, although she could not specify how many there were.
The CCP proposal began on November 1, 2017 and allowed her to hire facilitators who met FEMA criteria. They were people with a minimum of a bachelor’s degree in Education, Counseling, Psychology, Social Work or Criminal Justice. Initially, Roig said they only received funds for 18 months and subsequently got an extension to cover 24 months. The program’s maximum term is usually a year. Sometimes it’s extended to allow more time for the money to be spent, such as with Hurricane Katrina.
“We know what to do quickly in an emergency, which is to provide spaces for communication so people can share their experiences and emotions, strengthen them through self-help strategies, and let them know where to seek help. The goals were to avoid suicides and avoid diagnoses of post-traumatic stress,” Roig Fuertes spoke about a task that she said was done” house by house,” and that also included interventions in lines at commercial sites, workplaces, and community meeting places.
“This work is [done] house by house and they went where no one went,” said Roig Fuertes. In response to the number of people FEMA reported as receiving help through CCP, the administrator noted that many people believe they are fine when they really aren’t and resist mental health assistance. She also mentioned that when it came to group activities in the community centers and basketball courts, the fear of not being at home when supplies were being distributed in their neighborhoods, limited people from seeking other assistance, including primary medical and mental health services.
The ASSMCA administrator pointed out that 2017 closed with an increase in the number of suicides but noted that it was a trend that had been seen since the summer. However, she said that in 2018, when the ravages of the hurricane were still being experienced, there was a significant decline. She also mentioned that there has been no increase in diagnoses of post-traumatic stress syndrome, although she acknowledged that those numbers could change when the long-term consequences of the earthquakes and the COVID-19 pandemic are studied.
Upon analyzing data provided by FEMA and the Centers for Disease Control and Prevention, the Center for Public Integrity and Columbia Journalism Investigations identified 178 counties or municipalities in the United States and Puerto Rico that are predisposed to suffering from mental illness caused by disasters. Among these are 10 municipalities in Puerto Rico: Adjuntas, Aguas Buenas, Barranquitas, Cataño, Comerío, Jayuya, Loíza, Orocovis, Patillas, and Salinas.
These towns have a high index of social vulnerability, which is based on demographics, poverty, access to services, the health of the population and other social determinants of health, and they were also hit by multiple hurricanes or floods that caused property damage in the last 10 years.
By coupling the Puerto Rican reality and the Hurricane Maria disaster with the earthquakes that took place in the South in January 2020 and the current COVID-19 pandemic, significant losses are added that require grieving processes.
Medical Anthropologist Garriga López, who is also a professor at the University of Kalamazoo, in Michigan, described the sequence of disasters as a cascade in which each trauma worsens the previous trauma. “Freud says that when we are in mourning, we are not only mourning for the person who died, but also for all those who have died before.”
“We can talk about trauma because of what has been lost, but we can also talk about the uncertainty of what can be lost, and we’re feeling that too,” she said.
According to Psychiatric Epidemiologist Canino, the mental health consequences of experiencing one disaster after another without having completed the recovery period has yet to be studied in-depth in Puerto Rico.
Her team at the Behavioral Sciences Research Institute is in the process of submitting a proposal to investigate these consequences and how hospitals and community health centers can respond to mental health needs in crisis contexts when, for example, there’s no electricity and getting around is difficult.
Canino believes that people who are repeatedly affected by large stressors, such as natural disasters and their consequences, are more likely to develop symptoms related to mental health conditions or psychiatric disorders.
“This is the first time that we’re going to study the consequences of several disasters in such a short time. I don’t know what we’re going to find. It’s possible that more people meet the criteria for a psychiatric diagnosis in contrast to what is usually seen when it’s an isolated disaster. They are too many stressors and, more than stressors, for many people they were trauma,” she noted.
One of her theories is that, unlike what happens after a single disaster, when people no longer experience associated symptoms after a year, stressors related to consecutive traumatic events mean that more people meet the criteria for a psychiatric diagnosis.
“The dose response is when the person is reacting to a high dose of the stressor or trauma, either because of the extent or because they’re repeated in a short time. It’s known that the higher the dose of the stressor, the greater the probability of developing psychiatric symptoms or psychiatric disorders,” the specialist said.
For Disaster Sociologist Jenniffer Santos Hernández, one of the explanations for the number of people who were excluded from receiving mental health help from the government has to do with people’s mistrust of public services. And that mistrust, she warned, increases with the response that is offered after each emergency to meet the most basic needs, such as decent housing.
Besides, she said, an important segment of the people affected in disasters and who face damage to their homes are adults over 65 years of age, who comprise 20% of Puerto Rico’s total population, according to Census projections for 2020.
“The system is failing you and you see that very little is happening in terms of housing [repair]. Most of the money you see flowing goes to public infrastructure. So, you have people totally exposed at the basic level,” said Santos Hernández, who is a professor and researcher at the Center for Social Research at the UPR-Río Piedras campus.
The online survey done as part of this research confirmed a range of reasons why many people did not receive mental health help after the María disaster.
The majority felt that they did not need them, but there were also those who did not have time to think about themselves, did not have medical insurance, did not identify enough medical services providers in their area, found that the waiting list for services was too long, or were concerned about what that other people might think.
In Naguabo, Jonathan Alverio Rivera began having flashbacks after María. He didn’t have electricity for three months. Alverio Rivera, now a 29-year-old medical student, says he needed mental health help but couldn’t find any. “I didn’t see any ads or anything that said, ‘If you need help, call this number’,” he said.
Given the reality that only 18% of Puerto Rico residents benefited from the CCP’s help, Anthropologist Garriga López mentioned the idiosyncrasy of the “machismo” culture and the stigma that weighs on mental illnesses that often manage to prevent people from visiting mental health professionals.
“In Puerto Rico there is a culture of stoicism in the face of everything that has happened, especially among men. ‘Being well,’ ‘resisting,’ ‘making do,’ are all ways of dealing with traumas,” she said.
For Sociologist Santos Hernández, the response to disasters and mental health care has to be a coordinated effort with the leaders of each community and requires meeting people’s basic needs quickly.
“We have to take a critical look at what the essential needs are after a disaster event. One of those essential needs has to be housing,” the sociologist said.
Three years after Hurricane María, there are still 4,500 houses covered with blue tarps, Puerto Rico Housing Secretary Luis Fernández Trinchet said when storm Laura approached on August 21.
In addition, 26,995 people applied to the Department of Housing’s Repair, Reconstruction and Relocation program, known as R3. Of these, 6,052 homes were eligible, 266 are in the pre-construction process, 316 are under construction, and only 45 have been completed for a total of 627 cases to which the money was assigned. Of the total applications, 2,641 are for houses that still have roofs with blue tarps.
Although mental health problems are evident in southern communities, the reaction of government entities to address the issue during disasters is nonexistent, said Roberto Thomas, general coordinator of the Jobos Bay Eco-development Initiative (Idebajo, in Spanish), an organization that works to fight social inequality and to protect the natural and cultural heritage of Salinas, Arroyo and Guayama.
There, the neighbors themselves are organizing to create a health and social safety committee.
“What we want is for the community to organize itself jointly with other institutions and organizations to come up with alternatives, including solidarity and to keep in touch. Just so we at least know that we’re not alone because that feeling of abandonment is strong right now because we’ve had three years of non-stop disasters and the response is always poor,” said Thomas.
“This sense of loneliness and abandonment from the institutions contributes to this mental health problem because the expectation (that the urgent problems of the communities will be addressed) is almost nonexistent. There’s a kind of unease,” he said.
A person’s sense of well-being is closely related to their mental health and, also, with their life expectancies, so attention to housing needs shouldn’t take so long, Sociologist Santos Hernández said. The specialist recalled that disaster recovery around the world usually takes between eight and 10 years. It’s too long a period, and in Puerto Rico it is expected to be even longer, she anticipated.
Adding to the picture is the recurrence of disasters in such a short time, requiring people to respond to urgent situations while trying to move forward in their recovery from the previous event.
“So you have a person who is applying for Community Development Block Grant (CDBG-DR) Program funds, but at the same time, they’re calling her to distribute groceries in her community so that the elderly don’t have to go out in the middle of the pandemic,” Santos Hernández said.
“What you’re seeing are layers upon layers of stressors, of social inequality and a process in which the networks that community leaders have to handle each disaster erodes because they’re worn out,” she said.
Community Clinical Psychologist Eduardo Lugo has participated in multiple multidisciplinary efforts to encourage communities to develop strategies to cope with disasters.
“We know that with climate change and global warming we’ll be experiencing an increase in storms and hurricanes, and that they will disproportionately affect communities that have historically been oppressed and abandoned by the State,” said Lugo, who is an associate professor at the University of Puerto Rico, Mayagüez Campus.
He pointed out that what is evident, according to his experience, is the absence of a public policy to address social issues after natural disasters occur in Puerto Rico.
The reality of mental health due to the island’s economic crisis, compounded by the disasters of the last three years, is confronted with a health system that Lugo classified as critical.
“Psychologists can’t keep up. Those who are in private practice charge and are very poorly paid by the health insurance, and only a sector of the population has access to a psychologist in private practice,” he said.
“If we look at services that are offered through the State, they’re extremely deficient and there are many criticisms: there is a delay in appointments; the frequency of the service doesn’t necessarily respond to the needs of the people; and often, those covered by the government’s health insurance have to wait months for the first appointment, and that’s critical,” he warned.
He mentioned there are cases that should be handled individually, but they are addressed in a group session, and that therapy groups often mix people with different diagnoses, which affects the effectiveness of therapeutic treatment.
“It’s a system that isn’t working, especially for people with limited resources.”
“Puerto Rico’s structural mental health scenario is deficient by design because there’s no democracy in Puerto Rico, because we’re a colony and, therefore, Congress determined that Puerto Rico doesn’t deserve parity in federal health funds,” Garriga Lopez said.
Her premise points to a system that, despite the preparation, commitment and dedication of health providers, operates at a level lower than that of the United States, which, in itself, is lower than that of the other countries of the so-called First World.
“That’s like starting the race 10 minutes late. We’re in a situation of insufficiency and the greatest insufficiency is one of democracy and self-determination, which leads us to the existing limitations in the reimbursement and payment systems, and the availability of funds. This is coupled with the lack of interest of the federal government to really take care of the needs of the Puerto Rican population,” she said.
Lugo added that the austerity model imposed by the Fiscal Control Board has the effect of impoverishing the quality of services and reducing their availability.
For the community clinical psychologist, an island-wide plan to implement a robust long-term mental health system, which also enables disaster preparedness, involves much more than will.
He mentioned that the Multisectoral Health Council, created by virtue of Act 235 of 2015, integrates experts on the subject in Puerto Rico whose main recommendation, since 2016, has been the establishment of a universal health plan. In the area of mental health, it has recommended that services should be strengthened and integrated at all levels of the health system, especially at the primary care level.
Psychiatric Epidemiologist Canino added that mental health services should be available in community health centers.
Kio Herrera, Dean Russell and Jamie Smith Hopkins contributed to this report.
The Center for Public Integrity and Columbia Journalism Investigations collaborated with the following media in the United States and Puerto Rico to accomplish this research project: California Health Report; Center for Investigative Journalism; City Limits; InvestigateWest; IowaWatch; The Island Packet; The Lens; The Mendocino Voice; Side Effects Public Media; and, The State.
If you or someone you know is facing a mental health situation, you may contact:
The Mental Health and Anti-Addiction Services Administration’s Línea Pas, which offers telephone assistance in mental health emergencies
The United Way’s Information and Referral Center provides referrals to social and health services, according to specific needs and area of residence
Hospital Panamericano has a helpline
Hospital Capestrano also has a telephone helpline
National Network for Suicide Prevention addresses crisis situations
About this project
The Center for Public Integrity and Columbia Journalism Investigations collaborated on this project with newsrooms around the country: California Health Report, Centro de Periodismo Investigativo, City Limits, InvestigateWest, IowaWatch, The Island Packet, The Lens, The Mendocino Voice, Side Effects Public Media and The State.
We created our survey for disaster survivors and mental-health professionals with guidance and vetting from Sarah Lowe, clinical psychologist and assistant professor at Yale School of Public Health; Elana Newman, professor of psychology at the University of Tulsa and research director for the Dart Center for Journalism and Trauma at Columbia University; Gilbert Reyes, clinical psychologist and chair of the American Psychological Association’s trauma psychology division disaster relief committee; and Jonathan Sury, project director for communications and field operations for the National Center for Disaster Preparedness at Columbia University.
No government agency in the United States regularly tracks the psychological outcomes of disasters. And while academic studies may shed light on specific events, the questionnaire was meant to understand experiences from multiple disasters across the country, furthering on-the-ground reporting. It is not a formal, randomized survey. Respondents participated voluntarily and without compensation. For that reason, our results may not represent the general experience of disaster survivors.
In all, 197 survivors and 41 professionals responded from 17 states and Puerto Rico. Our questions focused on climate-related disasters — hurricanes, floods, wildfires — within the last 10 years, as well as COVID-19. We asked about financial, physical, behavioral and emotional outcomes, questions modeled on professional standards for mental-health surveys. We did not include a few responses in our findings because they came from people commenting on disasters other than wildfires, hurricanes or floods.
Public Integrity’s Kristine Villanueva led audience engagement on the survey. She and journalists Megan Cattel, Kio Herrera, Molly Taft and Alex Eichenstein assisted with that outreach. Rebekah Ward translated the questionnaire into Spanish. Dean Russell, Kristen Lombardi, Villanueva and Jamie Smith Hopkins developed it, and Hopkins analyzed it.