Forty days after Hurricane Maria struck Puerto Rico, most of the U.S. territory remains without power.
Over the weekend, the island's power company fired a key contractor working to restore electrical service. The cancellation of the $300 million contract with Whitefish Energy, after the Federal Emergency Management Agency and other agencies expressed significant concerns about the deal, is expected to further delay the return of power throughout Puerto Rico.
The Puerto Rican government has prioritized getting power back to hospitals. Many smaller clinics and doctor's offices, like other businesses on the island, still don't have electricity.
Take, for instance, San Patricio Medflix, a diagnostic imaging center in greater San Juan. The center has state-of-the-art MRI, CT and nuclear medicine equipment.
Dr. Fernando Zalduondo Dubner, medical director imaging center, says his biggest job is battling with a heavy-duty diesel generator to keep the power on. "We are having trouble with it now as we speak," he says.
With Puerto Rico's electric grid down since Sept. 20, the diesel generator, housed in a metal box the size of a shipping container, has been the sole source of power for his four-story medical complex.
Fuel has been a big problem. The generator consumers about 500 gallons of diesel a day.
In the weeks after the hurricane hit, the diesel supply was incredibly tight. Zalduondo ended up buying whatever fuel he could get from whoever was selling it. But some of it was of such poor quality that it gunked up the generator. "The other day we had to cancel 70 patients that were here because we had to rely 100 percent on the diesel plant, and it just got clogged from all kinds of diesel that had been around," he says.
For Zalduondo the stakes are higher than keeping the lights on. MRI machines like his need liquid helium to cool their superconducting magnets. If the MRI scanner loses power for very long, the helium overheats and evaporates quickly. If the helium level gets too low, the scanner can be permanently damaged.
Another radiologist in San Juan thought he had all the diesel, helium and other supplies he needed to ride out Hurricane Maria only to have his MRI machine seize up after looters drained his diesel tank. Early on Saturday morning engineers from Siemens, a medical equipment maker, were able to refill the center's last working MRI machine's liquid helium.
The hurricane's winds also opened a crack in the imaging center's roof that let water pour into much of the top floor. As the crisis has dragged on, some of Zalduondo's employees have packed up and headed to the mainland.
"Practicing high-end radiology in Puerto Rico is extremely challenging in the best of times," he says. "It seems like all the conditions conspire to make us radiologists leave Puerto Rico."
The electric blackout isn't just affecting high-end medical equipment that requires liquid helium.
Dr. Eduardo Ibarra says the conditions in Puerto Rico, including the lack of power, are killing patients who otherwise would survive.
Ibarra is making house calls to mostly elderly patients in devastated parts of Toa Baja just west of San Juan: "I would say that of the ones I visit, 100 percent don't have electricity.
That means his patients don't have air conditioning or even fans to keep cool, a situation which aggravates bedsores for his bedridden patients. A lot of people still don't have running water, never mind hot water, so sanitation is poor. Their refrigerators aren't working either, so some medicines are going bad. Some dialysis clinics have shut down, too, forcing patients to search for alternatives.
"Between no light and no water and no money and no help ... the patients are getting very sick," he says.
Even as October draws to a close, power has officially been restored to only 30 percent of customers in Puerto Rico.
On a hillside in Toa Baja, Carmen Garcia Lavoy's relatives and neighbors are rebuilding her home with hand tools. The hurricane blew the roof and walls out of her house leaving behind a tiled cement slab littered with debris.
Dr. Ibara comes to see Garcia, who is 77. She has a host of medical issues, including high blood pressure. Last year she had open heart surgery. She also can't see well.
Garcia she's been very anxious living in the basement of the destroyed house with her son. Dr. Ibarra examines her in the open air of what used to be her living room. As he takes her blood pressure she breaks down crying and says she hasn't been able to get to a doctor since the storm. "I've been dying to speak to my cardiologist and I've already cancelled or lost two appointments with him," Garcia says.
Ibarra writes her a prescription for a blood pressure medicine that she had run out of. Garcia clutches the prescription to her chest as if it's a treasure.
The official death toll from Hurricane Maria stands at 51, but Ibarra says far more people than that have likely died as a result of the storm. Doctors don't write "hurricane" as the cause of death on a death certificate, he says, "the physician puts cardiac arrest, respiratory arrest."
ARI SHAPIRO, HOST:
A lot of things can only happen with electricity, including providing adequate medical care. Most of Puerto Rico is still without power, and people expect further delays in bringing the electrical grid back online. The effort has been complicated since Puerto Rico canceled a controversial deal with a Montana company called Whitefish Energy. NPR's Jason Beaubien is in San Juan and brings us this story of the medical impact of the ongoing blackout.
JASON BEAUBIEN, BYLINE: One of Puerto Rico's top radiologists, Dr. Fernando Zalduondo Dubner, is battling with a diesel generator.
FERNANDO ZALDUONDO DUBNER: We're having trouble with it right now as we speak.
BEAUBIEN: Dr. Zalduondo is the medical director at the private San Patricio Medflix clinic in San Juan. With Puerto Rico's electric grid down, this generator that he's standing next to has been the sole source of power for his four-story medical complex.
ZALDUONDO: The other day, we had to cancel 70 patients that were here. Seventy patients...
ZALDUONDO: Seven-zero just because we rely a hundred percent on the diesel plant.
BEAUBIEN: For Dr. Zalduondo, the diesel isn't just a question of keeping the lights on in his office. MRI machines use liquid helium to cool superconductive magnets. If the MRI loses power for very long, the helium warms up, evaporates and causes serious damage to the imaging machine. That happened to 1 of his 2 MRIs.
Early Saturday morning engineers from Siemens, which makes the MRIs, are working to maintain his remaining MRI after the helium in that one dropped to a critical level. Forty days after Hurricane Maria, this section of San Juan is still without power. That's true for 70 percent of electric customers across the island.
UNIDENTIFIED MAN #1: (Speaking Spanish).
UNIDENTIFIED MAN #2: (Speaking Spanish).
UNIDENTIFIED MAN #1: (Speaking Spanish).
UNIDENTIFIED MAN #3: (Speaking Spanish).
BEAUBIEN: Including, for instance, parts of Toa Baja just west of San Juan. Dr. Eduardo Ibarra is there making house calls for mostly elderly patients. He says the extended blackout is wrecking his patients' health.
EDUARDO IBARRA: I would say the ones I have visited, a hundred percent don't have electricity.
BEAUBIEN: There is of course no air conditioning, no fans, no refrigeration for medicine, of course no hot water, with temperatures rising well into the 80s.
IBARRA: Between no light and no water and no money and no help - so the patients started getting very sick.
BEAUBIEN: Bed sores are aggravated. Respiratory problems get worse. One of Carmen Garcia Lavoy's neighbors is using a handsaw as he works on rebuilding her house the old-fashioned way. All that was left behind of Garcia's house is a tiled cement slab. The 77-year-old Garcia talks to Dr. Ibarra about a host of medical issues. She can't see well. She had open-heart surgery last year. The examination takes place in the open air of what used to be her living room. Dr. Ibarra takes her blood pressure. She breaks down crying and says she hasn't been able to get to a doctor since the storm.
CARMEN GARCIA LAVOY: (Through interpreter) I've already canceled or lost two appointments with my cardiologist.
BEAUBIEN: Dr. Ibarra writes her a prescription for a hypertension medicine that she's run out of. A nurse traveling with him rubs her back. Garcia clutches the prescription as if it's a treasure. The official death toll from Hurricane Maria stands at 51. Dr. Ibarra is one of many people here who are saying that the true death toll from the storm is higher.
IBARRA: When you as a physician certify the death of a patient, you just put on the certificate cardiac arrest. You don't put something like Maria's related and so on.
BEAUBIEN: Nor does anyone list lack of roof or lack of diesel or lack of electricity as the cause of death. Jason Beaubien, NPR News, San Juan. Transcript provided by NPR, Copyright NPR.