The hospitals have been crippled by floods, damage and shortages of diesel. The governor said that 20 of the island’s hospitals are in working order. The rest are not operational, and health officials are now trying to determine whether it is because they lack generators, fuel or have suffered structural damage. All five of the hospitals in Arecibo, Puerto Rico’s largest city in terms of size, not population, are closed.
Making matters worse, 911 still does not work, officials said.
“What do you think? There has to have been deaths,” said Dr. Rafael Rodríguez-Mercado, Puerto Rico’s health secretary. “I can’t give you a number, but we have to be conscious and realistic. To say no would be a lie.”
So far, seven regional hub hospitals are taking in patients. The island’s dialysis patients are also getting care. But none of it is easy. Hospitals should be required to have backup generators, diesel, a stockpile of medication and satellite phones, the doctor added. Even with those precautions, problems could arise. There is enough diesel on the island, but a shortage of gas tanker drivers — some cannot get to their jobs — and working gas stations. In Lares, the mayor, Roberto Pagan, said the municipal hospital almost had to close yesterday because it ran out of diesel fuel.
“We have been putting out fires,” Dr. Rodríguez-Mercado said. “The hospitals call you and say, ‘I have two hours of diesel left.’”
The potential for a public health crisis is a big concern, he said. Rats and decomposing animals can spread disease, the doctor added. Without running water, people are probably not washing their hands or boiling water often enough, or cooking their food well enough. This could lead to gastrointestinal outbreaks.
“What worries me is the sincere possibility of epidemics,” Dr. Rodríguez-Mercado added.
High mosquito counts on the island could also lead to a resurgence of mosquito-borne diseases, like Zika, dengue and chikungunya, doctors said.
A shortage of open pharmacies is another stressor, especially for the chronically ill and elderly residents. Most pharmacies in Puerto Rico remain closed, although they are slowly beginning to reopen. A CVS spokesman said that 21 out of 25 Puerto Rico-based CVS stores are now open, including 17 pharmacies. The first one reopened last Thursday. A Walgreens spokesman said about half of the island’s 120 stores are open and running on generators, but that hours vary. The stores are also receiving supplies of medication.
But many pharmacies in Puerto Rico are independently owned. With so many people pleading for medication, some pharmacists who know their clients are dispensing drugs without the required prescriptions or refill bottles.
Hospitals still have adequate supplies, and so do many of the open pharmacies, but there are concerns they may run out because suppliers are unable to get to them, said Dr. Victor M. Ramos Otero, the president of the College of Doctors and Surgeons of Puerto Rico.
Even when people find the drugs, they often cannot pay for them. Without electricity, A.T.M.’s do not work and stores cannot accept credit cards or process insurance plans. That is what happened to José Castillo when he showed up at the Express Care Pharmacy in Santurce, a San Juan neighborhood, on Tuesday, hoping for a refill on the anti-depressants that help him sleep.
Pharmacy workers were outside, tending to customers on the sidewalk. The manager, Yanissa Serrano, told Mr. Castillo the pills cost 25 cents each — cash only.
“But I don’t have the money,” he said.
Her patience worn out, Ms. Serrano erupted.
“I would have been able to give you your medicine, but three times they robbed my generator. Three! Thanks to the fine people of this neighborhood,” she shouted. “I lost my house. I lost everything. I could be home tending to my apartment, but instead I’m here providing this service to the community, and this is how they repay me.”