As President Donald Trump signals impatience to wind down emergency aid to Puerto Rico, the challenges wrought by Hurricane Maria to the health of Puerto Ricans and the island's fragile health system are in many ways just beginning.
Three weeks after that direct hit, four dozen deaths are associated with the storm. But the true toll on Puerto Rico's 3.4 million residents is likely to involve sickness and loss of life that will only become apparent in the coming months and in indirect ways.
As victims continue to be found and stranded people reached, it will take time to assess the consequences of their missed care or undertreatment.
The situation in Puerto Rico's health system is far more vulnerable than those in Texas or Florida, which also weathered hurricanes this fall -- medically, economically and politically. A month after Hurricane Katrina in 2005, only about half of the final official fatalities had been tallied.
Puerto Rico has a higher rate of diabetes than any state, according to 2015 data from the U.S. Centers for Disease Control and Prevention. About half of the island's population depends on Medicaid. And, unlike in the States, Puerto Rico's Medicaid system receives a fixed amount to meet residents' needs, a pot of money that could run dry next month, said Jenniffer Gonzalez-Colon, Puerto Rico's delegate to Congress.
"We've had a fiscal crisis, a Medicaid funding cliff, Hurricane Irma and Hurricane Maria -- we are being hit from every angle," she said.
Orlando Gutierrez, an associate professor of nephrology at the University of Alabama-Birmingham and a board member of the American Kidney Fund, said Puerto Rico is the "perfect storm" for a disaster.
The Federal Emergency Management Agency has distributed food and water to help stave off disease or dehydration, relief workers have prioritized efforts to get hospitals and other health facilities operating again, and the Navy dispatched the hospital ship USNS Comfort, which has 250 beds.
Coordinated efforts to deliver fuel, water and medications to health facilities have allowed some to reopen. As of Oct. 12, federal emergency officials said nearly all Puerto Rican hospitals were open, although some are still dependent on generators. The Puerto Rican government said electricity has been restored to more than half of the hospitals. Nearly all of the dialysis centers are operating now, though many patients have missed treatments.
But Katia Leon, deputy director of primary care for the Association of Primary Care in Puerto Rico, said she believes the population's health has worsened since the storm hit. Cases of diarrhea, pink eye and skin rashes are appearing in larger numbers, she said, and health officials are concerned about infections from contaminated water.