Every seat was taken on the flight from JFK to Puerto Rico and there was the usual air of excitement I’ve experienced traveling many times before to the island. On this occasion, the plane reflected a different mix of passengers – first responders, aid workers, technical experts,– but, most of the passengers were Puerto Ricans either returning home or going to help with recovery from Hurricane Maria and its predecessor Hurricane Irma.

Conceptually I knew when we boarded that this would be a shocking visit, but now the reality hit: Puerto Rico has had an abrupt, seismic shift.

I felt the excitement I’ve felt many times before as I spotted Puerto Rico in the distance; the waves were high, crashing along the coast. Soon we’d be on the ground and though I was a little uncertain about what we’d face on arrival, I was still excited to be back and get on with reconnecting with colleagues and delivering supplies to agencies we partnered with in our work. We crossed the northern shore of the island and then started to descend.

Then, the plane fell silent.

Arriving in Puerto Rico

This first thing I noticed was that everything was brown. No green anywhere. I heard a few gasps. Then as we continued to descend first over the coastal towns and then over the mountains, we saw the destruction. Swaths of destroyed houses, blown apart, with debris all over, especially in communities tucked into the mountains.

The plane fell absolutely quiet. No one spoke. And as we continued flying over the brown, broken landscape, and the reality set in, people started crying, softly. It was shocking to see this beautiful country – whose backbone is so strongly community-centered – shattered below. You could immediately feel the human impact – what happened to all the people in those towns? How horrific it must have been to live through such a destructive storm! Conceptually I knew when we boarded that this would be a shocking visit, but now the reality hit: Puerto Rico has had an abrupt, seismic shift.

Most people in the US are unfamiliar – really – with Puerto Rico, its history, and its relationship with the United States. Over many years of an unbalanced colonial relationship with the US, Puerto Ricans still cannot vote for US Presidents and have no voting representation in the US Congress. Decisions about the country are made in the US Congress, which oversees governance on the island.

The country had been recently hit by a serious economic crisis of a magnitude not seen elsewhere in North America, with a major shift in population migrating from the islands to the mainland USA, and from disease outbreaks…

Given its political status with the USA, responding to disasters in Puerto Rico is different than in its neighboring countries, like the Dominican Republic, Haiti, and Cuba. International organizations have to respond differently – if they can at all – on US-controlled soil. This delays and maybe prevents nimble, effective organizations that specialize in such recoveries from helping.

Puerto Rico has nonetheless remained a vibrant country with a few large urban areas and with many local mountain, coastal, and island towns, to where most people could trace their roots, traditions, cuisines. Puerto Rico has many mountain communities, and communities on outer islands, all of which have been marginalized for decades if not centuries.

The country had been recently hit by a serious economic crisis of a magnitude not seen elsewhere in North America, with a major shift in population migrating from the islands to the mainland USA, and from disease outbreaks – including mosquito-borne diseases like Zika, Chikunguyna, and Dengue, but also from chronic diseases like diabetes and hypertension.

My first thought was how all those people throughout the country were going to be served post-Hurricane Maria with this backdrop of great challenges. How were people going to be helped through the acute phase of this tragedy, with basic needs, to help bring communities back to their feet? This response is challenging; in my visit 17 days after the hurricane hit, remote communities were still cut off from roads, without water, medicines, and communications. Our partners were still receiving urgent requests for water, diabetes medications, food. The disaster response was not reaching the entire island – people are still in crisis, desperately trying to get help. When we asked what supplies communities needed from us, we heard back milk, rice, water. Such basic needs, still.

Then, what comes next? The ecology and landscape of Puerto Rico has changed. Everyone who works in global health or has lived in a community facing tragedy knows that much of the death and destruction comes after the acute event, when social structures break down, when insects and diseases spread, when people are forced to be in situations that place them at risk.

The main course I teach – Medical Ecology – is all about shocks and stressors in the environments that envelop us and within our own communities, households, and bodies – and how a set of adaptations and reactions act to bring us toward balance, or homeostasis.

René Dubos – one of the fathers of medical ecology – talks about the shifting of civilizations in response to both natural and social disasters, how people reorganize, how communities change, how bodies are impacted. Small towns and communities are essential in Puerto Rico and are where much of the country’s life emerges – what will happen now? Will communities just disappear? How will that change the fabric and assets of the country? Communities are like bodies – they persist through trauma, adapt, and are reborn.

I’m confident communities will rebuild, but how will they be different? Loiza – a small town on the Northeast coast of Puerto Rico and a mecca for Afro-Caribbean art and culture – was hit badly by the storms, with its streets flooded, buildings destroyed. I was just in Loiza a month ago, experiencing this unique resource within the country and indeed within the world, a place that many of my Puerto Rican friends are proud of and love. The local cultural resources of the mountain and coastal towns are essential to the country.

How will this tragedy impact families? Imagine trying to parent children through these times, in such dire circumstances. The stress on families and the impact that stress can have on health is known; we know that hurricanes and similar sudden stressors (like earthquakes) have implications for pregnant women and their fetuses, on stress levels, and on chronic disease.

Puerto Rico will face steep challenges in addressing these lasting physical, cultural, and health impacts, within a political structure that makes that difficult. The Puerto Rican diaspora and people-to-people based organizations will be central to helping in this recovery. The community health system of Puerto Rico – once the model primary care system for the entire world – is more important now than ever before, in helping keep populations healthy, adapting, and also as serving in a core role as a social institution in communities.

The flight continued to descend, crossing over San Juan and the somewhat random patterns of destroyed buildings, uprooted trees, downed power lines that dotted the city. We landed with a thud, the plane still silent. On the ground, finally, the lull of being suspended in air broken by our arrival, bringing reality back to us. And then, after the brakes were applied and the plane slowed and turned toward the SJU terminal, the flight attendant announced “Welcome to San Juan, Puerto Rico!”

And the plane erupted in applause.

You can read part 2 of Timothy Dye’s series here.