Since Maria, he’s made a 10-hour trip for dialysis three days a week. He’s not alone.

VIEQUES, Puerto Rico (En español)

Three times a week, Radamés Cabral wakes before dawn — accompanied only by a chorus of roosters and the chirps of coquí frogs — to begin a brutal but lifesaving commute. Over the course of 10 to 12 hours, he’ll take a pickup truck, an airplane and a taxi to receive dialysis in the town of Humacao and then make his way back home.

A 65-year-old diabetic with kidney disease, Cabral relies on the blood-cleansing procedure to keep him from drowning in his own fluids. For years, he received dialysis just a few miles from his house on Vieques, a spit of land off the coast of Puerto Rico’s big island that’s home to about 9,000 people.

But ever since Hurricane Maria turned the local hospital into a mold-infested hulk, he’s become a slave to the trip that he blames for shortening the lives of at least five of his fellow patients.

“I’m not going to die because of my kidneys,” Cabral said as he squeezed his linebacker’s frame onto a single-engine airplane recently. “I’m going to die because this plane’s going to crash. … I have no life anymore. My quality of life is zero.”

A year after Hurricane Maria slammed into Puerto Rico, a sense of normalcy is returning to the island. As of August, power, water and communications had been restored to most of the territory’s 3.3 million residents. Gov. Ricardo Rosselló, once busy coordinating disaster relief, is now occupied by ribbon-cuttings at Hard Rock Cafes and office complexes as he tries to convince the world that the island is open for business again.

But for Cabral, and thousands of others with chronic diseases, life is far from normal.

While the government says all 68 of the island’s public and private hospitals are up and running, that statistic doesn’t paint the full picture.

After the small hospital on Vieques was flooded by Maria and then overcome by toxic mold, authorities were forced to shut it down and set up a new clinic in what had been a hurricane shelter. While the new center has shiny new medical equipment, it doesn’t provide many basic services — including a delivery ward, X-rays and dialysis. And it’s unclear when, or if, those services will be provided.

Puerto Rico Health Secretary Rafael Rodríguez said the island’s healthcare system had made a miraculous recovery considering how devastating Maria had been.

“Imagine if the entire state of Connecticut had been totally razed by a natural disaster,” he told the Miami Herald. “That’s the magnitude of what happened in Puerto Rico, and a lot of people don’t recognize that.”

Support journalism that matters

Every day, the Miami Herald works to report the news that matters to you. This includes local government, sports, politics and investigating leaders and institutions to hold them accountable.

Stay informed. Take advantage of a 99-cent offer for your first month of access to the Miami Herald.

When the Category 4 monster punched through Puerto Rico on Sept. 20, 2017, everything — including hospitals — ground to a halt. Rodríguez said downed power and communication lines meant he only had contact with 17 of 68 hospitals. And he could only communicate with about 10 of the health department’s 5,000 employees.

The problems only grew worse as hospital generators — not designed for long-term use — began running out of fuel or breaking down.

The government now says 2,975 people died in the weeks and months after Maria, as disease ran rampant and blocked roads and downed bridges kept people from receiving medical attention.

Rodríguez says that hospitals have now been made “more resilient” with better generators and better emergency-response plans, but he admits that the healthcare system is only as strong as the island’s infrastructure. And by most accounts the island’s communications and power grid has been restored to its pre-Maria standard — not significantly better.

“Our principal problem was that we didn’t have electricity and our communications collapsed,” he said. “If we are hit with another storm, we would be back to a similar position where we were.”

But the island’s healthcare infrastructure is only part of the problem.

0039 Puerto Rico Vieques second trip 082118
A shuttered Centro de Diagnostico y Tratamiento de Vieques — diagnostic and treatment center — one year after Hurricane Maria struck Puerto Rico. Al Diaz

Starting in about 2013, amid Puerto Rico’s decade-long economic crisis, doctors began leaving the island in droves. The Board of Physicians and Surgeons of Puerto Rico, a medical association, says the island had 14,000 doctors in 2006 but that number is down to about 9,000 now. Last year alone, Puerto Rico is thought to have lost about 700 doctors, many of them Maria evacuees.

“The exodus is still increasing,” said Victor Ramos, the president of the association. “The lack of doctors continues to be one of our main problems.”

Driving the outflow is a health insurance system that is squeezing professionals, experts say.

About 60 percent of Puerto Rico residents are on Medicaid and Medicare plans for their healthcare. In the 50 states, the federal government provides matching funds for those programs at a rate based on the state’s needs. But because Puerto Rico is a U.S. territory — not a state — its “federal matching percentage,” or FMAP, has been fixed at between 55 and 57.2 percent, regardless of actual needs. (In the wake of Hurricane Maria, the U.S. Congress boosted matching funds to 100 percent through September 2019.)

But the system has long deprived low-income residents of Puerto Rico of adequate healthcare and created a scenario where doctors are chronically underpaid, Rodríguez said.

On a recent day in August, while Rosselló was inaugurating a new cancer ward in San Juan, a group of dentists had gathered in front of Puerto Rico’s domed legislative building to protest the commercial insurance industry they say is suffocating them.

José Crespi, who has been a dentist in San Juan for three decades, said insurance reimbursement rates haven’t been increased in 25 years — even as insurance premiums have at least tripled. Insurance companies on the island, including the government-run health plan, reimburse dentists $22 for extracting a tooth. “That won’t even cover the costs of having a dental assistant,” he said. On the U.S. mainland a dentist could easily be reimbursed $175 or $200 for the same procedure, he said.

“It’s ironic that the government talks about the exodus of doctors and dentists but refuses to do anything about it,” he said. “They’re not willing to help those of us who choose to stay here.”

0677 Puerto Rico Monday protest 082018
Demonstrator Margarita Santos Osorio yells in front of ‘El Capitolio,’ the capitol in San Juan, Puerto Rico, on Aug. 20, 2018. Osorio joined protesters seeking better medical treatment and facilities on the island of Vieques. Al Diaz

The local government does offer tax breaks for some high-demand medical specialties. And there are proposals in the works to subsidize medical degrees for those who commit to practicing on the island.

But Rodríguez, the health secretary, said many of the island’s problems — both before and after the hurricane — are tied to its status as an unincorporated territory. The chronic lack of federal funding and Puerto Rico’s lack of full political representation in Washington have created a profound imbalance, he said. While Puerto Ricans on the island cannot vote for U.S. president, for example, as soon as they move to Florida, or any other U.S. state, they can.

“It’s ridiculous that a person is treated like a second-class citizen in Puerto Rico and that as soon as they go [to the mainland] they have all the benefits of a U.S. citizen,” he said.

As people fled the island to Florida and other states after Maria, “they discovered they had more benefits there that they didn’t have here — that they were considered American citizens,” he said. “It makes it a challenge for [Puerto Rico] to stop losing more people.”

Back on Vieques, Cabral said he feels like it’s the local government trying to force him off his island. Since April, the administration has been promising to send a mobile dialysis unit to Vieques for Cabral and nine other patients with kidney disease. The government says that unit has been shipped from California to Jacksonville and will be in Puerto Rico by the end of September. But many have lost faith in the government’s promises after a year of waiting for health services to be restored.

0023 Puerto Rico dialysis 081518
Radamés Cabral, 65, waits at Antonio Rivera Rodríguez Airport, on the island of Vieques, Puerto Rico, for a plane that will take him to Fresenius Kidney Care dialysis center in Humacao on the big island on Aug. 15, 2018. By pickup truck, plane and taxi, he makes the grueling trip three times a week for treatment. Al Diaz

In the meantime, a patchwork of nonprofit and government agencies has been shouldering the cost of chartering a plane six days a week to fly the patients to the big island and then transporting them about 40 minutes to the dialysis center in Humacao, southeast of San Juan.

The Renal Council, a San Juan-based nonprofit, says it’s spending about $15,600 dollars a month on airfare alone for Vieques dialysis patients. What was supposed to be a stopgap emergency measure has dragged on for 11 months, and has easily racked up bills for at least $171,000. A new hospital-grade dialysis machine would be far cheaper, costing between $10,000 and $15,000.

“The most frustrating part about this is we never get any straight answers,” said Angela Díaz, the head of the Renal Council, which has been covering the costs since April. “We don’t really know what the long-term solution will be.”

0245 Puerto Rico Vieques cemetary 082118
Dialysis patient Radamés Cabral, 65, visits a cemetery in August in Vieques, Puerto Rico. Many of the island’s residents who have died since Hurricane Maria struck last September are buried there. Several of the dead were dialysis patients. Al Diaz

Díaz says dialysis patients have likely died prematurely on Vieques due to the grueling commute. Many of the dialysis patients are frail and elderly and reluctant to make the all-day trip “even though they know that if they don’t get on the airplane, it’s going to cost them their lives,” she said.

Cabral said at least five of his dialysis companions have died since the airlifts began.

“People feel helpless and they’re not dying due to lack of dialysis, they’re dying because of the situation, because of the problems with the trip,” he said.

A year after Hurricane Maria, Cabral said his life still feels tenuous. All of Vieques is still running on emergency generators because the undersea cable that connects the province to Puerto Rico’s main power grid was severed during Maria. And Cabral wonders what will happen if a new storm hits, grounding the airplanes and boats that take him and his friends to dialysis.

“When the next hurricane comes they are going to try to force us to live on [mainland] Puerto Rico, but I tell you now I’m not going to go,” he said. “This is my home and I prefer to stay here, even if it means swelling up with fluids and dying.”