On the side of the highway, cars whizzed by as the poor filled plastic bottles and paint buckets with water flowing out of the mountain.
Nearly six weeks after Hurricane Maria, they still had no running water and nowhere else to bathe or wash clothes. Some — from remote areas where bottled water was too expensive or difficult to obtain — also didn’t have anything else to drink.
And everyone was worried about getting sick.
“We’re drinking water from wherever we can get it, because the water doesn’t come,” said José Luís Gambo Rodríguez as he helped his mother and stepfather wash clothes. “The government says there’s [purified] water, but it’s not here.”
For Gambo Rodríguez’s family and thousands of others, the lack of clean water is posing a serious health concern.
Since the hurricane hit, there have been at least 18 confirmed cases of leptospirosis, a bacterial disease spread through contact with contaminated water that can be deadly if not quickly treated. At least four people have died from the disease so far, according to official figures. It’s likely both numbers could be higher because they don’t reflect other suspected but unconfirmed cases in remote areas.
Doctors and nurses also report seeing patients for other health problems related to a lack of clean water, including gastrointestinal illnesses and pink eye.
Although government officials say they’ve distributed water purification tablets and bottled water throughout the island, by late October there were still places where residents said the help hadn’t arrived.
The mountainous area outside Utuado in central Puerto Rico was one of those places. Gambo Rodríguez and his family said they hadn’t gotten any bottled water or purification tablets from the government and couldn’t afford to buy their own.
Two weeks after the hurricane, Gambo Rodríguez’s stepfather started vomiting and came down with a fever. Wilfredo Cosme de Jesús went to a local hospital, where he said the doctor diagnosed him with leptospirosis. After treating Cosme de Jesús with antibiotics, the doctor cautioned him not to use unpurified water.
But a week after he was released from the hospital, Cosme de Jesús was bathing and helping his wife wash clothes on the side of the road. His wife had also started to feel ill.
As she wrung out the laundry over a metal basin, María Rodríguez Rivera said she had come down with similar symptoms. “I feel sick with a headache and fever,” she said.
Failing water filtration plants
On Monday, nearly seven weeks after the storm, 20 percent of the island still had no running water.
The situation was slightly better in San Juan, where government figures showed 91 percent of customers had service, but on other parts of the island the percentage was as low as 62.
Even those with tap water have been advised to boil it or use purification tablets. With electricity still unreliable in the places where it has been restored and generators prone to breakdowns, water treatment plants can go down without warning.
After reaching a peak of 83 percent on Sunday, access to running water fell below 80 percent the next day when generators failed across the island and more than 45,000 customers lost service, Public Affairs Secretary Ramón Rosario Cortés said in a statement. By Wednesday morning, service had been restored to 85 percent.
Puerto Rico’s water and sewage authority did not respond to questions about when the entity expects full service to be restored.
In the meantime, finding bottled water can be a challenge even in San Juan. Prices have also increased since the hurricane, making it hard for low-income families to pay for filtered water.
In the town of Humacao on the eastern edge of the island, local officials were still concerned about getting clean drinking water to the surrounding area in late October.
“I have 58,000 inhabitants and only one truck to take water to the upper areas,” said Ramon Díaz, the assistant director of the local emergency management center. Díaz was meeting with a water and sanitation expert from the nonprofit Oxfam, which was trying to identify the nearby areas in most desperate need of water purification systems.
“Which ones should we prioritize?” water expert Andrea Chaves Arana asked, listing off the names of several places.
“All of them, because they don’t have water,” Díaz responded.
Chaves Arana had been traveling the island to assess the need in remote areas. Although she said the bottled water government officials and charity groups were passing out helped fill the immediate need, it wasn’t a long-term solution.
“The idea is to make it a little more sustainable and for that reason it’s best to think about systems that can do more with less,” she said.
Public health officials have distributed fliers at shelters, hospitals and grocery stores across the island as part of a campaign to get residents to boil water or use purification tablets. But even those with running water are struggling to boil it, Chaves Arana said. Some have no power for their electric stoves while others are reluctant to use gas to boil large quantities of water.
The Federal Emergency Management Agency and other government agencies have distributed filtration systems and purification tablets, but volunteer groups and charities say there’s still a need for more. They’re trying to fill the gaps, particularly in the most remote regions. Unions are also getting involved. The American Federation of Teachers, a national teachers union, has raised money to provide families and schools with water filtration systems, since a lack of running water has been one obstacle to reopening all of the island’s schools.
Risk of deadly disease
Public health officials say they’re hopeful the number of leptospirosis cases won’t keep climbing.
In late October, Puerto Rico’s state epidemiologist told the Miami Herald the island “could end up with an outbreak,” but by early November Carmen Deseda said she had a clearer picture of the disease and believed the number of cases had already reached its peak.
Given the strain on Puerto Rico’s healthcare system and the communication difficulties in remote areas of the island, however, it’s likely some suspected leptospirosis cases haven’t made it into the official count.
The symptoms of leptospirosis are easily confused with other diseases, including dengue fever, which doctors also screen for after a hurricane because standing water breeds mosquitoes.
There’s also no definitive testing for leptospirosis available in Puerto Rico; in order to confirm cases, samples have to be sent to a Centers for Disease Control and Prevention laboratory in Atlanta. So far, samples from roughly a hundred suspected cases have been sent to the CDC, of which the majority have come back negative, Deseda said. The CDC is still evaluating additional samples.
Most patients don’t develop the more serious symptoms associated with the disease, Deseda said, but because leptospirosis can cause kidney or liver failure in some people, public health officials are advising doctors to immediately treat any suspected cases.
“The testing can be a bit complicated to confirm leptospirosis, so we’re really pushing for early diagnosis and early treatment and then we’ll confirm,” said Henry Walke, head of the bacterial special pathogens branch for the CDC.
Not all the suspected cases have been evaluated by CDC laboratories, however.
At a federal medical shelter in Manatí on the island’s northern coast, medical personnel said in late October that they had treated a small number of suspected leptospirosis cases, but couldn’t know for sure without CDC testing. They were hoping to work with the CDC to confirm suspected cases in the future, but hadn’t yet been able to do so.
“It’s a little bit of a dilemma because a lot of these diseases in their early stages don’t clearly present themselves,” said Erik Larsen, the chief medical officer overseeing the Manatí shelter. “Sometimes we take our best guess and we try to err on the side of caution.”