They’d watched nervously as invasive Aedes mosquito species that can carry the virus appeared in Los Angeles about a decade ago and began to spread, likely introduced by international trade and enticed to stay by a warming climate that makes it easier for mosquitoes to thrive.

Then, in October 2023, an email came from the Pasadena Public Health Department: A person in the city had contracted California’s first-known case of dengue from a local mosquito.

“When it happens in real time, real life, you know, it is very different,” Farned said. “There’s no room for error here. We have to be quick and effective in identifying the most at-risk areas and responding.”

Across California, public health and pest control authorities are facing a new reality as the Aedes mosquitoes bring the threat of dengue and potentially other tropical diseases, such as chikungunya, Zika, and yellow fever, that were once of concern only to international travelers.

So far this year, authorities have identified at least 13 cases of locally acquired dengue, up from two in 2023, with 11 in Los Angeles County and two in the San Diego area. The Aedes mosquitoes spread the disease by biting an infected person and then biting a previously uninfected person.

Mosquito-borne viral illnesses, chiefly malaria, have long been a scourge in many tropical regions, and preventive measures focus mainly on controlling the mosquitoes. The Aedes mosquitoes, known for their aggressive, daytime biting, are now present in at least 24 California counties. They breed in water, in as little as a capful.

“When these locally acquired cases occur, … we want to act on them pretty quickly so that it does not become an endemic infection in our region,” said Aiman Halai, director of the Los Angeles County Department of Public Health’s Vector-Borne Disease Unit.

California officials are hoping to beat back dengue by expanding mosquito surveillance, developing detailed response plans for mosquito outbreaks and human infections, and improving data sharing across agencies. They’re also going door to door in neighborhoods to remove standing water sources and apply pesticides. Residents are advised to wear bug repellent and long-sleeved clothing and control mosquitoes around their homes to prevent biting and infection.

Some vector control districts — local agencies charged with managing disease-bearing insects and other animals — are even growing their own sterile mosquitoes to release into the wild to reduce local Aedes populations.

Outside of California, locally acquired dengue cases have occurred in Arizona, Florida, Hawaii, and Texas. In March, Puerto Rico declared a public health emergency after a spike in cases there, where dengue is endemic. Meanwhile, worldwide dengue cases are on track to , with 12.3 million documented through August, up from 6.5 million in 2023, according to the World Health Organization.

Most people who get dengue have no symptoms, but about 1 in 4 become ill. A mild case can feel like the flu and usually dissipates within a week, but about 5% of those infected with dengue , with symptoms that can include internal bleeding, shock, and organ failure, and the most severe cases can be fatal. People infected a second time are at especially high risk.

There is no specific medication to treat dengue. Japanese pharmaceutical company Takeda developed a vaccine that has won approval in Europe and elsewhere, though it withdrew an application to the FDA last year, saying it could not provide data requested by the agency. A vaccine developed in Brazil could soon be approved for use in that country. But the only FDA-approved vaccine is authorized only for children in narrow circumstances and will soon go out of production.

At the San Gabriel Valley Mosquito and Vector Control District, one of five agencies tasked with mosquito control across Los Angeles County, public health workers have put together an Aedes and dengue response plan based on from the state.

When they discover a case, they identify all the properties and public spaces within 150 meters — roughly the distance an Aedes mosquito can fly — and then go door to door, removing standing water, where mosquitoes can breed; applying pesticides from backpacks or trucks; and educating residents about the risk of dengue and how to protect themselves. District officials also set traps to catch mosquitoes so they can figure out their prevalence and test them for dengue.

Since local dengue cases began to appear, the district has gotten more efficient in implementing its response plan, district manager Farned said. All full-time and seasonal staff members — about 40 people — have been trained in a variety of tasks, such as door-to-door education and coming in during off-hours to answer phones, Farned said.

While vector control teams respond to cases, separate teams from the Los Angeles County Public Health Department go door to door in the affected neighborhood when they determine that a dengue case was locally acquired, surveying residents and offering free dengue testing to try to identify others who may be infected.

Additionally, the department has been sending alerts to local health providers, advising them to be on the lookout for possible dengue cases and test for it when suspected, even among patients who haven’t traveled to a place where dengue is endemic. This advice follows a put out by the Centers for Disease Control and Prevention in June. Health authorities are also emphasizing that people who travel to locations with dengue should continue to wear mosquito repellent when they get home, to reduce the risk of spreading the disease to local mosquitoes.

As happened during the covid-19 pandemic, mistrust of public health authorities can make outreach challenging for health and pest control teams in some neighborhoods, officials said.

Pest control officers can seek a warrant to enter and treat a property for mosquitoes if a homeowner refuses to give access, said Jeremy Wittie, a former president and the legislative committee chair for the Mosquito and Vector Control Association of California, which represents the more than 70 mosquito and vector control agencies in California. This is easier in districts such as his, the Coachella Valley Mosquito and Vector Control District, that have warrants giving officials standing permission to enter a property after 24 hours without needing to ask a judge.

In counties such as Santa Clara, where Aedes mosquitoes but have yet to establish themselves, officials hope to suppress the threat with stepped-up surveillance, speedy eradication efforts, and more public outreach. Santa Clara County Vector Control District Manager Nayer Zahiri said the aim was to eliminate Aedes but acknowledged the climate conditions that encourage the mosquitoes’ spread are “totally out of our control.”

In some counties with pervasive mosquito problems, including , San Joaquin, and , officials have sprayed pesticides from planes or helicopters to address spikes in local mosquito populations, Wittie said. These sprayings typically aim to control the larvae of a different type of mosquito, Culex, that can spread West Nile virus and which — unlike the Aedes species, which thrive in urban habitats — are found in harder-to-reach rural environments, Wittie said.

Aerial spraying hasn’t been deployed to address the recent dengue outbreaks, which are in more urban environments where spraying from trucks is a better option, Wittie said. Drones are another option that some vector control authorities are exploring.

Some districts are experimenting with the decades-old sterile insect technique, commonly used for other pests such as fruit and screwworm flies, in which males are sterilized with radiation and then released to mate, resulting in eggs that don’t hatch. (Female mosquitoes are separated from the males before sterilization and not released. Only the females bite).

Ultimately, the public will have to take the mosquito threat more seriously and contribute to prevention efforts, Wittie said. “This mosquito is going to be here to stay, unfortunately. I hope it kind of wakes people up and pushes them to be part of that solution.”

This article was produced by Ñî¹óåú´«Ã½Ò•îl Health News, which publishes , an editorially independent service of the .Ìý

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Wildelma Gastón asked for her rosary to be placed on her chest and motioned to her “good arm,” where Matos-Pagán injected a first dose of the Moderna vaccine. The Gastón household, made up of five family members, breathed a collective sigh of relief. Though the vaccine had been available for months, Wildelma had been unable to reach a vaccination site. According to the Centers for Disease Control and Prevention’s COVID Data Tracker, Puerto Rico’s vaccination rate in March was one of the lowest among U.S. states and territories despite receiving more than 1.3 million vaccine doses. The rollout highlighted disparities in access to medical services, and the challenges of tracking and reaching remote citizens, such as Wildelma.

With each trip to school or work, family members worried about bringing the virus into their home and the threat to Wildelma’s life. Matos-Pagán also vaccinated two of Beatriz’s children, who are students at the University of Puerto Rico-Mayaqüez, during her visit.

“We have been waiting a long time for this moment,” Beatriz Gastón said as she hugged Matos-Pagán goodbye, expressing gratitude for the home visit. To her, the vaccine is more than protection from the coronavirus — it clears the way for the family to be together with her mother.

To Matos-Pagán, it is her latest calling. The nurse practitioner, who has guided relief efforts after hurricanes and earthquakes in Puerto Rico and elsewhere, has made it her mission in the U.S. territory to vaccinate as many people as possible against covid. Some residents of Mayagüez, a city on the western shore of the main island, candidly call her “The Vaccination Queen” and show up at her home asking for help in getting a shot.

According to The New York Times’ case tracker, as of Friday, Puerto Rico has had more than 182,000 covid cases and at least 2,594 deaths. About 57% of the population is fully vaccinated, but many of the unvaccinated are hard to reach because they live in remote mountainous communities or have chronic illnesses that leave them homebound. Matos-Pagán has vaccinated around 1,800 people in Puerto Rico so far, including 1,000 who have chronic illnesses or are bedridden.

In the pandemic’s early days, Carmen Blas’ health declined, and she began using a wheelchair. Blas, 78, was confined to her home, on the third story of an apartment building, which kept her safe from contracting covid, but later she couldn’t find transportation to a vaccination site. In June, her two children, Lisette and Raymond, visited from Wisconsin to help and immediately called the public health officials to get Blas inoculated.

“I usually come back every year and this was the longest I’ve ever been away. It was especially hard as my mother’s health worsened, and I worried I might never see her again,” said Raymond, who planned to extend his visit for as long as he was needed.

Matos-Pagán came to Blas’ home in Aguadilla, Puerto Rico, to give her the vaccine. The family cheered the moment the vaccination was over.

“It’s been really special to have intimate moments in someone’s home during vaccinations. You can tell how much it means to their entire family,” Matos-Pagán said afterward.

Mobilizing during a crisis is nothing new for Matos-Pagán. In the aftermath of Hurricane Maria, which cut off water and electricity to the entire island and claimed more than 3,000 lives, Matos-Pagán conducted initial community assessments in Puerto Rico’s remotest and hardest-hit cities. Flooding and debris made many roads inaccessible, blocking these communities from basic needs such as food, water, prescription medications and transportation. Then, after a series of earthquakes in 2020 rocked the island, leaving even more people without housing or in substandard structures, Matos-Pagán organized local nurse practitioners to provide community health care. They supplied at-risk populations with their medicines when pharmacies closed, and teams set up mobile medical tents near overcrowded hospitals.

“I’m hyper and busy in my daily life, but when there is a crisis, I am calm and still. Grounded. I feel like I’m where I belong,” she said.

Matos-Pagán was born in New York City. She became interested in medicine after watching nurses support her mother, who died of complications from an aneurysm when Matos-Pagán was 9. Her mother’s death taught her “nothing was permanent,” she said, which has inspired her to act when disaster strikes and support people through personal tragedy and loss.

Matos-Pagán returned to Puerto Rico to study nursing and later earned a master’s degree and a doctorate at the University of Puerto Rico-Mayagüez. Through her work, she holds various titles: first commander of the Puerto Rican Disaster Response Team, and director and founder of the Coalition of Nurses for Communities in Disaster.

Her experiences managing medical professionals and resources during hurricanes have taken her to locations across the U.S. Atlantic coast and the Caribbean. During the covid pandemic, she was recruited to assist in triage leadership for an ICU floor short on resources in El Paso, Texas, and a hard-hit senior living facility in Maryland.

“Not everyone is built for this. It’s really sad, depressing work,” Matos-Pagán said. “But even when there are mass casualties, you can still save lives and get people’s basic needs met. I’ve seen communities come together in the most incredible ways. It’s a challenge, but that’s what keeps me going.”

And, even as she is rapidly trying to get more covid shots into the arms of Puerto Ricans, Matos-Pagán is preparing for the next crisis. Hurricane season officially began in June, and she will be on disaster-ready duty until the end of November.

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“Stay home!” another user replies.

The Facebook group called “” has been flooded with pointed, exasperated comments urging travelers to stay away. This is a marked change. Before the pandemic, the exchanges between vacationers and island residents resonated with promises of excitement and fun. Now, tour operators from the mainland who administer the Facebook page quickly try to delete any expressions of anger.

In nearby Puerto Rico, the friction has spilled into real life. have detailed multiple episodes in which tourists, having escaped pandemic restrictions back home, became violent and destroyed store merchandise after being asked to wear a mask.

The COVID-19 pandemic has pitted economic interests against public health guidance all across the United States. Puerto Rico and the Virgin Islands feel this tension acutely, as both U.S. territories rely on tourism to generate revenue and provide jobs. Increasingly, locals have begun to wonder now if welcoming visitors to these islands is worth the risk.

Tourism represents more than half of the Virgin Islands’ gross domestic product. In Puerto Rico, the industry accounts for 80,000 jobs and about 6.5% of the island’s total economy.

But islanders are not only vulnerable to COVID-19’s economic disruptions. Residents of both Puerto Rico and the Virgin Islands are diagnosed with chronic health conditions like diabetes and cardiovascular illness at higher rates than in most U.S. states, which puts them at higher risk for the virus’s complications.

In short, the very industry that represents an economic lifeline for islanders threatens their ability to protect their health.

One Step Forward

When COVID-19 triggered alarms in late winter, Puerto Rico and the USVI adopted strong COVID prevention strategies before most U.S. states did.

In Puerto Rico, Gov. Wanda Vázquez issued an executive order, effectively locking down the island by imposing a curfew, a stay-at-home order and business closures. The first coronavirus cases on the island were reported March 13.

Similarly, Virgin Islands Gov. Albert Bryan Jr. issued prohibiting hotels, villas and other accommodations from accepting leisure guests between March 25 and June 1. The area remained open to business travelers, flight crews, health officials, emergency personnel, government guests and residents. According to a March 20 Department of Health , the territory had — at that time — six confirmed COVID cases and 43 pending test results.

Neither territory, however, was able to close its airports. Local officials do not have the authority to do so because the federal government regulates aviation.

“Part of the challenge of being a U.S. colony, in particular, is that, you know, we don’t have control over our borders,” said Hadiya Sewer, president and co-founder of St. JanCo: the St John Heritage Collective, a cultural heritage preservation and land rights organization on the small island of St. John, U.S. Virgin Islands.

Still, the aggressive measures — while effective — came at a price for residents like Melina Aguilar.

Before the lockdown, the 31-year-old entrepreneur worked as a tour guide for Isla Caribe, a company she founded that offers historical walking tours of Ponce, Puerto Rico. The stay-at-home order in March shut down Aguilar’s business for three months and sequestered her in her house.

Aguilar said the sacrifice would have been worth it if the island could have maintained control of the spread by closing the border and enforcing the 14-day quarantine for travelers. It didn’t work out that way. According to from The New York Times, the seven-day average for cases on May 1 — while Puerto Rico was still in lockdown — was 42 cases per day. On July 1, the seven-day average was 102 cases. By July 15, the average was 233.

“We could’ve basically had the fruits of being locked up for three months,” Aguilar said. “But now we’re stuck.”

Reopening the Gateway

By summer, both territories were itching to get back to business. With many overseas vacation destinations banning U.S. travelers, it seemed like the nearby mainland would be full of beachgoers, who, after living under stay-at-home orders for months, would be ready to travel — no passport required — to the sun and sand.

The U.S. Virgin Islands formally welcomed tourists back to its shores on June 1 — with caveats. Travelers from coronavirus hot spots needed to submit COVID-19 test information through an to receive a negative result “certification code.” Those who didn’t were required to quarantine for 14 days or until they had documentation of a negative test result.

But locals and tourists alike said COVID enforcement measures haven’t been consistent. Capt. Matthias Bitterwolf, owner of Antillean Yacht Charters on St. Thomas, said he delivered a boat to Puerto Rico and was not allowed off the vessel until local police could verify his COVID paperwork. His COVID status was not checked upon returning to St. Thomas.

The Virgin Islands’ case counts soon began ticking up. Between June and mid-July, the case count increased by more than 3,500%, according to one.

Gov. Bryan responded by issuing other to regain control of the outbreak, including prohibiting beach visits after 4 p.m. and not allowing patrons to stand or eat at bars located in restaurants. As of Aug. 24, the USVI had a total of .

Puerto Rico formally welcomed tourists on July 15 while still imposing some COVID-related restrictions. As in the Virgin Islands, officials required travelers to present documentation of a negative COVID test result upon arrival.

Dr. Victor Ramos, president of the island’s medical association who is involved with the, said these decisions tended to expose the rift “between the medical task force that favors closing things and the economic task force that wants to leave everything open.”

By July, the local economy was in shambles. The Department of Labor reported over 21% of the island’s workforce was receiving unemployment assistance related to the pandemic in the .

But rising case counts attributed to travel prompted local officials to encourage that only essential travel be allowed. As of Aug. 24, had recorded over 30,700 COVID cases and at least 395 deaths, according to the New York Times database.

Government data, though, indicated Puerto Rico’s climbing case numbers were not being triggered by tourists. They are not the culprits, insisted Leah Chandler, chief marketing officer of Discover Puerto Rico, the island’s official tourism website. Rather, the spread was linked to island residents coming home after visiting COVID hot spots like Texas and Florida.

Life on the Ground

Despite the global pandemic and the restrictions, both territories have experienced no shortage of vacationers. “We would have expected this to be a slow moment for us in terms of tourism,” said Sewer. “It’s very busy.”

Still, the trend lines for COVID case counts weren’t moving in the right direction for either territory, so it was no surprise when Puerto Rico closed days after reopening and the USVI followed suit on Aug. 19.

The underlying socioeconomic and health issues put residents in both places at high risk. It’s not just the prevalence of chronic health conditions like diabetes and cardiovascular disease. The high number of multigenerational households in both areas complicates a family’s ability to socially distance from its most vulnerable members. Roughly of the population in Puerto Rico and the Virgin Islands is age 65 or older, and poverty is widespread.

At the same time, both territories have limited health care infrastructure — making it difficult to envision that they can care for their own populations in an emergency let alone visitors who could become ill and island-bound if the virus were to surge.

Currently, the USVI has two main hospitals — one in St. Thomas and one in St. Croix — and a health clinic in St. John. The territory has 20 intensive care unit beds and about 100 one-time-use ventilators for its residents, said Justa Encarnacion, the USVI’s health commissioner. Each island has about 30 full-capacity ventilators.

In Puerto Rico, about of the island’s ventilators for adults were available as of Aug. 24. However, ICU beds are harder to come by, said Ramos. They are filled with COVID patients and those whose conditions worsened after avoiding care out of fear of catching the virus, he said.

The string of problems that have besieged these islands magnifies the effects of the pandemic. That includes debt crises and infrastructure damage from hurricanes and earthquakes. Island residents also fear the possibility of battling a hurricane and a coronavirus outbreak at the same time — a reality that they’ve already confronted when COVID hampered the USVI’s emergency management agency’s ability to distribute sandbags ahead of a storm in .

Colorado State University hurricane researchers predict an 2020 Atlantic hurricane season.

“At this point, we literally have disasters layered on top of disasters,” said Sewer, of the St. John’s Collective.

Still, Joseph Boschulte, tourism commissioner for the Virgin Islands, is cautiously optimistic about finding a balance between health and economic interests.

“We appreciate the concerns of our tourism partners and stakeholders,” he said. But with the spike in cases, he said, “we must reset, take stock, safeguard human life and prepare for restarting our tourism economy at a later date.”

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The study in JAMA Network Open found that 7.2% of the students reported “clinically significant” symptoms of PTSD. More girls tended to show signs of PTSD than boys.

Researchers surveyed 96,108 public school students five to nine months after the 2017 hurricane. The cohort included youth in third through 12th grades across different regions of the island.

The Puerto Rico Department of Education — which partnered with the Medical University of South Carolina for this study — is using the data to target areas with the greatest need for mental health services, the study said.

Maria, which struck the island as a Category 4 hurricane in September 2017, killed an within the American commonwealth. Residents struggled to access clean water and some remained without electricity nearly a year after the storm.

It had dramatic effects on the students. Nearly 46% said their home was damaged. More than 32% experienced shortages of food and water. And roughly 58% reported they had a friend or family member leave the island. The effects did not vary based on where the students lived or their families’ income.

Rosaura Orengo-Aguayo, a clinical psychologist at the Medical University of South Carolina and the study’s lead author, said the findings show the breadth and indiscriminate nature of the devastation.

“That just speaks to how big Maria was, how destructive Maria was island-wide,” she said. “And it didn’t matter what your income was or your location was on the island — you were affected.”

Similar problems have been of the Caribbean also affected by hurricanes in 2017.

Congress is at a stalemate in passing an aid bill that would send more resources to Puerto Rico and other areas affected by natural disasters. President Donald Trump has to provide more money to the island.

The trauma caused by a natural disaster can manifest itself in a variety of ways, said Frank Zenere, district coordinator of the crisis management program at Miami-Dade County Public Schools, who was not associated with the study. Family units can break down through divorce or domestic violence, he said. Young children can revert to thumb-sucking or wetting the bed. Teens sometimes try to exert control by acting out or turning to drugs to self-medicate.

To be sure, Zenere said, most people who survive a natural disaster do not develop long-term mental health conditions.

“They’re distressed by it. It has impact on their life — yes,” said Zenere, who helped coordinate mental health efforts in Puerto Rico in Maria’s aftermath. “But the great majority are not going to develop psychiatric illness.”

Zenere said the differences by gender found among students reporting symptoms of PTSD align with existing literature — boys are more likely to act out, while girls are most likely to show depression and anxiety.

The study’s authors said the loss and disruption caused by Maria contributed about 20% toward the youth’s symptoms of PTSD. While the researchers did not measure what other circumstances played a role, Orengo-Aguayo said, other “protective factors” — like eventually securing basic needs and community support — influence resiliency.

Notably, Orengo-Aguayo said, the level of PTSD symptoms reported in the study is lower than what was expected. Some studies show up to a third of children will develop chronic symptoms after surviving a natural disaster, the authors wrote.

Familial ties or the fact that the study was conducted several months after the storm could have played a role in the children’s resilience, she said. Or the children might still be attuned to trying to survive.

“What we might be seeing is that children at that stage were still focused on getting access to basic needs,” she said.

Regan Stewart, a clinical psychologist at the Medical University of South Carolina and a study co-author, said the team has secured two grants from the federal Substance Abuse and Mental Health Services Administration to continue work on the island for at least three more years. It plans to use telehealth to expand access to mental health services and train school staff and mental health professionals on trauma-focused interventions.

However, public schools in Puerto Rico are burdened by economic constraints. The island — already facing a budget crisis — closed 300 schools over the past two years exacerbated by Hurricane Maria.

Zenere said school staff members are among those who need to be cared for first, “because they’re going to be the glue that keeps it together for that classroom of 20 children or so.”

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But not in Puerto Rico. Medicaid patients in the American territory get no coverage for these drugs.

The joint federal-territory health care program for the poor — which covers about half the island’s population — does not pay for hepatitis C medications.ÌýThey also do not cover liver transplants, a procedure patients need if the virus causes the organ to fail.

The Puerto Rico Department of Health created a separate pilot project in 2015 to provide hepatitis C medications to those sickened by the liver infection who also have HIV but expanded the program later to those with only hepatitis C. However, according to the Office of Patient Legal Services, an official territorial agency that advocates for consumers, the program ran out of funding and is no longer accepting patients only with hepatitis C.

The Puerto Rico Health Insurance Administration (ASES), which oversees Medicaid, said it is working with a pharmaceutical company to create a cost-effective system to provide these medications.

“Definitely, they need to be given coverage,” said ASES director Angela Ávila Marrero. “They need to be given care.”

Hepatitis C, a bloodborne infection, increases the risk of cirrhosis, liver cancer and death. Poor screening led many to contract the disease through tainted blood and organ transplants into the early 1990s. Today, intravenous drug use drives in the United States.

William Ramirez, executive director of the American Civil Liberties Union of Puerto Rico, said he is considering filing suit against Puerto Rico for failing to cover the cost of these medications for people enrolled in Medicaid.

“You’re holding back medication and thereby allowing certain people to die,” Ramirez said.

That reality is clear for Hector Marcano, 62, who stopped working roughly six years ago because of the illness. After recovering from a drug addiction, he was a case manager who worked to connect drug users to health resources.

His liver disease is leading to overall deterioration. He struggles with walking. A bout of pneumonia that left him hospitalized lingers in his racking coughs. He spends his days reading, listening to the radio and praying for the strength to keep searching for the cure.

He doesn’t understand why the government does not provide hepatitis C medications, he said, especially as there are so many people in need of them.

“So what are we waiting for?” asked Marcano. “For a pandemic to happen?”

Medicaid Costs Drive Island’s Debt Crisis

Hepatitis C afflicts approximately 3.5 million people in the United States. The virus can silently corrode the liver for years without causing symptoms.

Because of the condition’s stealthy nature and the absence of recent data, the number of people in Puerto Rico living with the virus is uncertain. Researchers on the island in 2010 2.3 percent of 21- to 64-year-old residents had the virus.

Documents provided by the Center for Health Law and Policy Innovation of Harvard Law School show medical providers reported more than 11,000 hepatitis C cases to the Puerto Rico Department of Health from 2010 to September 2016.

Cynthia Pérez Cardona, an epidemiology professor at the University of Puerto Rico and an author of multiple studies involving hepatitis C in Puerto Rico, said she is uncertain of how widespread the virus is on the island. But other statistics present a worrisome sign: A report from the island’s found the number of new liver cancer cases increased an average of 2.1 percent annually among men and 0.7 percent among women from 1987 to 2014. Hepatitis C can cause such cancers.

Despite these warnings, Puerto Rico has fewer resources than most of the nation to care for its impoverished.

Unlike states, Puerto Rico’s federal funding for Medicaid is capped. Historically, these federal dollars have fallen far short of covering the program’s costs on the island. The territory’s crushing Medicaid expenses helped drive the island into its $70 billion debt crisis.

Under these financial constraints, said Matt Salo, executive director of the National Association of Medicaid Directors, Puerto Rico’s officials are left with a difficult choice when considering covering hepatitis C drugs.

“Rather than blowing through their cap in six months,” Salo said, “they’d blow through their cap in one month.”

Pilot Project Falls Short

In the health department’s , patients with certain conditions like uncontrolled diabetes or an active mental health condition or those who could not prove they had been sober for six months were barred.

Such restrictions rankle patients and their advocates. “You know, we do not deny lung cancer treatment for a person who smokes or diabetes treatment to a person that doesn’t eat well,” said Robert Greenwald, a professor at Harvard Law School and faculty director of the Center for Health Law and Policy Innovation.

Dr. José Vargas Vidot, a member of Puerto Rico’s Senate and a physician, submitted a petition in 2017 to various territorial agencies questioning Medicaid’s coverage of hepatitis C medications.

The Office of Patient Legal Services responded to Vargas Vidot in a letter this year confirming that the island’s Medicaid program did not cover these drugs. It also noted the health department pilot project closed its wait list after reaching 100 patients because of a lack of funding. In November, Vargas Vidot submitted legislation to require that hepatitis C medication and treatment be part of basic coverage for insurance plans and Medicaid.

Ávila Marrero said ASES is in talks with a drugmaker to create a network separate from the Medicaid program to provide medications to the patients. She said she hopes the arrangement will allow the government to get lower prices for the drugs. But no agreements have yet been reached for such a program.

Despite its success in states, suing to get coverage may not be the best option for Puerto Rico because the debt rescue package passed by Congress in 2016 includes a provision that bars creditors from taking legal action to collect from the territory.

That could apply to a lawsuit filed against the territory for not covering hepatitis C treatment in its Medicaid program, said Phillip Escoriaza, a health and federal grants law attorney in Washington, D.C., who practiced in Puerto Rico. And even if the case can go forward, it would enter the docket for a special bankruptcy court with more than , as of Dec. 14. It may be in the Puerto Rican government’s interest for things to take a long time, said Escoriaza. Once there, it could stall for years — time hepatitis C patients such as Marcano might not have.

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“3000 people did not die” in Puerto Rico, the president tweeted.

The death toll from the Sept. 20 storm, a Category 4 hurricane, has been a point of contention between officials and residents who live there. George Washington University (GWU) researchers of an in-depth investigation commissioned by Puerto Rico’s government. They estimated 2,975 people died as a result of the storm.

3000 people did not die in the two hurricanes that hit Puerto Rico. When I left the Island, AFTER the storm had hit, they had anywhere from 6 to 18 deaths. As time went by it did not go up by much. Then, a long time later, they started to report really large numbers, like 3000…

— Donald J. Trump (@realDonaldTrump)

…..This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico. If a person died for any reason, like old age, just add them onto the list. Bad politics. I love Puerto Rico!

— Donald J. Trump (@realDonaldTrump)

The president questioned that report’s credibility, insinuating that the count was a ploy by his political opponents and that it included people who died from causes unrelated to the storm.

“This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico,” he tweeted. “If a person died for any reason, like old age, just add them onto the list.”

The tweets prompted a sharp rebuke from Puerto Rico Gov. Ricardo Rosselló, who called for recovery efforts to remain above the political fray.

“The victims and the people of Puerto Rico do not deserve to have their pain questioned,” the governor’s statement said.

Here is a brief look at the issue of casualties and Puerto Rico’s response to Hurricane Maria.

How many people died?

Calculating a death count is not an exact science. Estimates are influenced by a variety of factors including the period analyzed and the definition of a disaster-related death, according to Columbia University professor John Mutter.

The Puerto Rican government accepts GWU’s estimate of 2,975 deaths as the official count. Local officials had originally said 64 people died in Hurricane Maria, counting only fatalities directly attributable to the storm, such as drowning deaths or mortal injuries caused when buildings collapsed. During the summer they had risen to more than 1,400.

The GWU their estimated death toll, which is about double that tally, by comparing the number of people who died in the six months after Hurricane Maria to historical averages in previous years.

The university issued a statement Thursday, disputing Trump’s comments. The investigation was “carried out with complete independence and freedom from any kind of interference,” according to the .

Prior to the GWU study, other researchers and one newspaper released estimates that also garnered media attention.

One , published in the New England Journal of Medicine, put the number of excess deaths at 4,645 in the three months following the hurricane. A by The New York Times used vital records from the government to calculate an excess of 1,052 deaths in the first 42 days after the disaster.

Still, the numbers are important, said Mutter, who researches disaster management and worked on collecting the number of deaths in New Orleans after Hurricane Katrina. These death counts are a key way the public measures a disaster and perception drives donations for relief, he said.

Why was it so confusing getting a death toll?

When Hurricane Maria made landfall in Puerto Rico, it devastated the island’s infrastructure, which can limit access to health care and impact mortality, especially among residents who are frail or dealing with chronic health issues.

The storm knocked out electricity for the entire island, which took nearly a year to restore fully. At least 80 percent of communications towers were not operational, crippling phone services. Medical centers across the island relied on generators for power, which sometimes failed and jeopardized patients. Some medical facilities in Puerto Rico were irreparably damaged, like the only hospital on the island of Vieques, which housed its only dialysis center. Residents must now leave the island three times a week for treatment.

Many roads on the island were impassable because of debris or erosion. Roads near rivers, like those in the mountainous, rural province of Utuado, washed away. Bridges also fell, leaving some communities isolated and unable to access assistance.

Hurricane Maria also cut off drinking water to more than half of Puerto Rico. The lack of electricity meant water pumps could not work. Some people turned to other sources, like natural springs and rivers, for drinking water. At least 26 people died of leptospirosis, a bacterial infection caused by exposure to water or soil contaminated with the urine of infected animals, from CNN and the Centro de Periodismo Investigativo, a nonprofit group that promotes investigative journalism.

In addition to the physical disruption, the GWU researchers noted that officials in charge of certifying deaths did not have a process that automatically noted when a death was a consequence of the hurricane or its aftereffects.

How did the federal government do in its response to Hurricane Maria?

According to the federal government, not very well.

A released earlier this month by the U.S. Government Accountability Office (GAO) details how the Federal Emergency Management Agency (FEMA) struggled to meet the needs of Puerto Rico and the U.S. Virgin Islands after the storms.

The agency didn’t provide adequate staffing to the disasters on the islands, according to the GAO. It faced a 37 percent staffing shortage as of Sept. 1, 2017. Of the personnel deployed to the islands, some “were not physically able to handle the extreme or austere environment of the territories,” the report said. The lack of bilingual employees also led to delays since many Puerto Ricans speak Spanish.

Transporting materials to the island was also an issue for the agency, as both islands are located more than 1,000 nautical miles from the mainland, the report said.

FEMA Administrator Brock Long addressed some of those issues Tuesday in . “We threw as much as we could towards Puerto Rico,” he said.

He added that FEMA’s prime concern is preventing deaths from natural disasters, but also that “there’s a difference between direct deaths of, you know, the winds, water, collapsed buildings, things that kill people directly versus the indirect deaths. Indirect deaths are always higher than the direct deaths after many events. … But what I really believe is that we have to concentrate on the pre-disaster mitigation, fix the infrastructure that was crumbling before the storms in the commonwealth, so that we prevent this from ever happening again.”

He noted that FEMA is now the largest employer in Puerto Rico as repair efforts continue.

What has the Puerto Rican government done in response to the death counts in Hurricane Maria?

After the GWU findings were released, Gov. Rosselló changed the official death count and accepted responsibility for the territory government’s failure to adequately respond to residents’ needs. He also said he would form a commission to consider the recommendations suggested in the GWU study on how to improve the island’s response to disasters.

However, how many changes the territory’s government can make remains to be seen. Puerto Rico’s purse is under the control of a fiscal oversight board put in place by Congress to address the island’s debt crisis, which stands at more than $70 billion.

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Gov. Ricardo Rosselló, who asked for the research following criticism of the American territory’s low death count, said his government accepts the new numbers and wants to learn from the crisis.

“The magnitude of the catastrophe was without precedent in Puerto Rico and there was certainly disagreement with the total number,” Rosselló said at a press conference. The Ìýby researchers at the George Washington University’s Milken Institute School of Public Health who examined death records for six months after the storm and attributed 2,975 deaths to the disaster.

In comparison, Hurricane Katrina, which is one of the deadliest storms in U.S. history, killed more than 1,800 people.

Hurricane Maria barreled into Puerto Rico Sept. 20 as a Category 4 storm. Destruction was widespread, severely crippling the island. Both the electrical and water systems were knocked out in some areas for months. Hospitals and other public health services were damaged, doctors’ offices lost power and often remained closed and medical supplies were difficult to find.

Health advocates scoffed at the government’s initial death toll and said many people died after the storm because they lacked medicine, couldn’t get adequate medical treatment or had chronic diseases that were aggravated by the post-storm conditions.

The official government estimate of 64 deaths was low because it counted only those directly attributable to the storm, such as drowning deaths or injuries caused when buildings collapsed, according to the report. The George Washington researchers instead inspected death certificates and other records, and they calculated the excess deaths by comparing historical death rates to the actual number of people who perished.

In addition, the GW researchers analyzed death statistics for age groups, gender and geography.

“I would say this is a study that can provide everybody a sense of security that, yes, this is a number that you can use as a reference for the future,” said Carlos Santos-Burgoa, principal investigator and professor of global health at GW’sÌý school of public health.

According to the study, the number of excess deaths is 22 percent higher than what would be expected had the hurricane not hit the island. The risk of dying for men over the age of 65 was 35 percent higher than the baseline, and it remained elevated through the end of the study. And people living in poorer areas were 45 percent more likely to die.

Santos-Burgoa said the risk people in poorer municipalities faced is a “major concern” because it shows the level of inequity on the island before the hurricane hit and was exacerbated in the aftermath.

“It’s a very strong message in Puerto Rico and people addressing natural disasters all over the world: Don’t treat people as homogenous groups,” Santos-Burgoa said.

At a briefing for reporters in San Juan, Rosselló discussed several initiatives to bolster the island’s disaster preparedness, including counting vulnerable populations like the chronically ill and creating a commission to handle recommendations to improve the island’s emergency response systems.

“This is a time for Puerto Ricans to bind together, to mourn, to reflect on the things that were done properly and things that were mistakes,” he said. “And have the firm commitment to identify those mistakes and make sure that moving forward toward the future, those mistakes aren’t committed.”

The report is the latest in a series of analyses done by universities and one newspaper to answer the question of how many perished in the storm.

A survey published in May in the estimated more than 4,600 excess deaths occurred from the day the hurricane made landfall to the end of the year. A separate investigation by found 1,052 lives lost. A published in JAMA in August estimated more than 1,100 deaths.

Earlier this summer, Puerto Rican officials data that dramatically upgraded its official death toll to 1,427.

The researchers also examined Puerto Rico’s crisis communications and death certification process in place during Hurricane Maria. Interviews at the governor’s central communications office revealed there was no written plan in case of a disaster. Government officials said they had no knowledge of a coordinated plan between the health department and public safety department to report deaths.

Instructional materials about death certification did not tell providers how to handle deaths in the event of a disaster. And so many deaths that were related to the damage from the hurricane were not recorded as storm-related, complicating efforts by officials to identify Maria’s death total.

John Mutter, a professor at Columbia University who researches disaster management, said death certificates are “critical” to determining what is attributable to the hurricane. Mutter, who was not involved in the GW study, said specific death information can help researchers identify who died as a result of the disaster and who were the most vulnerable populations.

“It is the way we scale tragedy,” he said, noting that he believes the GW study is a good estimate.

The report offered recommendations on how Puerto Rico can improve its response systems, including updating communications plans and enhancing training for public health professionals. Those investments could prove tricky for the island, however, because its finances are controlled by a federally appointed fiscal control board.

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The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory’s agreement with the federal government as the island claws its way back from fiscal oblivion.

Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory’s historically astronomical Medicaid expenses — on an island where the average household earns $20,000 and diabetes and hypertension are widespread.

But physicians, health insurers and former government officials say the drastic cuts demanded defy actuarial science and provide too little money to care for a population still traumatized by Hurricane Maria.

The cutbacks will give private health insurance companies the incentive to shuttle around patients with costly chronic diseases or mental illness, critics warn. And they do nothing to address the underlying fiscal imbalance at the root of Puerto Rico’s health care woes, which stem from the fact that the federal government contributes a tiny fraction of the island’s Medicaid budget, compared to what it contributes to the 50 U.S. states.

“We are rearranging the chairs on the Titanic,” said Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.

Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.

“These people who have been under our service for the last four or five years, all of a sudden I have to abandon them,” said Dr. José Joaquín Vargas, chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.

Health Crippled By Debt

If Puerto Rico were a state, the federal government would pay 83 percent of Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in ,Ìýaccording to a formula that takes a state’s economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent, as a fixed annual payment — a so-called block grant.

In February, Congress approved $4.8 billion in additional funds to help pay the island’s Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory’sÌý.ÌýThat’s a federal control board established by Congress in 2016 to oversee Puerto Rico’s budget, negotiate with its creditors and help restructure at least some of the island’s debt.

Gov. Ricardo Rosselló’s administration aims to reduce Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló’s plan, the companies will be forced to offer island-wide insurance plans and compete for customers.

“We do not have the luxury” of continuing to spend inefficiently, said Ángela Ávila Marrero, executive director of Puerto Rico’s Health Insurance Administration.

If Rosselló’s overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Some — — are at risk of losing coverage next fall, their health held hostage to the island’s need to pay back its crippling debt.

Puerto Rico’s government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession,ÌýÌýand reckless spending by a bloated government.

But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico’s staggering Medicaid burden.

Poverty is so pervasive here that nearly 1 in 2 people qualify for public health insurance; Medicaid expensesÌý. Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.

Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island’s fiscal health, health economists say.

Researchers of health care say that, putting aside interest on Puerto Rico’s debt, the territory’s primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.

“The main issue is that we are not yet a state,” said Rep. Jenniffer González-Colón, the commonwealth’s nonvoting member of Congress. The island must pay for Medicaid, she added, “with local funds that we don’t have.”

Battered Even Before The Storm

Puerto Rico’s health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act and Ìýwould lose coverage.

Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology and fueled the exodus of thousands of physicians to the mainland in search of better incomes.

Today, Medicaid patients face long waits to see doctors on the island.

“If your kid needs a neurologist, for example, the waiting period is around six to 12 months,” said Dr. Jorge Rosado, a pediatrician in San Juan. “For a genetics specialty, it’s two to three years.”

The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.

Little Time To Waste

Barring the unlikely passage of that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out next fall. González-Colón also calling for statehood, which would eliminate the federal government’s unequal treatment toward the island’s Medicaid program.

The fiscal control board established by CongressÌýopenly acknowledges the impending disaster. In anÌýthe board projects monthly costs per Medicaid patient will rise nearlyÌýover the next six years, barring any changes, and that Puerto Rico “will hit a ‘Medicaid cliff.'”

Beginning this fall, Medicaid patients will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.

Puerto Rico has long capped monthly payments insurers receive for Medicaid patients regardless of how many medical services they use, a form of managed care. But the government here believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.

The island’s government has vowed to pay private insurers extra money to care for those with expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.

“I support the government on what they’re trying to do, but they didn’t price it properly,” said Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.

He added, “The oversight board is fixated on cuts, but we’re never going to improve health care unless more money is put into the system.”

Government health officials argue Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But the island’s clinics and hospitals fear they will be squeezed by insurers seeking to lower costs, just as they are still reeling from hurricane-related expenses.

Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.

Many experts are skeptical that managed-care companies will hire the army of social workers and nurses like Calderón needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty. Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.

Many people displaced by the storm haven’t yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.

“The managed-care companies need to produce revenue,” said Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. “That’s a setup for concern.”

Bottom line? The economic overhaul doesn’t rectify Puerto Rico’s fundamental problem — it can’t sustain its Medicaid program so long as Congress treats the territory differently than it treats states.

“Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens,” said Torres. But, he added, “it’s time the local government started thinking about a Plan B.”

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Their analysis found an increase of 1,139 deaths over what would be expected in Puerto Rico in the 2½ months following the storm. The Category 4 storm lashed the American territory last September, displacing tens of thousands of residents, destroying the electric grid and downing communications services. The National Hurricane Center estimates the storm caused $90 billion in damages in

The new count comes in a research letter published Thursday in the journal JAMA that compared death certificates obtained from the Puerto Rican government to the historical average for deaths over a three-month period.

Researchers first calculated the average number of deaths per month from January 2010 to December 2017 and an upper and lower limit for the number of deaths that had occurred in each month. Their findings concluded that an excess of 459 deaths occurred last September, 564 in October and 116 in November. The count normalized by December.

Alexis Santos-Lozada, a co-author of the research letter and an assistant professor of human development and family studies at Penn State University, said he was puzzled as to why the island’s government has kept the official death count at 64. The documents his team used came from the territory’s cache of data.

“We just didn’t want inaccurate numbers to guide policy decisions such as money to mitigate the effects of the hurricane or money to remediate and rebuild the island,” Santos-Lozada said.

The study’s results come close to one earlier estimate of the storm’s deaths. An analysis by of the government’s vital-statistics records found that the number of deaths in the 42 days after the storm were higher than expected by 1,052.

But other estimates have varied widely.

The Puerto Rican government’s official count has been widely criticized as too low. , published in May in The New England Journal of Medicine, reported 4,645 people died as a result of the storm. Those findings were calculated from a random survey of more than 3,200 households on the island.

Stung by the controversy over fatalities, Puerto Rico’s government contracted with George Washington University researchers to conduct an independent death count. Those results are expected later this summer.

John Mutter, a professor at Columbia University who researches disaster management and who worked on collecting the number of deaths in New Orleans after Hurricane Katrina, said the United States does not have a defined position on a federal or state level about who is responsible for estimating fatalities after natural disasters.

The Centers for Disease Control and Prevention does “a very, very conservative” count, he said, but these numbers can vary based on the parameters used by the researchers compiling the data.

“When people talk about the official death count,” Mutter said, “who’s the official who made the count?”

Among the factors that can influence the results of any estimate are the timespan analyzed and the definition of a hurricane-related death, Mutter said. People with preexisting medical conditions who perish in a natural disaster are sometimes not quickly picked up as part of the count since their illness preceded the natural emergency. However, Mutter said, these individuals are generally counted.

In Puerto Rico, this is an important group. Many people’s illnesses were exacerbated by the lack of supplies, clean water and especially the long-term power outages caused by Hurricane Maria. The lack of electricity meant ventilators could not run, medications such as insulin could not be refrigerated, and hospitals did not have the equipment available for fragile patients, such as premature newborns.

Regardless of who is included in the count, no assessment can capture everyone who died —especially in events that involve missing persons, said George Haddow, former deputy chief of staff for the Federal Emergency Management Agency during the Clinton administration.

“People disappear in disasters,” he said.

Mutter said it’s imperative that the most accurate death count possible be obtained because it drives the public’s attention — and dollars — to the needs of the survivors and to lessons for future disasters. Death counts like those seen in the aftermath of Hurricanes Katrina and Maria show a breakdown in the system that should be addressed.

“Big numbers always suggest something’s wrong,” Mutter said.

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Physicians are in short supply in Puerto Rico.

From 2006 to 2016, the number of doctors on the island declined from 14,000 to 9,000, according the College of Physicians and Surgeons of Puerto Rico. And Hurricane Maria has helped fuel the exodus.

Dr. José Cruz, a pediatrician with a practice in Ponce, said the island’s ongoing financial crisis and low payments from health insurers drove many physicians to seek work in the States.

Physicians say running a medical practice is a losing business in Puerto Rico. At San Jorge Children’s Hospital in San Juan, a pediatrician earning about $89,000 a year can double his salary just by moving to the States.

The low salaries reflect the island’s widespread poverty. Nearly 2 in 3 children — and half of all Puerto Ricans — rely on Medicaid, and the territory receives far less money from Congress to pay doctors than do low-income states.

KHN senior correspondent Sarah Varney reports in collaboration with “PBS NewsHour” on how Puerto Rico’s exodus of doctors is adding a new level of complication to delivering care.

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They’d watched nervously as invasive Aedes mosquito species that can carry the virus appeared in Los Angeles about a decade ago and began to spread, likely introduced by international trade and enticed to stay by a warming climate that makes it easier for mosquitoes to thrive.

Then, in October 2023, an email came from the Pasadena Public Health Department: A person in the city had contracted California’s first-known case of dengue from a local mosquito.

“When it happens in real time, real life, you know, it is very different,” Farned said. “There’s no room for error here. We have to be quick and effective in identifying the most at-risk areas and responding.”

Across California, public health and pest control authorities are facing a new reality as the Aedes mosquitoes bring the threat of dengue and potentially other tropical diseases, such as chikungunya, Zika, and yellow fever, that were once of concern only to international travelers.

So far this year, authorities have identified at least 13 cases of locally acquired dengue, up from two in 2023, with 11 in Los Angeles County and two in the San Diego area. The Aedes mosquitoes spread the disease by biting an infected person and then biting a previously uninfected person.

Mosquito-borne viral illnesses, chiefly malaria, have long been a scourge in many tropical regions, and preventive measures focus mainly on controlling the mosquitoes. The Aedes mosquitoes, known for their aggressive, daytime biting, are now present in at least 24 California counties. They breed in water, in as little as a capful.

“When these locally acquired cases occur, … we want to act on them pretty quickly so that it does not become an endemic infection in our region,” said Aiman Halai, director of the Los Angeles County Department of Public Health’s Vector-Borne Disease Unit.

California officials are hoping to beat back dengue by expanding mosquito surveillance, developing detailed response plans for mosquito outbreaks and human infections, and improving data sharing across agencies. They’re also going door to door in neighborhoods to remove standing water sources and apply pesticides. Residents are advised to wear bug repellent and long-sleeved clothing and control mosquitoes around their homes to prevent biting and infection.

Some vector control districts — local agencies charged with managing disease-bearing insects and other animals — are even growing their own sterile mosquitoes to release into the wild to reduce local Aedes populations.

Outside of California, locally acquired dengue cases have occurred in Arizona, Florida, Hawaii, and Texas. In March, Puerto Rico declared a public health emergency after a spike in cases there, where dengue is endemic. Meanwhile, worldwide dengue cases are on track to , with 12.3 million documented through August, up from 6.5 million in 2023, according to the World Health Organization.

Most people who get dengue have no symptoms, but about 1 in 4 become ill. A mild case can feel like the flu and usually dissipates within a week, but about 5% of those infected with dengue , with symptoms that can include internal bleeding, shock, and organ failure, and the most severe cases can be fatal. People infected a second time are at especially high risk.

There is no specific medication to treat dengue. Japanese pharmaceutical company Takeda developed a vaccine that has won approval in Europe and elsewhere, though it withdrew an application to the FDA last year, saying it could not provide data requested by the agency. A vaccine developed in Brazil could soon be approved for use in that country. But the only FDA-approved vaccine is authorized only for children in narrow circumstances and will soon go out of production.

At the San Gabriel Valley Mosquito and Vector Control District, one of five agencies tasked with mosquito control across Los Angeles County, public health workers have put together an Aedes and dengue response plan based on from the state.

When they discover a case, they identify all the properties and public spaces within 150 meters — roughly the distance an Aedes mosquito can fly — and then go door to door, removing standing water, where mosquitoes can breed; applying pesticides from backpacks or trucks; and educating residents about the risk of dengue and how to protect themselves. District officials also set traps to catch mosquitoes so they can figure out their prevalence and test them for dengue.

Since local dengue cases began to appear, the district has gotten more efficient in implementing its response plan, district manager Farned said. All full-time and seasonal staff members — about 40 people — have been trained in a variety of tasks, such as door-to-door education and coming in during off-hours to answer phones, Farned said.

While vector control teams respond to cases, separate teams from the Los Angeles County Public Health Department go door to door in the affected neighborhood when they determine that a dengue case was locally acquired, surveying residents and offering free dengue testing to try to identify others who may be infected.

Additionally, the department has been sending alerts to local health providers, advising them to be on the lookout for possible dengue cases and test for it when suspected, even among patients who haven’t traveled to a place where dengue is endemic. This advice follows a put out by the Centers for Disease Control and Prevention in June. Health authorities are also emphasizing that people who travel to locations with dengue should continue to wear mosquito repellent when they get home, to reduce the risk of spreading the disease to local mosquitoes.

As happened during the covid-19 pandemic, mistrust of public health authorities can make outreach challenging for health and pest control teams in some neighborhoods, officials said.

Pest control officers can seek a warrant to enter and treat a property for mosquitoes if a homeowner refuses to give access, said Jeremy Wittie, a former president and the legislative committee chair for the Mosquito and Vector Control Association of California, which represents the more than 70 mosquito and vector control agencies in California. This is easier in districts such as his, the Coachella Valley Mosquito and Vector Control District, that have warrants giving officials standing permission to enter a property after 24 hours without needing to ask a judge.

In counties such as Santa Clara, where Aedes mosquitoes but have yet to establish themselves, officials hope to suppress the threat with stepped-up surveillance, speedy eradication efforts, and more public outreach. Santa Clara County Vector Control District Manager Nayer Zahiri said the aim was to eliminate Aedes but acknowledged the climate conditions that encourage the mosquitoes’ spread are “totally out of our control.”

In some counties with pervasive mosquito problems, including , San Joaquin, and , officials have sprayed pesticides from planes or helicopters to address spikes in local mosquito populations, Wittie said. These sprayings typically aim to control the larvae of a different type of mosquito, Culex, that can spread West Nile virus and which — unlike the Aedes species, which thrive in urban habitats — are found in harder-to-reach rural environments, Wittie said.

Aerial spraying hasn’t been deployed to address the recent dengue outbreaks, which are in more urban environments where spraying from trucks is a better option, Wittie said. Drones are another option that some vector control authorities are exploring.

Some districts are experimenting with the decades-old sterile insect technique, commonly used for other pests such as fruit and screwworm flies, in which males are sterilized with radiation and then released to mate, resulting in eggs that don’t hatch. (Female mosquitoes are separated from the males before sterilization and not released. Only the females bite).

Ultimately, the public will have to take the mosquito threat more seriously and contribute to prevention efforts, Wittie said. “This mosquito is going to be here to stay, unfortunately. I hope it kind of wakes people up and pushes them to be part of that solution.”

This article was produced by Ñî¹óåú´«Ã½Ò•îl Health News, which publishes , an editorially independent service of the .Ìý

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Wildelma Gastón asked for her rosary to be placed on her chest and motioned to her “good arm,” where Matos-Pagán injected a first dose of the Moderna vaccine. The Gastón household, made up of five family members, breathed a collective sigh of relief. Though the vaccine had been available for months, Wildelma had been unable to reach a vaccination site. According to the Centers for Disease Control and Prevention’s COVID Data Tracker, Puerto Rico’s vaccination rate in March was one of the lowest among U.S. states and territories despite receiving more than 1.3 million vaccine doses. The rollout highlighted disparities in access to medical services, and the challenges of tracking and reaching remote citizens, such as Wildelma.

With each trip to school or work, family members worried about bringing the virus into their home and the threat to Wildelma’s life. Matos-Pagán also vaccinated two of Beatriz’s children, who are students at the University of Puerto Rico-Mayaqüez, during her visit.

“We have been waiting a long time for this moment,” Beatriz Gastón said as she hugged Matos-Pagán goodbye, expressing gratitude for the home visit. To her, the vaccine is more than protection from the coronavirus — it clears the way for the family to be together with her mother.

To Matos-Pagán, it is her latest calling. The nurse practitioner, who has guided relief efforts after hurricanes and earthquakes in Puerto Rico and elsewhere, has made it her mission in the U.S. territory to vaccinate as many people as possible against covid. Some residents of Mayagüez, a city on the western shore of the main island, candidly call her “The Vaccination Queen” and show up at her home asking for help in getting a shot.

According to The New York Times’ case tracker, as of Friday, Puerto Rico has had more than 182,000 covid cases and at least 2,594 deaths. About 57% of the population is fully vaccinated, but many of the unvaccinated are hard to reach because they live in remote mountainous communities or have chronic illnesses that leave them homebound. Matos-Pagán has vaccinated around 1,800 people in Puerto Rico so far, including 1,000 who have chronic illnesses or are bedridden.

In the pandemic’s early days, Carmen Blas’ health declined, and she began using a wheelchair. Blas, 78, was confined to her home, on the third story of an apartment building, which kept her safe from contracting covid, but later she couldn’t find transportation to a vaccination site. In June, her two children, Lisette and Raymond, visited from Wisconsin to help and immediately called the public health officials to get Blas inoculated.

“I usually come back every year and this was the longest I’ve ever been away. It was especially hard as my mother’s health worsened, and I worried I might never see her again,” said Raymond, who planned to extend his visit for as long as he was needed.

Matos-Pagán came to Blas’ home in Aguadilla, Puerto Rico, to give her the vaccine. The family cheered the moment the vaccination was over.

“It’s been really special to have intimate moments in someone’s home during vaccinations. You can tell how much it means to their entire family,” Matos-Pagán said afterward.

Mobilizing during a crisis is nothing new for Matos-Pagán. In the aftermath of Hurricane Maria, which cut off water and electricity to the entire island and claimed more than 3,000 lives, Matos-Pagán conducted initial community assessments in Puerto Rico’s remotest and hardest-hit cities. Flooding and debris made many roads inaccessible, blocking these communities from basic needs such as food, water, prescription medications and transportation. Then, after a series of earthquakes in 2020 rocked the island, leaving even more people without housing or in substandard structures, Matos-Pagán organized local nurse practitioners to provide community health care. They supplied at-risk populations with their medicines when pharmacies closed, and teams set up mobile medical tents near overcrowded hospitals.

“I’m hyper and busy in my daily life, but when there is a crisis, I am calm and still. Grounded. I feel like I’m where I belong,” she said.

Matos-Pagán was born in New York City. She became interested in medicine after watching nurses support her mother, who died of complications from an aneurysm when Matos-Pagán was 9. Her mother’s death taught her “nothing was permanent,” she said, which has inspired her to act when disaster strikes and support people through personal tragedy and loss.

Matos-Pagán returned to Puerto Rico to study nursing and later earned a master’s degree and a doctorate at the University of Puerto Rico-Mayagüez. Through her work, she holds various titles: first commander of the Puerto Rican Disaster Response Team, and director and founder of the Coalition of Nurses for Communities in Disaster.

Her experiences managing medical professionals and resources during hurricanes have taken her to locations across the U.S. Atlantic coast and the Caribbean. During the covid pandemic, she was recruited to assist in triage leadership for an ICU floor short on resources in El Paso, Texas, and a hard-hit senior living facility in Maryland.

“Not everyone is built for this. It’s really sad, depressing work,” Matos-Pagán said. “But even when there are mass casualties, you can still save lives and get people’s basic needs met. I’ve seen communities come together in the most incredible ways. It’s a challenge, but that’s what keeps me going.”

And, even as she is rapidly trying to get more covid shots into the arms of Puerto Ricans, Matos-Pagán is preparing for the next crisis. Hurricane season officially began in June, and she will be on disaster-ready duty until the end of November.

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“Stay home!” another user replies.

The Facebook group called “” has been flooded with pointed, exasperated comments urging travelers to stay away. This is a marked change. Before the pandemic, the exchanges between vacationers and island residents resonated with promises of excitement and fun. Now, tour operators from the mainland who administer the Facebook page quickly try to delete any expressions of anger.

In nearby Puerto Rico, the friction has spilled into real life. have detailed multiple episodes in which tourists, having escaped pandemic restrictions back home, became violent and destroyed store merchandise after being asked to wear a mask.

The COVID-19 pandemic has pitted economic interests against public health guidance all across the United States. Puerto Rico and the Virgin Islands feel this tension acutely, as both U.S. territories rely on tourism to generate revenue and provide jobs. Increasingly, locals have begun to wonder now if welcoming visitors to these islands is worth the risk.

Tourism represents more than half of the Virgin Islands’ gross domestic product. In Puerto Rico, the industry accounts for 80,000 jobs and about 6.5% of the island’s total economy.

But islanders are not only vulnerable to COVID-19’s economic disruptions. Residents of both Puerto Rico and the Virgin Islands are diagnosed with chronic health conditions like diabetes and cardiovascular illness at higher rates than in most U.S. states, which puts them at higher risk for the virus’s complications.

In short, the very industry that represents an economic lifeline for islanders threatens their ability to protect their health.

One Step Forward

When COVID-19 triggered alarms in late winter, Puerto Rico and the USVI adopted strong COVID prevention strategies before most U.S. states did.

In Puerto Rico, Gov. Wanda Vázquez issued an executive order, effectively locking down the island by imposing a curfew, a stay-at-home order and business closures. The first coronavirus cases on the island were reported March 13.

Similarly, Virgin Islands Gov. Albert Bryan Jr. issued prohibiting hotels, villas and other accommodations from accepting leisure guests between March 25 and June 1. The area remained open to business travelers, flight crews, health officials, emergency personnel, government guests and residents. According to a March 20 Department of Health , the territory had — at that time — six confirmed COVID cases and 43 pending test results.

Neither territory, however, was able to close its airports. Local officials do not have the authority to do so because the federal government regulates aviation.

“Part of the challenge of being a U.S. colony, in particular, is that, you know, we don’t have control over our borders,” said Hadiya Sewer, president and co-founder of St. JanCo: the St John Heritage Collective, a cultural heritage preservation and land rights organization on the small island of St. John, U.S. Virgin Islands.

Still, the aggressive measures — while effective — came at a price for residents like Melina Aguilar.

Before the lockdown, the 31-year-old entrepreneur worked as a tour guide for Isla Caribe, a company she founded that offers historical walking tours of Ponce, Puerto Rico. The stay-at-home order in March shut down Aguilar’s business for three months and sequestered her in her house.

Aguilar said the sacrifice would have been worth it if the island could have maintained control of the spread by closing the border and enforcing the 14-day quarantine for travelers. It didn’t work out that way. According to from The New York Times, the seven-day average for cases on May 1 — while Puerto Rico was still in lockdown — was 42 cases per day. On July 1, the seven-day average was 102 cases. By July 15, the average was 233.

“We could’ve basically had the fruits of being locked up for three months,” Aguilar said. “But now we’re stuck.”

Reopening the Gateway

By summer, both territories were itching to get back to business. With many overseas vacation destinations banning U.S. travelers, it seemed like the nearby mainland would be full of beachgoers, who, after living under stay-at-home orders for months, would be ready to travel — no passport required — to the sun and sand.

The U.S. Virgin Islands formally welcomed tourists back to its shores on June 1 — with caveats. Travelers from coronavirus hot spots needed to submit COVID-19 test information through an to receive a negative result “certification code.” Those who didn’t were required to quarantine for 14 days or until they had documentation of a negative test result.

But locals and tourists alike said COVID enforcement measures haven’t been consistent. Capt. Matthias Bitterwolf, owner of Antillean Yacht Charters on St. Thomas, said he delivered a boat to Puerto Rico and was not allowed off the vessel until local police could verify his COVID paperwork. His COVID status was not checked upon returning to St. Thomas.

The Virgin Islands’ case counts soon began ticking up. Between June and mid-July, the case count increased by more than 3,500%, according to one.

Gov. Bryan responded by issuing other to regain control of the outbreak, including prohibiting beach visits after 4 p.m. and not allowing patrons to stand or eat at bars located in restaurants. As of Aug. 24, the USVI had a total of .

Puerto Rico formally welcomed tourists on July 15 while still imposing some COVID-related restrictions. As in the Virgin Islands, officials required travelers to present documentation of a negative COVID test result upon arrival.

Dr. Victor Ramos, president of the island’s medical association who is involved with the, said these decisions tended to expose the rift “between the medical task force that favors closing things and the economic task force that wants to leave everything open.”

By July, the local economy was in shambles. The Department of Labor reported over 21% of the island’s workforce was receiving unemployment assistance related to the pandemic in the .

But rising case counts attributed to travel prompted local officials to encourage that only essential travel be allowed. As of Aug. 24, had recorded over 30,700 COVID cases and at least 395 deaths, according to the New York Times database.

Government data, though, indicated Puerto Rico’s climbing case numbers were not being triggered by tourists. They are not the culprits, insisted Leah Chandler, chief marketing officer of Discover Puerto Rico, the island’s official tourism website. Rather, the spread was linked to island residents coming home after visiting COVID hot spots like Texas and Florida.

Life on the Ground

Despite the global pandemic and the restrictions, both territories have experienced no shortage of vacationers. “We would have expected this to be a slow moment for us in terms of tourism,” said Sewer. “It’s very busy.”

Still, the trend lines for COVID case counts weren’t moving in the right direction for either territory, so it was no surprise when Puerto Rico closed days after reopening and the USVI followed suit on Aug. 19.

The underlying socioeconomic and health issues put residents in both places at high risk. It’s not just the prevalence of chronic health conditions like diabetes and cardiovascular disease. The high number of multigenerational households in both areas complicates a family’s ability to socially distance from its most vulnerable members. Roughly of the population in Puerto Rico and the Virgin Islands is age 65 or older, and poverty is widespread.

At the same time, both territories have limited health care infrastructure — making it difficult to envision that they can care for their own populations in an emergency let alone visitors who could become ill and island-bound if the virus were to surge.

Currently, the USVI has two main hospitals — one in St. Thomas and one in St. Croix — and a health clinic in St. John. The territory has 20 intensive care unit beds and about 100 one-time-use ventilators for its residents, said Justa Encarnacion, the USVI’s health commissioner. Each island has about 30 full-capacity ventilators.

In Puerto Rico, about of the island’s ventilators for adults were available as of Aug. 24. However, ICU beds are harder to come by, said Ramos. They are filled with COVID patients and those whose conditions worsened after avoiding care out of fear of catching the virus, he said.

The string of problems that have besieged these islands magnifies the effects of the pandemic. That includes debt crises and infrastructure damage from hurricanes and earthquakes. Island residents also fear the possibility of battling a hurricane and a coronavirus outbreak at the same time — a reality that they’ve already confronted when COVID hampered the USVI’s emergency management agency’s ability to distribute sandbags ahead of a storm in .

Colorado State University hurricane researchers predict an 2020 Atlantic hurricane season.

“At this point, we literally have disasters layered on top of disasters,” said Sewer, of the St. John’s Collective.

Still, Joseph Boschulte, tourism commissioner for the Virgin Islands, is cautiously optimistic about finding a balance between health and economic interests.

“We appreciate the concerns of our tourism partners and stakeholders,” he said. But with the spike in cases, he said, “we must reset, take stock, safeguard human life and prepare for restarting our tourism economy at a later date.”

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The study in JAMA Network Open found that 7.2% of the students reported “clinically significant” symptoms of PTSD. More girls tended to show signs of PTSD than boys.

Researchers surveyed 96,108 public school students five to nine months after the 2017 hurricane. The cohort included youth in third through 12th grades across different regions of the island.

The Puerto Rico Department of Education — which partnered with the Medical University of South Carolina for this study — is using the data to target areas with the greatest need for mental health services, the study said.

Maria, which struck the island as a Category 4 hurricane in September 2017, killed an within the American commonwealth. Residents struggled to access clean water and some remained without electricity nearly a year after the storm.

It had dramatic effects on the students. Nearly 46% said their home was damaged. More than 32% experienced shortages of food and water. And roughly 58% reported they had a friend or family member leave the island. The effects did not vary based on where the students lived or their families’ income.

Rosaura Orengo-Aguayo, a clinical psychologist at the Medical University of South Carolina and the study’s lead author, said the findings show the breadth and indiscriminate nature of the devastation.

“That just speaks to how big Maria was, how destructive Maria was island-wide,” she said. “And it didn’t matter what your income was or your location was on the island — you were affected.”

Similar problems have been of the Caribbean also affected by hurricanes in 2017.

Congress is at a stalemate in passing an aid bill that would send more resources to Puerto Rico and other areas affected by natural disasters. President Donald Trump has to provide more money to the island.

The trauma caused by a natural disaster can manifest itself in a variety of ways, said Frank Zenere, district coordinator of the crisis management program at Miami-Dade County Public Schools, who was not associated with the study. Family units can break down through divorce or domestic violence, he said. Young children can revert to thumb-sucking or wetting the bed. Teens sometimes try to exert control by acting out or turning to drugs to self-medicate.

To be sure, Zenere said, most people who survive a natural disaster do not develop long-term mental health conditions.

“They’re distressed by it. It has impact on their life — yes,” said Zenere, who helped coordinate mental health efforts in Puerto Rico in Maria’s aftermath. “But the great majority are not going to develop psychiatric illness.”

Zenere said the differences by gender found among students reporting symptoms of PTSD align with existing literature — boys are more likely to act out, while girls are most likely to show depression and anxiety.

The study’s authors said the loss and disruption caused by Maria contributed about 20% toward the youth’s symptoms of PTSD. While the researchers did not measure what other circumstances played a role, Orengo-Aguayo said, other “protective factors” — like eventually securing basic needs and community support — influence resiliency.

Notably, Orengo-Aguayo said, the level of PTSD symptoms reported in the study is lower than what was expected. Some studies show up to a third of children will develop chronic symptoms after surviving a natural disaster, the authors wrote.

Familial ties or the fact that the study was conducted several months after the storm could have played a role in the children’s resilience, she said. Or the children might still be attuned to trying to survive.

“What we might be seeing is that children at that stage were still focused on getting access to basic needs,” she said.

Regan Stewart, a clinical psychologist at the Medical University of South Carolina and a study co-author, said the team has secured two grants from the federal Substance Abuse and Mental Health Services Administration to continue work on the island for at least three more years. It plans to use telehealth to expand access to mental health services and train school staff and mental health professionals on trauma-focused interventions.

However, public schools in Puerto Rico are burdened by economic constraints. The island — already facing a budget crisis — closed 300 schools over the past two years exacerbated by Hurricane Maria.

Zenere said school staff members are among those who need to be cared for first, “because they’re going to be the glue that keeps it together for that classroom of 20 children or so.”

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But not in Puerto Rico. Medicaid patients in the American territory get no coverage for these drugs.

The joint federal-territory health care program for the poor — which covers about half the island’s population — does not pay for hepatitis C medications.ÌýThey also do not cover liver transplants, a procedure patients need if the virus causes the organ to fail.

The Puerto Rico Department of Health created a separate pilot project in 2015 to provide hepatitis C medications to those sickened by the liver infection who also have HIV but expanded the program later to those with only hepatitis C. However, according to the Office of Patient Legal Services, an official territorial agency that advocates for consumers, the program ran out of funding and is no longer accepting patients only with hepatitis C.

The Puerto Rico Health Insurance Administration (ASES), which oversees Medicaid, said it is working with a pharmaceutical company to create a cost-effective system to provide these medications.

“Definitely, they need to be given coverage,” said ASES director Angela Ávila Marrero. “They need to be given care.”

Hepatitis C, a bloodborne infection, increases the risk of cirrhosis, liver cancer and death. Poor screening led many to contract the disease through tainted blood and organ transplants into the early 1990s. Today, intravenous drug use drives in the United States.

William Ramirez, executive director of the American Civil Liberties Union of Puerto Rico, said he is considering filing suit against Puerto Rico for failing to cover the cost of these medications for people enrolled in Medicaid.

“You’re holding back medication and thereby allowing certain people to die,” Ramirez said.

That reality is clear for Hector Marcano, 62, who stopped working roughly six years ago because of the illness. After recovering from a drug addiction, he was a case manager who worked to connect drug users to health resources.

His liver disease is leading to overall deterioration. He struggles with walking. A bout of pneumonia that left him hospitalized lingers in his racking coughs. He spends his days reading, listening to the radio and praying for the strength to keep searching for the cure.

He doesn’t understand why the government does not provide hepatitis C medications, he said, especially as there are so many people in need of them.

“So what are we waiting for?” asked Marcano. “For a pandemic to happen?”

Medicaid Costs Drive Island’s Debt Crisis

Hepatitis C afflicts approximately 3.5 million people in the United States. The virus can silently corrode the liver for years without causing symptoms.

Because of the condition’s stealthy nature and the absence of recent data, the number of people in Puerto Rico living with the virus is uncertain. Researchers on the island in 2010 2.3 percent of 21- to 64-year-old residents had the virus.

Documents provided by the Center for Health Law and Policy Innovation of Harvard Law School show medical providers reported more than 11,000 hepatitis C cases to the Puerto Rico Department of Health from 2010 to September 2016.

Cynthia Pérez Cardona, an epidemiology professor at the University of Puerto Rico and an author of multiple studies involving hepatitis C in Puerto Rico, said she is uncertain of how widespread the virus is on the island. But other statistics present a worrisome sign: A report from the island’s found the number of new liver cancer cases increased an average of 2.1 percent annually among men and 0.7 percent among women from 1987 to 2014. Hepatitis C can cause such cancers.

Despite these warnings, Puerto Rico has fewer resources than most of the nation to care for its impoverished.

Unlike states, Puerto Rico’s federal funding for Medicaid is capped. Historically, these federal dollars have fallen far short of covering the program’s costs on the island. The territory’s crushing Medicaid expenses helped drive the island into its $70 billion debt crisis.

Under these financial constraints, said Matt Salo, executive director of the National Association of Medicaid Directors, Puerto Rico’s officials are left with a difficult choice when considering covering hepatitis C drugs.

“Rather than blowing through their cap in six months,” Salo said, “they’d blow through their cap in one month.”

Pilot Project Falls Short

In the health department’s , patients with certain conditions like uncontrolled diabetes or an active mental health condition or those who could not prove they had been sober for six months were barred.

Such restrictions rankle patients and their advocates. “You know, we do not deny lung cancer treatment for a person who smokes or diabetes treatment to a person that doesn’t eat well,” said Robert Greenwald, a professor at Harvard Law School and faculty director of the Center for Health Law and Policy Innovation.

Dr. José Vargas Vidot, a member of Puerto Rico’s Senate and a physician, submitted a petition in 2017 to various territorial agencies questioning Medicaid’s coverage of hepatitis C medications.

The Office of Patient Legal Services responded to Vargas Vidot in a letter this year confirming that the island’s Medicaid program did not cover these drugs. It also noted the health department pilot project closed its wait list after reaching 100 patients because of a lack of funding. In November, Vargas Vidot submitted legislation to require that hepatitis C medication and treatment be part of basic coverage for insurance plans and Medicaid.

Ávila Marrero said ASES is in talks with a drugmaker to create a network separate from the Medicaid program to provide medications to the patients. She said she hopes the arrangement will allow the government to get lower prices for the drugs. But no agreements have yet been reached for such a program.

Despite its success in states, suing to get coverage may not be the best option for Puerto Rico because the debt rescue package passed by Congress in 2016 includes a provision that bars creditors from taking legal action to collect from the territory.

That could apply to a lawsuit filed against the territory for not covering hepatitis C treatment in its Medicaid program, said Phillip Escoriaza, a health and federal grants law attorney in Washington, D.C., who practiced in Puerto Rico. And even if the case can go forward, it would enter the docket for a special bankruptcy court with more than , as of Dec. 14. It may be in the Puerto Rican government’s interest for things to take a long time, said Escoriaza. Once there, it could stall for years — time hepatitis C patients such as Marcano might not have.

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“3000 people did not die” in Puerto Rico, the president tweeted.

The death toll from the Sept. 20 storm, a Category 4 hurricane, has been a point of contention between officials and residents who live there. George Washington University (GWU) researchers of an in-depth investigation commissioned by Puerto Rico’s government. They estimated 2,975 people died as a result of the storm.

3000 people did not die in the two hurricanes that hit Puerto Rico. When I left the Island, AFTER the storm had hit, they had anywhere from 6 to 18 deaths. As time went by it did not go up by much. Then, a long time later, they started to report really large numbers, like 3000…

— Donald J. Trump (@realDonaldTrump)

…..This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico. If a person died for any reason, like old age, just add them onto the list. Bad politics. I love Puerto Rico!

— Donald J. Trump (@realDonaldTrump)

The president questioned that report’s credibility, insinuating that the count was a ploy by his political opponents and that it included people who died from causes unrelated to the storm.

“This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico,” he tweeted. “If a person died for any reason, like old age, just add them onto the list.”

The tweets prompted a sharp rebuke from Puerto Rico Gov. Ricardo Rosselló, who called for recovery efforts to remain above the political fray.

“The victims and the people of Puerto Rico do not deserve to have their pain questioned,” the governor’s statement said.

Here is a brief look at the issue of casualties and Puerto Rico’s response to Hurricane Maria.

How many people died?

Calculating a death count is not an exact science. Estimates are influenced by a variety of factors including the period analyzed and the definition of a disaster-related death, according to Columbia University professor John Mutter.

The Puerto Rican government accepts GWU’s estimate of 2,975 deaths as the official count. Local officials had originally said 64 people died in Hurricane Maria, counting only fatalities directly attributable to the storm, such as drowning deaths or mortal injuries caused when buildings collapsed. During the summer they had risen to more than 1,400.

The GWU their estimated death toll, which is about double that tally, by comparing the number of people who died in the six months after Hurricane Maria to historical averages in previous years.

The university issued a statement Thursday, disputing Trump’s comments. The investigation was “carried out with complete independence and freedom from any kind of interference,” according to the .

Prior to the GWU study, other researchers and one newspaper released estimates that also garnered media attention.

One , published in the New England Journal of Medicine, put the number of excess deaths at 4,645 in the three months following the hurricane. A by The New York Times used vital records from the government to calculate an excess of 1,052 deaths in the first 42 days after the disaster.

Still, the numbers are important, said Mutter, who researches disaster management and worked on collecting the number of deaths in New Orleans after Hurricane Katrina. These death counts are a key way the public measures a disaster and perception drives donations for relief, he said.

Why was it so confusing getting a death toll?

When Hurricane Maria made landfall in Puerto Rico, it devastated the island’s infrastructure, which can limit access to health care and impact mortality, especially among residents who are frail or dealing with chronic health issues.

The storm knocked out electricity for the entire island, which took nearly a year to restore fully. At least 80 percent of communications towers were not operational, crippling phone services. Medical centers across the island relied on generators for power, which sometimes failed and jeopardized patients. Some medical facilities in Puerto Rico were irreparably damaged, like the only hospital on the island of Vieques, which housed its only dialysis center. Residents must now leave the island three times a week for treatment.

Many roads on the island were impassable because of debris or erosion. Roads near rivers, like those in the mountainous, rural province of Utuado, washed away. Bridges also fell, leaving some communities isolated and unable to access assistance.

Hurricane Maria also cut off drinking water to more than half of Puerto Rico. The lack of electricity meant water pumps could not work. Some people turned to other sources, like natural springs and rivers, for drinking water. At least 26 people died of leptospirosis, a bacterial infection caused by exposure to water or soil contaminated with the urine of infected animals, from CNN and the Centro de Periodismo Investigativo, a nonprofit group that promotes investigative journalism.

In addition to the physical disruption, the GWU researchers noted that officials in charge of certifying deaths did not have a process that automatically noted when a death was a consequence of the hurricane or its aftereffects.

How did the federal government do in its response to Hurricane Maria?

According to the federal government, not very well.

A released earlier this month by the U.S. Government Accountability Office (GAO) details how the Federal Emergency Management Agency (FEMA) struggled to meet the needs of Puerto Rico and the U.S. Virgin Islands after the storms.

The agency didn’t provide adequate staffing to the disasters on the islands, according to the GAO. It faced a 37 percent staffing shortage as of Sept. 1, 2017. Of the personnel deployed to the islands, some “were not physically able to handle the extreme or austere environment of the territories,” the report said. The lack of bilingual employees also led to delays since many Puerto Ricans speak Spanish.

Transporting materials to the island was also an issue for the agency, as both islands are located more than 1,000 nautical miles from the mainland, the report said.

FEMA Administrator Brock Long addressed some of those issues Tuesday in . “We threw as much as we could towards Puerto Rico,” he said.

He added that FEMA’s prime concern is preventing deaths from natural disasters, but also that “there’s a difference between direct deaths of, you know, the winds, water, collapsed buildings, things that kill people directly versus the indirect deaths. Indirect deaths are always higher than the direct deaths after many events. … But what I really believe is that we have to concentrate on the pre-disaster mitigation, fix the infrastructure that was crumbling before the storms in the commonwealth, so that we prevent this from ever happening again.”

He noted that FEMA is now the largest employer in Puerto Rico as repair efforts continue.

What has the Puerto Rican government done in response to the death counts in Hurricane Maria?

After the GWU findings were released, Gov. Rosselló changed the official death count and accepted responsibility for the territory government’s failure to adequately respond to residents’ needs. He also said he would form a commission to consider the recommendations suggested in the GWU study on how to improve the island’s response to disasters.

However, how many changes the territory’s government can make remains to be seen. Puerto Rico’s purse is under the control of a fiscal oversight board put in place by Congress to address the island’s debt crisis, which stands at more than $70 billion.

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Gov. Ricardo Rosselló, who asked for the research following criticism of the American territory’s low death count, said his government accepts the new numbers and wants to learn from the crisis.

“The magnitude of the catastrophe was without precedent in Puerto Rico and there was certainly disagreement with the total number,” Rosselló said at a press conference. The Ìýby researchers at the George Washington University’s Milken Institute School of Public Health who examined death records for six months after the storm and attributed 2,975 deaths to the disaster.

In comparison, Hurricane Katrina, which is one of the deadliest storms in U.S. history, killed more than 1,800 people.

Hurricane Maria barreled into Puerto Rico Sept. 20 as a Category 4 storm. Destruction was widespread, severely crippling the island. Both the electrical and water systems were knocked out in some areas for months. Hospitals and other public health services were damaged, doctors’ offices lost power and often remained closed and medical supplies were difficult to find.

Health advocates scoffed at the government’s initial death toll and said many people died after the storm because they lacked medicine, couldn’t get adequate medical treatment or had chronic diseases that were aggravated by the post-storm conditions.

The official government estimate of 64 deaths was low because it counted only those directly attributable to the storm, such as drowning deaths or injuries caused when buildings collapsed, according to the report. The George Washington researchers instead inspected death certificates and other records, and they calculated the excess deaths by comparing historical death rates to the actual number of people who perished.

In addition, the GW researchers analyzed death statistics for age groups, gender and geography.

“I would say this is a study that can provide everybody a sense of security that, yes, this is a number that you can use as a reference for the future,” said Carlos Santos-Burgoa, principal investigator and professor of global health at GW’sÌý school of public health.

According to the study, the number of excess deaths is 22 percent higher than what would be expected had the hurricane not hit the island. The risk of dying for men over the age of 65 was 35 percent higher than the baseline, and it remained elevated through the end of the study. And people living in poorer areas were 45 percent more likely to die.

Santos-Burgoa said the risk people in poorer municipalities faced is a “major concern” because it shows the level of inequity on the island before the hurricane hit and was exacerbated in the aftermath.

“It’s a very strong message in Puerto Rico and people addressing natural disasters all over the world: Don’t treat people as homogenous groups,” Santos-Burgoa said.

At a briefing for reporters in San Juan, Rosselló discussed several initiatives to bolster the island’s disaster preparedness, including counting vulnerable populations like the chronically ill and creating a commission to handle recommendations to improve the island’s emergency response systems.

“This is a time for Puerto Ricans to bind together, to mourn, to reflect on the things that were done properly and things that were mistakes,” he said. “And have the firm commitment to identify those mistakes and make sure that moving forward toward the future, those mistakes aren’t committed.”

The report is the latest in a series of analyses done by universities and one newspaper to answer the question of how many perished in the storm.

A survey published in May in the estimated more than 4,600 excess deaths occurred from the day the hurricane made landfall to the end of the year. A separate investigation by found 1,052 lives lost. A published in JAMA in August estimated more than 1,100 deaths.

Earlier this summer, Puerto Rican officials data that dramatically upgraded its official death toll to 1,427.

The researchers also examined Puerto Rico’s crisis communications and death certification process in place during Hurricane Maria. Interviews at the governor’s central communications office revealed there was no written plan in case of a disaster. Government officials said they had no knowledge of a coordinated plan between the health department and public safety department to report deaths.

Instructional materials about death certification did not tell providers how to handle deaths in the event of a disaster. And so many deaths that were related to the damage from the hurricane were not recorded as storm-related, complicating efforts by officials to identify Maria’s death total.

John Mutter, a professor at Columbia University who researches disaster management, said death certificates are “critical” to determining what is attributable to the hurricane. Mutter, who was not involved in the GW study, said specific death information can help researchers identify who died as a result of the disaster and who were the most vulnerable populations.

“It is the way we scale tragedy,” he said, noting that he believes the GW study is a good estimate.

The report offered recommendations on how Puerto Rico can improve its response systems, including updating communications plans and enhancing training for public health professionals. Those investments could prove tricky for the island, however, because its finances are controlled by a federally appointed fiscal control board.

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The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory’s agreement with the federal government as the island claws its way back from fiscal oblivion.

Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory’s historically astronomical Medicaid expenses — on an island where the average household earns $20,000 and diabetes and hypertension are widespread.

But physicians, health insurers and former government officials say the drastic cuts demanded defy actuarial science and provide too little money to care for a population still traumatized by Hurricane Maria.

The cutbacks will give private health insurance companies the incentive to shuttle around patients with costly chronic diseases or mental illness, critics warn. And they do nothing to address the underlying fiscal imbalance at the root of Puerto Rico’s health care woes, which stem from the fact that the federal government contributes a tiny fraction of the island’s Medicaid budget, compared to what it contributes to the 50 U.S. states.

“We are rearranging the chairs on the Titanic,” said Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.

Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.

“These people who have been under our service for the last four or five years, all of a sudden I have to abandon them,” said Dr. José Joaquín Vargas, chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.

Health Crippled By Debt

If Puerto Rico were a state, the federal government would pay 83 percent of Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in ,Ìýaccording to a formula that takes a state’s economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent, as a fixed annual payment — a so-called block grant.

In February, Congress approved $4.8 billion in additional funds to help pay the island’s Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory’sÌý.ÌýThat’s a federal control board established by Congress in 2016 to oversee Puerto Rico’s budget, negotiate with its creditors and help restructure at least some of the island’s debt.

Gov. Ricardo Rosselló’s administration aims to reduce Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló’s plan, the companies will be forced to offer island-wide insurance plans and compete for customers.

“We do not have the luxury” of continuing to spend inefficiently, said Ángela Ávila Marrero, executive director of Puerto Rico’s Health Insurance Administration.

If Rosselló’s overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Some — — are at risk of losing coverage next fall, their health held hostage to the island’s need to pay back its crippling debt.

Puerto Rico’s government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession,ÌýÌýand reckless spending by a bloated government.

But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico’s staggering Medicaid burden.

Poverty is so pervasive here that nearly 1 in 2 people qualify for public health insurance; Medicaid expensesÌý. Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.

Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island’s fiscal health, health economists say.

Researchers of health care say that, putting aside interest on Puerto Rico’s debt, the territory’s primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.

“The main issue is that we are not yet a state,” said Rep. Jenniffer González-Colón, the commonwealth’s nonvoting member of Congress. The island must pay for Medicaid, she added, “with local funds that we don’t have.”

Battered Even Before The Storm

Puerto Rico’s health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act and Ìýwould lose coverage.

Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology and fueled the exodus of thousands of physicians to the mainland in search of better incomes.

Today, Medicaid patients face long waits to see doctors on the island.

“If your kid needs a neurologist, for example, the waiting period is around six to 12 months,” said Dr. Jorge Rosado, a pediatrician in San Juan. “For a genetics specialty, it’s two to three years.”

The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.

Little Time To Waste

Barring the unlikely passage of that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out next fall. González-Colón also calling for statehood, which would eliminate the federal government’s unequal treatment toward the island’s Medicaid program.

The fiscal control board established by CongressÌýopenly acknowledges the impending disaster. In anÌýthe board projects monthly costs per Medicaid patient will rise nearlyÌýover the next six years, barring any changes, and that Puerto Rico “will hit a ‘Medicaid cliff.'”

Beginning this fall, Medicaid patients will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.

Puerto Rico has long capped monthly payments insurers receive for Medicaid patients regardless of how many medical services they use, a form of managed care. But the government here believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.

The island’s government has vowed to pay private insurers extra money to care for those with expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.

“I support the government on what they’re trying to do, but they didn’t price it properly,” said Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.

He added, “The oversight board is fixated on cuts, but we’re never going to improve health care unless more money is put into the system.”

Government health officials argue Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But the island’s clinics and hospitals fear they will be squeezed by insurers seeking to lower costs, just as they are still reeling from hurricane-related expenses.

Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.

Many experts are skeptical that managed-care companies will hire the army of social workers and nurses like Calderón needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty. Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.

Many people displaced by the storm haven’t yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.

“The managed-care companies need to produce revenue,” said Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. “That’s a setup for concern.”

Bottom line? The economic overhaul doesn’t rectify Puerto Rico’s fundamental problem — it can’t sustain its Medicaid program so long as Congress treats the territory differently than it treats states.

“Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens,” said Torres. But, he added, “it’s time the local government started thinking about a Plan B.”

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Their analysis found an increase of 1,139 deaths over what would be expected in Puerto Rico in the 2½ months following the storm. The Category 4 storm lashed the American territory last September, displacing tens of thousands of residents, destroying the electric grid and downing communications services. The National Hurricane Center estimates the storm caused $90 billion in damages in

The new count comes in a research letter published Thursday in the journal JAMA that compared death certificates obtained from the Puerto Rican government to the historical average for deaths over a three-month period.

Researchers first calculated the average number of deaths per month from January 2010 to December 2017 and an upper and lower limit for the number of deaths that had occurred in each month. Their findings concluded that an excess of 459 deaths occurred last September, 564 in October and 116 in November. The count normalized by December.

Alexis Santos-Lozada, a co-author of the research letter and an assistant professor of human development and family studies at Penn State University, said he was puzzled as to why the island’s government has kept the official death count at 64. The documents his team used came from the territory’s cache of data.

“We just didn’t want inaccurate numbers to guide policy decisions such as money to mitigate the effects of the hurricane or money to remediate and rebuild the island,” Santos-Lozada said.

The study’s results come close to one earlier estimate of the storm’s deaths. An analysis by of the government’s vital-statistics records found that the number of deaths in the 42 days after the storm were higher than expected by 1,052.

But other estimates have varied widely.

The Puerto Rican government’s official count has been widely criticized as too low. , published in May in The New England Journal of Medicine, reported 4,645 people died as a result of the storm. Those findings were calculated from a random survey of more than 3,200 households on the island.

Stung by the controversy over fatalities, Puerto Rico’s government contracted with George Washington University researchers to conduct an independent death count. Those results are expected later this summer.

John Mutter, a professor at Columbia University who researches disaster management and who worked on collecting the number of deaths in New Orleans after Hurricane Katrina, said the United States does not have a defined position on a federal or state level about who is responsible for estimating fatalities after natural disasters.

The Centers for Disease Control and Prevention does “a very, very conservative” count, he said, but these numbers can vary based on the parameters used by the researchers compiling the data.

“When people talk about the official death count,” Mutter said, “who’s the official who made the count?”

Among the factors that can influence the results of any estimate are the timespan analyzed and the definition of a hurricane-related death, Mutter said. People with preexisting medical conditions who perish in a natural disaster are sometimes not quickly picked up as part of the count since their illness preceded the natural emergency. However, Mutter said, these individuals are generally counted.

In Puerto Rico, this is an important group. Many people’s illnesses were exacerbated by the lack of supplies, clean water and especially the long-term power outages caused by Hurricane Maria. The lack of electricity meant ventilators could not run, medications such as insulin could not be refrigerated, and hospitals did not have the equipment available for fragile patients, such as premature newborns.

Regardless of who is included in the count, no assessment can capture everyone who died —especially in events that involve missing persons, said George Haddow, former deputy chief of staff for the Federal Emergency Management Agency during the Clinton administration.

“People disappear in disasters,” he said.

Mutter said it’s imperative that the most accurate death count possible be obtained because it drives the public’s attention — and dollars — to the needs of the survivors and to lessons for future disasters. Death counts like those seen in the aftermath of Hurricanes Katrina and Maria show a breakdown in the system that should be addressed.

“Big numbers always suggest something’s wrong,” Mutter said.

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Physicians are in short supply in Puerto Rico.

From 2006 to 2016, the number of doctors on the island declined from 14,000 to 9,000, according the College of Physicians and Surgeons of Puerto Rico. And Hurricane Maria has helped fuel the exodus.

Dr. José Cruz, a pediatrician with a practice in Ponce, said the island’s ongoing financial crisis and low payments from health insurers drove many physicians to seek work in the States.

Physicians say running a medical practice is a losing business in Puerto Rico. At San Jorge Children’s Hospital in San Juan, a pediatrician earning about $89,000 a year can double his salary just by moving to the States.

The low salaries reflect the island’s widespread poverty. Nearly 2 in 3 children — and half of all Puerto Ricans — rely on Medicaid, and the territory receives far less money from Congress to pay doctors than do low-income states.

KHN senior correspondent Sarah Varney reports in collaboration with “PBS NewsHour” on how Puerto Rico’s exodus of doctors is adding a new level of complication to delivering care.

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