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Opinion: The staggering toll of this constant state of emergency

Editor's Note: (Brenda Rivera-García, DVM, MPH is senior director of Latin America and Caribbean Programs for Americares, a former US Centers for Disease Control and Prevention Dengue Branch-Guest Researcher and Puerto Rico Department of Health Territorial Epidemiologist. The views expressed in this commentary are her own. View more opinion articles on CNN.)

(CNN) Across the world, mental health is having a moment, in large part courtesy of the Covid-19 pandemic. Never before have we focused so much on emotional well-being. Months of isolation, fear and remote schooling have changed how we define our health.

But here in Puerto Rico, we had already been through so much even before the virus reached our shores.

The constant state of emergency that is life in Puerto Rico has taken an enormous toll. Nearly 10% suffered from a major depressive disorder before 2017's Hurricane Maria made landfall -- slightly more than the US average -- according to data analyzed by researchers from the University of Puerto Rico, Harvard Medical School and New York University. And in the months following the storm, mental health issues greatly intensified, with calls from people who had suicidal ideations or decompensated mental health conditions to Puerto Rico's mental health hotline tripling -- 3,050 calls from November 2017 to January 2018 compared with 882 over the same period the year before.

Maria hit Puerto Rico on September 20, 2017. It was the biggest shock our island suffered in a generation. Millions were left in the dark, some for months. Thousands died, especially during the aftermath, due to the lack of communication, running water and power. Never before had we seen ourselves this vulnerable and helpless. We are resilient people, yes. But the storm really tested our mettle and showed us we needed to re-visit preparedness plans at every level. These circumstances and the ongoing recovery work seem to have drained the optimism that characterizes the Puerto Rican community.

Nearly five years to the day since Maria slammed our island, on September 18 of this year, Hurricane Fiona delivered yet another knockout punch. With Maria, we thought we experienced a 100-year flood. But, after only a half-decade later, it seems another century of water has enveloped us: Maria dumped more than three dozen inches of rain in some parts of the island over two days and last week Hurricane Fiona drowned us with 31 inches in a 72 hour period. A week after the storm, nearly 20% of the island was still without potable water, and nearly 60% still had no power, according to Puerto Rico's government data. Once again, our air is filled with a familiar lullaby—the hum of generators.

More and more, I hear from family, friends, neighbors and people on the street saying, "I'm tired. It's one crisis after another. I can't take it anymore." With multiple generations often living together, family members have always been each other's rock. But what happens when that rock is shattered?

What happens to those with mobility issues or conditions that weaken the immune system, who need access to water -- for them, access to water is a life-saving necessity to avoid infections and maintain good hydration. Or those who need electricity to power medical devices that allow people with respiratory conditions to breathe or refrigerate life-saving medications such as insulin?

I can certainly understand and empathize. I was born and raised here and, after spending some time in the states, I moved back nearly 30 years ago. In the months following Hurricane Maria, I was leading the relief efforts for Americares and saw up close the physical destruction, the loss of lives and the emotional toll.

By the time we heard of Covid-19, we were more than two years into the hurricane recovery, still struggling with frequent power outages and daily intermittent blackouts. A series of earthquakes in late December 2019 and January 2020 -- more than 300 including 10 that were 5.0 magnitude or higher, according to the US Geological Survey -- had just shaken the southern part of the island, and families were sleeping in tents outdoors fearful of being trapped within the walls of their homes.

It is no wonder that the need for mental health support continues unabated -- especially for our first responders and caregivers. Health workers, firefighters, police officers and teachers have been on the frontlines of this new, constant state of recovery, while also being survivors of multiple disasters themselves.

Through Americares, we have put in place programs to help caregivers learn coping skills so they take care of themselves and continue helping others. We are bringing knowledge and tools on psychological first aid to first responders across the island. Most recently, we launched a pilot program to train teachers and others in the school community to better help their students navigate the psychological impact of disasters and link these schools to the local community health centers.

This is empowering those in the school environment to provide that initial assistance but also linking them to the next level of care, creating a pathway for those affected to receive critically needed services. We began by training 154 school employees -- teachers, counselors, social workers, psychologists and more -- in our first session this summer, and we plan to continue the sessions throughout the school year. We're getting requests from schools and community health centers and other health organizations across the island to implement the new program in their communities.

Our children are especially at risk. In fact, more than 7% of children on the island meet clinical standards for post-traumatic stress disorder (PTSD), according to a Medical University of South Carolina study published in the Journal of the American Medical Association.

The researchers found 45% of public-school students surveyed in the months after the storm reported damage to their homes, nearly one-third experienced a shortage of food or water and nearly 30% perceived their lives to be at risk.

While mental health programs provided by relief organizations like Americares are essential to Puerto Rico's recovery efforts, more can be done at every level -- from the government to local schools and health centers. This includes:

  • Providing more support for community health centers, which play an important role supporting local communities in the aftermath of emergencies. They need accessible tools and training to bolster their disaster response plans considering their patients' particular vulnerabilities through the lens of climate-change driven disasters and adverse health effects.

  • Ending the stigma around mental health care. We need to shift our thinking to incorporate training on mental health, developmental and social needs and support as an integral part of primary health services.

  • Incorporating concepts of trauma-informed care into training for primary health care providers and first responders, not only in Puerto Rico but in many areas around the world. We also need to work toward making psychosocial and mental health support key elements of preparedness and response plans.

Puerto Ricans -- and anyone at risk of climate-driven disasters, which is most of society at large -- can never again be as unprepared as we were when Hurricane Maria hit. As our changing climate helps churn even greater and stronger storms, droughts, heat waves, rising sea levels and epidemics of mosquito-borne diseases and other conditions, we need to redesign our emergency preparedness plans and have a more holistic understanding of health.

An emergency preparedness plan must mean more than binders full of plans that few know exist and even fewer are prepared to implement. And central to any, and all, of those plans is the need for psychosocial and mental health preparedness.