“Y no quedó nada, nada de la casa, todo salió volando” (And there was nothing left, nothing of the house, everything flew away): a critical medical ecological perspective on the lived experience of hurricane María in Puerto Rico

The research team had several layers. This project was embedded in a larger CDC-funded initiative partnering with Puerto Rican communities and the University of Puerto Rico [21], with Dr. Dye and Dr. Pérez Ramos involved from the beginning, including a research pause to create the #p2p4PUR (people-to-people for Puerto Rico) hurricane relief initiative [22]. Drs. Dye and Pérez Ramos came to know many of the communities involved in this present study through their efforts with the CDC-funded initiative and #p2p4PUR. After the hurricanes of 2017 and with resumption of the team’s research in Puerto Rico, Dr. Vega Ocasio and Dr. Ivelisse Rivera joined Dr. Dye and Dr. Pérez Ramos in creating the protocol that governed this project. As a demonstration of equity and to deliberately avoid a hierarchical structure, the four investigators (Drs. Vega Ocasio, Rivera, Pérez Ramos, and Dye) serve as Co-Principal Investigators. All four Co-PIs were deeply familiar with Puerto Rico, with family in the islands, and directly impacted by the hurricanes. The entire field team was fluently bilingual (Spanish and English), and culturally Latin American and all coding team members were fully bilingual (Spanish-English) with Spanish as their first language. Two team members identify as men and six as women. Several team members were full-time PhD students in the University of Rochester’s Translational Biomedical Science program at the time of their involvement with this project.

The investigator team had pre-existing relationships with some communities or individuals within particular locales before starting this work. In some cases, the team networked through other contacts to reach interested organizational partners at the community level. While the team had prior experience conducting fieldwork and in coordinating the aid response throughout Puerto Rico, they did not have prior experience nor existing research relationships in Orlando, Florida, but networked through social and professional contacts to reach research partners.

Project participants knew that the field team was Puerto Rican, based in Rochester, New York, and had conducted health research in Puerto Rico before. The team members from Puerto Rico were from different parts of the country and had different diaspora experiences in the USA. The team members introduced themselves before interviews or focus groups started, sharing this background. The presence of Latin American, Caribbean, and European-American team members (in the field team and in the wider analytic team) helped us bring both etic and emic perspectives to coding and analysis.

Our work examining the lived experience of the 2017 hurricanes among Puerto Rican residents and the diaspora used the medical ecology paradigm as a heuristic device [20, 23]. Medical ecology is particularly well-suited to help organize data and to help interpret environmental or ecological-related events in the social, biological, health care, and physical environments. The model requires that we attend to multiple levels of organization (individuals, households, communities) and across domains (biological, sociocultural, abiotic, health care), address the processes of stressors and adaptations, and evaluate different types of data. For this project, while the medical ecological paradigm helped us shape the development of an interview guide, the fieldwork was predominantly ethnographic and qualitative. This approach allowed for full expression of community voices to capture lived experience.

Participants met the inclusion criteria of a) Age 18 and over, b) self-identified as Puerto Rican, and c) were resident in Puerto Rico, the USA, or relocated to the USA since the hurricanes. We worked with local community organizations in Puerto Rico and in the USA, who serve the populations impacted by the hurricanes to help organize discussion groups and interviews (identifying venues, setting times, staffing check-in, referrals). We deliberately included a range of geographic locations to help capture variety in experience, and conducted groups and interviews in urban, mountain, coastal, and outer island locales throughout Puerto Rico. Specifically, we included the following types of municipalities and ecosystems in our study, “Urban/Metro,” “Mountain,” “Coastal,” and “Outer Island.” In the state of Florida, we concentrated groups and interviews in Orlando, to where most Puerto Ricans who left Puerto Rico for the mainland after the hurricanes relocated [24].

We worked with local community partner organizations in each ecological zone to identify potential participants in their catchment areas through flyers distributed or through social networking and word-of-mouth. In total, 96 people (31 men, 65 women) participated in a total of 23 discussion encounters (17 focus groups (four of which were in Orlando), 6 interviews). Groups were hosted in organizational or community facilities and interviews were completed in spaces determined by participants.

The ethnographic instrument used was the same for individual and group interviews, and was pretested with the project team and with people for whom Spanish was their first language. The interview guide was structured using Spradley’s “Grand Tour” and “Experience” approach [25], asking participants to describe sequentially how events unfolded before, during, and after the storms and with questions asking participants to recount their lived experience. For participants in Orlando, we asked more experiential questions regarding their decisions, circumstances, and lived experiences of relocating from Puerto Rico to Florida. Following presentation of the Information Sheet with IRB-required language, participants provided verbal informed consent to participate in the interview and also to be audio recorded. Documentation of written consent was waived since literacy is unclear, formal signing of documents in this population is typically restricted to formal legal and contractual transactions, and a signature would be the only written identifier in this study. An IRB-approved information sheet about the project and protections, with contact details for the investigators and IRB, was provided to participants. Topics and discussions often branched from the original script, following a local format of conversation. One field investigator guided the interview and the other took notes. A third attended to logistics of recording, processing paperwork, and assisting participants and moderators as needed. Refreshments were provided to all participants. Due to local institutional requirements and cost of participating, Orlando participants received $20 gift cards. All participants were provided with referral sheets in the interview that listed local and national hotlines, resources, and suggestions for counseling and assistance, and any local referrals were handled by partner organizations. The investigator teams debriefed at the end of each day, summarizing that day’s experience and planned for the next. All recordings were transcribed by people for whom Spanish was their first language, and transcripts were edited and corrected by project team members. Community participants did not review completed transcriptions. Demographic questions (place of residence, gender) were self-reported.

The average time for group interviews in Puerto Rico was 70 min, and in Orlando 90 min. The average individual interview lasted 73 min. Repeat interviews were not conducted and each participant participated only once. No one refused to participate and no one refused recording.

We developed a mixed codebook, mostly using grounded procedures (emic codes) but also with several model-led codes (etic) [26]. First, the seven coders and investigators reviewed a sample of transcripts, generating a list of candidate codes arising from the data. Those codes were reviewed, merged, and consolidated. Next, codes were applied to a sample of transcripts and a final codebook assembled. The final codebook (Additional file 1) contained thematic, structural, theoretical, narrative, and descriptive codes and subcodes. The final codebook contained definitions and examples for coders to reference, and was entered into Dedoose for cloud-based coding [27]. The codebook was ordered sequentially to capture the chronological sequence of pre−/during−/post-hurricane emic codes followed by investigator-driven etic codes.

While themes were not determined in advance, codes were mapped to the component of the medical ecological model with which they best fit, to facilitate analysis within the medical ecological framework.

Coders were trained with a 10% sample of records in Dedoose until > 90% agreement was accomplished, with discrepant codes discussed and resolved. Subsequently, two coders fully coded every interview, again with discrepant codes discussed and resolved to achieve a final coded transcript. We used a range of analytic methods in Dedoose to identify frequency of codes, to pull excerpts for closer manual analysis, to examine code co-occurrences and to stratify codes by geographic unit (rural, urban, mountain, coastal, outer island, and Florida).

Analysis consisted of identifying the most commonly coded themes, and presenting codes and themes in sequential order to approximate the participants’ temporal experience. Examples are presented from each code to illustrate both typical and outlier situations to help portray the full range of lived experience. Codes were assigned domain (sociocultural, abiotic, biological, and health care) and level (individual, household, and community) values that were aggregated over the total period, and the periods before, during, and after the hurricanes. These summaries are presented as multilevel qualitative models to synthesize the types of ecological dynamics of each period.

Each partner organization provided a letter of support after reviewing the protocol, materials, and discussing the project with investigators. The University of Rochester’s Research Subjects Review Board reviewed and approved the project (RSRB00071756) as expedited, minimal risk research. All investigator and research team members completed CITI Program research, ethics, and compliance training required by the University of Rochester. Dr. Pérez Ramos and Dr. Dye also completed the required ethics training from the University of Puerto Rico earlier for the parent project.

We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [28] to organize the reporting of qualitative findings.

Overall, half of the codes applied in reference to the period before the hurricanes related to the Community level of the ecological model (see Fig. 3), while 41% of codes applied in this period related to Household level issues, and with 7 % of the codes applied to the Individual level. All of the codes applied from the period before the hurricanes related to either Social (58%) or Abiotic (42%) factors, with no codes applied in the Biological or Health Care domains during this period.

Shown in Table 2, overall “hurricane preparation” (considered predominantly as a Household-level/ Abiotic set of codes, Fig. 3) was the most commonly-mentioned theme (particularly in the metro areas) when participants recalled the period before the hurricanes –– as people assembled food and water supplies, protected windows with shutters, and relocated to shelters or to the homes of relatives. Lack of preparation was also commonly noted, especially in coastal and rural areas, in particular a lack of prevention by government agencies. Participants in coastal and metro areas noted that flooding was already frequent common in their communities, even before María.

From a participant who lives in a rural, coastal area:

“Nosotros, en mi casa empezamos una preparación, pero al ir a las ferreterías no habían paneles ya y el precio que te estaban dando por un panel de un cuarto de PVC era sobre 40 dólares. El presupuesto no daba para comprar siete u ocho paneles que yo necesitaba. En mi caso yo rompí los closets y tapé las ventanas que eran de cristal, las que pude con la poca madera que tenía dentro de mi casa, sacamos y cubrimos la parte de, que es la que, como yo vivo en una lomita, la que recibe la mayor parte del impacto pero no fue suficiente. Me preparé con lo poco que tenía, forré y lo demás, compra y eso siempre los suministros para esta época pues en casa siempre se suplen, pero en el trabajo de ventanas, eso no se pudo hacer más que la mitad porque en las ferreterías la gente ya había sacado todo el panel que había y lo que quedó pues no fue suficiente. Y nosotros pues, el dinero no daba para comprar el material necesario para-- no había tormenteras y mis ventanas son de cristal. Lo poco que se pudo hacer, se hizo, lo demás pues se quedó a la intemperie y fue lo que sufrieron las consecuencias.”

“We started a preparation at my house, but when we went to the hardware stores there were no panels anymore and the price, they were giving you for a one-quarter PVC panel was about $ 40. The budget was not enough to buy seven or eight panels that I needed. In my case I broke the closets and covered the windows that were glass, which I could with the little wood that I had inside my house, we took out and covered the part of, which is the one that, since I live on a mound, the it receives most of the impact but it was not enough. I prepared myself with what little I had, I lined and the rest, buy and that is always the supplies for this time because at home they are always supplied, but in the work of windows, that could not be done more than half because in hardware stores the People had already removed all the panel there was and what was left was not enough. And we, therefore, the money was not enough to buy the necessary material for ... there were no storm shutters and my windows are glass. The little that could be done was done, the rest was left out in the open and it was what suffered the consequences.”

From a participant who lives in a rural, coastal area:

“Para nada, yo no me preparé. O sea, había una compra que habíamos hecho, cobramos el cheque y hacemos la compra grande del mes. Yo no vi en mi casa preparación porque “no vamos para ningún lado, nos vamos a trancar aquí y mañana es otro día, nada va a pasar””

“Not at all, I didn’t prepare. In other words, there was a purchase that we had made, we cashed the check and we make the big purchase of the month. I did not see preparation in my house because “we are not going anywhere, we are going to lock up here and tomorrow is another day, nothing will happen”

From a participant living in a rural area:

“Lo que pasa es que mira la gente dice “entonces, no te preparaste” pero el gobierno está preparado, nadie está preparado, ninguna agencia de gobierno se preparó, aun teniendo más conocimiento que el pueblo, ahí nadie se preparó.”

“What happens is that when people look, they say “then, you did not prepare” but the government is prepared, nobody is prepared, no government agency was prepared, even though they have more knowledge than the people, no one was prepared there.”

Almost all codes applied at both the Community and Individual levels in the period before the hurricanes related to sociocultural factors (Fig. 4). For instance, participants also noted challenging social circumstances that pre-existed the hurricanes such as crime, violence, and unemployment in communities, and migration from Puerto Rico to the USA. Outer island residents were particularly concerned about crime in their communities.

From a participant living in an outer island:

“Muchas veces está bien tranquilo, pero llega una temporada que está caliente, empiezan los robos, empiezan a asaltar, la verdad? La guerra de la calle y pues estamos en ese tiempo ahora, que no puede estar por ahí mucha, mucho…. Verda? Sola… no puedes estar tan tarde por ahí y tienes que tener cuidado donde te metes.”

“Many times, it is very calm, but there comes a season that is hot, the robberies begin, they begin to assault, right? The street war and well we are in that time now, that there cannot be around much, much…. Right? Alone… you can’t be that late out there and you have to be careful where you go.”

From a participant living in a coastal zone:

“Aquí trataron de montar un puntito [drogas ilícitas] acá en frente y los mismos vecinos nos organizamos y le caímos arriba a los muchachos, un poquito problemático”.

“Here they tried to set up a little point [illicit drugs] here in front and the same neighbors organized ourselves and we fell on top of the boys, a bit problematic.”

Several Orlando participants indicated that people were already leaving the island in the times before María. Participants who eventually migrated to Florida were less likely to mention their communities as tranquil before the hurricanes arrived and generally were less likely to mention preparedness-related issues.

From a participant living in Orlando:

“…que en el área médica los médicos ya se están yendo de Puerto Rico, y hay, hay especialistas que no, que ya ni existen. O sea, básicamente. O sea que antes que pasara María, es como dijo el caballero, fue el-el-el último hachazo que nos dieron, ¿verdad?, para que Puerto Rico terminara como está.”

“... that in the medical area the doctors are already leaving Puerto Rico, and there are, there are specialists who are not, who no longer exist. I mean, basically. In other words, before María passed, it is as the gentleman said, it was the-the-last hack that they gave us, right? So that Puerto Rico ended as it is.”

From a participant living in Orlando:

“No hay para lo cual se sacrificaron, y como dicen en mi campo, se pelaron las pestañas. Si nosotros como padres hasta nosotros mismos los impulsamos a que busquen bienestar y yo tengo tres hijos varones. Los tres se me salieron para acá ya hace más de los últimos cuatro años. Con dolor en el alma vi a nuestros hijos partir con nuestros nietos sacándolos de-de prácticamente de debajo de nuestras sábanas, pero buscando bienestar.”

“There is none for which they sacrificed themselves, and as they say in my field, they peeled their eyelashes. If we, as parents, even encourage them to seek well-being and I have three sons. The three of them left me here for more than the last four years. With pain in my soul, I saw our children leave with our grandchildren, pulling them out practically from under our sheets, but seeking well-being.”

Some participants mentioned a sense of “invincibility” before the hurricanes and that no harm would come to them, with a few noting that the comparatively low amount of damage from Hurricane Irma may have created an air of overconfidence in facing María. Also at the individual level, some participants said that they felt their faith was a tool to protect them from harm.

From a participant living in a coastal area:

“Algunos decían que no iba a venir nada, “no, eso no viene nada”. Eso es como en otros casos que la gente decía como el cuento del lobo, viene y viene y a última hora me preparo, gasto y no viene.”

“Some said that nothing was going to come, “no, nothing is coming.” That is like in other cases that people said like the story of the wolf, it comes and it comes and at the last minute I prepare myself, I spend and it does not come.”

From a participant living in a coastal area:

“Entonces “Dios mío mami, entonces ¡Ay Dios! yo no puedo creer que esto va a pasar” ¿sabes?, entonces [comenzamos] rogando a Dios “vete, vete por la curvita y vete por otro lado” porque Irma lo hizo así.”

“Then “My God, mom, then Oh God! I can’t believe this is going to happen” you know, then [started] praying to God “leave, leave on the curve and go the other way” because Irma did it like that.”

From a participant living in a coastal area:

“Yo tenía miedo de lo que llegara a suceder, pero yo estaba confiado de verdad, de que, si pasaba algo, yo iba con Dios porque yo estoy en la iglesia.”

“I was afraid of what would happen, but I was truly confident that, if something happened, I would go to God because I am in church.”

Despite these challenges, participants frequently describe their communities before the hurricanes as tranquil and unified. Consistent with these sentiments, some participants noted that they underestimated the level of destruction that was about to come.

From a participant living in a rural, mountainous area:

“Aquí, como todo el mundo se conoce, entonces pues, este se unen. Entonces pues, todo es tranquilo, ¿sabes? Mayormente tranquilo. Este, no tenemos así, pues, problemas mayores de pelea, ni robo. Este, pues, podemos, pues, tratar de convivir juntos y vamos, poco a poco, uniéndonos, este, como dijo.”

“Here, as everyone knows each other, then, well, they come together. So, everything is quiet, you know? Mostly calm. This, then, we do not have major fighting problems, nor robbery. This, then, we can, therefore, try to live together and we will, little by little, unite, this, as he said.”

From a participant living in a metro area:

“Eh… es una, es una comunidad relativamente area tranquila que uno tiene una comunidad al lado que de hecho son una, que de hecho son los residentes originales de esa área que dura como un poquito más de ingresos, verdad, más humilde, más pobre”.

“Eh ... it is a, it is a relatively quiet area community that one has a community next to it that in fact are one, that in fact are the original residents of that area that lasts a little more income, right, more humble, poorer.”

From a participant living in a mountainous area;

“Tuvimos el evento de [Hurricane] Georges. Eso fue en el ‘98, ese fue fuerte. Pero anunciaban muchos fenómenos que venían, y muchas veces, pues, no llegaron, por suerte se desviaban. Había como una confianza de... digo muchos, ¿verdad? Yo entiendo que tuvimos como una confianza de que se iba a desviar. A lo mejor en muchos lugares no nos preparamos como... porque de hecho, nadie, por lo menos, de esta generación, nadie había visto algo tan fuerte como esto.”

“We had the [Hurricane] Georges event. That was in ‘98, that was strong. But they announced many phenomena that were coming, and many times, well, they did not arrive, luckily, they deviated. There was like a confidence of ... I mean many, right? I understand that we had a kind of confidence that he was going to deviate. Maybe in many places we don’t prepare like ... because in fact, at least no one from this generation, no one had ever seen something as strong as this.”

From a participant living in a coastal area:

“Pusimos tormenteras en la puerta del frente pero jamás y nunca pensábamos que se iba a ser como fue.”

“We put storm shutters on the front door but never, never thought it was going to be the way it was.”

From a participant living in a rural town:

“Pero no esperábamos el fuetazo que vino.”

“But we did not expect the thump that came.”

Codes applied to the period of the hurricane’s landfall, traverse across Puerto Rico, and exit (see Figs. 3 and 4) were markedly distinct from the other two periods (before and after) examined in this study: the experience of the hurricane’s strike was highly personal (reflected by most codes – 92% - relating to the Individual level) and, at this level, reflecting a mix of sociocultural, biological, and abiotic factors (Fig. 4). Specifically, the predominant themes of participants from the period before the hurricanes (see Table 3) were fear and anxiety (in the Biological domain), and experiences related to the wind (in the Abiotic domain).

Participants described Hurricane María’s experience mostly as one filled with fear and anxiety (see Table 3), most prevalent in those living in coastal areas followed by those living in rural areas. The main causes of fear and anxiety were described as a result of a rapidly deteriorating built and natural environment during the storm, combined with not knowing what was happening due to communications black-outs (telephone services, internet, and social media). This uncertainty, combined with the strong winds and the darkness, made individuals feel fearful.

From one rural, coastal participant:

“Era como si fuera eterno. No acababa. Nos metimos en la iglesia como desde las siete de la noche hasta el otro día que terminó el huracán. Y era un miedo horrible, y la puerta comenzó a hamaquearse, la de enfrente, y estábamos en esa de que en cualquier momento se fuera a despegar. Y el agua entrando por las ventanas.”

“It was as if it was eternal. It didn’t end. We went into church from about seven at night until the other day the hurricane ended. And it was a horrible fear, and the door began to swing, the one in front, and we were in the position that at any moment it would take off. And the water entering through the windows.”

From a participant living in a rural area:

“Pero a mí me dio ansiedad cuando no había ningún tipo de comunicación. No había forma de... no había celulares, no había, este, televisión, no había señal. Este, bueno, tampoco tenía luz, no había”

“But it gave me anxiety when there was any type of communication. There was no way to … there were no cellphones, no television, there was no signal. This, well, we had no electricity either, there wasn’t”

From a rural, mountainous area:

“Entonces, pues, según iba aumentando la situación, nos íbamos poniendo nerviosos, ¿verdad? Porque es algo que no… desconocemos. Entonces, este, cuando nosotros nos reunimos todos aquí la familia, pues, dejaron la puerta del frente abierta, verdad, y cuando comenzó esa tormenta... pues….digo yo, para mí, yo nunca había visto algo así tan fuerte. Porque cuando Georges, esto, ese fue de noche, y me dio miedo porque la casa como que vibraba y era un zumbido terrible. Entonces, pues, yo pensé que eso podía suceder. Pero dejaron la puerta abierta y todos ahí, mirando por la puerta porque el viento se metió por aquí, por aquí al frente. Y era como un humo, el agua se convertía como en un humo, que tú no veías nada. Solamente un zumbido, verdad, como un bramido de algo...”

“So, then, as the situation increased, we were getting nervous, right? Because it is something that we are not… unknown. So, this, when we all gathered here, the family, well, they left the front door open, right, and when that storm started ... well ... I say, for me, I had never seen something like this so strong. Because when Georges, this, that was at night, and it scared me because the house kind of vibrated and was a terrible hum. So, well, I thought that could happen. But they left the door open and everyone there, looking out the door because the wind blew in here, this way out front. And it was like a smoke, the water became like a smoke, that you didn’t see anything. Just a buzz, right, like a bellow of something ...”

From one participant – who had relocated to Orlando:

“Cuando pasó el huracán yo estaba refugiada en una iglesia. Resulta que la iglesia es de dos niveles, y la parte de abajo tiene un colegio. Habíamos treinta familias allí. Resulta que, en el paso del huracán, el techo de la iglesia se abrió en dos, y la iglesia se desplomó completamente la parte de arriba. O sea que la experiencia mía fue mas difícil aun, porque tuve que pasar el huracán allí en vivo, que eso fue… teníamos el agua acá arriba. Pensábamos que nos, que nos íbamos a morir, porque esa estructura empezó a temblar. Entonces, no tuvimos ropa algunos por tres días, bueno. La historia es larga. La cosa es, que, (pausa) (empieza a reír) …me fui, se me fue el hilo.”

“And when the hurricane passed I was taking refuge in a church. It turns out that the church is on two levels, and the lower part has a school. There were 30 families there. It turns out that, in the wake of the hurricane, the roof of the church split in two, and the church completely collapsed on top. So my experience was even more difficult, because I had to pass the hurricane there live, that that was ... we had the water up here. We thought that we, that we were going to die, because that structure began to shake. So we didn’t have some clothes for 3 days, well. The story is long. The thing is, that (pause) (starts to laugh) ... I left, the thread ran out.”

From a participant living in a rural area:

“Eso le da pánico a cualquiera, al que no le dio pánico allí, le dio cualquier otra cosa.”

“That makes anyone panic, who didn’t panic there, gave anything else.”

Mentioned previously, the vast majority of codes applied to the period of the hurricane strike itself related to Individual-level experience, which differed significantly from the pre-hurricane Individual-level experience in that the Biological and Abiotic domains are much more commonly mentioned during the lived experience of the storm (Fig. 3). Among the range of lived experience at the individual and abiotic domain, recollections of the “wind” generated by the storm are notable as the second most commonly applied code to this period. During the hurricane, many participants – especially those from the coastal and rural areas – narrated wind-related experiences: the strong winds felt like tremors, caused damage to their and their neighbors’ homes, and required creation of physical barriers to reinforce doors and windows to prevent damage significant injuries.

From a participant living in an outer island:

“Tú sentías, la casa que quería levantar la tierra, tu sentías la casa temblaba. Como que se metió por debajo…”

“You felt the house that wanted to raise the earth, you felt the house trembled. It kind of got underneath…”

From a participant living in a rural town:

“Eso es angustioso, es preocupante porque, pues, nosotros sabíamos, pues, que estábamos ahí resguardados, que con esto, de verdad que ahí ya no había nada seguro…”

“That is distressing, it is worrying because, well, we knew, well, that we were there sheltered, that with this, there really was nothing safe there ...“

From a participant living in a coastal area:

“Eso fue horrible, y el ruido de las cosas cuando se van yendo, eso te da…te lleva a un estado de desesperación, que….. horrible. Lo que más era el ruido, el ruido es lo que te ponía, porque tú estás seguro, sin ver; todo cerrado, todo tapado, eso es lo que más te desespera, ¿sabes? de que como estará afuera, ya el momento en el que tú sales, te da una depresión horrible, porque eso es una depresión, tú ves todo en el piso, los postes en el piso, no hay paso por ningún lado.”

“That was horrible, and the noise of things when they are leaving, that gives you … it takes you to a state of despair, which … horrible. The most was the noise, the noise is what made you, because you are safe, without seeing; everything closed, everything covered, that’s what makes you desperate the most, you know? How things will be outside, the moment you leave, it gives you a horrible depression, because that is a depression, you see everything on the floor, the [utility] posts on the floor, there is no passage anywhere.”

From a participant living in a metro area:

“Durante del huracán. Este…nosotras nos levantamos y mi pareja me dice, “Se va a meter el agua, ¿sabes?, no hay opción, el agua se va a meter -y venía con bastante fuerza- recoge, todo lo que puedas, sube todo lo que puedas que nos vamos.”

“During the hurricane. Um …. We got up and my partner tells me: “The water is going to get in, you know? There is no option, the water is going to get in and it came with enough force … “pick up everything you can, raise up everything you can, we are leaving””

From a participant living on an outer island:

“Si, cuando, ese momento cuando el árbol le da al carro, que ahí empezamos a escuchar, no sabíamos lo que se escuchaba, verdad? lo que era, pero se escuchaba tan fuerte. Eche yo estaba bien asustada… Yo literal me metí una Benadryl a ver si me dormía, pero los nervios eran tantos que no pude dormir. Fue bien fuerte.”

“Yes, when, that moment when the tree hits the car, which we began to hear there, we didn’t know what we heard, right? what it was, but it sounded so loud. Eche I was very scared ... I literally put a Benadryl to see if I fell asleep, but the nerves were so many that I could not sleep. It was very strong.”

From a participant living in the metro San Juan area:

“Ero[a] una cosa que ahí me-me llamó mucho la atención que el oído—incluso en algunos videos que ahora podido descubrir que están en YouTube de gente que toma videos, en aquel momento era—había un sonido bien particular que se estaba dando, que yo decía: “De dónde r-rayos salió ese sonido?” Porque era como si estuviera pasando por, el viento por algún tipo de estructura que le estuviera dándole un silbido, un sonido bien particular y era un sonido de fondo, como, como bien fuerte d-del viento, como si algo estuviera rugiendo. Y entonces e-ese sonido ahí yo no lo había sentido nunca en ninguno, en ninguno otro de los, de los eventos y era como un sonido que-que aumentaba y disminuía, pero que siempre estaba ahí presente; y ese sonido yo-yo lo he podido ver en… lo he oído en uno d-d-de los videos que han puesto de la gente que ha tomado de María que me di cuenta de repente que no era particular de ahí de donde yo estaba. Ese sonido se estaba dando en todo Puerto Rico, tú sabe, y también suena como si fuera un jet, e-e-el motor de un jet de un avión que estuviera ahí prendido y hace un ruido bien fuerte que se queda ahí, constante y es donde ahí veo: “Uy, esto… es otra cosa”

“It was one thing that caught my attention there - even in some videos that I have now been able to discover on YouTube of people who take videos, at that time it was - there was a very particular sound that was taking place, that I said: “Where did the sound come from? Because it was as if it were passing by, the wind through some kind of structure that was giving it a whistle, a very particular sound and it was a background sound, like, as strong d-from the wind, as if something was roaring. And then e-that sound there I had never felt in any, in any other, of the events and it was like a sound that-that increased and decreased, but that was always there; and that I-I sound I could see it in ... I heard it in one of the videos that they have put up of the people that they have taken from Maria that I suddenly realized that I was not particular from where I was. That sound was happening all over Puerto Rico, you know, and it also sounds like it was a jet, ee-the jet engine of an airplane that was on there and makes a very loud noise that stays there, constant and is where there I see: “oops, this ... is something else”.”

Shown in Fig. 3, narratives after the hurricane returned to a focus – overall – on community-level factors, as was the case before the hurricanes. The pre-hurricane focus on household factors (largely, preparation) was replaced after the hurricanes with a focus on individuals, largely around factors in the social and biological domains (see Fig. 4). The predominant themes of participants from the period after the hurricanes (see Table 4) were collapse of basic services, help and response, community health, and relocation to the USA.

Many participants report a total collapse of essential services such as electricity, water, and communication systems (internet and cellphone service). Those participants living in coastal and rural areas reported feeling secluded and experienced power outages for almost 1 year after Hurricane María.

From a participant living in a rural, coastal area:

“aquí lo que más afectó fue pues, al no haber electricidad, fue el agua potable… pues, ocasionó bastantes problemas.”

“here what affected the most was, since there was no electricity, it was drinking water ... well, it caused quite a few problems.”

From a participant living in a rural area:

“ni agua, y ya va casi un año ahora, se cumple un año del huracán. Eso sí que es triste”

“No water, and it’s been almost a year now, it’s a year since the hurricane. That is sad”

From a participant living in a rural area:

“Ya yo había pasado por la experiencia de George. Cuando George yo vivía en San Juan. Y esa experiencia fue espantosa o sea y pasé por esa experiencia. Nosotros a los 3 meses ya nos habíamos recuperado de George, no fue como ahora que pasaron todavía son ocho meses y hay gente que no tienen, que están llenos de toldo y no tienen, hasta luz, hay personas que todavía no tienen electricidad.”

“I had already been through George’s experience. When George came to San Juan. And that experience was horrible, I mean, I went through that experience. At 3 months we had already recovered from George, it was not like now that 8 months have passed and there are people who do not have, who are full of awning and do not have, even light, there are people who still do not have electricity.”

From a participant living in metro San Juan:

“Fueron días de levantarse temprano, muy temprano, fueron días de quizá no levantarme temprano, de levantarme a cualquier hora, ir a darle rewind, quizás a las tres de la mañana va a haber señal, quizás a las 5 de la mañana va a haber señal, quizás a las 11 de la noche va a haber señal, y tú seguías llamando, tú seguías cargando el celular y tratando de llamar.”

“There were days of getting up early, very early, there were days of maybe not getting up early, getting up at any time, going to give him a rewind, maybe at three in the morning there will be a signal, maybe at 5 in the morning there will be signal, maybe at 11 at night there will be a signal, and you kept calling, you kept carrying the cell phone and trying to call.”

The failure of essential services in the archipelago resulted, as described, in long waiting lines to access services such as food, water, and money.

From a participant living in a coastal area:

“Lo que quería decirte era que creé un oído biónico para helicóptero. Cuando yo oía ese helicóptero de lejos, ya yo.. el oido biónico. Eso fue grande, tu sabes, correr al parque a buscar comida, wao correr al parque, esperar que un helicóptero te trajera comida. En una película es que se da eso. Y lo hicieron mucho, todos los días venían a traernos muchas cosas, un helicóptero a traernos comida.”

“What I wanted to tell you was that I created a bionic helicopter ear. When I heard that helicopter from afar, I already ... the bionic ear. That was great, you know, running to the park to get food, wow running to the park, waiting for a helicopter to bring you food. In a movie, that happens. And they did a lot, every day they came to bring us many things, a helicopter to bring us food.”

From a participant living in a metro area:

“Y entonces al otro día pues como “Estas bien” “Estoy bien” entonces pues comenzamos como había mencionado, desayuno, almuerzo, cena, este…..el cash, la gasolina, las filas, a la hora de dormir cuando llegaba la noche para dormir eso era horrible.”

“And then the next day as “Are you okay” “I’m fine” then we started as mentioned, breakfast, lunch, dinner, this ... the cash, the gas, the lines, at bedtime when night came to sleep that was horrible.”

From a participant living in a metro area:

“esa situación que todos vivimos en esos primeros días, desesperante. Si vas a sacar chavos obviamente la ATH no funcionaban y las que funcionaban las filas eran… kilométricas. O sea, era el problema de que tú ibas echar gasolina, tenías que hacer una fila que ibas a estar 3–4 horas, pero tenías que hacer 2–3 horas del día para sacar chavos de la ATH. Todo lo que aquí te tomaba en un día, recuerdo unos quince minutos. Eh, o sea que todo el día le podías dedicar a eso nada más. Así que comenzando por ahí era bien desesperante.”

“That situation that we all lived in those first days, desperate. If you are going to get money, obviously the ATM did not work and the ones that worked the lines were ... kilometers. I mean, it was the problem that you were going to fill up gasoline, you had to stand in a line that was going to be 3–4 h, but you had to do 2–3 h a day to get money out of the ATM. Everything that took you here in 1 day, I remember about 15 minutes. Hey, so you could spend all day just that. So starting there was really maddening.”

Some participants described feeling “hopeless” and “scared” (Individual-level variables) in the time after the hurricane struck since they could not seek help or communicate with others in other parts of the island. Participants from these areas described how the debris and collapse of bridges made it impossible for them to seek outside help. Most participants believe that the lack of services combined with limited resources and unequal distribution of resources (e.g., food and water) resulted in the high crime rate in different parts of the island.

From a participant living in a rural area:

“Porque yo misma estuve 50 días sin luz y a mí nadie fue a llevarme un pote de agua.”

“Because I myself, was without electricity for 50 days and nobody came to give me a bottle of water.”

From a participant now living in Orlando, Florida:

“Entonces cuando llego con mi tarjetita que fui con lo que uno se acostumbra a usar, pues no, tienes que pagar en efectivo, no esto es efectivo, todo es en efectivo y no tenía ni el efectivo ni teníamos para comer y pasamos un hambre terrible, eh, muchas veces así sin poder caminar llegaba a los lugares para buscar agua y cuando ya estábamos a punto de llegar al lugar donde estaba el agua, ya nos gritaban “se acabó, ya no hay más””

“When I arrived with my card I went with it what you are used to use, well no, you have to pay in cash, this is not cash, everything is cash and I had neither the cash nor we had to eat and we were terribly hungry. Many times, without being able to walk I would arrive at the places to look for water and when we were about to reach the place where the water was, they would yell at us “it’s over, there is no more””

From a participant from an outer island:

“Sí, muchas veces porque también hace poco empezaron a asaltar este los negocios. Se han llevado a varios presos, pero asaltaron los negocios, se llevaban mercancías, si quedaba dinero se lo llevaban.”

“Yes, many times because also recently they began to storm this business. They have taken several prisoners, but they robbed the businesses, they took merchandise, if there was money they took it.”

While participants sometimes described feeling abandoned by both local and the federal government, this response was particularly noted in the coastal areas. Individuals reported that initial assistance was among community members: clearing debris, opening roads, and finding water and food. Coastal and rural participants described the assistance arriving mainly from two non-governmental organizations and volunteer workers from different community-level organizations.

From a participant living in a coastal area:

“Bueno, yo por, en mi casa había un banco de, todo lo comida y los primeros, pues, cosas de primeros auxilios todo eso estaba en mi casa guardado, en un cuarto, verdad. Reservábamos un cuarto ahí, y había una lista de personas encamadas. A esos se les daba, siempre se les daban, siempre se les llevaban el agua, comida, pampers, chops, este, todo eso se les llevaba. Casi siempre…La mayor parte de la gente aquí siempre velaba por los vecinos de que estuvieran bien los que estaban encamados.”

“Well, for me, in my house there was a storage of food, first aid things, all of that was stored in my house, in a room tight. We reserved a room there, and there was a list of bedridden people. They [food] were given to those, we always give them, they were always given water, food, pampers, chops, this, all of it. Almost always … Most of the people here always watched over their neighbors to make sure that those who were bedridden were well.”

From a participant living on an outer island:

“Muchacha gracias a Dios a la Marina que la Marina trajo cajas de raciones que ni botándolas se acaban. Troces y troces y troces.”

“Girl thank God to the Navy that the Navy brought boxes of rations that even throwing them out. Pieces and pieces and pieces.”

Some participants described that - amidst the circumstances concerning the aftermath of Hurricane María – some positive experiences (largely at the Community level) were of importance: for example, communities got together to help each other – participants described that in the aftermath of Hurricane María community members assisted each other (removing debris, sharing power generators), and communities were spending time with each other for the first time (playing card games, meeting each other, sharing food).

From a participant living in a rural area:

“Si supieras... yo que estoy de presidente de comunidad desde enero de este año 2018 y lo que he visto, al contrario, había una desunión y ahora la comunidad se ha unido más, y a través de esta situación, de los problemas del agua y todas esas cosas, ha habido gente que no se hablaba y ahora se hablan, y esto ha traído, como que, ante las adversidades han salido cosas nuevas y buenas.”

“If you knew … I have been the president of the community since January 2018 and what I have seen, on the contrary, there was a disunity and now the community has become more united, and through this situation, of the water problems and all those things, there have been people who did not speak to each other, and this has brought, like, in the face of adversity new and good things have come out.”

While the least common category mentioned in the ecological framework was “health care,” participants (particularly in rural areas) described challenges finding medications to manage pre-existing health conditions including such as diabetes and blood pressure. Additionally, individuals described challenges to access medical treatments including dialysis, chemotherapy treatment, as a result of medical systems collapse. Florida participants described that seeking medical care was sometimes a motivation for leaving. Participants in general, described emotional strains as the primary adverse health outcomes.

From a participant now living in Orlando, Florida:

“En cuestión de hospital, mi pueblo perdió el único hospital que tenía. Nosotros no teníamos hospital. Así que, si ocurría una emergencia, tenía que correr la persona que estuviese conmigo, o con cualquier otra persona, para Guayama que son dos pueblos más allá o para Humacao, pero estaban cerrados, lo que había era uno nada más, era el Domínguez.”

“When it comes to hospital, my town lost the only hospital it had. We didn’t have a hospital. So, if an emergency occurred the person who was with me, or with anyone else, had to run to Guayama, which are two towns away, or to Humacao, but they were closed, there was just one, it was the Dominguez.”

From a participant living in a coastal area:

“El daño más grande que ha hecho el paso de María a los sobrevivientes es el daño emocional que ha dejado en la isla. Me explico. El cual no sabía trabajar con ese daño emocional, ¿por qué? Volvemos a lo mismo, la persona que se afectaron emocional, son personas de tercera edad y niños. ¿Qué pasa? Que. aquí hay muy pocos psicólogos, pero esas personas que no vienen a hospitals.”

“The greatest damage that María’s passage has done to the survivors is the emotional damage it has left on the island. I explain. Who did not know how to work with that emotional damage, why? We return to the same thing, the person who was emotionally affected, are the elderly and children. What happens? That there are very few psychologists here, but those people who don’t come to hospitals.”

The main factors described influencing the decision to leave to the United States included: need of medical assistance, loss of property, losing employment, and the fear related to uncertainty based on the aftermath. Furthermore, participants living in Orlando, described that their main reason was related to overall better quality of life (e.g., the school for their children, lower crime rates). In contrast, some participants described challenges concerning financial limitations and the ability to seek medical care.

From a participant now living in Orlando, Florida:

“Sí, lo mío fue más bien, yo como perdí mi carro este, me quedé sin trabajo, ahí conseguí lo de, lo de (nombre institución) que era temporal, pero luego de eso este…decidí moverme, y si voy a empezar desde cero, como muchas cosas, pues decidí hacerlo acá porque pienso que aquí hay bastantes oportunidades, pero, de hecho, si yo no hubiera perdido mi carro y mi trabajo, yo hubiera seguido en Puerto Rico, totalmente.”

“Yes, mine was rather, since I lost my car, I was left without a job, that’s where I got the one from the (institution name) that was temporary, but after that … I decided to move, and if I go to start from scratch, like many things, because I decided to do it here because I think there are plenty of opportunities here, but, in fact, if I had not lost my car and my job, I would have remained in Puerto Rico, totally.”

From a participant living in a coastal area:

“Mi hijo me envió el pasaje porque me tuvo que sacar. Por que yo soy de las que estaba en la calle y a mí me había dado un derrame cerebral completo y estaba en recuperación. Tuvieron que sacarme porque del asma no podía respirar ya. Tenía vecinos con generadores Diesel y le instalaron unos tubos bien alto para sacarlos de su casa el humo.”

“My son sent me the ticket because he has to take me out. Because I am one of those who was on the street and I had a complete stroke and was in recovery. They had to take me out because of the asthma I couldn’t breathe anymore. He had neighbors with diesel generators, and they installed some pipes high up to get the smoke out of this house.”