Forty days after Hurricane Maria struck Puerto Rico, most of the U.S. territory remains without power.
Over the weekend, the island's power company fired a key contractor working to restore electrical service. The cancellation of the $300 million contract with Whitefish Energy, after the Federal Emergency Management Agency and other agencies expressed significant concerns about the deal, is expected to further delay the return of power throughout Puerto Rico.
The Puerto Rican government has prioritized getting power back to hospitals. Many smaller clinics and doctor's offices, like other businesses on the island, still don't have electricity.
Take, for instance, San Patricio Medflix, a diagnostic imaging center in greater San Juan. The center has state-of-the-art MRI, CT and nuclear medicine equipment.
Dr. Fernando Zalduondo Dubner, medical director imaging center, says his biggest job is battling with a heavy-duty diesel generator to keep the power on. "We are having trouble with it now as we speak," he says.
With Puerto Rico's electric grid down since Sept. 20, the diesel generator, housed in a metal box the size of a shipping container, has been the sole source of power for his four-story medical complex.
Fuel has been a big problem. The generator consumers about 500 gallons of diesel a day.
In the weeks after the hurricane hit, the diesel supply was incredibly tight. Zalduondo ended up buying whatever fuel he could get from whoever was selling it. But some of it was of such poor quality that it gunked up the generator. "The other day we had to cancel 70 patients that were here because we had to rely 100 percent on the diesel plant, and it just got clogged from all kinds of diesel that had been around," he says.
For Zalduondo the stakes are higher than keeping the lights on. MRI machines like his need liquid helium to cool their superconducting magnets. If the MRI scanner loses power for very long, the helium overheats and evaporates quickly. If the helium level gets too low, the scanner can be permanently damaged.
Another radiologist in San Juan thought he had all the diesel, helium and other supplies he needed to ride out Hurricane Maria only to have his MRI machine seize up after looters drained his diesel tank. Early on Saturday morning engineers from Siemens, a medical equipment maker, were able to refill the center's last working MRI machine's liquid helium.
The hurricane's winds also opened a crack in the imaging center's roof that let water pour into much of the top floor. As the crisis has dragged on, some of Zalduondo's employees have packed up and headed to the mainland.
"Practicing high-end radiology in Puerto Rico is extremely challenging in the best of times," he says. "It seems like all the conditions conspire to make us radiologists leave Puerto Rico."
The electric blackout isn't just affecting high-end medical equipment that requires liquid helium.
Dr. Eduardo Ibarra says the conditions in Puerto Rico, including the lack of power, are killing patients who otherwise would survive.
Ibarra is making house calls to mostly elderly patients in devastated parts of Toa Baja just west of San Juan: "I would say that of the ones I visit, 100 percent don't have electricity.
That means his patients don't have air conditioning or even fans to keep cool, a situation which aggravates bedsores for his bedridden patients. A lot of people still don't have running water, never mind hot water, so sanitation is poor. Their refrigerators aren't working either, so some medicines are going bad. Some dialysis clinics have shut down, too, forcing patients to search for alternatives.
"Between no light and no water and no money and no help ... the patients are getting very sick," he says.
Even as October draws to a close, power has officially been restored to only 30 percent of customers in Puerto Rico.
On a hillside in Toa Baja, Carmen Garcia Lavoy's relatives and neighbors are rebuilding her home with hand tools. The hurricane blew the roof and walls out of her house leaving behind a tiled cement slab littered with debris.
Dr. Ibara comes to see Garcia, who is 77. She has a host of medical issues, including high blood pressure. Last year she had open heart surgery. She also can't see well.
Garcia she's been very anxious living in the basement of the destroyed house with her son. Dr. Ibarra examines her in the open air of what used to be her living room. As he takes her blood pressure she breaks down crying and says she hasn't been able to get to a doctor since the storm. "I've been dying to speak to my cardiologist and I've already cancelled or lost two appointments with him," Garcia says.
Ibarra writes her a prescription for a blood pressure medicine that she had run out of. Garcia clutches the prescription to her chest as if it's a treasure.
The official death toll from Hurricane Maria stands at 51, but Ibarra says far more people than that have likely died as a result of the storm. Doctors don't write "hurricane" as the cause of death on a death certificate, he says, "the physician puts cardiac arrest, respiratory arrest."