In rural and impoverished areas of Puerto Rico, a new day means a new search for food and safe water as the humanitarian crisis there continues to escalate.

More than three weeks after Hurricane Maria, more than a quarter of homes in the U.S. territory lack clean water, about 85 percent are without electricity, and President Trump is raising anxieties further as he tweets threats to end federal assistance that aid workers on the ground say has been slow to reach hard-hit areas if it has reached them at all.

With no electricity, some people are using car batteries for power. Others are relying on propane from rapidly depleting tanks to boil what water they are able to find. It becomes a survival calculation, said Roberto José Thomas Ramírez, general coordinator of the Eco-Development Initiative of Jobos Bay in southern Puerto Rico.

“Every day, I visited at least three or four stores looking for bottled water, and I didn’t get any, so every night I try to do the math to be able to boil water and not use enough gas to be able to also cook,” Ramírez said.

As the island struggles to recover, the impacts have hit the poor hard. Half of Puerto Ricans live below the poverty level. One of the most sought-after commodities in big box stores are generators strong enough to power an air conditioner. They sell for around $6,000—nearly one-third the median annual household income.

Getting money, food and fuel can mean hours-long waits under a sweltering sun, something that is especially challenging for the sick, elderly and families with young children.  

“Maria didn’t just hit the island and strip the trees and the infrastructure,” Ramírez said. It also laid bare “the inequalities and injustices that existed for many years.”   

The depth of desperation showed last week when the U.S. EPA said it had received reports of residents “obtaining, or trying to obtain,” drinking water from wells at hazardous waste Superfund sites. At least one well, near Dorado, had signs that people had been pulling water from it, though it wasn’t clear how many people had been there, EPA spokesperson Rusty Harris-Bishop said.  

“Sampling of these wells done in 2015 indicated that some exceeded drinking water standards for volatile organic chemicals,” Harris-Bishop said in an email. He said the agency would secure the wells and take new samples, and that a truck was distributing water in the community on Friday, with power expected to be restored to the water plant soon so water service could resume.

The Good Samaritan Hospital in Aguadilla in northwest Puerto Rico is using private security companies or the police to escort water shipments needed to keep conditions sterile and patients alive, said Gisela Gonzalez, a special projects coordinator at the hospital.

At home, she has been using rainwater for washing clothes, flushing toilets and doing the dishes. What little potable water she was able to save up in soda bottles before the storm hit, she is using for drinking. Shipments sent by family on the mainland two weeks ago haven’t arrived.

Disease Outbreaks and a Rising Death Toll

Twenty-three days after Maria made landfall, outbreaks of leptospirosis, a deadly bacterial disease, scabies and conjunctivitis have been reported, as well signs of an uptick in Zika and chikungunya, mosquito borne diseases that were present on the island before the hurricane. In Yabucoa, where the median household income is just $15,600, the mayor said food distributions aren’t going far enough and people are going hungry.

Official government figures place the death toll from the storm at 48 in Puerto Rico. Members of Congress requested an audit of those figures last week after news reports suggested actual deaths related to the storm may be 10 times higher.

Electricity has been restored to many of the territory’s hospitals, but the medical situation remains fragile.

“Generators are failing, and when generators fail, you go back into darkness,” Jim Mitchum, CEO of Heart to Heart International, a volunteer organization providing emergency medical care in the remote interior of Puerto Rico, said.  “A hospital we worked with in Caguas had a major generator failure the other day and had to evacuate its patients.”  

Another hospital connected to the grid in San Juan recently lost power as a surgeon was in the middle of heart surgery, he said.  

Frustration with the Federal Response

As frustrations on the island grow, people are increasingly placing the blame on FEMA.

“As more people are going hungry, FEMA keeps doing paperwork,” said José Andrés, founder of non-profit food assistance organization World Central Kitchen.  “When we should have less people hungry, it seems every day we have more.  Puerto Rico was hit by two disasters, the first disaster was natural, the second disaster is man-made by clear lack of leadership.”

World Central Kitchen had a contract with FEMA to provide 20,000 meals per day that expired on Tuesday.  Andrés said his group was providing 70,000 warm meals per day out of 6 kitchens across Puerto Rico without FEMA support as of Wednesday. The group hoped to expand to 100,000 meals by the end of the week but much more was needed for Puerto Rico’s 3.4 million people, Andrés said. FEMA said it is providing 200,000 meals per day with more than 300,000 additional meals per day coming from volunteer groups.  

As the daily struggle for food and water persists, President Trump threatened to cut off federal support to the U.S. territory on Thursday. After intense backlash, Trump reversed himself on Friday, offering renewed pledges of assistance.

The federal government has dedicated more than 19,000 personnel to emergency response efforts in Puerto Rico and the U.S. Virgin Islands, according to FEMA. Yet, even if all those workers were sent to Puerto Rico alone, they could only provide about half the necessary food and water, according to an analysis by researchers at University of California, Davis, described on Undark.

“I see health problems not only being very serious right now, I don’t see them ending anytime soon,” Mitchum said.