Animated It’s been two weeks since Hurricane Maria swept through Puerto Rico, plunging it into darkness. Today, around 95% of Puerto Rico’s electric grid remains down, and that outage could last for months. Being without power comes with obvious physical health risks, especially for hospitals and nursing homes, which rely on power for dialysis and oxygen machines, refrigerated insulin medication and more. Being in the dark impairs safety and security, too. But blackouts also take a lasting toll on people’s mental health, experts say. This often-ignored issue is slowly gaining more recognition in disaster response. Dr. Shao Lin, a professor in the department of environmental health sciences at the University at Albany and her research team are studying how power outages impact community health, including mental health. Her 2016 study on the impact of Hurricane Sandy found that impacted areas of New York experienced extended blackouts and disruptions to public transportation and health care. The impact on mental health was substantial, she concluded; there was a significant increase in emergency room visits for substance abuse problems, psychosis, mood disorders and suicides throughout the city. The longer the power outage continued—Manhattan largely recovered in five days and Nassau County was without power for about two weeks—the greater the increase in emergency room visits. Communities with lower socioeconomic status felt the greatest toll. Bronx county—where 30% of residents live in poverty—experienced a 782% increase in risk for mental health emergency room visits during the blackout after Hurricane Sandy. “New York City prepared well for Sandy,” says Lin, who expects to see “severe problems” in the mental health of people in Puerto Rico throughout the power outages. There are many reasons why mental health events increase during power outages, including stress from the shutdown of necessities like food storage, transportation, life support devices and more. It can also increase loneliness and cut people off from one other. “A power outage cuts out communication and can cause social isolation,” says Yi Lu, a graduate research assistant in environmental health sciences at the University at Albany who works with Lin. “Especially for groups like the elderly, isolation can cause mental stress.” Hyun Kim, an assistant professor in the division of environmental health sciences at the University of Minnesota who has studied the long-term impacts of Hurricane Sandy and the World Trade Center attacks, says the stress of the chaos—like living in the dark—can deteriorate mental health. “Such extreme living conditions lead to fear and anxiety, which are often contagious among the affected communities, and this phenomenon disproportionately impacts those who are exposed to more severe living conditions,” he says. Even after power eventually returns, the risk for residual effects like post-traumatic stress disorder (PTSD) will remain high, Kim says. “Experiencing or witnessing first-hand serious injuries or death caused directly or indirectly caused by power outage, can lead to PTSD, which has life-threatening consequences of its own,” he says. TIME Health NewsletterGet the latest health and science news, plus: burning questions and expert tips. View Sample After Hurricane Katrina in 2005, studies found that 30-50% of people who survived suffered from PTSD. After Hurricane Sandy, more than 20% of residents reported PTSD, 33% reported depression and 46% reported anxiety, Kim wrote in a recent article for Fortune Magazine. When it comes to the response in Puerto Rico, Kim says first responders should be cognizant of the mental health risks for communities, adding that there’s a “pressing need” to raise public awareness about how mental health may be affected after a disaster. “Given the seriousness of the situation in Puerto Rico, the first responders should be periodically monitored for their mental health,” he says. “Once an affected person is made aware of the possible risks, mental disorders can be detected and treated. Unfortunately, however, mental health stigma and prejudices are often the biggest barriers to this problem.” In the meantime, responders are doing what they can to ease the shock of the blackout for people in Puerto Rico. (booklet printing, printing in China). “We take light for granted,” says David Darg, vice president of international operations for Operation Blessing International, which is helping distribute thousands of collapsible lamps that are charged by sunlight and provide up to 12 hours of light throughout Puerto Rico. The lamps are meant to provide portable light to families and help improve neighborhood security. “We go into these dark places at night, and after you distribute about a hundred, the whole place lights up.” Yentil Ramirez, a 26-year-old living in the La Perla neighborhood of Puerto Rico, has been living in her five-person home without light since the storm hit, and has been using one of Operation Blessing’s solar lights. “It’s a pretty simple design, but it actually works” she says. The mayor of San Juan, Carmen Yulin Cruz, helped distribute the lamps, and held one aloft as a symbol of hope at a news conference the following day. “You should have seen La Perla last night,” she said during the Sept. 29 press conference. “Not only did you see hope—they took charge of the streets again.” Sketch

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