The doctor’s office closed on Tuesday. The electricity went down around 11 a.m., making it impossible to see any more patients, says Dr. Helen Rosa, a geriatrician and family practitioner in Plaza Las Americas, a major shopping area in San Juan, Puerto Rico.

Rosa’s practice is located on the sixth floor of an office building. “We have elevators but if we don’t have electricity, patients can’t come up,” she says. Without electricity, there’s no working air conditioning for patients in their 80s and 90s. Electronic health records fade in and out. When Rosa can’t prescribe electronically, patients who call her office — assuming phone service is available — can’t obtain refills for needed medications.

[See: 7 Ways Technology Can Torpedo Your Health.]

As older patients do their best to deal with the devastation three weeks after Hurricane Maria, it’s no wonder they’re stressed out, Rosa says. Ongoing power shortages affect every aspect of their lives, amplified by health, frailty and mobility issues. “Today, patients I saw had to go 10 floors down in the building where they live because they do not have electricity,” she says. “That means they have to go up 10 floors — and I’m talking about 80-year-old patients, and one of them is blind.”

Darkened streetlights and traffic signals pose transportation hazards. “Driving is really challenging, even for younger drivers,” Rosa says. Usually, her practice offers extended hours to accommodate family caregivers who can only bring in patients after work. But it’s already getting dark by 5 p.m., she says, and now, terrible visibility on the roads makes evening driving too dangerous.

Rosa hopes to reopen the office soon. If not, she says, at least one of her patients may need to go to the hospital if her condition worsens. That’s not an ideal solution, though, as hospitals must rely on troubled power plants. “Hospitals don’t have energy from the electric grid,” she says. “We want to get medical offices that give specialty and primary care up and running, so hospitals don’t get this overflow of patients who, to begin with, should not be there.”

As of Tuesday, 65 of 67 hospitals in Puerto Rico were open, with 36 on the power grid and 29 operating on generator power, according to a Department of Defense report. As of Thursday, 17 percent of residents had electricity, according to figures posted by the Puerto Rican government.

“I’m a doctor — I’m not an engineer,” Rosa says. “But as a doctor I can tell you, we need electricity so we can take care of our patients.”

[See: 14 Tips for Traveling With Diabetes.]

Many older patients need access to medications for chronic health conditions like diabetes. Last week, Direct Relief, a humanitarian medical aid organization, shipped about 16,000 doses of insulin to Puerto Rican public health agencies. Since Hurricane Maria hit the island, the relief organization has been shipping emergency health kits via FedEx, including diabetes supplies, antibiotics and medications to treat high blood pressure and asthma.

“When supply chains are interrupted and disasters occur, people — especially those with chronic health conditions — remain extremely vulnerable,” says Damon Taugher, director of U.S. programs for Direct Relief.

In addition to pills, inhalers and injectable drugs, many older Americans rely on nutritional products like Ensure to maintain their health. “When those are in short supply it can obviously exacerbate health conditions,” Taugher says.

Just returned from Puerto Rico, Taugher says he found “a very challenging situation. The magnitude of the storm really touched every part of the island.” As he and a fellow team member assessed the situation in areas including San Juan, Mayagüez and Aguadilla, they saw drastically reduced cell service, and severe fuel and power shortages.

“Colleagues who provide care to older adults in clinics and health centers say they and others were forced to wait six to eight hours in line to get gas,” Taugher says. For older patients with compromised health, he points out, that’s simply not feasible.

In some cases, health providers have shifted their approach by venturing out into communities rather than waiting for patients to come to clinics or federally qualified health centers, Taugher says. It’s one way to provide better access for older patients living in mountainous areas or smaller, distant towns.

[See: 14 Things You Didn’t Know About Nurses.]

Enormous needs and dire conditions in Puerto Rico pose a health and safety crisis, according to a team of 50 registered nurses volunteering on the ground. Black mold growing within soaked, roofless homes; breakouts of a dangerous bacterial disease called leptospirosis; limited rations of food and water and inadequate federal relief efforts all leave residents suffering, volunteers say.

Cathy Kennedy, a nurse volunteer, is a team leader with Registered Nurses Response Network, part of National Nurses United. Her group, RNRN, is part of the multi-union relief effort under the AFL-CIO umbrella. Groups representing construction workers, painters, electricians, plumbers and other nurses are participating to help the people of Puerto Rico.

Kennedy describes an outreach bus trip to a residential development with a senior complex. Some of the small duplex-type houses were pretty clean, Kennedy says, while others contained wet areas. “I went into an elderly couple’s home,” she says. “The door was off; they had no roof.” A tarp perched on top of the wooden house frame served as a makeshift roof, but when it rained, water gathered.

During the visit, the man tried to get water off the tarp, only to have it come pouring into the house. It was unclear whether the couple had a bathroom available to them, Kennedy says, or if they were able to wash their hands.

“There are many communities where families take care of the elderly, which is a beautiful thing,” Kennedy says. “But then you find those that don’t. So it becomes a struggle.” Older adults are stressed out and can’t sleep, she says. Many seniors live in houses that should be condemned, but they don’t want to leave their homes. “They don’t have any electricity; they don’t have any gas,” she says. “It’s heartbreaking.”

Water is the most-needed supply, but distribution has been slow. “FEMA has been kind of absent,” Kennedy says, especially in the poorest inland communities. To receive aid, people have to wait outdoors in extremely long lines or go online to fill out forms, which she finds frustrating. “Who has the internet?” she asks. “Who has electricity?”

More from U.S. News

How Social Workers Help Your Health

14 Ways Caregivers Can Care for Themselves

16 Ways Your Body Adjusts to a New Climate

Electricity, Water and Shelter Issues Plague Older Adults in Puerto Rico originally appeared on usnews.com