MANATI, Puerto Rico — On days like this, high among banana tree mountains topped with cloud mist, the decision to stay feels like the right one.
Luma Al-Attar takes one of the finger-length fruits from her patient Felix Rodriguez and peels it while listening to the stories of his childhood in these mountains, his work on the neighboring cacao farms, his 11 children, his 104 years on the island and the way her medical practice — the closest one to his home in years — has helped him.
Her time with patients such as Rodriguez is nothing like the other side of her double life. In that world, the one where she sees patients two days a week near her hometown in the nation’s capital region, business is booming, traffic lights function, schools are open, patients are on time, the electricity works. Things work. People work.
But then the 44-year-old gets back on the plane to return to the island where her husband and three kids live, where patients can’t make it to appointments because roads remain treacherous, where she struggles to make payroll for her loyal employees, where power outages are still routine, where crime is spiking and the police force is shrinking, where she can’t find a pediatric endocrinologist or the physical therapist her children need. And that’s when she wonders whether they all shouldn’t just go. Why stay?
Stay? Or go? Stayorgo. It’s the constant soundtrack in her head.
And it’s the looming, unsexy, social catastrophe after any natural disaster. There’s a brain drain, a generational gap, a cultural chasm when people leave to survive.
And it’s part of the crisis in Puerto Rico’s recovery. A year after Hurricane Maria devastated the island, most of the thousands of residents who fled haven’t returned home. Florida and Texas, New Jersey and Connecticut have more Puerto Ricans.
San Juan and Orocovis, Manati and Bayamon have empty homes, vacant shops.
“It’s the middle class — the teachers, the nurses, the secretaries who can’t find work — who left,” said Al-Attar, as we drove on tight switchbacks into the mountains to visit her patients. “The growing divide between the rich and the poor here is frustrating. And maybe you have your generator and your hurricane-proof windows. But what about the rest of your community?”
Al-Attar has been trying to do both — to stay and to go.
She’s at home in the prosperous Washington region, where she graduated from the National Cathedral School in the District before going to Harvard University and then medical school at Johns Hopkins University.
She found her second home after falling in love with and marrying another intern, Ricardo Marrero Cortes. They both agreed they hated the cold, so they moved to Miami, where they had three kids and did their residencies. He’s a gastroenterologist. She completed her chief residency and surgical retina fellowship at one her field’s primo facilities there.
Then, they made the move to Puerto Rico. Marrero Cortes missed his native island and wanted to help the underserved there. Al-Attar saw the chance to make a big difference in the island’s health-care system, serving as the only surgeon in the area who specializes in the back part of the eye — the retina — and can treat macular degeneration or diabetic issues with lasers, surgeries or injections.
For a decade, their practices thrived, and their lives in paradise worked. The kids were growing up bilingual, in a fantastic neighborhood close to the beach.
Then, Maria happened.
They hustled the kids into the few remaining airplane seats as the storm closed in Sept. 19. Grandpa picked them up.
The hurricane hit and flooded their home in Puerto Rico. “Agua, agua, agua,” Al-Attar described it. “Water everywhere.”
Grandpa enrolled the kids in Montgomery County schools, where they slipped into weirdly normal, suburban lives. Bethesda-Chevy Chase High School’s newspaper did a feature on freshman Ricardo Marrero. He loved it there.
Meanwhile, back on the island, there was chaos. People slept in their cars for hours and waited in line for gas — the lifeblood of the island post-hurricane. Potable water was running out; ice was rationed. Insects were flourishing, and the heat was stifling. There was no power and very little communication.
“People were hot and hungry. Everyone was running out of food,” she said. “People couldn’t reach each other to find out who was okay.”
This is the part of everyone’s hurricane story when they begin to cry. All of them. The isolation was devastating.
More than $100,000 in refrigerated medications in Al-Attar’s office went bad. The generator could run only a few hours a day because of fuel rationing. What would she do if patients showed up? There was no way her staff could make it to work — some of them lived more than an hour away.
They showed up.
Without power or water, surviving on rice or crackers and canned cheese, her workers came. Some of them brought their kids because the schools were closed, even destroyed. She’d never seen anything like it. “The resilience. They just didn’t give up,” she said.
And her patients came, too. There was the 104-year-old mountain man, Rodriguez, who didn’t slow down and came in for his eye exam. Fifty-year-old Angel Rosario, who nearly lost his eyesight during his last construction job, showed her photos of his devastated home — a few walls, some concrete blocks — when he arrived for his treatments.
And there was the funeral director, Fernando Diaz Ramos, whose workload has been overwhelming following the storm. He couldn’t keep caskets in stock.
For months after the storm, more dead than ever before were arriving at his office.
“A lot of people couldn’t afford the services,” he said. “So we helped out many times.” While the officialgovernment death toll stayed at 64 for months, the rest of the island — especially Diaz Ramos — knew the real number was closer to about 3,000, which Puerto Rico Gov. Ricardo Rosselló acknowledged last month.
Most of Al-Attar’s patients have a story about a family member’s quick death after the storm.
Although her patient load dropped by 50 percent, she wouldn’t lay off her staff. Most of them had small children and were the only breadwinners. And that’s when she decided to go. Sort of.
The Retina Group of Washington, which also has offices in Virginia and Maryland, knew that Al-Attar was an exceptional doctor. So they made her an exceptional offer, a contract to work just two days a week, allowing her to commute back and forth between Washington and Puerto Rico.
She took a deep breath and dove into this life, trying to stay and go. Two days for D.C.-area patients, two days for Puerto Rican patients and two days with her husband and kids, who had returned to their Puerto Rican school after it reopened with a new generator.
Life as the ultimate commuter has replenished her bank account and kept her office near Puerto Rico’s northern mountains open, helped her reconnect with her large, Montgomery County family and sated her Type A need for order.
The kids applied to the schools where Al-Attar and her brother attended, National Cathedral School and Landon. They got in. Her son — who competes in math tournaments and represented Puerto Rico at the National Spelling Bee — longed for a bigger, more challenging school. Maybe they should go.
But her husband’s practice was thriving.
His waiting room, in a raucous suburb of San Juan inside an aging building, is constantly packed.
“I grew up here,” he said. “After the storm, 365 doctors left. That’s one per day. I couldn’t be another one.”
There’s that noble doctor dream — to join the Peace Corps, to go to some far-flung place to help those in need. That dream, he argues, is happening right in his hometown — in Puerto Rico. “If anyone should stay, it should be us.”
This is their constant conversation.
She emailed me a memo, two parts each with subsections A through F: Stay? Or Go?
And she made a decision.
After Al-Attar saw her final patient on her Tuesday schedule in the Fairfax office, she packed up her D.C. clothes and took her usual flight back to San Juan. Then she switched to her Puerto Rico clothes — a sundress the color of banana leaves — and took me on a tour of her favorite patients’ homes, where their families served home-cooked rice and beans or fancy Puerto Rican cheese on toothpicks and Pinot Grigio, and told their hurricane stories and asked her the big question: Stay? Or go?
And she told them: “Stay.”
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