The darkness is persistent. Power and clean water are still tenuous and reliant on generators and outside aid. Contamination threatens basic necessities for dozens of municipalities, and the death toll—already likely a serious undercount—is only rising as diseases and the attrition from devastated infrastructure take their toll. Even with the aid of the federal government and the military, a health-care system facing multiple threats might not be able to protect some of the island’s most vulnerable citizens.

Many of those people are facing hard choices in Puerto Rico’s hospitals, which are at the front lines of disaster-relief efforts. While most hospitals have recovered from the storm’s early blows—which knocked most of them out of commission and left a few others dependant on generators—they have had to make do with shortages of power, water, and supplies; personnel crunches; and intensifying health-care needs from accidents and emergent diseases. Last week, a photograph posted by former Governor Alejandro García Padilla on Twitter showed doctors performing surgery by flashlight. From what physicians on the island tell me, such scenarios are common, as is physicians working double and triple shifts—circumstances made even more remarkable by the fact that the doctors themselves are victims of the storm.