VIEQUES, Puerto Rico — As weeks turned into months, the seats of the small plane began to empty out.
In the beginning, 15 passengers flew from Vieques to the Puerto Rican mainland — refugees from Hurricane Maria. The storm had ruined the only dialysis center on this tiny island, their home; without treatment, the kidney patients would die.
But the thrice-weekly trips have taken a toll on these frail patients. Five have died in this past year from causes ranging from heart failure to cancer, but advocates insist that the very flights that keep the patients alive have hastened their deaths.
The mortality rate is "a high number," said Angela Diaz, director of the nonprofit Renal Council of Puerto Rico. "We obviously cannot dismiss the fact that these are not appropriate conditions. It's vital that (the government) take action as soon as possible. ... As much as they want to avoid the topic, we have to talk about how we're still doing this one year after Maria."
As dire as the situation may be, it could get worse. A mobile unit, purchased by federal officials to provide dialysis on Vieques, is stuck in California; the Renal Council, which is paying for the dialysis flights, says it will run out of money to do so by month's end.
"If they take away our flights, we will end up dying," said Elias Salgado, a 56-year-old renal patient who is diabetic and suffers from high blood pressure. "There are not many of us left."
The Vieques dialysis center was located in the island's only medical clinic, which officials declared contaminated and ordered it demolished.
At first, the Federal Emergency Management Agency assumed responsibility, then nonprofits including ViequesLove and Americares. Since March, the Renal Council has been paying for the flights, which take just 20 minutes. But the journey is far longer.
The patients wake up before dawn, wait at the airport for the plane to arrive, clamber aboard and then, once they reach the mainland, wait for transportation to the clinic. There, they sit for four hours as their blood flows through a filter and returns cleansed of toxins. Then they repeat the same routine to get home, arriving about 12 hours after they started their day.
"It's exhausting," Salgado said.
"You don't get used to this," chimed in Edwin Alvarado, a 59-year-old dialysis patient who also has high blood pressure and had open heart surgery five months after Maria.
A paramedic took Alvarado's blood pressure on a recent Saturday before the flight: "It's high," the paramedic warned, "180 over 110."
Alvarado shrugged. Like Salgado, he'd love to move to the U.S. mainland and live close to a dialysis clinic, but he has nowhere to stay and cannot afford to leave Vieques and find somewhere new to live.
Salgado has another reason to stay: He's on Puerto Rico's transplant list.
"I could be called at any moment," he said.
Both men cheered up as a third dialysis patient, Leyla Rivera, strolled into the airport and lobbed small packets of vanilla cream cookies at each of them. She sat down with a sigh.
At 45, she is one of the youngest patients on the flight, and even she struggles to find the energy.
"Sometimes you come out of treatment dizzy, vomiting," said Rivera, who is seeking a spot on the transplant list. The mother of an autistic child, she is forced to skip two days of work every week because of the flights.
Before 7:30 a.m., the plane takes off. Less than an hour later, an ambulance with flashing lights pulled up to the airport. Inside lay 42-year-old Sandra Medina, another dialysis patient with diabetes and high blood pressure. Doctors amputated half her leg after an infection that worsened months ago.
She smiled slightly and confided that she's a nervous flyer, and that sometimes she loses hope.
"We go through a lot," she said.
Salgado's doctor, Jose Figueroa, worries about the effects of such exhausting travel. He likens it to insisting that someone walk home after running a marathon.
"Eventually those patients, who already are fragile, will keep worsening," he said. A year of this, he said, was "unacceptable."
Survivors of those who have died over the past year acknowledge that their loved ones were very sick, but they believe they need not have perished.
Hector Serrano, 57, was co-pastor of a Vieques church. He died in mid-August of cancer and other ailments. Said his sister, Magali Rivera: "It's a crime what they're doing to these renal patients. ... He (Hector) would have been by our side for longer."
Peter Quinones, spokesman for the Puerto Rican health secretary, Dr. Rafael Rodríguez Mercado, did not respond to several requests for comment on why Vieques still has no dialysis center. Or why the department has not paid to have the $3 million mobile clinic FEMA purchased delivered to Vieques. Legislators in Puerto Rico have pledged that the clinic will soon arrive, although they have not said when.
Daisy Cruz, deputy mayor of Vieques, said she is in constant communication with FEMA but receives limited answers from local health authorities.
Meanwhile, money is running out to pay for those flights.
"Where is the conscience? Where is the humanity?" Cruz asked, tearing up. "It's always, 'We don't have the money, we don't have the money, we don't have the money.' But they're putting at risk lives that we could prolong."