When the first earthquake hit, Luz Noguera was in the shower.

Noguera, 36, grabbed her keys, forced the door open and ran out into the street in a panic. Her first thoughts were for her kids and family members, and their immediate safety. Then, it was survival.

“We gathered on the main road and stayed there,” she says. “It started to rain, the electricity went out and there was no cell service, no way to contact our families. We spent the whole night in the street.”

The last thing on Noguera’s mind was her asthma medication — still in a bag on her nightstand.

The numbers following the June 24 earthquakes trace a devastating outline: At least 3,535 dead, with thousands more missing. And some 16,700 injured.

As hopes fade of live rescues from the rubble, health workers have turned their focus to the living. With an estimated 18,000 people now homeless, doctors must face a new wave of health issues — the kind that happen when thousands of people are suddenly displaced in the heat, the rain and the dust.

“We’re seeing diarrhea, respiratory infections — skin diseases, because they’re exposed to the sun for many hours,” says Dr. Eduardo Celades, a senior health adviser for UNICEF.

Dehydration. Asthma attacks. Sunburn. The ailments of normally healthy people, who no longer have easy access to their medications, regular meals, or running water.

“As well, there will be risks of outbreaks — like for example measles, respiratory infections. This is going to be our priority,” Celades tells NPR.

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Three hospitals suffered critical structural damage and were knocked out of service during the earthquakes, the World Health Organization said. Several others are only partially functional, with staff doctors and other frontline health workers among the victims of the disaster.

“The lady who was running the entire maternal pathways (maternity program) is missing, and unfortunately is presumed to have perished in the earthquake,” says Ian Clarke, incident manager for the WHO’s health emergency response in Venezuela.

International aid groups have flown in doctors and set up field clinics to help. A 56-bed field hospital set up by the nonprofit Samaritan’s Purse includes intensive care units and operating theaters. Project Hope has set up a mobile clinic offering primary care at a shelter in one of the hardest hit neighborhoods, including ultrasounds for pregnant women.

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Rescue turns to recovery in Venezuela

Doctors say they struggled to help the first victims treated after the disaster: patients who needed limb amputations or who had suffered crushing injuries or cuts from broken glass. Now, they are focused on caring for a traumatized, displaced population that no longer has a functional healthcare system. Doctors in other parts of Venezuela and abroad have stepped up to volunteer for telehealth services, while other aid groups have focused on reinforcing primary care providers and mobile clinics.

“A team of doctors and psychologists travels there daily to provide primary healthcare to all those affected and to offer psychological first aid,” said Dr. Lydia Gordon, an OB-GYN with Project Hope in La Guaira. “What I see with my own eyes as I pass by all these buildings are thousands of people walking in the street, disoriented, who need help.”

The World Health Organization has delivered six metric tons of medical supplies, with another 28 tons of aid on the way from its hub in Dubai. The donations included trauma kits, personal protective equipment for frontline workers, and supplies to prevent communicable diseases. Vaccines to prevent tetanus, diphtheria and yellow fever are being donated by the Chilean and Brazilian governments. The International Federation of Red Cross and Red Crescent Societies has dispatched 36 tons of aid, including hygiene kits, cleaning supplies and water filters.

“But even prior to the earthquake, there were massive shortages, up to 37% of essential medicines in many hospitals,” Clarke says.

Under the rule of ousted president Nicolas Maduro, Venezuela’s economy collapsed under hyperinflation and oil sanctions. Medical supplies grew scarce, vaccination rates dropped and cases of measles, diphtheria and malaria surged. Many Venezuelans emigrated, including about a third of the nation’s doctors, according to the Venezuelan Medical Federation. The remains of the country’s once-robust public health system was ill-equipped to respond to the scale of the disaster and its aftermath.

“That’s the normal situation. But in a crisis, that spike in demand — it’s exacerbated by the history,” says Alejandro Arrieta, a health economist at Florida International University.

Even in normal times, most patients are required to purchase their own medical supplies at pharmacies and shops near the hospital. It’s not an unusual practice in many Latin American countries, but the scale is more extreme in Venezuela’s underfunded system.

“You go to the doctor, and the doctor tells you okay, you need surgery, here’s the [shopping] list,” Arietta says.

This leaves patients at the mercy of price increases and supply issues, which are common in a disaster scenario.

Luz Noguera and her family were among those temporarily displaced by the earthquake and its aftershocks. They spent two weeks in an informal encampment near the wreckage of her sister’s home.

“Some people don’t even have tents, so their situation is even more difficult,” Noguera said. “They sleep on mattresses placed directly on the ground, with their children.”

Replacing her asthma medication felt like a daunting task, but she reached out to friends and family for help. Through her nephew, she was able to get in touch with an education nonprofit in another state, which has joined the earthquake response effort.

“It was a race against the clock to find the medicine she needed and the right equipment,” says Nicolle Giraud, who runs the E-VEN project, an education nonprofit that pivoted to help with the aid effort.

She and her team reached out to WhatsApp groups, to see if they could find the right medication in another city.

“Checking the obvious places like pharmacies, but then asking in [WhatsApp] groups because they were either sold out or it was very expensive, or not the kind they were looking for,” Giraud recalls.

Finally, a volunteer for the project found the medicine and drove it to Noguera personally, along with tents and other supplies.

This, Giraud says, is the reality on the ground. While medical workers do the best they can with the resources they have, it’s everyday people who have stepped up to fill the gaps.

“There’s a saying here,” Giraud says. “Los buenos somos más. The good people, we’re the majority.”

Noguera and her family are safe. She says she feels as if she has another chance at life. The only thing left to do, she says, is pray that the situation stabilizes.

“But I am alive, thank God,” Noguera says.