LAS CRUCES – The digital painting by Las Cruces artist Micah Pearson tells two stories — one that’s fictional, one that’s grounded in a painful reality.
It’s an image of a person kneeling, seemingly in anguish, with an array of color splattered against the background.
The first story is an artistic creation, the final frame in Pearson’s recent gallery show. It depicts an otherworldly being who struggles to create the matter of the universe.
The second, more subtle story is that of Pearson’s own battle with mental illness.
The image depicts an episode of manic activity, one of the characteristics of Pearson’s bipolar disorder. In such frenzied states, his mind goes into hyperdrive. He feels compelled to create. He’ll go days without much sleep.
The heightened mental activity overwhelms Pearson physically — hence the anguish of the person in the image. He loses his appetite, has dizzy spells and sometimes gets dehydrated. When he does sleep, his dreams are anxiety-laden. He often doesn’t awake rested.
Pearson, in a blog post from 2016, recounted describing to his girlfriend what prompted the painting. He said he felt he could “see worlds” in his mind’s eye.
“I can see all of them,” he wrote. “And I can make them, too. But they’re so big, and I’m so tired. I just want to rest and sleep, but I can’t. Because they’re all in here, and I need to get them out.”
On a night in October, dozens of people streamed through a gallery on Lohman Avenue, scrutinizing that image and Pearson’s other intricately detailed, fantastic images — some still, some animated. The digital art gives vibrant life to Pearson’s self-published novella that’s also part of the show.
Pearson mingled with the attendees, explaining the two-year creative process leading up to the exhibit, his third so far in Las Cruces. He spoke quickly, with a contagious energy. That was partly due to the enthusiasm any artist feels on opening night of a show, but it also had a second source: Preparing for the show, with its myriad details and looming deadline, helped trigger and feed a manic phase.
The multimedia art project, “The Voyage,” tells the story of time-and-space traveler Jamie Hendrickson, who visits one far-flung world after the next, documenting her adventures in the process.
Interwoven throughout is the story of Pearson’s own arduous path to recovery from mental illness. It’s a journey that has included hospitalization, jail time and, more recently, a role as one of the foremost advocates seeking to improve a fragmented system of mental health care in Doña Ana County. The fragile network has been rocked by one controversy after another in recent years. While several proactive efforts toward improvement are underway, challenges remain.
In addition to bipolar disorder, Pearson, 41, has two other diagnoses: attention deficit hyperactivity and post-traumatic stress disorders. He emphasizes that his illness doesn’t define him. He’s an artist and an advocate. He’s a politics aficionado, deftly discussing the latest national news with sarcasm-infused insight. He’s a board-game enthusiast and a sci-fi film buff.
Pearson weaves all of these interests into often rapid-fire, humor-laced conversations. Even when he’s depressed, a spirit of idealism bubbles to the surface.
“On the mental health side, I want to make a better world for those of us with mental health conditions and our families,” he said. “On the art side, I want to see my work in a museum because I did something that moved art forward.”
“I want to make sure my time on this planet was time well spent,” he said, “that I left my mark and that the world was a better place because I was here.”
Pearson’s is both a hopeful story of overcoming challenges and a cautionary tale for a community whose system of care needs dramatic improvements. Without the change Pearson and others seek, Doña Ana County isn’t adequately equipped to help many people struggling with mental illness live healthy, productive lives.
As NMPolitics.net, the Las Cruces Sun-News and KRWG News reported Monday, that currently means law enforcement is increasingly forced to deal with people in crisis, and the results are often tragic. While equipping police to better deal with such moments is important, real solutions come in creating a stronger network of care to reduce the number of crises that end up in the hands of cops.
The state of care
Pearson’s struggles began as a child growing up in Washington, D.C. in the 1980s. He recounts being obsessed with “death and dying” at a young age.
“My parents tried to explain to my providers that I was exhibiting behaviors that were not normal for a 4-year-old,” he said. “The doctors, of course, told my parents I was too young to have any sort of mood disorder.”
Pearson said his parents wouldn’t find out he had bipolar disorder until he was 22. By then he already was taking medication for hyperactivity disorder that had been causing psychosis.
But psychosis is a symptom — not a mental illness itself. It describes when a person loses touch with reality, hearing or seeing things that aren’t there. Pearson recalls believing at one point the family cat was calling his name. Another time he was convinced he was a “prophet of the Lord.” That was especially strange, he noted humorously at a conference earlier this year, because he’s an atheist.
For four years, Pearson held a job as an IT manager for a division of The Washington Post. Even as he achieved professional success, Pearson struggled in his personal life. Routine responsibilities, like a budget and paying bills, often overwhelmed him.
“I was either in a manic phase and spent, spent, spent, spent, spent. Or I was depressed and scared of my own mail,” he said.
In 2011, Pearson hit rock bottom. After a failed marriage, an assault charge and the loss of his job, he moved cross-country to live with his parents in Las Cruces and began putting his life back together. He’d soon be witness to a figurative earthquake that would upend New Mexico’s behavioral health care system. He couldn’t have predicted then how big a role he’d come to play in advocating for better systems and care for patients.
In mid-2013, Gov. Susana Martinez’s administration abruptly froze Medicaid payments to 15 community mental health and addiction care providers across New Mexico, including four that provided services in Doña Ana County. The justification? Allegations of possible fraud.
By 2016, the state attorney general had cleared all 15 organizations of any wrongdoing. In the meantime, chaos ensued for health workers and patients. When the state froze funding in 2013, it brought in replacement providers from Arizona without serious planning.
And by early 2015, La Frontera, the Arizona company that had replaced a network of providers in southern New Mexico, left the state, sparking yet another transition for workers and patients. La Clinica de Familia, a safety-net primary care clinic network in Doña Ana County, stepped in to fill the void in Doña Ana County, picking up behavioral health as a major division of its services. It was perhaps a courageous move, considering the organization hadn’t previously planned to take on such a large division of operations.
During La Frontera’s tenure, hundreds of behavioral health patients countywide dropped out of care or lost access as programs were cut. La Clinica was tasked with picking up the pieces.
“The Medicaid crisis hit and scarred our community, and that wound has not healed,” said Suzan Martinez de Gonzales, former executive director of La Clinica, in an interview earlier this year.
Pearson said he was among the affected patients.
“I didn’t have access to services for almost two years because of delays in scheduling and lack of availability,” he said.
When La Clinica took over Medicaid-funded behavioral health care in August 2015, it took on about 1,700 patients countywide. In the more than two years since, the number has climbed past 4,000, officials say, as the clinic has worked to re-establish ties with patients who left service during La Frontera’s tenure.
While the patient growth is positive, La Clinica officials said staffing levels haven’t significantly changed. Therapists and other practitioners are strained and staff turnover is high. And adopting behavioral health care has taken a big financial toll on the organization.
Also, patients, including people in crisis, have wait times for follow-up visits that span a few weeks, which is problematic for people actively struggling with their mental health. That points to another problem — a shortage of behavioral health professionals.
“If the workforce was bigger, we would be able to see patients more often,” said Rosario Olivera, behavioral health director for La Clinica.
The shakeup caused by the Martinez administration freezing Medicaid funds was dramatic — and wasn’t the only disruption in recent years:
- In 2014, Memorial Medical Center in Las Cruces all but closed its 12-bed psychiatric unit, sparking a wave of protests by local mental health advocates. The service was eventually restored.
- Earlier this year, a local private psychiatric services and addiction treatment provider, Epoch Integrated Health Services, abruptly closed its doors after the attorney general’s office raided its facility, seizing documents. The practice closed. The investigation is pending.
- Counseling services for students at New Mexico State University underwent a consolidation with primary care at the Las Cruces campus’ student health center. The move is in line with a national trend to integrate mental health care with primary care, but it also means fewer behavioral health professionals are available to see students.
Meanwhile, more than 200,000 New Mexicans gained medical coverage because of Martinez’s decision to expand Medicaid eligibility in January 2014 as part of the implementation of the federal Affordable Care Act.
The sum of it all? More people have the ability to seek the treatment they need, but they place additional demand on a system that is still recovering from the turmoil of recent years and suffering from a limited workforce.
The high cost of NM’s poverty
About one in five New Mexicans — more than 300,000 people — had a mild, moderate or serious mental illness in 2015, only slightly higher than the national rate, according to the organization Mental Health America’s most recent report card. About 9 percent of the state’s population had an alcohol or drug addiction, again just higher than the nationwide rate.
But in general, New Mexicans are less equipped because of the state’s poverty to cope with mental illness and addiction than in more affluent states, experts said.
The “social determinants” of a person’s mental health are hurdles to staying healthy for people who live in poverty, said Mauricio Tohen, head of the department of psychiatry at the University of New Mexico. Can he or she afford the co-pays for treatment and medication? Does an individual have enough food to eat?
In New Mexico, consistently one of the states with the worst poverty, the results are disastrous. The state logged the fourth-highest suicide rate in the nation in 2015, when nearly 500 residents took their own lives. New Mexico’s rate increased by 32 percent from 2005 to 2015, and spiked even more quickly from 2013, the year the Martinez administration froze Medicaid funding for behavioral health services, to 2015 — up by 17.5 percent in just two years.
New Mexico is also among the worst states for fatal drug overdoses, including from opioid addiction.
Struggles to build better systems
Even before the most-recent tumultuous events, the system of care in Doña Ana County wasn’t robust. In the absence of a stronger network, the resulting burden of dealing with residents in crisis has often fallen on law enforcement and other first responders. The cost can be heavy.
A single wooden cross memorializes Juan Gabriel Torres, a 36-year-old man fatally shot by police in August 2016, next to the Lohman Avenue bridge that spans Interstate 25. After stealing a truck earlier in the day, Torres, a father of three, was armed with a 14-inch knife and lunged at officers. The district attorney cleared the two officers who fired on him of any wrongdoing.
Torres, who attended high school in Carlsbad before moving to Las Cruces in the early 2000s, cycled in and out of incarceration for years. At one point, he told probation officials he was diagnosed with schizophrenia and anti-social disorder, court records state. In addition, Torres struggled with addiction and drug use, including of meth, opioids, spice and alcohol, according to court records.
Maggie Calderon, Torres’ ex-girlfriend and the mother of his children, said his death took a heavy toll. Her daughter and two sons were depressed and didn’t want to attend school. She sought psychiatric help. The situation was worsened when strangers bullied them and carried out mean-spirited social media attacks after Torres’ death.
“I never thought this community or anybody would bash on kids — grown adults bashing on my kids and bashing on me,” she said. “I am just like: We didn’t do anything wrong.”
Calderon said she’d always hoped Torres would remain in the kids’ lives. It’s difficult to accept that he’s gone, she said during an interview on Torres’ birthday in June. As for Torres’ behavior the day he was shot, Calderon said it was a “cry for help.” Police should have tried to de-escalate the situation, she said.
Calderon recalled her ex-boyfriend had once left prison with a mental health prescription, but, after he was kicked out “on the street” by family, it was hard to get that filled.
The county jail and local hospital emergency rooms have been the go-to places for authorities to take residents who are in behavioral health crisis.
There are other ideas for building better systems of care, but local officials have struggled to implement some of them. Others are fledgling efforts that show promise but depend on grant funding that will expire in future years.
The county has yet to open a crisis triage center that was built four years ago. Some say the state needs a second psychiatric hospital in Las Cruces to be closer to families in the southern half of the state and bolster the network of care in and around Doña Ana County. How to fund it isn’t clear.
A grant-funded pilot project is underway that could lead to a jail-diversion court for people suffering from mental illness in Doña Ana County, but how the court would be funded also isn’t clear. The effort is boosting community services for people not in the program.
Separately, some providers are trying to increase the number of peer support specialists in the community — a support system considered a best practice by the federal Substance Abuse and Mental Health Services Administration. These are people who’ve lived with addiction and mental illness and are tasked with helping others stay engaged in care or find community resources.
Success stories, and help
Chronic mental illness or addiction can be a major challenge for a person to overcome. But there are success stories — people who’ve stopped bouncing from crisis to crisis and are living healthy, self-directed lives most of the time. Those are exactly the sort of people providers want to become peer support specialists — people like Pearson.
His journey toward improved mental health began when he moved to Las Cruces. He took up art, a long-held interest he’d let fall by the wayside. He painted 22 pieces in his first three months in Las Cruces. Within a year, he had a gallery show.
Pearson had support and stability. His parents provided him a place to live and helped him get back on his feet. His mother, a retired federal employee, helped him apply for Social Security Disability. Because of her meticulous work, the application was approved on the first submission, he said. With that source of income, he was able to move into his own apartment.
Hailing from an upper middle-class background, Pearson said he benefited from plenty of “privilege” many others battling mental health conditions don’t have.
“I had a wide system of resources available to me,” he said.
Perhaps that helped Pearson accept realities about his life.
He said he first had to accept his diagnoses. Then he decided he shouldn’t drink alcohol. He chose to have someone else manage his money — something he said has been “the most effective treatment I have ever had.” That’s because, with his conditions, impulse control is a weakness. Having a financial manager oversee his money means his bills get paid on time, he has enough for day-to-day expenses, and he has less anxiety.
Also, Pearson said he’s learned coping skills that help him counter his mental health conditions. For instance, he carries headphones – not necessarily to listen to music, but to block out background noise. Otherwise, ringing cell phones or conversations nearby distract him.
Pearson said he pays attention to feedback from family and close friends. Sometimes they can tell he’s headed toward an episode of depression. Crashes are impactful, but not outwardly flashy.
“When I’m not functional I’m at home, scared to leave my house,” he said. “I’m worried that the people who say they care about me really don’t. I’m worried that I’m going to have it all come crumbling down and not be able to do what I have dedicated my life to doing.”
Experts said a strong social network is key to someone seeking recovery from a mental illness or an addiction. Pearson further broadened his support network by joining the Unitarian Universalist Church and volunteering there. He became active in the local chapter of the National Alliance on Mental Illness, a major support and advocacy group he first discovered in 2004.
He was certified by the state this year as one of about two dozen new peer support specialists in Doña Ana County. A major goal now, Pearson says, is helping others who are on the same journey.
As experts note, people living in behavioral health crisis often have strained or broken relationships with family. They might be kicked out of a family member’s house, becoming homeless or near-homeless, which can worsen a mental health condition. From there, it becomes much more difficult to recover.
In the absence of family support, social services play a bigger role.
But resources aren’t robust in Las Cruces. Sometimes they don’t exist at all. That’s according to James Sassak, a peer support worker for St. Luke’s Health Care Clinic, a medical and behavioral health clinic that serves homeless residents. He’s tasked with helping those residents navigate systems to get housing and behavioral health care. He said people who’ve had a recent crisis tend to be more willing to get help. But that window of opportunity is short-lived.
Sometimes, because of a shortage of services, clients lose interest before they’re able to plug into programs that could help them.
UNM’s Tohen said New Mexico’s shortage of behavioral health providers is another consequence of its poor economy. Salaries tend to be lower than in wealthier places. About a quarter of Doña Ana County’s population lives in poverty, federal statistics state.
“There are enough psychiatrists in Santa Fe or even Albuquerque, but there’s definitely a need in the rest of the state,” he said.
Average pay for a psychiatrist in Denver is about $217,700 yearly, according to Salary.com. In Albuquerque it’s about $201,000. In Las Cruces it’s $182,600.
New Mexico is faring better than most states in the overall number of behavioral health providers per capita, according to Mental Health America’s report. But, according to federal assessments, gaps still exist across much of the state — including in Doña Ana County.
The federal Health Resources & Services Administration considers Doña Ana County a Health Professional Shortage Area in the category of behavioral health. A 0-to-25 scale takes into account several factors related to patients accessing care, including psychiatrist-to-resident ratios in an area. A rating of 25 is the worst. Doña Ana County scored a 21.
The workforce recruitment difficulties deepen for public and nonprofit providers, which most often are serving the lowest-income patients under more challenging conditions than providers working in private practice, experts said.
Those were the agencies hit hardest by Martinez’s Medicaid freeze. Many behavioral health workers quit during that tumultuous transition.
Coping with a provider shortage
Two psychiatrists outlined what they see as an additional problem for New Mexicans: inaccurate diagnoses and treatment. At issue, they said, is that New Mexico is one of the few states to let health professionals who aren’t doctors write prescriptions. It’s an attempt to address a provider shortage that might have unintended negative consequences.
Manuel Mota-Castillo, a Las Cruces-area psychiatrist at Memorial Medical Center and Burrell College of Osteopathic Medicine, said he’s seen nurse practitioners prescribe the drug Adderall, for an incorrect diagnosis of ADHD, to people who are addicted to methamphetamine. Adderall contains a compound closely related to meth; prescribing it to meth addicts is an unsafe practice that should be investigated by licensing authorities, he said.
New Mexico is one of 12 states in which nurse practitioners aren’t required to have physician oversight to prescribe medication, according to the American Medical Association. Other states require partial or full oversight. Five states, including New Mexico, grant prescriptive authority to psychologists.
Recognizing the need for more psychiatrists, Mota-Castillo helped recruit one of his colleagues to Las Cruces in 2016. Psychiatrist Daniel Pistone spent less than a year practicing in the city before leaving for California, frustrated at the lack of medical oversight of psychiatric nurse practitioners at the organization where he worked. Some nurses were interested in learning and improving their practices, he said. Others weren’t.
Because of the problem, Pistone said, “the situation was so substandard it was more harmful than helpful.” He said he tried unsuccessfully to push for change, and is speaking now in hopes that doing so might lead to improvements in care.
Pistone said he was also frustrated by what he called the hindrance created by the education levels of patients. One patient lodged a complaint because he refused to prescribe an anti-depressant, which he said wasn’t the correct treatment for her condition. The complaint was dismissed, he said.
“I made a commitment because I’m Hispanic, I’m Latino,” he said of his decision to move to Las Cruces. “I wanted to help that under-served population. But No. 1, I couldn’t do what I wanted to do, and No. 2, the liability risk was very high.”
Given his experience in Doña Ana County, Pistone agreed that salary levels should be raised to attract well-qualified psychiatrists to the state. Plus, he said prescribing psychologists and psychiatric nurse practitioners should report to psychiatrists so they can receive “appropriate supervision.”
Other providers contend that psychiatric nurse practitioners, who have medical training but not on the same scale as a doctor, and prescribing psychologists, who train under psychiatrists initially, are needed to address provider shortages in New Mexico. Rural areas can’t afford to pay psychiatrists, they said, and access to a nurse practitioner is better than no provider at all.
Dario Silva, a Ph.D.-level counselor, currently heads NMSU’s counseling services for students and employees. He said a psychiatric nurse practitioner is the main medication prescriber for patients at the clinic and described her as “very, very good at what she does.”
While psychiatrists have the most medical training and education, Silva said they cost double the salary of a nurse practitioner. NMSU has faced steep budget cuts in recent years.
St. Luke’s Health Care Clinic is seeking to hire a psychiatric nurse practitioner, said Pamela Angell, executive director of the nonprofit.
“That’s definitely a hole or a gap in our services,” she said.
Tohen said what’s key for prescribing personnel who aren’t doctors is knowing when to refer a patient to a higher-level expert. He said he’s worked with some “outstanding” psychiatric nurse practitioners.
“We need good nurse practitioners, but we also need good psychiatrists,” he said.
Mota-Castillo said he’s comfortable sending his patients to three psychiatric nurse practitioners with whom he’s worked, so he doesn’t believe all of them require supervision by a psychiatrist. He can think of about five, however, who should be under supervision of a doctor.
Requiring more supervision for psychiatric nurse practitioners or prescribing psychologists would require changes to a state law that’s generally seen as helping to attract members of these professions to New Mexico.
To address the shortage of psychiatrists, La Clinica de Familia, along with Doña Ana County government, has plans to launch a physicians’ residency program next year to train three new doctors to practice psychiatry. The new psychiatrists could go anywhere upon completing the residency, officials noted, but research has shown that people who go to medical school and do their residency in the same state tend to stay there.
“If they stay in the region, it’s a win,” Martinez de Gonzales said. “If they stay in the community, it’s a win-win.”
La Clinica is also working with NMSU to support a faculty position to boost the number of social workers being trained. While this program has increased training capacity for certain mental health professionals, another program at NMSU, an accredited internship for students pursuing a doctorate in psychology, has been cut back.
New Mexico’s poor Health Professional Shortage Area ranking does mean some educational advantages for medical school students and graduates, as well as some other types of mental health professionals. They can apply for scholarships or loan repayment if they commit to serving a set amount of time with a qualifying provider in a shortage area, state and federal officials said.
Good things happening
Though the provider shortage and many other problems don’t have easy solutions, there are some good things happening in Doña Ana County when it comes to behavioral health.
Pearson is one of five people across the U.S. who were elected in June to the NAMI national board. Along with that role, he’s vice president of the local NAMI chapter and was certified by the state as a peer support specialist.
For the first time in about 15 years, the state hosted a training session for peer specialists in Las Cruces, garnering about two dozen participants. La Clinica officials said that was a success, but a continuing challenge is that a follow-up testing and certification process is held only in Albuquerque, requiring out-of-pocket travel costs for participants.
Experts say peer support specialists are a critical link in care. Their experience living with mental illness or addiction can give them credibility with people in crisis, which can help them connect people in need to community resources.
Pearson is working as a peer support specialist through a $2.8 million federal grant Doña Ana County was awarded in 2017 to launch what’s known as assisted outpatient treatment, a jail and hospital diversion pilot project.
The grant, which goes hand-in-hand with a statute dubbed Kendra’s Law, pays for intensive treatment for people who, up until now, have been stuck in a cycle of hospitalization and detention because of mental illness, addiction or both.
Before the law and the money that was awarded to enact it, a person in need of intensive treatment for a crisis had only the option of being involuntarily hospitalized, and only with a judge’s approval. The new program gives the judge another option: ordering a person participate in an intensive outpatient care program, which includes peer support from someone like Pearson, to avoid hospitalization.
While the grant pays for more staff at La Clinica de Familia to serve clients, there are certain costs it doesn’t cover, including housing, food, transportation, clothing and cell phones, said state District Judge Mary Rosner. She’s pushing for staff to find access to these resources elsewhere. Already, the county has assigned a housing coordinator to work with the outpatient clients. An estimated 30 people with mental illness and addiction will be served in the current calendar year.
Rosner said she’s already seen positive results in clients’ lives. But she notes the grant is set to expire after four years. By then, she’s hoping public support will have grown to establish a mental health court. The pilot outpatient program is setting up the structure for such a court, but it will need to be funded – which she said will be a state responsibility.
At St. Luke’s Health Care Clinic, a nearly $1.3 million federal grant called Hurry Home aims to help house chronically homeless people who also have a mental illness or addiction. The savings to the community come in the form of the clients not winding up in jail or hospitalized, clinic officials say. Sassak, the peer support worker for the clinic, who has battled addiction and homelessness, said he believes his experience gives him credibility with potential clients, many of whom don’t trust people in authority.
“They think most people are against them,” he said.
The grant is in the second year and has one year remaining. Angell, the clinic’s executive director, said of the nearly 70 people who’ve applied so far, about 50 have remained housed within six months of beginning the program.
Though the program shows positive results, Sassak notes that success still hinges on a person’s willingness to participate. He’s noticed younger people aren’t as interested in getting help as people who’ve been homeless for decades.
St. Luke’s will have to find new funding to continue the project once the grant runs out.
‘Recovery is a journey’
Because of his interest in improving the behavioral health system for patients locally, Pearson is an active advocate on many fronts. He keeps a busy schedule. But he admits there are times he must retreat from the public eye because of his illness — a recognized limitation of peer support specialists.
“I fully expect that I’m probably going to collapse tomorrow,” Pearson told two women who attended his art exhibit in October.
Creating “The Voyage” did take a toll on Pearson. In the weeks since opening night, he admitted he’s been struggling with a major depressive episode. Even for someone in recovery from mental illness, relapses are expected from time to time, he noted. Perhaps the biggest differences between his life now and his life before moving to Las Cruces are that he’s aware of his limitations and knows when and where to seek help.
“Recovery is a journey, one that is never over once you’ve started it,” he said.
Even if he was offered a miracle cure for his mental health disorders, Pearson doesn’t think he would take it. His conditions, he said, have helped shape him into the person he’s become. And his mission — to improve the lives of people with mental illness — keeps him motivated.
Some of the changes taking place in Doña Ana County, like the outpatient treatment program that employs Pearson, have never been tried here before, and are encouraging, he said. The program has allowed the local chapter of the National Alliance on Mental Illness to increase the number of support classes offered to both patients and their families. And for the first time this year, the local chapter of the organization hosted classes in Spanish in a county with a high percentage of Spanish speakers.
Though ups and downs will come in Pearson’s life, his commitment appears to be for the long-haul.
“I want to change things and make the system better,” he said. “That is my hope.”
Diana Alba Soular may be reached at 575-541-5443, firstname.lastname@example.org or @AlbaSoular on Twitter. Las Cruces Sun-News photographer Robin Zielinski and Sun-News reporter Carlos Andres López contributed to this report.