Puerto Rico’s unique public health challenges hasten need for action

Puerto Rico’s unique public health challenges hasten need for action
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On Sept. 20, Hurricane Maria made landfall in Puerto Rico, a U.S. territory in the Caribbean islands. The hurricane struck as a Category 4 storm marked by torrential rain and forceful winds, devastating conditions that left the much of the island in ruins.

This came right after Hurricane Irma left one million without power in early September. Hurricane Maria was far more damaging, leaving the vast majority of Puerto Ricans without access to critical supplies such as electricity or clean water. These are critical elements in the prevention of a public health crisis, and we’re simply not doing enough.

We know the importance of preparation and have several systems in place to brace us for an event, known or unknown, to help us react efficiently in the face of crisis. We develop policy, perform drills regularly and ensure that adequate supply and processes are in place to prevent disruption of services or to handle a spike in patient admittance.


These systems and processes guided us through the intense time following the horrific Pulse nightclub mass shooting of 2016.

However such health system specific preparedness efforts occur in the geographic and societal context of the communities where those health systems are located. And it can be this larger context with its own uniqueness, infrastructure characteristics, assets and challenges that drive preparedness and response related outcomes in the face of natural disasters, as unfolding in Puerto Rico after Hurricane Maria.

Puerto Rico faces an uphill battle dealing with disaster compared to states on the mainland for many reasons. Suboptimal economic growth, resultant fiscal crises, national debt, and poverty have been major challenges. These elements are important to note because often following a natural disaster, the most vulnerable groups: the poor, the elderly, the children, the disabled, the ones with special needs, the ones who are in remote, rural areas or even urban poor in overcrowded areas tend to be disproportionately affected. Relative to the Puerto Ricans living on the U.S. mainland, many disparities exist, including e.g., lower household incomes and higher child poverty.

On a backdrop of a decade long recession, and continued migration to the U.S. mainland, there is a high demand for care. Several structural challenges exist for the Puerto Rican health care system, involving the privatization of the public health care system and the rise of managed care; the aging of the population along with high rates of poverty and chronic diseases (e.g., high blood pressure and diabetes); economic instability and low private-sector tax base of the commonwealth; and the high cost of living.

The risk of disease rises when access to safe drinking water, sanitation systems, and running water and soap for handwashing is limited. After natural disasters, outbreaks of communicable disease can occur especially when populations are displaced; waterborne infections, vector-borne infections (e.g., Zika, dengue) and overcrowding related conditions may be seen. Though progress is being made, field reports indicate continued challenges, in reestablishing power, communication, food and clean drinking water supplies and hospital-based care delivery. Fuel, which is needed to distribute aid when rations ultimately arrive to the island, is in dangerously short supply.

To administer health care to people in need, the island is in desperate need of power. The impact of downed power lines and the shortage of gas are felt across all spectrums of patients. Diabetic patients who require their medications refrigerated, patients in the ICU who need ventilators, chronically disabled patients who rely on equipment — all require power to survive. In the absence of electricity, a hospital’s primary fallback is to rely on generators functioning on fuel.

If these patients don’t receive the power they need, months by some estimate, their conditions will deteriorate. Loss of power can result in a domino effect with greater amounts of disease and disability, and even resultant death.

It can be argued that Puerto Rico being a U.S. territory should receive response funding comparable to that which mainland states saw in the wake of earlier hurricanes. Expectations may arise for levels of assistance sufficient to effectively address the physical, social, political, economic and health challenges presented by this natural disaster. At the time of this article, it is likely that for Puerto Rican residents so deeply impacted by Maria, overall response efforts have been slower than anticipated.

As a matter of not only principle but strategic application of the most current relevant science we have, hurricane events like Maria must focus and unify our attention as a society.  The relevant issues are important for us as a country not only on the contiguous states affected by hurricanes like Florida, Texas and others, but also on our territories, which are even less suited to deal with the adverse effects of natural disasters than we are in the states.

The response to the damage caused by Hurricane Maria should teach us three major lessons related to health care preparedness and response: the need for continued vigilance related to response times in the aftermath of natural disasters; proactively facilitating the longer term investment needed for full recovery and mitigation of continued damage to health, property and infrastructure; and that territories like Puerto Rico face unique challenges in responding to such natural disasters. Economic disparities — related to both root causes and resultant effects, exacerbate the issues and need to be addressed through the social justice lens, especially in matters of health.

Dr. Asim Jani is an infectious disease physician at Orlando Health.