3 Lessons from Puerto Rico: Mitigating the Health Effects of Future Hurricanes

May 30, 2018 Sandro Galea

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Nearly one year after Hurricane Maria devastated Puerto Rico, the official death toll for the disaster stands at 64. However, a new study, published Tuesday in The New England Journal of Medicine, estimates that at least 4,645 people have died as a consequence of the storm. That is more than 70 times the official estimate. Perhaps most worrisome, it is not at all clear that we are taking steps to mitigate the consequences of future hurricanes. This observation, as a new hurricane season is about to begin, should give us all pause.

With this in mind, what lessons can we learn from Hurricane Maria to better prepare us for future disasters? Here are three.

1. Communities should be ready to handle the full range of health consequences of these disasters.

While the new data on the deaths due to Hurricane Maria are sobering, the health effects of disasters such as the hurricane undoubtedly extend well beyond these deaths. They include worsened mental health, lack of access to essential care, and a general deterioration in the health of vulnerable populations. The physical and mental health consequences of disasters are lasting, shaping health for weeks, months, even years after the trauma of the event. When Hurricane Harvey struck Texas and Louisiana, for example, affected populations had to contend with the lacerations, broken bones, flood risk, and sudden death they faced not only on the day of the storm but also in the weeks and months that followed, with mold in their homes, contaminated flood waters, and disruptions in medical care due to flooded hospitals and waterlogged medications. This accumulated hazard continued to undermine health long after the storm had passed.

Reviews of the mental health consequences of disasters have found that as many as half of those directly in the path of a hurricane risk developing post-traumatic stress disorder, and 10% of those who live in the general area of the storm run a similar risk. Disasters can also fuel depression and substance use disorders. After the September 11 terrorist attacks, for example, rates of alcohol, cigarette, and drug use increased in New York City.

Assessments of those affected by storms should look not only at deaths but entire populations exposed to storms and their aftermath. Health systems need to be prepared to deal with the full range of consequences of these events.

2. Efforts to shore up basic infrastructure must happen well before hurricanes hit.

The primary reason for the heavy damage to Puerto Rico was that the stability — or lack — of basic infrastructure in Puerto Rico made the island less able to endure the high-force winds, heavy rains, and physical damage from the storm. Puerto Rico has shown us the fragility of power systems, water systems, and roadways. On September 26, six days after Hurricane Maria made landfall, 58 of Puerto Rico’s 69 hospitals had neither power nor fuel. Weeks later, the situation did not improve. Households went an average of 84 days without electricity, 68 days without water, and 41 days without cellular service. Citizens lacked access not only to health care but also to basic resources.

Low-lying coastal regions, like Puerto Rico, are particularly susceptible to damage from natural disasters. There is simply no substitute for shoring up basic infrastructure and creating disaster plans to bring damaged systems back online ahead of a hurricane to allow these areas to withstand high-force winds and to mitigate loss of life after hurricanes hit.

3. We must invest in human capital well in advance of disasters.

The social, economic, and environmental conditions that shape health before disaster strikes are core to deciding how much damage the event is able to inflict, and how quickly communities can recover. While our narratives of recovery often focus on individual resilience, it is the strength of a society as a whole that most determines its capacity to bounce back after the worst happens.

We saw this in Puerto Rico, where generations of economic and political marginalization, combined with a shoddy physical infrastructure, set the stage for the misery that continues to unfold. These issues were known about for years. Had they been properly handled, Puerto Rico might have been far more resilient in the face of Maria.

Unfortunately, what happened after Hurricane Maria was eminently predictable. We had decades to invest in the island, to fix its roads and power grid, and to reject the economic colonialism that has done so much to undermine Puerto Rico’s fiscal health. In the age of climate change, with extreme weather events becoming more powerful and frequent, we can ill afford to ignore areas that are likely to suffer the devastating consequences of natural disasters. That we will have more Marias is certain, and how we can prepare for them should be clear if we are paying attention.

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