Data Collection

News articles from The New York Times, The Washington Post, The Guardian, El Vocero and other reliable news sources were gathered and read in detail. Government publications such as the 2017 Hurricane Season FEMA After-Action Report; the U.S. Energy Information Administration and the U.S. Census Bureau reports were thoroughly examined to obtain information and data about the infrastructure of Puerto Rico. Scholarly journal articles and research from the Milken Institute School of Public Health in collaboration with the University of Puerto Rico Graduate School of Public Health and the Yale School of Medicine were studied to understand the effects of the hurricane and the official death toll. CDC Morbidity and Mortality reports as well as CDC blog recommendations for enhanced communication were collected and analyzed. In all, about 60 of these government publications, news articles, scholarly journal entries and previous research were examined in depth to effectively understand the infrastructure of Puerto Rico before the hurricane, and to study its aftermath.

Interviews

Leading public health professionals such as Dr. José Cordero, former Dean of the School of Public Health at the University of Puerto Rico, and Co-Director of the Puerto Rico Test site for Exploring Contamination Threats (PROTECT) and Center for Research on Childhood Exposure and Development Projects (CRECE), Dr. Gredia Huerta-Montañez, a pediatrician and researcher for PROTECT and CRECE were interviewed regarding the health preparedness of Puerto Rico and the status of public health after the hurricane [6, 7]. The Director of FEMA Interpreters, Anna Canaparo, was interviewed to learn more about the relief efforts conducted by FEMA after Hurricane María [8]. Twenty Puerto Rican residents who had experienced the hurricane first-hand in different parts of the island were interviewed to gather information about what it was like to live through the natural disaster. Ten interviews of Puerto Ricans who were living outside the island were conducted. These, as well as the insights of the author’s personal experience provided the perspective of Puerto Ricans who were living on the U.S. mainland during this crisis.

Pre-existing infrastructural deficiencies

A significant precursor event that occurred roughly a decade before the hurricane and paved the way for the disaster was a major restructuring of Puerto Rico’s economy. The island’s economy had been based on manufacturing because a section of the Internal Revenue Code had allowed special advantages to corporations operating on the island. In 2006 this tax exemption was abolished, resulting in the collapse of the manufacturing sector, which in turn caused the island to go into a deep recession. In 2016, a federal law, the Puerto Rico Oversight, Management, and Economic Stability Act (PROMESA) was passed with the intent of alleviating the government-debt crisis and restructuring its massive debt. However, the debt restructuring plan was poorly designed and caused cuts in services and infrastructure. Consequently, the government continued to borrow more money until the debt burden became unsustainable.

A component of the island’s infrastructure that was severely affected by the economic downturn was the Puerto Rican Electric Power Authority (PREPA). The president of Advantage Business Consulting, Vicente Feliciano, explained that PREPA had limited options to remain afloat. Among those options were to increase the electricity rates, which were already high; stop paying bondholders, or abandon the maintenance of its plants. PREPA management chose the last option leading to the shutdown of several of its electricity generating plants. The system now had limited surge capacity and less ability to restore the power after the hurricane. The U.S. Army Corps of Engineers’ head of power grid restoration observed that there were elements that had not been replaced in years leaving Puerto Rico lacking both power plants, and reconstruction of the grid itself.

In addition to the electric grid, multiple other components of Puerto Rico’s infrastructure were deteriorating because of the lack of monetary resources. Before the hurricane, Puerto Rico had closed about 184 public schools because of the economic crisis. The Puerto Rico Highways and Transportation Authority (PRHTA) was starved for investments, leaving roads and bridges without the appropriate maintenance. People’s homes were not as safe and structurally stable as expected, because “before the storm, the island could afford only five building code inspectors, for a population of 3.5 million people [9].” All these factors contributed to the devastation that followed the hurricane and magnified its repercussions.

Another deteriorating component of the island’s infrastructure was its water system. In Dorado, a municipality in the northern coast of the island, the problems with water began in the 1980’s. During that time, water testing had identified industrial solvents and cleaning compounds in local wells. In the 30 years since the problems were first recognized, both Puerto Rico’s water authority and health department continued to test the water and continue finding contaminants. It was not until 2016 that the Environmental Protection Agency (EPA) declared Dorado’s water system a Superfund site. In 2017, the Natural Resources Defense Council (NRDC) reported that Puerto Rico’s systems of pipes had registered more drinking water violations than any other state or territory in the United States. About 70% of the island’s population obtains its water supply from sources that are in violation of federal health standards for drinking water [10].

The same utility that provides water also manages the sewage system; this has likely resulted in cross-contamination. In 2015, both the US Justice Department and the Environmental Protection Agency sued the PRASA because they had been dumping 6 million gallons of untreated sewage into waterways daily [11]. In multiple other municipalities, such as Salinas, on the south coast of the island, which has always been a dry area, drinking water quantity is at risk resulting in water rationing. Nearby Guayama had a coal-fired power plant that required 225 000 gallons of water per minute to circulate which also contributed to a water shortage. This plant also generated millions of tons of coal ash, which contains dangerous heavy metals including arsenic, cadmium, and mercury, contaminating the aquifers. The Agency of Toxic Substances and Disease Registry reported that some of the chemicals found in coal ash could cause cancer after continued long-term ingestion and inhalation [12].

The lack of access to clean water and the widespread use of contaminated water has many health repercussions in the Puerto Rican community. These include high rates of cancer and a high number of leptospirosis cases. A study by the Yale School of Public Health found that this potentially deadly disease was far more prevalent on the island than previously thought. The researchers, in conjunction with the CDC and PR Department of Health, had conducted serology tests on residents before the hurricane in the San Juan environs and discovered that 27% tested positive for exposure to the pathogen. These findings demonstrated that leptospirosis is a major public health problem in Puerto Rico.

The health status of the citizens of Puerto Rico reflected sharp disparities with the mainland before the hurricane, and this magnified the impact that the hurricane had on the health of the people. Even before the natural disaster, the health care system was facing challenges. About 34% of Puerto Ricans reported having fair or poor health and 15.4% of people live with disabilities, compared to the percentages of the United States being 18% and 8.6% respectively. In Puerto Rico the prevalence of diabetes is 17.2%; it is 10.5% on the mainland. The asthma rate is 12.2%; the mainland’s is 9.4%. High blood pressure occurs in 44.7% here compared to 32.3% on the mainland. The Centers for Disease Control and Prevention found that the island has one of the highest high blood pressure-related death rates among adults over 35 years of age. Overall, Puerto Ricans have a higher risk of cancer, diabetes, alcohol consumption, asthma, and infant mortality rates than other US citizens [13]. Forty-nine percent of Puerto Ricans rely on Medicaid and only 35% have employer-sponsored health insurance [14]. Access to quality health care has been hindered because of the mass migration of doctors and specialists to the U.S mainland. The American Heart Association reported that between 2014 and 2016, more than 1 400 doctors canceled their medical licenses issued in Puerto Rico. All of these are concerning public health issues by themselves, but with the addition of lack of access to insulin, the prolonged consumption of processed foods, the drinking of tainted water, and the lack of electricity that followed Hurricane Maria, it is not surprising that these pre-existing conditions increased the hurricane’s adverse effects and hindered recovery.

A major unanswered question is how to develop preventive measures that will protect public health against future disasters. Given the recent acceleration of global climate change, it is very likely that hurricanes of such magnitude will continue to occur in the coming years. If the climate continues to warm, the possibility that hurricanes will become even stronger and more destructive will increase. A 2013 study concluded that since 1975 there has been a substantial regional and global increase in the proportion of category 4 and category 5 hurricanes of 25–30% per degree Celsius of anthropogenic global warming [15]. Climate change will have a significant global impact with aggravated erosion, landslides, flooding, increased temperatures, wildfires, and many other natural disasters. The potential damage that could occur because of the combination of stronger storms, rise in sea-level and infrastructure that has continuously been exposed to these disasters is alarming.

Acute and Delayed Aftermath

The magnitude of Hurricane María combined with the previously deteriorating infrastructure resulted in catastrophic damage to Puerto Rico. Its vast destruction devastated the power grid and left the entire island without electricity, some even 328 days, the longest blackout in United States history. The island’s communications infrastructure was also severely damaged with 85% of the 1 600 cell towers not functioning.

The collapse of the power system resulted in several immediate problems for hospitals and other health facilities. According to the US Department of Defense, “The health infrastructure was already in crisis before Hurricane María – now a majority of the island’s 69 hospitals are without electricity or fuel for generators [16].” The use of emergency generators, while helpful, was a limited substitute for electrical current because of the need for redirection of the power generated and the frequent need for maintenance and refueling. The largest private children’s medical center in the Caribbean, San Jorge Children’s Hospital, was without electricity and dependent on its generators. The generators would run out of diesel fuel multiple times during a week and the diesel fuel was not easily accessible. These generators were insufficient to power all of the essentials in a hospital such as lighting, refrigeration, emergency and operating rooms, and central air-conditioning and air flow systems; the latter is a critical need in sealed buildings with tropical climates.

Hospitals could not communicate with ambulance services or other clinics for people who needed urgent care because the power outage had disabled most cable service and telephone lines. Patients who received dialysis had not been treated in days, nebulizer treatments for asthmatics were not working because patients lacked electric services, and diabetics did not have working refrigerators to properly store their insulin. Doctor’s offices and walk-in clinics were not open initially because they had no electricity and, in some cases, no accessible path to get there. A month after the hurricane only about a dozen hospitals were operating and they were mostly located in San Juan and other major cities.

The lack of electricity and the constant difficulty of finding generators or diesel fuel also resulted in increased stress which deteriorated the mental health of the citizens. People stood in long lines outside overnight in hopes of receiving some fuel for either their car or generators. Those that could afford generators and the high costs of refueling had the luxury of having power yet those who did not have the access to generators or the money to obtain them spent months without electricity. By December 2017, close to half the population of Puerto Rico was still without power, most of these in rural areas where the reconstruction was further hindered by inaccessible roads and lack of personnel.

Another negative result of the destruction of the power grid was the lack of access to clean water, as electricity is needed to power water treatment plants. Lacking clean water, people drank water from rivers or other contaminated sources. The risk of using these waters was proved by EPA’s findings of enterococcus, the bacteria responsible for diverticulitis, and the bacteria responsible for UTIs and meningitis in the freshwater of Puerto Rico [17]. Leptospirosis, a public health problem that was already present on the island worsened after the hurricane. By the end of October there were 121 cases and 4 confirmed deaths from leptospirosis since the hurricane, about twice the average cases yearly.

The intense rain resulted in major flooding throughout Puerto Rico which caused many drownings. Flooding also caused many to lose their homes. Houses were built in flood zones and the government’s decisions of removing natural water systems, such as wetlands, increase flood damage. San Isidro, a neighborhood in Canóvanas, Puerto Rico, is in a flood zone in the middle of the Atlantic hurricane belt, making it one of the most vulnerable communities in the world due to the intensifying climate crisis. Many houses have not been repaired because FEMA often conditions recovery resources on the purchase of flood insurance, which is not affordable for the citizens of this impoverished community. Many of these people find themselves with no other options but to move from their homes.

Hurricane María seemed to have a longer lasting impact on certain vulnerable groups of the population including children. A study conducted by researchers from Puerto Rico’s government agencies and universities surveyed nearly 100 000 Puerto Rican students between the 1st of February to the 29th of June of 2018, in the island’s seven education districts. This study is one of the largest attempts in the history of the United States to survey young people after a major natural disaster [18]. The researchers found that about 47.5% of children’s family’s homes were damaged and 83.9% of children saw damaged homes. Likewise, 32% of the youth experienced shortages of food and water and 16.7% of youth did not have electricity 5 to 9 months after Hurricane María. Additionally, 7.2% of the 100 000 students reported clinically significant symptoms of post-traumatic stress disorder. The children who experienced this natural disaster were left to handle the repercussions in isolation since schools were closed for months. The economic crisis which had resulted in the closure of hundreds of schools led to thousands of children suddenly leave their stable learning community for a different school. Once they adapted to being in a new school, the schools were again closed because the hurricane destroyed them or because their school lacked electricity.

The death toll caused by Hurricane María resulted in very controversial discussions between citizens, government agencies and research institutions. The most recent tally of 2 975 deaths due to the hurricane is very different from the initial count of 64 fatalities, as reported by the government of Puerto Rico. One of the factors that made this recording so difficult was the lack of awareness of appropriate death certification practices after a natural disaster. Following the hurricane, the Department of Health instituted requirements that all licensed physicians in Puerto Rico must undergo training on how to properly fill out death certificates where a hurricane was a factor in the person’s death. The reliance on paper documents instead of electronic submissions of the patient’s files led to difficulties accurately accessing all death reports and information whether related to the hurricanes or not. The number of fatalities caused by the hurricane is not limited to the immediate deaths or physical injuries caused by the hurricane such as drowning and blunt-force trauma from collapsed buildings. These also include casualties caused by the lack of treatment, medications or surgical procedures that would have been available if it were not for the lack of resources caused by the hurricane. Although the latest investigations contain different figures, they all fall within a shared range that provides greater and more reliable numbers than the initial government report.