Puerto Rico Health System Resilience After Hurricane Maria: Implications for Disaster Preparedness in the COVID-19 Era

Abstract

Background: Every year, Puerto Rico faces a hurricane season fraught with potentially catastrophic structural, emotional and health consequences. In 2017, Puerto Rico was hit by Hurricane Maria, the largest natural disaster to ever affect the island. Several studies have estimated the excess morbidity and mortality following Hurricane Maria in Puerto Rico, yet no study has comprehensively examined the underlying health system weaknesses contributing to the deleterious health outcomes. Methods: A qualitative case study was conducted to assess the ability of the UPR health system to provide patient care in response to Hurricane Maria. An established five key resilience framework and inductive analysis was used to identify factors that affected health system resilience. Thirteen Emergency Medicine Physicians, Family Medicine Physicians, and Hospital Administrators in a University of Puerto Rico (UPR) Community Hospital were interviewed as part of our study. Results: Of the five key resiliency components, three domains were notably weak with respect to UPR resiliency. Prior to the Hurricane, key personnel at the UPR hospital were unaware of the limited capacity of back-up generators at hospitals and were ill-prepared to transfer ICU patients to appropriate hospitals. Post Hurricane, the hospital faced self-regulation challenges when triaging the provision of Hurricane-related emergency services with delivering core health services, in particular for patients with chronic conditions. Finally, during and after the Hurricane, integration of patient care coordination between the UPR hospital ambulances, neighboring hospitals, and national and state government was suboptimal. The two remaining resiliency factors, addressing diverse needs and system adaptiveness in a time of crisis, were seen as strengths. Conclusions: Hurricane Maria exposed weaknesses in the Puerto Rican health system, notably the lack of awareness about the limited capacity of backup generators, poor patient care coordination, and interruption of medical care for patients with chronic conditions. As in other countries, the current COVID epidemic is taxing the capacity of the Puerto Rico health system, which could increase the likelihood of another health system collapse should another hurricane hit the island. Therefore, a resilience framework is a useful tool to help health systems identify areas of improvement in preparation for possible natural disasters.

A Rapid Assessment of Disaster Preparedness Needs and Resources during the COVID-19 Pandemic

“…Thus, while CBOs have benefited from disaster preparedness training and planning and their experiences with prior disasters, the pandemic has created new and unanticipated challenges that must be addressed immediately, even in communities highly experienced in disaster response, including with community engagement strategies [ 23 , 24 ]. The strain on the disaster preparedness and response infrastructure caused by the pandemic could place communities vulnerable to natural disasters in particular jeopardy [ 57 ]. As noted in a recently published study of the impact of the pandemic on emergency first responders in Poland [ 58 ], addressing these challenges will require broader “out of the box” solutions that may at times deviate from standard disaster response practices and procedures.…”

Metrics and indicators used to assess health system resilience in response to shocks to health systems in high income countries—A systematic review

“…Of course, not all resources related to staff. Physical infrastructure was also measured in terms of availability of beds (general or ICU) or backup generators, for example, or innovative changes in response to the shock [ 38 , 39 ]. In terms of the aforementioned surge capacity for COVID-19, this took the form of ambulatory clinics converted into wards or operating theatres to intensive care units, anesthesia machines converted to ventilators, or indeed changes to standard practice for example, using ventilators for more than one patient [ 40 , 41 ].…”

“…Rios et al. [ 39 ] highlighted the impact that Hurricane Maria had on chronically ill patients. Smith et al.…”

“…Metrics related to disasters were the second most commonly reported within the preparedness stage ( n = 8). The presence of preparedness plans, surveillance data, early warning systems and communication strategies were key metrics within these studies [ 42 , 59 , [69] , [70] , [71] ] as was the availability of appropriately trained staff, medical infrastructure and surge capacity within these facilities [ 27 , 39 , 69 , 71 ]. Finally, patient activity was used as a metric to assess preparedness and surge capacity, although to a lesser degree [ 27 , 42 , 72 ].…”

A Rapid Assessment of Disaster Preparedness Needs and Resources during the COVID-19 Pandemic

“…Thus, while CBOs have benefited from disaster preparedness training and planning and their experiences with prior disasters, the pandemic has created new and unanticipated challenges that must be addressed immediately, even in communities highly experienced in disaster response, including with community engagement strategies [23,24]. The strain on the disaster preparedness and response infrastructure caused by the pandemic could place communities vulnerable to natural disasters in particular jeopardy [49]. Implications…”