The
NEW ENGLA ND JOURNAL
of
MEDICINE
Perspective
The View from Puerto Rico — Hurricane Maria and Its Aftermath Carmen D. Zorrilla, M.D. The View from Puerto Rico
H
urricane Maria hit Puerto Rico on September 20 and caused unprecedented damage affecting the island’s 3.4 million inhabitants (see Fig. 1). Though no one in Puerto Rico was
spared at least some impact, the poor and vulnerable were disproportionately affected. Loss of communication and electricity, scarcity of water, isolation of some residents, slow coordination of the aid that has been sent, and the magnitude and scope of the necessary repairs all merit a call for help from and the engagement of the global community. Indeed, Puerto Ricans and U.S. Virgin Islanders are U.S. citizens and expect the same federal aid and support during natural disasters as the rest of the United States. In contrast to sudden disasters, hurricanes often allow officials and populations a window of opportunity to prepare, evacuate people, and update emergency plans. Yet our infrastructure, in-
cluding the health care infrastructure, was already in crisis, and the much milder hit from Hurricane Irma 2 weeks earlier had caused a partial collapse of the power system. In addition, the island’s economic situation, causing concerns about lack of income or reductions in wages, fueled a sense of uncertainty and despair among many Puerto Ricans, as we were faced with the most powerful hurricane to hit Puerto Rico in nearly a century. We prepared for the worst while hoping for the best — and we got the worst. Destruction of health care facilities, paired with the “survival mode” in which patients and the community had already been living, disrupted the health care system. During the storm, the ma-
jority of the island’s 69 hospitals were left without electricity or fuel for generators.1 Much construction is cement-based and withstood the hurricane, but wooden structures built in mountain regions or elsewhere were lost or severely damaged. During and after the hurricane, people described their experiences and searched for family members and friends through social networks. Our sources of information were the only operational radio station on the island and limited social networks. The governor declared a curfew of 6 p.m. and made it later as safe access to roads was established. Among our cultural values is responsibility for family, which I believe is what kept the number of people in shelters as low as about 12,000. As an obstetrician–gynecologist on the faculty of the University of Puerto Rico School of Medicine who is involved in patient care, clinical and behavioral research,
n engl j med nejm.org
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved.
1
Figure 1. Streets in Puerto Rico Blocked by Debris from Hurricane Maria.
and education of residents, medical students, and undergraduates, I experienced Hurricane Maria through the lens not only of my own fears, but also the concerns of our patients and staff. I had lived through two previous hurricanes: Hugo (category 3) in 1989 and Georges (category 4) in 1998. This time, I dared to stay on an 18th floor, covering doors and windows as best as I could. The experience was worse than I remembered from prior hurricanes, since the building moved with the winds. My personal experience was less frightening than those of my patients, but our shared story created a new bond between us. It became clear to all of us that nature is stronger than medical interventions. Yet obstetrical services had to be available 24/7 for pregnant women. Women in labor cannot wait for services to be reinstated or for staff to show up, and we try to avoid home deliveries. The
2
hospitals that didn’t have major structural damage attempted to continue operations with backup power generators. But only three major hospitals were functioning 3 or 4 days after the hurricane, and information was scarce, since most communications systems had been disrupted. Neither hospitals, patients, nor staff had the means to connect with one another. Located at the Puerto Rico Medical Center in San Juan, the University Hospital provides care to any patient from the island who has a complicated medical condition. We house most of Puerto Rico’s residency programs and subspecialty training programs. All these programs established emergency coverage rosters with 24-hour shifts. All elective surgeries and clinics were canceled. We continued working with the help of the power generator, but the water supply was limited (see Fig. 2).
On one of my night shifts, we had double the maximum occupancy in labor rooms, and the wards were full of patients who had been discharged but had no contact with relatives, no means of transportation, or no place to go. By the sixth day, we had no clean sheets, only a weak drip of water from the faucets, and no way to autoclave our surgical instruments. My residents were overwhelmed, not just from physical exhaustion but from our patients’ stories and the difficult decisions we had to make. We are not trained in disaster management, so we had to draw on our own personal and emotional strengths in managing the situation, aiming to provide high-quality and efficient care while maintaining our professionalism, humanism, and empathy. We were fully functional on day 8, by which time many patients had been transferred to their own or relatives’ homes. By 9 days after the hurricane, we had seen a 33% increase in September 2017 deliveries over those for September 2016. Our research areas include HIV, Zika, high-risk pregnancies, and prevention studies. But our pharmacy and laboratory facilities were affected by the storm. We transferred medications to the hospital pharmacy 2 days after the hurricane. Our research and clinic staff returned to work 5 days after Maria, even though some of them had lost their homes or had major difficulties with road access and gasoline supply. Our clinics opened 10 days, and our labs 14 days, after the hurricane passed. None of our stored samples were lost. The impact of this disaster on morbidity, survival, adherence to treatments, and medical compli-
n engl j med nejm.org
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved.
Lourdes De Jesus.
The View from Puerto Rico
PERS PE C T IV E
The View from Puerto Rico
PE R S PE C T IV E
Figure 2. Tents Provided by the U.S. Department of Health and Human Services for Overflow from the Puerto Rico Medical Center Emergency Room.
ing to modify behaviors that affect their seeking of food, water, and gasoline or repairing of their homes. In an attempt to save babies born with congenital heart disease, pediatric cardiovascular surgeons whose hospital lacked power attempted to establish an operating room in the nursery. Surgeries could not be performed, and the babies had to be transferred to the mainland United States by the medical emergency teams that were established on the third day after the hurricane. Two pregnant women whose fetuses had heart defects were also expediently transferred to the mainland. Fortunately, general pediatric surgery (excluding cardiac) continues to
Disclosure forms provided by the author are available at NEJM.org. From the Department of Obstetrics and Gynecology and the Maternal-Infant Studies Center, University of Puerto Rico School of Medicine, San Juan. This article was published on October 11, 2017, at NEJM.org. 1. Department of Defense. DoD accelerates hurricane relief: response efforts in Puerto Rico (https://w ww.defense.gov/News/Article/ Article/1330501/dod-accelerates-hurricane -relief-response-efforts-in-puerto-rico/). 2. Puerto Rico Health Department. Zika statistics: informe semanal de enfermedades arbovirales (ArboV) (http://www .salud.gov.pr/Estadisticas-Registros-y -Publicaciones/Informes%20Arbovirales/ Reporte%20ArboV%20semana%2035-2017 .pdf). 3. El Nuevo Día (http://epaper .elnuevodia .com/el-nuevo-d%C3%ADa/). DOI: 10.1056/NEJMp1713196 Copyright © 2017 Massachusetts Medical Society. The View from Puerto Rico
Jorge Matta.
cations has yet to be documented. The potential development of infectious disease outbreaks and reactivation of dengue, Zika, and chikungunya epidemics is one major concern. As of December 22, 2016, there were 2591 pregnant women diagnosed with Zika and 36,364 total Zika cases that had been confirmed by laboratory testing.2 Of an estimated 28,200 live births in 2016, Zika affected at least 9.2%. By September 15 of this year, 1546 pregnant women had confirmed cases of Zika. Though the numbers are decreasing, cases are still being reported. This hurricane might well increase the mosquito population, and people may not pay attention to prevention messages or be will-
be performed at our medical center, but some pregnant women are leaving the island to avoid additional medical crises. Many physicians have volunteered to take care of people in shelters through an initiative of the Puerto Rico College of Physicians and Surgeons. Physicians who want to help can join the diverse national organizations that represent our specialties. As of 16 days after the hurricane, 25 hospitals were working, only 9.2% of people had power, 54% had water, 45% had cell phone service, and the Federal Emergency Management Agency had distributed 433,000 food packages and 42,000 gallons of water.3 Puerto Rico clearly faces a long road to recovery.
n engl j med nejm.org
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved.
3
NEW ENGLA ND JOURNAL
of
MEDICINE
Perspective
The View from Puerto Rico — Hurricane Maria and Its Aftermath Carmen D. Zorrilla, M.D. The View from Puerto Rico
H
urricane Maria hit Puerto Rico on September 20 and caused unprecedented damage affecting the island’s 3.4 million inhabitants (see Fig. 1). Though no one in Puerto Rico was
spared at least some impact, the poor and vulnerable were disproportionately affected. Loss of communication and electricity, scarcity of water, isolation of some residents, slow coordination of the aid that has been sent, and the magnitude and scope of the necessary repairs all merit a call for help from and the engagement of the global community. Indeed, Puerto Ricans and U.S. Virgin Islanders are U.S. citizens and expect the same federal aid and support during natural disasters as the rest of the United States. In contrast to sudden disasters, hurricanes often allow officials and populations a window of opportunity to prepare, evacuate people, and update emergency plans. Yet our infrastructure, in-
cluding the health care infrastructure, was already in crisis, and the much milder hit from Hurricane Irma 2 weeks earlier had caused a partial collapse of the power system. In addition, the island’s economic situation, causing concerns about lack of income or reductions in wages, fueled a sense of uncertainty and despair among many Puerto Ricans, as we were faced with the most powerful hurricane to hit Puerto Rico in nearly a century. We prepared for the worst while hoping for the best — and we got the worst. Destruction of health care facilities, paired with the “survival mode” in which patients and the community had already been living, disrupted the health care system. During the storm, the ma-
jority of the island’s 69 hospitals were left without electricity or fuel for generators.1 Much construction is cement-based and withstood the hurricane, but wooden structures built in mountain regions or elsewhere were lost or severely damaged. During and after the hurricane, people described their experiences and searched for family members and friends through social networks. Our sources of information were the only operational radio station on the island and limited social networks. The governor declared a curfew of 6 p.m. and made it later as safe access to roads was established. Among our cultural values is responsibility for family, which I believe is what kept the number of people in shelters as low as about 12,000. As an obstetrician–gynecologist on the faculty of the University of Puerto Rico School of Medicine who is involved in patient care, clinical and behavioral research,
n engl j med nejm.org
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved.
1
Figure 1. Streets in Puerto Rico Blocked by Debris from Hurricane Maria.
and education of residents, medical students, and undergraduates, I experienced Hurricane Maria through the lens not only of my own fears, but also the concerns of our patients and staff. I had lived through two previous hurricanes: Hugo (category 3) in 1989 and Georges (category 4) in 1998. This time, I dared to stay on an 18th floor, covering doors and windows as best as I could. The experience was worse than I remembered from prior hurricanes, since the building moved with the winds. My personal experience was less frightening than those of my patients, but our shared story created a new bond between us. It became clear to all of us that nature is stronger than medical interventions. Yet obstetrical services had to be available 24/7 for pregnant women. Women in labor cannot wait for services to be reinstated or for staff to show up, and we try to avoid home deliveries. The
2
hospitals that didn’t have major structural damage attempted to continue operations with backup power generators. But only three major hospitals were functioning 3 or 4 days after the hurricane, and information was scarce, since most communications systems had been disrupted. Neither hospitals, patients, nor staff had the means to connect with one another. Located at the Puerto Rico Medical Center in San Juan, the University Hospital provides care to any patient from the island who has a complicated medical condition. We house most of Puerto Rico’s residency programs and subspecialty training programs. All these programs established emergency coverage rosters with 24-hour shifts. All elective surgeries and clinics were canceled. We continued working with the help of the power generator, but the water supply was limited (see Fig. 2).
On one of my night shifts, we had double the maximum occupancy in labor rooms, and the wards were full of patients who had been discharged but had no contact with relatives, no means of transportation, or no place to go. By the sixth day, we had no clean sheets, only a weak drip of water from the faucets, and no way to autoclave our surgical instruments. My residents were overwhelmed, not just from physical exhaustion but from our patients’ stories and the difficult decisions we had to make. We are not trained in disaster management, so we had to draw on our own personal and emotional strengths in managing the situation, aiming to provide high-quality and efficient care while maintaining our professionalism, humanism, and empathy. We were fully functional on day 8, by which time many patients had been transferred to their own or relatives’ homes. By 9 days after the hurricane, we had seen a 33% increase in September 2017 deliveries over those for September 2016. Our research areas include HIV, Zika, high-risk pregnancies, and prevention studies. But our pharmacy and laboratory facilities were affected by the storm. We transferred medications to the hospital pharmacy 2 days after the hurricane. Our research and clinic staff returned to work 5 days after Maria, even though some of them had lost their homes or had major difficulties with road access and gasoline supply. Our clinics opened 10 days, and our labs 14 days, after the hurricane passed. None of our stored samples were lost. The impact of this disaster on morbidity, survival, adherence to treatments, and medical compli-
n engl j med nejm.org
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved.
Lourdes De Jesus.
The View from Puerto Rico
PERS PE C T IV E
The View from Puerto Rico
PE R S PE C T IV E
Figure 2. Tents Provided by the U.S. Department of Health and Human Services for Overflow from the Puerto Rico Medical Center Emergency Room.
ing to modify behaviors that affect their seeking of food, water, and gasoline or repairing of their homes. In an attempt to save babies born with congenital heart disease, pediatric cardiovascular surgeons whose hospital lacked power attempted to establish an operating room in the nursery. Surgeries could not be performed, and the babies had to be transferred to the mainland United States by the medical emergency teams that were established on the third day after the hurricane. Two pregnant women whose fetuses had heart defects were also expediently transferred to the mainland. Fortunately, general pediatric surgery (excluding cardiac) continues to
Disclosure forms provided by the author are available at NEJM.org. From the Department of Obstetrics and Gynecology and the Maternal-Infant Studies Center, University of Puerto Rico School of Medicine, San Juan. This article was published on October 11, 2017, at NEJM.org. 1. Department of Defense. DoD accelerates hurricane relief: response efforts in Puerto Rico (https://w ww.defense.gov/News/Article/ Article/1330501/dod-accelerates-hurricane -relief-response-efforts-in-puerto-rico/). 2. Puerto Rico Health Department. Zika statistics: informe semanal de enfermedades arbovirales (ArboV) (http://www .salud.gov.pr/Estadisticas-Registros-y -Publicaciones/Informes%20Arbovirales/ Reporte%20ArboV%20semana%2035-2017 .pdf). 3. El Nuevo Día (http://epaper .elnuevodia .com/el-nuevo-d%C3%ADa/). DOI: 10.1056/NEJMp1713196 Copyright © 2017 Massachusetts Medical Society. The View from Puerto Rico
Jorge Matta.
cations has yet to be documented. The potential development of infectious disease outbreaks and reactivation of dengue, Zika, and chikungunya epidemics is one major concern. As of December 22, 2016, there were 2591 pregnant women diagnosed with Zika and 36,364 total Zika cases that had been confirmed by laboratory testing.2 Of an estimated 28,200 live births in 2016, Zika affected at least 9.2%. By September 15 of this year, 1546 pregnant women had confirmed cases of Zika. Though the numbers are decreasing, cases are still being reported. This hurricane might well increase the mosquito population, and people may not pay attention to prevention messages or be will-
be performed at our medical center, but some pregnant women are leaving the island to avoid additional medical crises. Many physicians have volunteered to take care of people in shelters through an initiative of the Puerto Rico College of Physicians and Surgeons. Physicians who want to help can join the diverse national organizations that represent our specialties. As of 16 days after the hurricane, 25 hospitals were working, only 9.2% of people had power, 54% had water, 45% had cell phone service, and the Federal Emergency Management Agency had distributed 433,000 food packages and 42,000 gallons of water.3 Puerto Rico clearly faces a long road to recovery.
n engl j med nejm.org
The New England Journal of Medicine Downloaded from nejm.org on October 13, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved.
3
