Puerto Rico Health System Resilience After Hurricane Maria: Implications for Disaster Preparedness in the COVID-19 Era
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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's 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.
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SciScore for 10.1101/2020.09.20.20198531: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement Consent: Confidentiality and anonymity were discussed with participants during the consent process.
IRB: The Stanford Institutional Review Board approved all research procedures as an exempt study.Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Our study did have limitations. Most …
SciScore for 10.1101/2020.09.20.20198531: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement Consent: Confidentiality and anonymity were discussed with participants during the consent process.
IRB: The Stanford Institutional Review Board approved all research procedures as an exempt study.Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Our study did have limitations. Most significantly, this is a qualitative case study with a limited number of participants. Because this was a single-institution case study our findings may not be generalizable. However, the study was designed to sample a ‘critical case’ scenario, and while our findings cannot be generalizable to all healthcare systems, a logical generalization can be made that, similar to the UPR Community Hospital, other PR hospitals logically may have had similar or worse experiences. In addition, although we interviewed a range of providers and administrators, we did reach data saturation and our respondents were able to speak not just to about the UPR Community Hospital but also to its interplay within Puerto Rico and the healthcare system as a whole. That being said, future resilience framework studies should incorporate the perspectives to health providers and other institutions and to public health professionals. In September 2017, the people of Puerto Rico were devastated by Hurricane Maria. When there is a stress to a health system, the population will inevitably experience some heightened degree of social disruption, morbidity and mortality. As we have seen with the outbreak of COVID-19, it is as important as ever that both developed and developing countries are fortified with resilient health systems so that when an inevitable stress occurs, social disruption and excess morbidity can be minimized. Unfortunately, the degree of devastation experienc...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
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