Dev­as­tated by two hur­ri­canes, Puerto Rico’s health­care sys­tem faces a long road to re­cov­ery

Modern Healthcare - - NEWS - By Steven Ross John­son

The one-two punch of hur­ri­canes Irma and Maria have dev­as­tated Puerto Rico. The im­pact on the is­land’s hos­pi­tal sys­tem paints a grim pic­ture for an al­ready-frag­ile health in­fra­struc­ture at a time when a slew of pub­lic health chal­lenges are ex­pected to arise.

Most of Puerto Rico re­mained with­out elec­tri­cal power late last week in the wake of the dev­as­ta­tion left when Maria slammed into the is­land Sept. 20. Maria piled on to the dam­age wreaked ear­lier in Septem­ber when Hur­ri­cane Irma sideswiped the is­land. It’s ex­pected to be months be­fore all power is re­stored, with an es­ti­mated 1.6 mil­lion res­i­dents af­fected, the Fed- eral Emer­gency Man­age­ment Agency said last week.

Com­mu­ni­ca­tions were largely down through­out the is­land, with roughly 95% of cell­phone tow­ers out of service. Fuel short­ages were re­ported in many parts, and nearly half of the pop­u­la­tion had no ac­cess to drink­ing wa­ter. To­tal cost of dam­age from Hur­ri­cane Maria could range from $30 bil­lion to as much as $95 bil­lion, ac­cord­ing to mar­ket an­a­lysts.

“Right now, the whole is­land, the in­fra­struc­ture is dev­as­tated,” Puerto Rico Gov. Ri­cardo Rosello said dur­ing an interview on ABC’s “The View” on Wed­nes­day. “This hur­ri­cane has hit every cor­ner of Puerto Rico—we have no en­ergy grid, we have lit­tle ac­cess to wa­ter—it is crit­i­cal that we get more help.”

The sit­u­a­tion ap­pears es­pe­cially dire for Puerto Rico’s health­care sys­tem. As of Sept. 26, only 11 of the is­land’s 69 hos­pi­tals re­ported hav­ing ei­ther power or a fuel sup­ply, ac­cord­ing to a FEMA re­port, with 58 fa­cil­i­ties de­scribed as “op­er­a­tional with un­known sta­tus.”

The Amer­i­can Col­lege of Physi­cians sent Pres­i­dent Don­ald Trump a let-

ter re­quest­ing that ad­di­tional re­sources be sent to the is­land to aid in the re­lief ef­fort, ex­press­ing con­cern that the sit­u­a­tion could quickly turn into a hu­man­i­tar­ian cri­sis if more is not done to get med­i­cal ser­vices up and run­ning. As of Sept. 28, at least 16 peo­ple had died as a re­sult of Hur­ri­cane Maria.

“It is es­pe­cially im­por­tant the fed­eral gov­ern­ment’s re­cov­ery and re­lief ef­forts pri­or­i­tize mak­ing it pos­si­ble for hos­pi­tals and other health care fa­cil­i­ties to op­er­ate with ad­e­quate elec­tric­ity, run­ning wa­ter and san­i­ta­tion, sup­plies, and med­i­ca­tions, and to fa­cil­i­tate the abil­ity of physi­cians and other health pro­fes­sional within the is­lands, and on the main­land, to pro­vide as­sis­tance,” wrote ACP Pres­i­dent Dr. Jack Ende.

The fed­eral gov­ern­ment’s re­lief ef­fort thus far has in­cluded send­ing more than 300 per­son­nel from HHS’ Na­tional Dis­as­ter Med­i­cal Sys­tem to Puerto Rico to set up a base of op­er­a­tions with med­i­cal equip­ment and sup­plies near Cen­tro Medico, an emer­gency and trauma cen­ter based in San Juan. Ac­cord­ing to HHS, med­i­cal pro­fes­sion­als from NDMS and the U.S. Pub­lic Health Service Com­mis­sioned Corps as­sisted area hos­pi­tals, which they said were see­ing an in­flux of pa­tients while many fa­cil­i­ties re­mained short-staffed.

The fed­eral gov­ern­ment’s re­sponse has thus far been no­tice­ably smaller than the mo­bi­liza­tion in the days af­ter Hur­ri­cane Har­vey hit Texas, or in Florida in the af­ter­math of Hur­ri­cane Irma. The dif­fer­ence has been a source of con­tention among crit­ics who worry about the scope of the emer­gency af­fect­ing the is­land.

Rep. Luis Gutier­rez (D-Ill.) late last week an­nounced plans to travel to Puerto Rico to as­sess both the dam­age and the speed of the re­cov­ery ef­fort.

“It has been more than a week and ba­sic aid like food, wa­ter, medicine and fuel isn’t get­ting where it needs to be to help peo­ple,” Gu­tiér­rez said Thurs­day in state­ment. “We can’t al­low in­ac­tion in Wash­ing­ton to cre­ate a hu­man­i­tar­ian cri­sis for 3.4 mil­lion Amer­i­can citi- zens in Puerto Rico.”

Many feel the chal­lenges fac­ing Puerto Rico in Maria’s af­ter­math could po­ten­tially take a much greater toll on the pop­u­la­tion’s long-term health than what res­i­dents of Texas and Florida are ex­pe­ri­enc­ing.

One of the more im­me­di­ate con­cerns is the sus­tained loss of elec­tri­cal power to many of the is­land’s med­i­cal fa­cil­i­ties. Get­ting elec­tric­ity up and run­ning is crit­i­cal to en­sure ev­ery­thing from pow­er­ing dial­y­sis and oxy­gen ma­chines, to en­abling hand and wa­ter san­i­ta­tion, equip­ment ster­il­iza­tion, and re­frig­er­ated stor­age of vi­tal med­i­ca­tions.

“Things can go from emer­gency to com­plex hu­man­i­tar­ian cri­sis at the drop of a hat,” said Lau­ren Sauer, an as­sis­tant pro­fes­sor of emer­gency medicine at Johns Hop­kins Univer­sity School of Medicine. Johns Hop­kins cur­rently has a team of six med­i­cal ex­perts on the is­land of St. John in the U.S. Vir­gin Is­lands to of­fer ex­per­tise and sup­port in the wake of the storms.

Like the U.S. main­land, Puerto Rico’s pop­u­la­tion has been ag­ing for more than a decade, which in turn has led to a larger pro­por­tion of res­i­dents be­ing in poorer health. While the is­land has sim­i­lar life ex­pectancy rates to the U.S. main­land, 35% of the is­land’s 3.5 mil­lion res­i­dents re­ported be­ing in fair or poor health, com­pared to just 18% of the pop­u­la­tion re­sid­ing in the 50 states and the District of Columbia, ac­cord­ing to a 2016 re­port by the Kaiser Fam­ily Foun­da­tion.

Puerto Ri­can adults had higher rates of asthma, di­a­betes and hy­per­ten­sion than the U.S. main­land, con­di­tions Sauer said will be dif­fi­cult to man­age in the wake of a dis­as­ter like Maria. Since 2010, Puerto Rico has ex­pe­ri­enced an ar­ray of out­breaks of such vec­tor-borne in­fec­tious dis­eases as dengue fever, chikun­gunya and the Zika virus. Ex­perts say such dis­eases have a higher risk of re­turn­ing as de­bris left over from the storms cre­ate stand­ing pools of wa­ter for mosquitoes to breed.

“You’re cre­at­ing a pop­u­la­tion that fun­da­men­tally can’t be cared for in a timely man­ner and it can turn into a com­plex sit­u­a­tion that the health­care sys­tem there may not be able to in­cor­po­rate,” Sauer said.

Com­pared with the main­land, Puerto Rico poses greater lo­gis­ti­cal prob­lems in dis­tribut­ing aid in a timely fash­ion sim­ply be­cause ev­ery­thing must be shipped by boat or plane; but larger is­sues could fur­ther com­pli­cate the re­lief ef­fort. One con­cern is the fact that fed­eral dis­as­ter fund­ing is al­ready be­ing used to ad­dress the re­cov­ery ef­forts in Texas and Florida. An­other in­volves the con­di­tion of the is­land’s health­care sys­tem prior to the storms. A com­bi­na­tion of de­clin­ing health in­vest­ments and an ex­o­dus of health­care pro­fes­sion­als over the past two decades for work on the U.S. main­land has caused an eco­nomic strain for Puerto Rico.

The is­land has been in the mid­dle of a debt cri­sis to­tal­ing $73 bil­lion. Ac­cord­ing to a Jan­uary re­port by the Ur­ban In­sti­tute, pub­lic and pri­vate health­care spend­ing fell by 10% be­tween 2010 and 2014, about $1.2 bil­lion.

Congress is ex­pected to use a por­tion of the $15 bil­lion in emer­gency aid it au­tho­rized in the wake of Har­vey to go to­ward the re­lief ef­fort in Puerto Rico; the Trump ad­min­is­tra­tion is not ex­pected to make a for­mal re­quest for emer­gency fund­ing un­til around the first week of Oc­to­ber.

“The Puerto Ri­can pop­u­la­tion is truly go­ing to suf­fer the im­pact of Maria be­cause it’s the last of the dis­as­ters to hit so they’re go­ing to be last in line for re­sources,” Sauer said.

REUTERS

Nurses and pa­tients at a San Juan hos­pi­tal in Puerto Rico on Sept. 23.

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