A public health disaster in Puerto Rico

{***Pause/Music***}

{***Noah***}

Coming up on Harvard Chan: This Week in Health…

A public health disaster in Puerto Rico in the wake of Hurricane Maria.

{***Stephanie Kayden Soundbite***}

(STEPHANIE KAYDEN: The biggest priorities for first responders and relief agencies right now would be to get people clean, safe water, electricity that’s needed for hospital medical interventions, and clean, safe food.)

In this week’s episode: There are widespread power outages—and shortages of food and water in Puerto Rico in the wake of another devastating hurricane.

We’ll speak to an expert on disaster response to learn about the public health and medical challenges ahead.

{***Pause/Music***}

{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health, It’s Thursday, September 28, 2017. I’m Noah Leavitt

In this week’s episode we’ll be talking about the unfolding emergency in Puerto Rico.

The U.S. territory was battered by Hurricane Maria—which is being blamed for at least two dozen deaths.

It also devastated the island’s infrastructure—destroying the power grid, leaving more than three million people without electricity and leaving many hospitals unable to operate.

There are also widespread shortages of food and water.

To get some perspective on the situation in Puerto Rico we spoke with Stephanie Kayden, who is vice-chair and chief of international emergency medicine and humanitarian programs in the department of emergency medicine at Brigham and Women’s Hospital and Harvard Medical School. She is also an assistant professor in the Department of Global Health at the Harvard Chan School.

Kayden has delivered emergency medical care around the world—including constructing a field hospital for survivors of the 2010 Haiti earthquake.

I began our conversation by asking her to assess the major priorities for first responders and relief agencies.

{***Stephanie Kayden Interview***}

STEPHANIE KAYDEN: The biggest priorities for first responders and relief agencies right now would be to get people clean, safe water, electricity that’s needed for hospital medical interventions, and clean, safe food.

NOAH LEAVITT: And so there are widespread power outages in Puerto Rico right now, so a two-part question. When that happens, how does that affect the relief effort? And then what are the public implications of these widespread power outages?

STEPHANIE KAYDEN: The power outages in Puerto Rico are important because a lot of the clean water supply depends upon pumps that are run by electricity. And so while, of course, people can live without electricity, they can’t live without clean water. And that’s one of the complicating factors right now. Of course, without electricity, it’s difficult to have good, safe food storage. A lot of us depend upon our refrigerators for things like that. And of course, without power, many functions in modern hospitals can’t work. And of course, the other thing is this is a tropical island that a lot of people are dependent upon electricity for air conditioning. And all of these things can add up to real safety issues.

NOAH LEAVITT: And so you touched on hospitals there. So in terms of providing direct medical care, what kinds of challenges are doctors and health workers likely facing at this time? And again, in the broader public health context, are we looking at maybe disease outbreaks down the line?

STEPHANIE KAYDEN: So hospitals are going to be focused on the things that they absolutely can’t do without the electricity, so high-level medical services like dialysis can’t happen without electricity. Operations don’t happen without electricity. And a lot of basic medical care, like x-rays, are all electricity-dependent in a modern hospital. So getting the electricity restored, even if it’s through generators, is a top priority. As far as disease outbreaks, one of the most important things that we do to prevent disease outbreaks is to have proper sanitation systems– that is, flush toilets, a place for people to use the bathroom and make sure that they can get human and other waste away from where people live. And in modern infrastructure, a lot of that is based on the water and sewage systems working. So restoring water and sewage systems are a top priority for reducing disease outbreaks.

NOAH LEAVITT: And you’ve stressed the importance of clean water. And I know there was a report recently from the US military that nearly half of the people did not have access to safe, clean drinking water. So what is the response to that? How can that be addressed?

STEPHANIE KAYDEN: The number one priority for restoring safe drinking water is actually to restore the water purification systems and water delivery systems through the usual pipes that are there in country. Now, that’s the ultimate and best solution. In the meantime, there are distributions of bottled water that are going on. But honestly, with this many people affected throughout the country, it’s going to be very difficult for any entity to deliver enough bottled water to be enough for the people there. So the real focus will be on restoring the water systems.

NOAH LEAVITT: And so in a situation like this when there’s so many different health concerns at once– the power outages, the food, drinking water shortages– how do those responding to the emergency prioritize where to focus their efforts? And do all the different stakeholders maybe have different agendas throughout this process?

STEPHANIE KAYDEN: Well, the basic priorities in a disaster response are often similar. And in a case like this, water and sanitation services really need to be at the top of the list after the immediate lifesaving measures, like search and rescue. But now that we are a week out, it’s really water and sanitation services. The power grid that goes along with providing those water and sanitation services also helps the medical services. And then after that, it would be food. Now, sometimes different agencies have different focuses depending on what they are there to do. Essentially, if you’re a hammer, the world looks like a nail. So the different relief agencies may be focused on different priorities depending on what they think that they can actually get done on the ground. But overall, the human needs are clear. Water and sanitation would be at the top of the list.

NOAH LEAVITT: So we’ve seen several major hurricanes over the last month or so. Are there any unique challenges with this disaster in Puerto Rico? And I’m wondering if its status as a US territory will affect relief efforts

STEPHANIE KAYDEN: Well, anytime you have a disaster that happens on an island, the delivery of services is a little more complicated because things have to be shipped in through the ports, by sea, or shipped in by air, which is much more expensive and much harder to do, because you just can’t get as many supplies in. So I think the challenges on Puerto Rico are not only that it’s an island, but also because it has seen such devastating infrastructure damage that it’s going to be really difficult to essentially rebuild the entire Puerto Rican power grid.  In many ways, it should work toward Puerto Rico’s advantage to be a US territory because the US is one of the richest countries in the world. And unlike some of its neighbors in the Caribbean, it should be able to look to the US for help. However, this kind of help requires, of course, political will, as it always does anywhere in the world. And I think the world will indeed be looking to the United States to fund and carry out much of this rebuilding effort.

NOAH LEAVITT: And so you mentioned the world looking towards the United States. So in terms of the disaster response and what’s playing out on the ground, how much of the relief work is likely to be handled directly by the US government versus how much work do you see NGOs taking over?

STEPHANIE KAYDEN: Aid agencies and direct government efforts work together on the ground. But throughout the world, even aid agency funding mostly comes from the world’s major Western governments. And so in this particular case of Puerto Rico, I think that if you look at where the funding will come from, that will largely be US government funding, because Puerto Rico is a US territory, no matter who is carrying out the work on the ground.

NOAH LEAVITT: And so just the last question. This storm obviously comes on the heels of other devastating hurricanes not just on the US mainland, but all over the Caribbean we’ve seen the devastation. How do repeated storms like this stress the relief workers and the agencies that are providing support on the ground? I guess, how thinly stretched are organizations right now?

STEPHANIE KAYDEN: Aid agencies who are responding in the Caribbean to the recent hurricanes, I think, are all feeling a bit stretched. Because there are just so many places that need immediate relief. The workers who do this kind of humanitarian response worldwide, in some ways, are accustomed to going from disaster to disaster. But I think it is unusual to have so many hurricanes hitting so many places in quick succession. And I would imagine that the people on the ground are feeling pretty stressed at the moment.

NOAH LEAVITT: So looking for long term, what are some of the challenges you see people in Puerto Rico facing?

STEPHANIE KAYDEN: Long term, there are a number of challenges. Hopefully the water and sanitation systems can be restored. But even after that happens, one thing to look out for is the situation with the food supply. About 85% of food on Puerto Rico is imported. And if the food distribution systems can’t be restored, we will possibly see an increase in food prices and difficulty with people being able to afford food. That might lead to a major food crisis down the line.

{***Noah***}

That was our interview with Stephanie Kayden.

And we also wanted to get some perspective from Richard Serino, who you’ve heard from before on this podcast. Serino served as deputy administrator of FEMA from 2009 to 2014 and is currently distinguished visiting fellow at the National Preparedness Leadership Initiative at the Harvard Chan School and Harvard Kennedy School.

I asked him to put Maria in perspective compared to previous storms like Harvey and Irma. He said that Maria poses a unique challenge not just because of Puerto Rico’s island location—but because the territory itself is billions of dollars in debt.

{***Richard Serino Soundbite***}

(RICHARD SERINO: These are three different types of events. And with Harvey and Irma, both of those Texas and Florida, the relief could come, as I mentioned earlier, by a highway. And people can come in and get help that way. An island is complex. And Puerto Rico is even more complex because financially they’re in a difficult shape. They’re already $70 billion in debt. And how we typically do things may have to change and start to look at ways to do things and hopefully help rebuild better than they were. That’s a bit of a ways off, but we have to start looking at that. In the Pacific Islands after the tsunamis in American Samoa and some of the other islands, they were able to rebuild better. That they were able to have some private corporations go in and actually give power that they didn’t need to use, fuel. I believe it was Tesla that went on to one of the islands and gave these huge battery packs and solar, and they became self-generating with their power. So they were able to rebuild better. And I think there’s some opportunities, once we continue with the life safety, the life sustaining activities over the next few weeks. But as this is going to go on for, literally, the rebuilding is months and years, is to take that opportunity to how can we look and make this better, how to make the rebuild better and safer for the community.)

{***Noah***}

And after hearing that you probably want to help.

You may recall an interview we did with one of Stephanie Kayden’s colleagues—Julia Brooks—in which she said that giving cash is the best way to help following a disaster—as opposed to sending clothing or supplies. Brooks says that in the wake of a disaster the supplies are not most useful—but money to support relief efforts can be put to use immediately. In particular, she urges you to donate to local organizations that direct the money where it’s needed most as priorities change.

If you want to read more about the best ways to help after a disaster, we’ll have a link to an article Brooks’ wrote on our website hsph.me/thisweekinhealth.

And that’s all for this week’s episode. You can always find us on iTunes, Soundcloud, or Stitcher. And if you are a regular listener of this podcast, we’d love for you to leave a review. It helps us to know what you think about the show—and it helps more people find our podcast.