A report by Vann R. Newkirk II for The Atlantic.
Our thanks to Peter Jordens for bringing this item to our attention.
With hurricane season again approaching, the island’s health-care infrastructure remains brittle.
Puerto Rico still doesn’t know how many people died from Hurricane Maria. The official death toll of people drowned in floods, killed by landslides, caught in collapsed houses, or who perished from environmental or health problems in the immediate aftermath of the storm seven months ago sits at 64. By just about all accounts, that is an undercount by at least an order of magnitude. A New York Times review of daily mortality rates found just over 1,000 more people died during and after the storm than expected. Additional analyses suggest similar figures. Governor Ricardo Rosselló is expected to release a full review of the island’s death toll next month.
But even when the lights are on and hospitals run smoothly, demographic, geographic, and political features all contribute to a slate of inherent health challenges. Puerto Rico has experienced mass outmigration to the mainland over the past few decades, leaving behind on the island a population that is disproportionately elderly and sick. Puerto Rico has a health profile more akin to developing countries and poor communities of color than to the United States as a whole. Infant mortality has always been higher on the island than on the mainland. The infectious-disease burden is also higher than on the mainland, with forests and damp places on the island serving as reservoirs for old tropical-fever diseases that have all but been forgotten on the north side of the Caribbean.
In all, what Hurricane Maria encountered was a system perched only a small disaster away from complete chaos. But the hurricane was a very large disaster. The lackluster and slow federal response, the lack of coordination between different levels of government, the Puerto Rican Power Authority’s complete failure, and the ongoing Congress-imposed austerity plan all contributed to a months-long power outage and a drawn-out, patchwork recovery—one punctuated by a total blackout last week. Even in the best of circumstances, Maria would have created a public-health catastrophe, but what ensued was worse than it needed to be.
New evidence details the ongoing public-health fallout from the storm over half a year later. An April commentary from Pennsylvania State University researcher Alexis R. Santos-Lozada in Health Affairs indicates just who’s been at risk in the post-Maria landscape:
In particular, we have found that the excess deaths were concentrated among older age groups. For example, among people in Puerto Rico ages seventy and older, the death rate for the period September-October was 27 percent higher in 2017, compared to previous years. Excess deaths were also concentrated in nursing homes (where the numbers of deaths were 45 percent higher in 2017 than in 2016) and emergency departments (where there was a 41 percent increase).
A comprehensive analysis released yesterday by the Kaiser Family Foundation finds evidence of significant progress since last winter, but also some lingering problems settling in. A series of interviews with residents and other stakeholders found a heavy reliance on temporary shelters and tarps among many Puerto Ricans, continuing financial instability, and disruption of daily health care. The sole constant for many people is that there are no constants; no real ability to set health-care routines and engage in healthy behaviors.
The rolling blackouts and damaged infrastructure are just one component of the health-care situation. The Kaiser Family Foundation report highlights the accelerating outmigration since the storm and the resultant aging and sickening of the island’s population.“The Puerto Rican government projects a 10.9 percent cumulative decline in population over the six years following the hurricanes,” it said. An NPR story finds that among the remaining elderly residents, access to long-term support and nursing is declining.
KFF also reports that the physical health needs of those remaining on the island have increased since the storm. While major outbreaks have been contained or averted, “some individuals experienced worsened chronic conditions, such as diabetes and hypertension, due to gaps in care and medications following the storms.” With reduced access to quality food, exercise, and healthy lifestyle choices, stress-linked conditions like ulcers, orthopedic problems, and weight gain are increasing in prevalence. Other reports find that dialysis patients—especially in rural places where local hospitals have been destroyed or incapacitated—are facing worsening outcomes.
Mental-health professionals are noticing a marked increase in suicides. According to the Kaiser Family Foundation, “from November 2017 through January 2018, a crisis hotline run by Puerto Rico’s Department of Health received 3,050 calls from people who said they had attempted suicide, a 246 percent increase compared to the same time last year. In the same three-month period, the hotline received 9,645 calls from people who said that they had thought about attempting suicide—an 83 percent jump from the same time last year.” These findings are supported by a March story from Quartz, which found suicides up by a third compared to the same time period in 2016.
This slowly unfolding public-health crisis lacks the drama of the major outbreaks predicted in the immediate aftermath of Hurricane Maria, but presents tremendous challenges. Still, it remains possible that an improved financial plan and outlook, along with increased access to sustainable energy, assistance from the federal government, and massive public-health campaigns from the Puerto Rican government, could combine to right the ship.
The progress that has been made, though, is extraordinarily fragile. Puerto Rico simply cannot abide another hit from a hurricane while it recovers. Historical luck is on its side—for being smack dab in the middle of the Atlantic’s hurricane alley, it’s faced remarkably few direct hits from major storms over the past few decades—but the fate of public health on the island depends mostly on the hope that those historical winds keep on blowing. It’s unclear if Puerto Rico will even know how many people died from the last hurricane season before the next one begins in June.