The Acute Phase of the Hurricane and Its Short-Term Consequences

As the tenth-most intense Atlantic hurricane on record and the most intense tropical cyclone worldwide of 2017, Hurricane Maria is regarded as one of the worst natural disasters on record in the United States.^{Reference Newkirk2} It was the deadliest storm of the rather active 2017 Atlantic hurricane season, with an estimated 2000-5000 human lives lost to post-Maria conditions.^{Reference Santos-Burgoa, Sandberg and Suárez3,Reference Kishore, Marqués and Mahmud4} (As of late August 2018, the official government figure estimates that 2,975 Puerto Ricans were killed by the hurricane or its aftermath. This figure was raised from 1,427 fatalities, only a few weeks earlier.) Indeed, there has been an on-going controversy as to the final mortality figures. In May 2018, Harvard University released a study that received much media buzz claiming that 4645 Puerto Ricans had perished from reasons related to Maria.^{Reference Kishore, Marqués and Mahmud4} For this reason alone, it seems prudent to encourage comprehensive, long-term epidemiologic surveillance in post-disaster settings with high levels of mortality.

This statement proposes using a Life Course Approach to disaster response, including surveillance and longitudinal research. The author has written previously about the long-term impacts of disasters on human health, with a focus on cancer and trauma outcomes in post-war Kuwait.^{Reference Cange5} In this study, our Life Course Approach relies on 3 phases for determining health outcomes: Critical Period, Latency Period, and Post-Disaster Resilience.

Natural Disaster as a Critical Period: Hurricane Maria on Puerto Rico

The Critical Period represents a time period when an exposure, such as a hurricane and the subsequent flooding, has a stronger effect on human development and, hence, disease risk than it would at other times.^{Reference Kuh and Shlomo6} Exposures, in the broadest sense of the term, could be compounded from the stressful effects of disasters, especially in the face of climate change. In the Puerto Rican context, there have been a series of chemical and psychological Maria-era exposures that left permanent damage. More specifically, the critical period is September 20, 2017, until the date of the publication of this policy. Exposures of these types present different risk and protective factors. Similarly, exposures are of many varieties: chemical, spatial, economic, social, racial, among others. One specific biological exposure from raw sewage recorded in Puerto Rico was E. coli bacteria in drinking water,^{Reference Panditharatne7} which can lead to diarrheal infections. Another chemical exposure that continues to pose a problem in post-Maria Puerto Rico is heavy-metal-laden coal ash contamination.^{Reference Brown, Vega and Murphy8} These types of chemical exposures will lead to short- and long-term health outcomes in any disaster setting, such as chronic heavy metal poisoning and, possibly over time, cancer. Specifically, in terms of children’s post-disaster health, there are no mandated federal, state, or local inspections of damaged educational facilities for the safe re-occupancy by children. It has been common practice that health agencies do not log or track children’s exposures in these post-disaster settings.⁹

Puerto Rico suffered catastrophic damage from the storm, including destruction of its previously damaged electrical grid from Hurricane Irma.^{Reference Meyer10} For weeks in Maria’s wake, most of the island’s population suffered from flooding and lack of resources, compounded by the slow relief process. Flooding and wind caused significant damage to the electric grid, houses, and roads, resulting in the declaration of disaster zones in nearly 30 municipalities.^{Reference Robles and Glanz11} Total losses from the hurricane are estimated at upward of $91.61 billion,¹² mostly in Puerto Rico, ranking it as the third-costliest tropical cyclone on record.

The federal response to the emergency in Puerto Rico was slow and limited, leading to calls for a Congressional investigation.¹³ Health inequities have gotten worse after the hurricane and magnify the impact of social determinants of Puerto Ricans’ health (eg, housing, health-care services, access to clear water, and sanitation).^{Reference Dietrich, Garriga-Lopez and Garriga-Lopez14} The possible implementation of further austerity measures on Puerto Rico’s government budget raises even more concerns about the availability of local resources to address the health-care challenges posed by the public health situation after Hurricane Maria.

Puerto Rico’s average annual income is $18,314,¹⁵ and its income inequality is rated 0.46 on the Gini Index,¹⁶ which is the lowest in the United States. Furthermore, the territory has had economic woes for several years, including high national debt and relatively high unemployment.¹⁵ The territory suffered from health disparities before Maria; now these health disparities may likely get even worse. Indeed, Puerto Rico’s health-care system was already facing serious changes several years before Maria hit the island.^{Reference Evans17} Puerto Rico could serve as a good case study for other post-disaster settings with high health disparities.

According to APHA Disaster Policy 6211 “In the event of a disaster, state and local public health officials have primary responsibility for responding to the health needs of the victims. Moreover, it is these public agencies appropriate role to work with other responding agencies by actively coordinating the various response efforts that impact physical and psychological health.”¹⁸ However, it is not clear which governmental agencies have responsibility for long-term health surveillance and research. In the Hurricane Maria: A Case Study section of this statement, we describe the proposed long-term, public health approach for these types of disasters in the future.

Maria’s adverse long-term health outcomes necessitate the re-establishment of more sustainable infrastructure, but also robust, long-term responses to psychological and physical health, along with management of policy factors.

The Latency Period After Natural Disasters

The latency model of the life course approach theorizes that discrete events have a strong independent effect in later life.^{Reference Kuh and Shlomo6} The Latency Period is the time between exposure and the emergence of the first symptoms of illness. In the Puerto Rican example and other post-disaster settings, there may be an increase of certain adverse health impacts, such as post-traumatic stress disorder (PTSD), birth defects, autism, and/or cancers, with an environmental etiology, subsequent to a 5- to 15-year latency period.

The latency period also reflects the stress-vulnerability theory.^{Reference Kuh and Shlomo6} In looking at the World Trade Center disaster, Adams and Boscarino found that the affected communities in New York City recorded higher levels of alcohol abuse, domestic violence, and other related social tensions, and these levels were particularly higher among African-American and Latino communities.^{Reference Adams and Boscarino19} Indeed, a recent study by Ratnapradipa et al. (2018) highlights the unique health risks that vulnerable populations faced in Houston during Hurricane Harvey.^{Reference Ratnapradipa, Cardinal and Ratnapradipa20} Vulnerable populations, including visible minorities, pregnant women, undocumented immigrants, people living in lower-income housing, children, individuals living with functional disabilities or chronic medical conditions, and sexual minorities, are most at risk of experiencing stress during the latency period.

The extreme stress that individuals may experience during high-impact disasters from a disaster such as Hurricane Maria, can speed up the usual latency period, and may be part of a synergistic effect that leads to negative health outcomes over a much shorter period of time in Puerto Rico as well as other post-disaster settings. These secondary stressors should not be overlooked in the post-disaster period as studies indicate long-term mental health is affected during this period.^{Reference Lock, Rubin and Murray21}

Post-Disaster Resilience

After disaster hits, it is obvious that some level of distress among inhabitants is nearly a universal reaction. These reactions can be grouped into twin maladaptive and adaptive reactions to the disaster’s stress that evolve as a function of vulnerability and resilience factors. Researchers have shown that the single most important factor to encourage resilience is social support.^{Reference Bonanno22}

In post-disaster communities, information and communication resources are often poor, unreliable or untrustworthy. This perceived lack of adequate communication may be detrimental to helping the community heal its psychological wounds in the post-disaster area.

For these reasons, we need to better understand the effect of vulnerability and resilience factors on the advent of post-traumatic stress in post-disaster settings. Other post-disaster projects on traumatic events have developed conceptual models around such adaptive and maladaptive factors, such as disaster-zone stressors, pre-disaster risk factors, stressful life events, social support, and alienation.^{Reference Somerfield and McCrae23}

Long-Term, Post-Disaster Research

In terms of future public health interventions, to the authors’ best knowledge, there are only a couple of federal plans for studying the long-term effects of Hurricane Maria in Puerto Rico as one or more cohort study(ies). (There have been several NIH RFAs for cross-sectional studies on the effects of Maria on Puerto Ricans. These will be important baseline studies, but do not respond to the aims of this policy.) These studies, however, are not stand-alone studies, but rather are “tag-ons” to other, existing cohort survey studies. An analogous example, Hurricane Katrina in 2005, has been widely studied by public health researchers at Louisiana State University, Tulane University, and other universities, including with substantial National Institutes of Health (NIH) funding.²⁴ Specifically, the NIH Disaster Research Response Program (DR2), the national framework for public health research on disasters and public health emergencies, has offered funding for short- to limited mid-term post-disaster health research. However, it is not clear if there is an extant longitudinal cohort that is being followed to determine if there are unique outcomes among Katrina survivors. From this Katrina-focused research, the most unusual finding has been “Katrina Brain,” which is defined as a condition wherein the patient struggles with short-term memory loss and cognitive impairment.^{Reference Vasterling25} In the Puerto Rico context, researchers could consider investigating if there will be short-term memory loss and cognitive impairment among Puerto Rican survivors.

Another Katrina retrospective cohort study of the effect of Hurricane Katrina on incidence of acute myocardial infarction (AMI) in New Orleans found the mean age of onset of AMI decreased from 62 years before Katrina to 59 years after Katrina.^{Reference Jiao, Kakoulides and Moscona26}

According to other post-Katrina studies, there are many other negative health outcomes ranging from asthma, allergies, birth defects, learning delays, PTSD, and cancers.^{Reference Vasterling25,Reference Jiao, Kakoulides and Moscona26}

Long-Term, Post-Disaster Surveillance

One example in support of more long-term surveillance was during Typhoon Haiyan (2013), which struck the Philippines. The death toll of Haiyan is estimated to be 6300 individuals.²⁷ Although the immediate medical needs were not necessarily injury-related, a lack of prevention of infectious diseases and the worsening of noncommunicable diseases due to the lack of access to food, water, housing, and medicine, which could suggest that the death toll figures stated above could still be rising.^{Reference Egawa and Imamura28}

Another example of post-disaster surveillance would be from the tsunami that hit the Eastern Japanese coast in March 2011. In this example, the Fukushima nuclear plant suffered a massive meltdown and caused radioactive releases. Beyond an increase in allergies, study participants reported suffering from an increase of vertigo and/or dizziness during the first few years after the disaster.^{Reference Hasegawa, Ohira and Kuriyama29} The World Health Organization (WHO) has reported that there was sharp increase in mortality among elderly people who were put in temporary housing. In addition, there was an increased risk of non-communicable diseases, such as diabetes^{Reference Satoh, Hidaka and Hosoya30} and mental health problems.^{Reference Suzuki, Yabe and Yasumura31} The lack of ample health-care access further contributed to these health concerns.³²

Extending Current Short-Term, Post-Disaster Responses

Post-disaster research could be supported through specific funding mechanisms for short-term responses, such as existing evaluation funding from the Centers for Disease Control and Prevention (CDC). For instance, Bipartisan Budget Act of 2018 (H.R. 1892) includes $200 million in one-time funding appropriated to CDC for response, recovery, preparation, mitigation, and other expenses directly related to the consequences of Hurricanes Harvey, Irma, and Maria.

The CDC already has drafted and implemented a Disaster Health Response Cooperative Agreement: Public Health Crisis Response 2017 Hurricane Recovery Crisis Cooperative Agreement Interim Guidance.³³ This agreement provides support for biosurveillance; however, the time-frame is not specified. It does not provide support for post-disaster research activities.³³

Given the urgency associated with the post-disaster setting, preexisting cooperative agreements between federal agencies and local research institutions (e.g., a university), often involve cost-sharing and/or task-sharing to ensure evaluation. In the future, this evaluation piece could include a research and/or surveillance component that may already be included in short to mid-term response projects.