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Puerto Rico, many Caribbean Islands, and the East Coast of the United States were severely impacted in September 2017 by two major hurricanes within two weeks, an extraordinary event. Hurricane Irma formed on August 30, 2017 and dissipated on Sept. 13, 2017. The highest sustained wind gusts were 180 mph. Irma proved to be the fifth costliest cyclone on record costing $64.76 billion (2017 USD). Irma impacted Cape Verde, the Leeward Islands, Cuba, Puerto Rico, Turks and Caicos, Bahamas and the Eastern United States. Two weeks after Irma, Hurricane Maria formed on September 16 and dissipated on October 2, 2017. The highest reported sustained wind gusts were 175 mph. Maria is the third costliest hurricane on record and the costliest hurricane ever experienced by Puerto Rico with an estimated $91.61 billion in total in damages (2017 USD). Maria caused catastrophic damage entirely to Dominica, Guadeloupe, Martinique and Puerto Rico. Puerto Rico suffered a major humanitarian crisis with major flooding, loss of homes, compete loss of communications, the worst blackout in US history, shortage of food and lack of access to potable water. The population of Puerto Rico suffered from a general lack of resources compounded by a slow relief effort.
Recovery in Puerto Rico and other Caribbean islands was slow and, even two years later, much remains to be done to reach full recovery and even more to achieve a level of resiliency that would ensure a much higher level of preparedness to quickly respond post-event and to ensure a rapid recovery. These events impacted many sectors of society: housing, educational institutions, transportation, commerce and banking, communication, public safety, and health systems among them. The damage to the physical environment was massive throughout the region and the slow recovery impacted education as schools used as shelters had to remain open because of the delay in reconstruction of homes and lack of planning for long term accommodation of displaced families who lost their homes in areas where rebuilding was not possible or too risky. It was clear that the way communities were able to prepare for the hurricane event, and their experience of the hurricane event, the response phase, and the recovery phase were strongly limited by where people lived (urban vs. rural), how much money they had access to, and other barriers (level of education, income, gender, social connections and presence or lack of a support system, among many other factors). Obvious gaps in equity of community resilience post disaster were and are being experienced.
The Robert Wood Johnson Foundation has identified nine social determinants that drive health equity: transportation, housing, employment, education, health systems and services, income and wealth, physical environment, public safety and social environment1. Building “disaster resilience with equity” is similarly dependent upon social determinants as was demonstrated by the voices of the summit participants. The purpose of the Caribbean Strong: Building Resilience with Equity summit was to gather a group of experienced voices to represent the diverse sectors impacted by the hurricanes to define a model of resilience for the region going forward. This effort is committed to working side by side with all communities with respect, inclusion and purpose to build a resilient Puerto Rico that can provide communities with a fair opportunity for a good post disaster outcome in the future.
In February of 2018, a three-day summit was convened by the Puerto Rico Hurricane Response Hub (PRHRHTAC) and the Brain Trust for Tropical Disease Research and Prevention, both programs of the Puerto Rico Science, Technology and Research Trust, to focus on lessons learned following Hurricanes Irma and Maria. Participants were invited to share their experiences, lessons learned and recommendations for enhanced community resilience in the face of future disasters. An emphasis was placed on the critical need for collaboration and integration across a diverse group of sectors to improve and strengthen the health and resilience of the Caribbean’s communities during recovery and rebuilding phases. An integrated examination of the resilient capacity of all sectors and their interdependence was essential to develop evidence and experience-based best practices for the future. Each of the three days had a distinct purpose: Day 1 focused on “Caribbean Voices: Lessons Learned from Local Leaders,” Day 2 featured plenary presentations by local and federal government leaders with a series of sector-based breakout session presentations in the afternoon, and Day 3 participants focused on creating recommendations for building resilience moving forward.
NARRATIVE
The Planning Committee established the goals of the summit, set the agenda, identified key presenters, created the call for abstracts, and identified financial supporters. 553 uniquely registered participants attended and 104 were presenters. Heart to Heart International supported travel expenses for 25 student scholars. 70 abstracts and 47 posters were presented. Continuing Medical Education credits were offered by the Ponce Health Sciences University. Participants were invited to submit articles to a special supplement dedicated to the serial hurricanes Irma, Maria and Harvey by the journal of the Society for Disaster Medicine and Public Health Preparedness, under a grant from the Robert Wood Johnson Foundation. As a result, enough manuscripts were submitted and accepted to enable the publication of two full journal issues.
AGENDA
The agenda of Day 1 was planned to highlight the experiences and voices of the Caribbean community who represented non-governmental organizations, institutions and the private sector. Two keynote speakers were featured: Mr. John Englander, who addressed climate change and rising sea levels, and Dr. Vincent LaFronza, who spoke about the National Network for Public Health Institute’s (NNPHI) Hurricane Response Hub Technical Assistance Center (HRHTAC) Program, and the Puerto Rico Hurricane Hub was officially launched as one of NNPHI’s five jurisdictions. Community leaders from Federally Qualified Health Centers, Jamaica’s health care system, and experts on supply chain and logistics provided a broad regional perspective. Day 1 closed with a moderated plenary session with Puerto Rico’s Business Emergency Operation Center that provided insight into the private sector’s critical role in disaster preparedness, response and recovery.
Day 2 featured keynote speaker Dr. Richard Besser, President of the Robert Wood Johnson Foundation, who shared his message that “To learn we must listen,” emphasizing the value of listening to the perspective of local communities to understand needs and gaps in services, and to focus this work on creating healthy resilient communities. Dr. Besser dedicated the first Puerto Rico Public Health Award to José F. Cordero. Ms. Ada Monson, an authority on meteorology and hurricanes, presented a dramatic summary of Hurricane Maria’s impact in its path through Puerto Rico. Plenary sessions featuring recommendations for resilience from local and federal government agency leaders followed. Breakout sessions of brief oral presentations included four tracks: 1) Medically Fragile Populations and Mental Health, 2) Infrastructure, 3) Resilience and Communications and 4) Public Health. Day 2 closed with a moderated session, “Storm Hardening 2.0 - Infrastructure Lessons in the Aftermath of Hurricane Maria,” and featured technical experts from the food, water, power, transportation and telecom sectors who shared their experiences and recommendations.
Day 3 of the summit was focused on discussion and ranking of evidence-based recommendations for resilience. Dr. Georges Benjamin, the Executive Director of the American Public Health Association, offered several recommendations and strategies on planning for resilience when long-term power outages occur. This was followed by a plenary session on post-disaster mortality surveillance methods featuring Dr. Lynn Goldman from George Washington University and Dr. Satchit Balsari from Harvard Medical School, followed by Rebecca Noe from the CDC who discussed the importance of the documentation of deaths post environmental catastrophe. The remainder of the day was devoted to developing recommendations based on the presentations of the conference. Participants divided themselves into three breakout sessions based on the three phases of disasters: preparedness or risk mitigation, response, and recovery. A full agenda with a list of presenters is available at: http://prsciencetrust.org/caribbeanstrong/#register.
DISCUSSION OF THE IMPLICATIONS OF EVENT
The Caribbean Strong Summit was a tremendous success. It generated a total of 155 useful recommendations from a diverse group of leaders representing a wide range of sectors. A representative sampling is presented below with the full number, and their analysis will appear in a future publication. The integration of multi-sectorial expertise is essential to building true resilience moving forward. The two main mortality studies on deaths due to Hurricane Maria specifically stated that a great proportion of deaths occurred due to a delay in access to health care and medicines over timeReference Kishore, Marqués and Mahmud2,Reference Santos-Burgoa, Sandberg and Suárez3 . A more resilient health care system is needed in the region to prevent unnecessary deaths due to delay in medical care and lack of access to life saving and life sustaining medications. The recommendations ranked as most important and actionable strongly reflect this need to build resilience of the health care system with a focus on strengthening the health of the community and focusing on those most impacted by inequities and/or medical fragility. The most important themes for enhanced resilience that emerged from presenters at Caribbean Strong were:
Focus on preparedness and disaster mitigation to promote community resilience.
Integrate all sectors that drive health and resilience equity (social determinants of health and disaster preparedness and response sectors).
Establish and maintain registries and data on community members most impacted by inequities (to include the medically dependent, elderly, and other fragile populations)
The model of community-based health care as exemplified by the work of Federally Qualified Health Centers and the Puerto Rico Primary Care Association should be replicated and made more resilient.
Review and modify as required statutory impediments to more effective preparedness and response, for example taxes and fees that discourage preparation and transportation restrictions.
As this report was being written, Puerto Rico has begun recovering from the serial earthquakes of January 6 and 7, 2020. Too often in the field of disaster medicine and public health preparedness, we can get trapped into focusing all of our preparedness efforts on the most recent events, but it is essential that resilience efforts in the Caribbean focus on mitigating risk from the wide range of potential disasters that continually threaten our region. Foremost among these are the acute events such as hurricanes, earthquakes and tsunamis and the longer term threats posed by emerging infectious diseases and relentlessly rising sea levels. Regardless of the cause, the effects on human societies is the same—the destruction of the societal infrastructure that is the overarching provider of Public Health. In the face of such portentous events it is individual, community and national resilience that provide the most effective “vaccine” in the efforts to preserve and enhance lives in the face of disasters.
Acknowledgements
We would like to acknowledge the contribution of the Caribbean Strong Planning Committee Members: Lucy Crespo, Dr. José F. Cordero, Dr. Emma Fernandez, Dr. Jim James, Dr. Carmen M.Vélez, Lupe Vazquez, Martin Montoya, Maria del Carmen Agueros and Sandra Colón. In addition, we would like to acknowledge the contributions of our generous sponsors to Caribbean Strong: Heart to Heart International, Center for Collaboration Research in Health Disparities, H2O Worldwide, National Network for Public Health Institutes, KOHLER, Water Mission, EC Waste, Americares, OXFAM, Colors and More, Direct Relief, T-Mobile, Project Hope, American Red Cross, Line Master Road Markings, Serrallés, and the CIC Construction Group.
Funding statement
Supported in part by the Puerto Rico Science, Technology and Science Trust, Puerto Rico Hurricane Response Hub for Technical Assistance (HRHTAC), and the Hurricane Response Hub, National Network of Public Health Institutes and NIH Grant 5R21MD013709-01.
