Abstract
Background:Every year, Puerto Rico faces a hurricane season fraught with potentially catastrophic structural, emotional and health consequences. In 2017, Puerto Rico was hit by Hurricane Maria, the largest natural disaster to ever affect the island. Several studies have estimated the excess morbidity and mortality following Hurricane Maria in Puerto Rico, yet no study has comprehensively examined the underlying health system weaknesses contributing to the deleterious health outcomes.Methods:A qualitative case study was conducted to assess the ability of the UPR health system to provide patient care in response to Hurricane Maria. An established five key resilience framework and inductive analysis was used to identify factors that affected health system resilience. Thirteen Emergency Medicine Physicians, Family Medicine Physicians, and Hospital Administrators in a University of Puerto Rico (UPR) Community Hospital were interviewed as part of our study.Results:Of the five key resiliency components, three domains were notably weak with respect to UPR's resiliency. Prior to the Hurricane, key personnel at the UPR hospital wereunawareof the limited capacity of back-up generators at hospitals and were ill-prepared to transfer ICU patients to appropriate hospitals. Post Hurricane, the hospital facedself-regulationchallenges when triaging the provision of Hurricane-related emergency services with delivering core health services, in particular for patients with chronic conditions. Finally, during and after the Hurricane,integrationof patient care coordination between the UPR hospital ambulances, neighboring hospitals, and national and state government was suboptimal. The two remaining resiliency factors, addressingdiverseneeds and systemadaptivenessin a time of crisis, were seen as strengths.Conclusions:Hurricane Maria exposed weaknesses in the Puerto Rican health system, notably the lack of awareness about the limited capacity of backup generators, poor patient care coordination, and interruption of medical care for patients with chronic conditions. As in other countries, the current COVID epidemic is taxing the capacity of the Puerto Rico health system, which could increase the likelihood of another health system collapse should another hurricane hit the island. Therefore, a resilience framework is a useful tool to help health systems identify areas of improvement in preparation for possible natural disasters.
Highlights
In September 2017, Hurricanes Irma and Maria devastated Puerto Rico and caused severe damage to critical infrastructure and essential health systems (Kishore et al, 2018; SantosBurgoa, 2018)
The UPR Community Hospital was purposefully selected as the “critical case” given its central location in San Juan, because it was one of the few hospitals that remained open throughout Hurricane Maria and the critical weeks following the natural disaster, and it has disaster-preparedness systems similar to other hospitals
The Kruk et al framework was constructed for both hospitals and health systems, and with the critical case sampling, we can make a logical generalization of the UPR Hospital that may be indicative of the greater Puerto Rican health system
Summary
In September 2017, Hurricanes Irma and Maria devastated Puerto Rico and caused severe damage to critical infrastructure and essential health systems (Kishore et al, 2018; SantosBurgoa, 2018). Resilience, defined as the capability of a health system to prepare, respond and reorganize under conditions of stress, is posited to protect the population from excess morbidity and mortality (Greenstein et al, 2016; Kutzin and Sparkes, 2016; Blanchet et al, 2017; Kruk et al, 2017; Ling et al, 2017; Abimbola and Topp, 2018). In this setting, excess mortality and morbidity is defined as an elevation in the number of deaths and/or prevalence of disease in the months to years following the stressor as compared to the expected number of deaths and/or prevalence of disease if the stressor had not occurred. Several studies have estimated the excess morbidity and mortality following Hurricane Maria in Puerto Rico, yet no study has comprehensively examined the underlying health system weaknesses contributing to the deleterious health outcomes
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