by Emma Fiala and Carlie Derouin
After our morning with Lionel, our two groups (University of Minnesota and SUNY-Albany) resumed for a presentation by Jonathan Castillo Polanco. Jonathan is a graduate student at the University of Puerto Rico-San Juan studying Public Health and Environmental Policy. He currently is also a researcher at the National Institute of Energy and Sustainability (INESI) and is assisting with energy public policies with the Puerto Rican Senate. His presentation focused on the impacts of Hurricane Maria on public health in Puerto Rico. His presentation began with a definition of public health to ground the conversation: the organized response from a society aimed at promoting and protecting the health of a community by acting to prevent sickness, injury and disability. The fundamental purpose of public health is to reach higher levels in well-being using knowledge and existing resources. His presentation then covered several public health concerns Puerto Rico faced in the disaster: issues with hospitals, electric generators, fresh water, and food and related it back to the official definition of public health to make the case that Puerto Rico had not been taking public health seriously.
A month after Maria, only a few dozen hospitals were operational in Puerto Rico. Many were located within the capital of San Juan and some larger cities, such as Ponce and Mayaguez. Only a few were operational in the center of the island. Due to Maria, roads and bridges were destroyed, so travel to operational hospitals was impossible during the first week and extremely difficult thereafter. For example, a woman who lived in the center of the island had died and because she needed to be pronounced dead by a doctor, she was left there for a week until an ambulance was able to come to her home. Clearly, this represents a huge public health crisis. Appropriately, the mainland sent the US Navy Ship Comfort, which had around 1000 beds, 12 operating rooms, and various sub-specialties. However, the USNS Comfort was stationed outside of San Juan, while other locations, particularly within the center of the island, were left without aid. In addition to the suboptimal location of the USNS Comfort, protocol dictated use of ship for true emergencies and only after being evaluated by a hospital. This meant that patients with chronic diseases that were at the time well-managed, could not seek care for likely future emergencies. Of around 400 people that were sent to the USNS Comfort, only 10 were admitted.
Relating this back to the public health definition from the Puerto Rican government, public health is not defined as emergency care for acute conditions, but as protecting the health of a community. This leads to a few questions: Why send the USNS Comfort if it is not fully utilized and not in a location of extreme need? Why send sick patients to a hospital first when there is a ship equipped to manage their conditions? What happens to those patients who need dialysis, refrigeration of medications, or patients with other chronic conditions that require close follow up?
When the hurricane hit, many transmission lines were damaged resulting in the supply and demand imbalance that caused Puerto Rico to lose power completely. It took more than a year to resupply the entire island with power and many rural inland communities suffered the most. The lack of electricity is significant as many resorted to using diesel generators for power. Some examples of the uses of electricity that may be overlooked include nebulizer treatments for asthmatics, ventilators for life support, and storage of insulin and other medications. Jonathan told stories of people who had no more gas to fuel the generators that provided electricity to ventilators, so families were forced to watch loved ones die. In addition to the negative outcomes from lack of power, there are significant negative outcomes to using diesel generators. Emissions are correlated with cardiovascular disease, respiratory disease, meningitis and even low birth weights. Some people did not understand the potential dangers of generators and developed carbon monoxide poisoning. This energy poverty exacerbated health conditions, such as stress and mental illness, which is also a significant public health problem.
An island without electricity is an island without the ability to power water treatment plants that produce drinking water. When the people depleted their supply, many resorted to drinking water in the rivers. As upstream residents used the river for all hygiene as well, the water became dirty for downstream drinkers. The EPA found enterococcus, a bacteria responsible for diverticulitis, UTIs and meningitis in all the freshwater of Puerto Rico. In addition to enterococcus, leptospirosis became rampant. Leptospirosis is a disease caused by bacteria in the water and can be very serious if left untreated or improperly diagnosed. Normally, there are around five cases per year of leptospirosis, however within two months, there were 114 confirmed cases. It took Puerto Rico months to recover their water systems.
In addition to the public health concerns relating to hospitals, electricity and water, lack of sufficient and nutritious food remained a problem for Puerto Rico long after the hurricane hit. By the WHO, food security is defined as access to permanent, sufficient and nutritious food. By this definition, 86% of Puerto Rico met that definition. Puerto Ricans ate mainly “hurricane food,” such as beans, canned meat, and other canned foods. There is significant sodium in canned foods, particularly canned meats, meaning those with sodium sensitivity were without viable options. This exacerbated patients with hypertension as one can of meat is the daily recommended limit of sodium. Hypertension is not usually an acute illness, but a chronic one, so eating a high sodium diet over a long period of time can cause kidney damage, dehydration, stroke, and more.
To wrap up the lecture, Jonathan facilitated a quick workshop in which small groups rotated through the four public health needs: hospitals, clean water, nutritious food, and addressing pollution from electric generators. We generated a variety of ideas that could have helped prevent problems from occurs or alleviate their burden. Examples included education on drinking water and disease, policies on generator use and increased capacity of community centers as distribution hubs for food and medications. The discussion of the cascade of health issues directly related to the electrical grid failure after hurricane Maria emphasized the importance of energy systems in society and how the future of the energy system in Puerto Rico is embedded in other social concerns. In the era of climate change in which storms, such as hurricane Maria threaten the island, it is important that work being done on energy transition here take into account the vulnerability Puerto Rico faced in this disaster and ways in which Puerto Rico can be more resilient.
What ideas do you have for solving these public health issues?