Delivering Regular Care in Irregular Times: Public Health in the Wake of a Natural Disaster

Hayden Tornabene

Dr. Sue Anne Bell is a Clinical Associate Professor of Nursing and Health Behavior and Biological Sciences at the University of Michigan School of Nursing. Her research focus is on disaster preparedness and response, particularly on the long-term impact of disasters on human health in the United States and in settings around the world.

You are currently in Puerto Rico assisting with the response to Hurricane Maria. Can you give a few examples of the long-term public health challenges Puerto Rico faces?

Right now I am standing in the center of Old San Juan, which is usually a tourist mecca. Under normal conditions, this area would be filled with cruise ships, musicians, open restaurants and stores, the sort of bustling you would expect. Right now there is a single Starbucks running on generator that closes at 5:30pm. Other than that, there is really nothing else going on, very few other places are open. Almost everything is shuttered and many buildings are still boarded up.

There is a real breakdown in continuity of care for people, especially for people with chronic health conditions. Many physicians’ offices are closed, and hospitals are operating under limited capability as many staff members, whether nurses or other support staff, have left the island. Shortages in supplies, power, clean water, and functioning clinics make it impossible to deliver regular and quality care in many places across the island. All these factors and conditions exacerbate chronic health conditions, further stressing the overwhelmed response effort.  

Another very pressing problem is the lack of communication, the circulation of rumors, and the overall communications network breakdown. Communities are reeling from the lack of infrastructure and basic community health services cannot effectively provide public health information or regular support. 

What kinds of resources, in terms of public health infrastructure and preparedness, do you think Puerto Rico most needs in order to emerge intact and stronger?

Those almost feel like two entirely separate questions. Normalcy is still so far away that it is hard to think about preparedness as we deal with what is going on right now. 

As much as there was a system of preparedness in place, nobody was prepared for two huge hurricanes back-to-back. We always think about all hazards preparedness as being ready for any kind of disaster, but something this overwhelming stretched an already over-burdened economy too thin. In order for the communities to heal, the biggest focus needs to be on repairing the destroyed infrastructure and delivering basic care.

Relative to this issue of untreated chronic conditions, some people have not had power since hurricane Irma hit in early September. I’ve heard from diabetics whose insulin is floating in a cooler of warm water. Chronic pain conditions, which in some cases were not well controlled before the disaster, are further exacerbated by current conditions here. Imagine sitting in your house with no power for weeks on end, without any of the sort of quality of life distractions, like internet or cold clean water, that work to soothe that chronic pain. The damage done to the infrastructure in Puerto Rico affects every facet of life, which introduces a host of new stressors that contribute to the chronic conditions of someone who doesn’t have a normal pattern of living. I’m also seeing a lot of upper respiratory complaints from people who are operating and living in areas that experienced flooding, which exposes them to mold and other allergens. High levels of humidity and the continued lack of electricity are further exacerbating these conditions. Until there is power and regular clean water, and until schools and stores reopen, the focus will remain on repairing that infrastructure to return a basic quality of life.

How do our preparedness approaches to natural disasters compare to our preparedness approaches to public health threats like epidemics or chronic disease? Are these two separate questions or should they be considered as part of a larger disease intervention strategy?

There is definitely some overlap. If you think about pandemic preparedness versus disaster preparedness versus terrorism threat preparedness, one common link is resource allocation. Whether it is supplies, or staffing, or care facilities, strategic allocation and deployment of resources is definitely a common thread. Another common concern with all of these types of incidents is instituting a system of communication and command like the Incident Command System. Having an organized framework for how the response is going to be run is crucial for the effective deployment of staff and resources, especially in areas where communication networks have been hit the hardest.

Our Public Health Thank You Day theme this week is “Imagine a disease-free world?” In your opinion, what are the most threatening public health challenges we should be addressing now?

A lot of my work concerns how older adults bounce back or are resilient to the effects of a disaster. So in thinking about a disease-free world, I would think about the very pressing and overwhelming incidents of chronic disease that stress the public health system, especially those that are made worse by the acute disruption of disasters like Hurricanes Irma and Maria. The work of public health officials has been instrumental here in helping individuals rebuild the quality of life they knew before these hurricanes. A disease-free world here starts with those kinds of efforts.


To learn more about the status of the rebuilding efforts taking place in Puerto Rico, click here. To read more about the public health challenges in providing care for older victims following a natural disaster, click here.

Hayden Tornabene is a science policy intern at Research!America.

This blog post is part of a series focusing on different aspects of public health in recognition of Public Health Thank You Day, held each year on the Monday before Thanksgiving. Visit is external) for more information, and join us on social media using the hashtag #PHTYD

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If concerted, long-term investments in research are not made, America will lose an entire generation of young scientists.
Brenda Canine, PhD; McLaughlin Research Institute, Montana