PROJECT SUMMARY/ABSTRACT
Intense natural disasters including hurricanes, floods, and earthquakes have become more frequent and
closely spaced in recent years. Large scale natural disasters can severely damage and degrade health care
facility structural integrity and equipment, create environmental hazards, and negatively affect health service
delivery (e.g., cancelled surgeries; postponed preventive care; pharmacy closures; staffing, medication, and
medical supply shortages; large transient surges in emergency department volume) – all of which contribute to
increased stress among health care providers. Superimposing infectious disease epidemics on the natural
disasters further exacerbates stress on the health care system. Over the span of 3 years, Puerto Rico suffered
from 3 major back-to-back public health emergencies including 2 natural disasters and a pandemic. First,
Hurricane Maria hit in September 2017 causing major devastation throughout the island. Communities lost
access to essential services such as electricity, potable water, safe roads and bridges, and health care. Most
of the island’s public and private health care facilities closed or had limited capacity for months. Second, in
December 2019, a series of more than 500 quakes of magnitude 2.0 or greater struck Puerto Rico causing
more infrastructure damage to many struggling health facilities and leaving thousands homeless or living
outside in their yards. Third, Puerto Rico continues to deal with the novel coronavirus-19 (COVID-19)
pandemic. This study will provide a unique opportunity to understand the effects of 3 distinct public health
emergencies on a minority population with significant health and health care disparities. We have designed a
mixed methods, multi-level study that will triangulate quantitative and qualitative data to study the pre and post
effects of the 3 public health emergencies on Puerto Rico’s health care system’s preparedness, response, and
recovery efforts and how the emergencies have affected the resiliency, experiences, and utilization of the
island’s health care system. The study will use administrative utilization data from 50 general hospitals and 20
federally funded health centers on the island, qualitative interviews of health system leaders and providers, and
follow-up interviews of a representative cohort of 3,062 island adult residents. Using the Donabedian quality of
care model and concepts from an emerging literature on health system resilience as our study framework, we
will 1) identify factors that influenced the capacity of Puerto Rico’s health care system to prepare for, respond
to, and recover from Hurricane Maria, the earthquakes, and COVID-19, 2) model the cumulative effects of
multiple disasters on health system resiliency and how these effects interact, and 3) elicit lessons learned from
health care leaders and providers. We will synthesize the information from our triangulated research approach
to provide data driven recommendations for an effective and coordinated approach to mitigation,
preparedness, response, and resiliency under conditions of increasing frequency and intensity of disasters.